Georgia epidemiology report, Vol. 22, no. 03 (Mar. 2006)

March 2006

volume 22 number 03

Georgia Tick-borne Disease Surveillance

Announcement of Tick Attach
Study
The Georgia Department of Human Resources, Division of Public Health has partnered with the University of Georgia and the Georgia Poison Center to conduct a tick attach study. The study will help identify areas in Georgia where the chances of getting sick from a tick bite are the greatest. Enrollees must have had a tick at-
tached to them (i.e. mouth parts inserted
into the skin) and that tick must be available for identification and testing. The study is open to all Georgia residents with or without symptoms of tick-borne disease. Residents may enroll on their own without their physician's assistance.
To enroll a patient, save the tick in a small
amount of rubbing alcohol and call the Geor-
gia Poison Center (404-616-9000 or 800-2221222) 24 hours a day, 7 days a week. The Georgia Poison Center will provide instructions for how to mail the tick for testing. The University of Georgia will test the tick for the bacteria that cause tick-borne diseases like Rocky Mountain spotted fever, ehrlichiosis, Lyme disease, southern tick-associated rash illness (STARI), and tularemia, depending on the species of tick.
Results of tick testing will not be available in
time to guide diagnosis should an enrollee
develop symptoms of tick-borne disease. Suspected cases of tick-borne disease should be treated empirically, appropriate laboratory tests should be ordered, and cases should be reported promptly to public health whether or not they are enrolled in the Tick Attach Study.
Three weeks after the patient has enrolled through the Georgia Poison Center, an expert in tick illness from the Georgia Division of Public Health will call the enrollee to ask some questions about exposures to tick habitats and any symptoms of tick-borne disease. The enrollee will get the results of the tick testing when it is done. The only cost is the cost of mailing the tick. The Tick Attach Study began in April 2005 and will continue through fall 2006.

Tick-borne Disease Surveillance Highlights for 2005 Rocky Mountain spotted fever (RMSF) was the most commonly reported tickborne disease in Georgia for the eleventh straight year. Although fewer in number, cases of human monocytic ehrlichiosis (HME), human granulocytic anaplasmosis (HGA), and Lyme disease were also reported.
There were 23 confirmed and 63 probable RMSF cases reported to the Georgia Department of Human Resources, Division of Public Health (GDPH) in 2005. All cases met laboratory and/or clinical criteria, as required by the CDC case definition (Figure 1).
Of the 86 cases of confirmed and probable RMSF in Georgia in 2005, 47 (55%) were male, and the median age was 46 (range 4-92). Of the 72 cases where both race and ethnicity were known, 66 (92%) were non-Hispanic whites. One case, a 9-year-old from northwest Georgia, was fatal. Ninety-two percent of cases had onsets during April-September, with numbers peaking during the second week of June (Figure 2).
Figure 1. Surveillance Case Definitions and Laboratory Criteria--RMSF A confirmed case of Rocky Mountain spotted fever (RMSF) is defined as a clinically compatible case that is laboratory confirmed using the following criteria:
Serological evidence of a significant change in serum antibody titer reactive with
Rickettsia rickettsii antigen between paired acute- and convalescent-phase specimens ideally taken 3 weeks apart, or
Positive polymerase chain reaction assay to R. rickettsii, or
Demonstration of positive immunofluorescence of skin lesion (biopsy) or organ
tissue (autopsy), or
Isolation of R. rickettsii from a clinical specimen
A probable case is a clinically compatible case with a single serum sample at a titer considered indicative of current or past infection (cutoff titers are determined by individual laboratories).

Number of Cases

Number of Rocky Mountain Spotted Fever Cases by Week, Georgia, 2005
12

10
Confirmed Cases

8

Probable Cases

6

4

2

0
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51
Week of Onset
Figure 2. Although RMSF can be acquired any time of the year, most cases have onsets during warmer months due to increased activity of hosts and tick vectors.

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.

The incidence of Rocky Mountain spotted fever cases continued to increase during 2005, following a 3-year trend (Figure 3). Changes in the number of cases from year to year may reflect changes in surveillance and/or changes in environmental factors that affect tick abundance. The incidence of RMSF in Georgia is generally much higher than the national incidence, but pattern of highs and lows are generally comparable.
Incidence of Rocky Mountain Spotted Fever in
Georgia, 1987 - 2005

Incidence of Rocky Mountain Spotted Fever by County of Residence, 2005

Incidence (per 100,000)

1 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1
0
87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05
Year
Figure 3. Incidence of RMSF continued to increase in 2005.

Counties with the most confirmed cases of RMSF were Gordon

and Polk, each reporting three. The Northwest Georgia Health

District (Rome) had more confirmed cases (nine) than any other

Health District. It is likely that increased testing in the northwest

corner of the state was the result of increased awareness associ-

ated with the highly publicized RMSF death in that area. Other

Health Districts with significant RMSF activity during 2005 were

LaGrange (serving Butts, Carroll, Coweta, Fayette, Heard, Henry, Lamar, Meriwether, Pike, Spalding, Troup, and Upson counties), Lawrenceville (serving Gwinnett, Newