Georgia epidemiology report, Vol. 22, no. 12 (Dec. 2006)

December 2006

volume 22 number 12

Mumps Outbreaks Exemplify the Need to Recognize and Report Vaccine Preventable Diseases

Two mumps outbreaks have been identified in the United States during the past 18 months. During December 2005, an outbreak of mumps began in Iowa and spread to several surrounding states throughout the spring of this year. Between January 1 and May 2, 2006, 11 states reported 2,597 cases of mumps to the Centers for Disease Control and Prevention (CDC)(1). During the summer of 2005, the New York Department of Health (NYDOH) investigated an outbreak of mumps among campers and staff at a camp. Thirty-one cases were identified(2). Even though measles, mumps, rubella, and other vaccine preventable diseases are rarely seen in the United States, sporadic outbreaks of vaccine preventable diseases can and do occur. These outbreaks underscore the need for healthcare providers to be vigilant for vaccine preventable diseases in their daily practice and report suspect cases to Public Health immediately.

immunization, and/or post exposure prophylaxis. These efforts are often successful in minimizing disease transmission among close contacts and household members and can therefore prevent outbreaks.
Outbreaks of vaccine preventable diseases usually occur where immunization coverage is poor but can occur in highly vaccinated populations, since no vaccine is 100% effective. Disease outbreaks are widespread in areas of the world where resources are limited. Today, air travel permits access to far-reaching and remote areas of the world within hours, and risk for exposure to vaccine preventable disease is significant. Health care providers should stay current on the clinical presentations and diagnostic methods for vaccine preventable diseases, especially those that are rare in the United States.

The first mumps cases in the Iowa outbreak were identified among college students. The source of these cases is unknown; however the mumps virus genotype was the same type responsible for a large outbreak in the United Kingdom (UK) in 2004 2005(3). In the Iowa outbreak, multiple factors potentially contributed to the spread of mumps. First, campus dormitory living, settings in which students are in close contact with each other for extended periods of time, facilitates transmission of infectious diseases. Second, delayed recognition, diagnosis and reporting of mumps cases may have also contributed to the spread of mumps. Third, Iowa (and many other states) does not have a college admission requirement for 2 doses of measles, mumps, and rubella (MMR) vaccine. Even so, 2 doses of MMR are not 100% effective in preventing disease(1). CDC suggests that an accumulation of susceptible persons who were not successfully immunized might be sufficient to sustain transmission in certain settings(1). There are other possible contributing factors which are discussed in the May 18, 2006 Morbidity and Mortality Weekly Report (MMWR) Dispatch.
In the NY outbreak last summer, the index patient was identified as a 20year-old man who came to the United States from the UK on June 19, 2005 to work as a counselor at the camp. He had not been vaccinated for mumps and there was a large ongoing outbreak of mumps in the UK. On June 30, he developed left-sided parotitis, sore throat, and a low-grade fever. The counselor sought medical care at the camp's infirmary, however mumps was not considered as a diagnosis. Therefore, he was not isolated and continued to work among the camp population. Twenty-five additional cases of parotitis were identified among campers and staff between July 15-23, consistent with exposure beginning June 28th. Mumps was not recognized by the health care staff at the infirmary or by community health-care providers until July 24.
These outbreaks emphasize the need for prompt recognition, diagnosis and reporting of vaccine preventable diseases. All vaccine preventable diseases are reportable in Georgia, excluding influenza and varicella. A report of vaccine preventable disease leads to a prompt Public Health investigation. Public Health collaborates with health care providers to collect the appropriate laboratory specimens for disease confirmation, recommends and implements prevention and control measures, such as patient isolation,

The Georgia Division of Public Health (GDPH) launched a campaign to raise medical providers' awareness of the Iowa mumps outbreak as well as mumps diagnosis and reporting this spring. Information was disseminated to the medical community through the GDPH web site and directly through other community partners (hospital staff and those involved in primary and secondary education). In Georgia, there are typically fewer than 10 15 suspect cases of mumps reported annually, and of those, < 5 are laboratory confirmed (see Table 1). This year, however, over 50 suspect mumps cases were investigated, of which 4 were laboratory confirmed. None of the four confirmed cases had an epidemiologic link to the outbreak in the Midwest. The number of suspect cases reported this year was likely a result of increased mumps awareness associated with the large multi-state outbreak. Even though Georgia did not identify an increase in confirmed cases this year, these outbreaks illustrate the need for medical providers to continue to be vigilant for vaccine preventable diseases in their patients.

Table 1. Laboratory Confirmed Mumps Cases in GA, 2001-2006

Year

# Cases

2001

9

2002

2

2003

3

2004

2

2005

2

2006*

4*

* Provisional data: January 1, 2006 December 1, 2006

When a vaccine preventable disease is suspected in your practice you should:
Call your local or District Health Office or 866-782-4584 (866-PUB-
HLTH) to report a suspect case or clusters.
Collect appropriate laboratory specimens, (Public Health can assist).
All vaccine preventable diseases should be lab confirmed with the exception of tetanus, for which a clinical diagnosis is appropriate.
Collaborate with Public Health to implement prevention and control
measures.

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 Georgia Division of Public Health has a web-based disease reporting system, the State Electronic Notifiable Disease Surveillance System (SendSS). Providers can report cases of notifiable disease conveniently from an office computer. To register, please go to http://sendss.state. ga.us. However, The Division of Public Health encourages providers to call immediately when they suspect a vaccine preventable disease since rapid collaboration and coordination of diagnostics and prevention measures is often necessary.

References 1. Centers for Disease Control and Prevention. Update: Multistate
Outbreak of Mumps United States, January 1 May 2, 2006. MMWR. 2006; 55 (No. 20): 559-563 2. Centers for Disease Control and Prevention. Mumps Outbreak at a Summer Camp New York, 2005. MMWR. 2006; 55 (No. 7): 175-177 3. Centers for Disease Control and Prevention. Mumps Epidemic Iowa, 2006. MMWR. 2006; 55 (No. 13):

This article was written by Julie Gabel, D.V.M., M.P.H., Medical Epidemiologist, Notifiable Diseases Epidemiology Section, Georgia Division of Public Health.

Hepatitis B Prevention: Avoiding Missed Opportunities

Hepatitis B is caused by a bloodborne and sexually transmitted virus. It causes infection of the liver that can lead to lifelong chronic infection, cirrhosis, hepatocellular carcinoma, and death. Despite the availability of hepatitis B vaccine in the United States (U.S.) since 1982, transmission of hepatitis B infection continues to occur in infants, adolescents, and adults in Georgia who have not been immunized. Hepatitis B is a notifiable disease in Georgia, including
Acute hepatitis B Newly identified HBsAg-positive carriers HBsAg-positive pregnant women
Public Health and private clinicians in Georgia are currently promoting viral hepatitis awareness, including prevention, intervention, and clinical management.
Preventing Perinatal Infection Universal prenatal testing for hepatitis B surface antigen (HBsAg) has been recommended by the Centers for Disease Control and Prevention (CDC) since 1988 [1]. The Georgia Division of Public Health (GDPH) and other State Health Departments have had perinatal hepatitis B prevention programs since 1991 to identify obstetric patients who are infected with hepatitis B and protect their newborns from subsequent perinatal infection. These infants need to receive hepatitis B immune globulin (HBIG) and the first dose of hepatitis B vaccine--preferably within 12 hours of birth.
Problems can arise when HBsAg-positive women present for delivery with no history of prenatal care or their prenatal records are not available upon admission. For example, if a patient is admitted to the hospital in labor with no documented HBsAg test, and the hospital does not have standing orders to test the woman STAT and give the universal hepatitis B birth dose of vaccine, the infant could potentially become infected. In addition, when errors occur in the documentation of maternal test results, the exposed newborn may be sent home without prophylactic immunization and develop infection. If the infant is not immunized properly within 7 days of birth, the risk of infection is 90%.
Failure to identify an HBsAg-positive woman during pregnancy, potential transcription errors, and chart omissions can negatively impact the newborn infant. Perinatal hepatitis B infection carries a 90% risk of lifelong chronic infection, with the possibility of subsequent premature death in childhood

or young adulthood due to cirrhosis or liver cancer. To prevent perinatal hepatitis B infection, recommendations from CDC and the Advisory Committee on Immunization Practices (ACIP) [2] include:
Testing all pregnant women for HBsAg during each pregnancy and
including a copy of the lab report in the hospital admission record and in the neonatal record.
Providing HBIG and first dose of hepatitis B vaccine to infants born
to HBsAg-positive women, prior to hospital discharge.
Providing dose 2 and dose 3 of hepatitis B vaccine to exposed infants
at age 1-2 months and 6 months and testing them for anti-HBs and HBsAg between 9 and 18 months of age to determine immunity or infection status.
Identifying and initiating postexposure immunization of infants born
to mothers with unknown HBsAg status at delivery.
Vaccinating women who tested negative for HBsAg prenatally, if they
are at high risk of hepatitis B infection (Hepatitis B vaccine is not contraindicated during pregnancy).
Public Health staff in Georgia are aware of private providers who fail to test obstetric patients for HBsAg because they believe that hepatitis B is not a problem in their communities. According to estimated data from CDC,* Georgia's Perinatal Hepatitis B Prevention Program should identify 668 HBsAg-positive pregnant women annually; however, only 398 (60%) and 261 (39%) were identified during 2004 and 2005, respectively. In addition, some providers are unaware of the need to conduct hepatitis B post-vaccination serology for infants born to infected mothers. Of the perinatal cases tracked by the GDPH during 2004 and 2005, very few of the documented infants were tested after vaccination (14% and 10%, respectively).
Birth Dose as a Safety Net Because even when best practices are followed, the potential for atrisk babies to "fall through the cracks" exists, which is why the ACIP supports giving the hepatitis B birth dose universally, prior to hospital discharge. CDC reports that when the birth dose is given (within 7 days of birth), there is a 70%-90% chance that the infant will be protected from perinatal hepatitis B infection, even without the administration of HBIG. In this way, the birth dose acts as a "safety net" for those infants

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
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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

born to mothers who were not identified as HBsAg positive prior to the birth. It is important to provide the birth dose in the hospital, rather than waiting until the first clinic visit. In the rare case where a provider opts to give dose 1 of hepatitis B vaccine after the infant's hospital discharge, the provider should ensure that documentation of the mother's negative HBsAg status is placed in the infant's medical record. For infants who do not receive a first dose before hospital discharge, dose 1 should be administered no later than age 2 months.
Protecting Patients of All Ages Healthcare providers should routinely assess for hepatitis B risk factors and immunize susceptible patients. Check immunization records of infants, children, and adolescents to verify that patients have completed the hepatitis B vaccine series. In Georgia, patients currently over the age of 15 may remain unprotected, due to having missed the school entry requirement for documenting hepatitis B immunization.** Adult patients should be asked about history of drug use and high-risk sexual activity, birth or travel in foreign countries where hepatitis B is highly endemic, hemodialysis or transplant, and household contact with an infected person.
When a pregnant patient tests positive for HBsAg, please report it to GDPH, Perinatal Hepatitis B Prevention Program (404-657-0278) or your local or District Health Office. Acute and chronic hepatitis B infections can be reported by calling the Notifiable Disease Epidemiology Section

(404-657-2588) or electronically through the web-based State Electronic Notifiable Disease Surveillance System (SendSS). To register, please go to http://sendss.state.ga.us.
* Patient estimates are based on 1997 National Health and Nutrition Examination Survey (NHANES) hepatitis B seroprevalence data applied to National Center for Health Statistics birth data.
** If a student started school in Georgia prior to 1997, the hepatitis B vaccine school requirement did not apply; however, this vaccine is encouraged.
References 1. Centers for Disease Control and Prevention. Recommendations
of the Immunization Practices Advisory Committee Prevention of Perinatal Transmission of Hepatitis B Virus: Prenatal Screening of all Pregnant Women for Hepatitis B Surface Antigen. MMWR 1988; 37(No.22); 341-6, 351 2. Centers for Disease Control and Prevention. A Comprehensive Immunization Strategy to Eliminate Transmission of Hepatitis B Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices (ACIP) Part 1: Immunization of Infants, Children, and Adolescents. MMWR 2005; 54(No.RR-16); 1-33
This article was written by Lynne Mercedes, Hepatitis Program Director, Notifiable Diseases Epidemiology Section, Georgia Division of Public Health.

2005 Georgia Immunization Study - Executive Summary

The 2005 Immunization Study was conducted by the Georgia Department of Human Resources, Division of Public Health, Epidemiology Branch, Immunization Program and Public Health Districts. However, this study could not have been conducted without the assistance of the private providers, non-public health providers and the Vaccines for Children providers that contributed to this collaborative effort. Their cooperation and assistance throughout the study is greatly appreciated.

population that has almost tripled, Georgia had no reported cases of tetanus or diphtheria, and just 36 cases of pertussis. In 2005, 86 percent of children 12 months of age were appropriately immunized against diphtheria, tetanus and pertussis, and 77 percent of Georgia's two-year-olds were adequately immunized against ten vaccine-preventable childhood diseases (diphtheria, tetanus, pertussis, hepatitis B, H. influenzae type B, mumps, measles, rubella, polio and varicella).

The Immunization Study employs a non-experimental retrospective cohort research design to ascertain the immunization coverage rate for children born in the State of Georgia. This study design allows for the calculation of immunization rates for children who turned two in January 2005. Identifying information about the children and their parents was collected from birth certificates.
The Immunization Study showed that during 2005, most childhood immunizations (77 percent) were administered in the private sector, while County Health Departments immunized 13 percent, and the sources for 10 percent are unknown. The proportion of children in Georgia who have received all of the recommended vaccinations showed a steady increase from 16 percent in 1997 to 79 percent in 2002, a slight decrease in 2003 to 74 percent, but an increase in 2004 to 81 percent. The 2005 study results showed another slight decrease in the immunization rate at 77 percent.
Acute infection with Hepatitis B causes severe disease in only a small proportion of those infected, but it can lead to chronic infection, cirrhosis, and cancer of the liver. In Georgia in 2005, 93 percent of infants received two doses of hepatitis B vaccine by 12 months of age, and by 24 months, 89 percent of children received the recommended three doses.
Vaccines have largely controlled diphtheria, measles, pertussis, and other scourges of the past. In 1923, with a population of less than three million, Georgia recorded 274 deaths from diphtheria, 347 deaths from measles, and 254 deaths from pertussis, while in 2003, just 80 years later, and with a

There was considerable variation from Health District to Health District in the proportion of two-year-olds reported to be fully immunized, ranging from 53 percent in the Clayton Health District to 98 percent in the North (Gainesville) Health District. Twelve of the state's Public Health Districts (Dalton, Gainesville, Gwinnett, Dublin, Waycross, Macon, Augusta, Columbus, Valdosta, Albany, Savannah, and Athens) succeeded in immunizing at least 85 percent of their two-year-olds against the 10 vaccine-preventable childhood diseases. Three of the state's Public Health Districts (Fulton, Clayton, and DeKalb) had a rate less than 75 percent. Within metropolitan Atlanta, the immunization rates varied from 53 percent in Clayton to 90 percent in Gwinnett. In Georgia outside metropolitan Atlanta, the immunization rates ranged from 80 percent in Rome to 98 percent in the Gainesville district.
Disparities in immunization status of children by the race and education of their mothers, and by whether their mothers were Medicaid recipients were identified. Among children of white women, 85 percent were adequately immunized, while among children of black women, 74 percent were adequately immunized. Children of college-educated mothers were less likely to be adequately immunized (83 percent) than children of mothers with less than high school education (87 percent). The children of mothers who did not receive Medicaid were more likely to be adequately immunized (82 percent) than were children of mothers who did receive Medicaid (79 percent).
This article was written by Carol A. Hoban, M.S., M.P.H.

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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

December 2006

Volume 22 Number 12

Reported Cases of Selected Notifiable Diseases in Georgia Profile* for September 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 September 2006
2006 45 2994 41 8 83 1648 3 3 14 3 0 3 0 4 0 280 141 4 29 14 46 0 38

Previous 3 Months Total Ending in September

2004

2005 2006

190

194

168

8936

8613

9416

77

58

97

0

12

19

280

216

217

4350

4285

5249

19

18

17

86

44

25

107

43

48

12

12

12

3

3

3

3

2

3

1

0

0

5

15

11

0

0

0

878

785

807

153

183

344

17

43

18

112

138

98

76

97

70

226

239

167

1

0

1

105

132

137

Previous 12 Months Total Ending in September

2004 2005

2006

562

611

552

34684

33161

36630

176

148

245

19

32

45

881

786

685

16179

15773

18193

114

113

108

463

149

72

455

273

188

41

32

35

12

5

8

24

17

17

1

2

5

27

51

29

1

0

0

2046

1843

1956

690

585

1061

130

129

117

506

512

434

463

370

356

867

968

885

5

3

6

518

518

497

* 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**: 11/05-10/06 Five Years Ago: 11/01-10/02 Cumulative: 07/81-10/06

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

Percent Female

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

5

1,305 1,310

26.7

31.8

6.6

2.4

9.3

0.2

49.2

1

1,543 1,544

26.6

38.1

7.6

2.9

18.9

0.8

31.7

231

30,261 30,492

19.8

44.3

15.3

4.9

14

0.9

19.8

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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Race Distribution (%) White Black Other

18.9 75.8

5.3

17.5 77.2

5.3

30.9 66.1

3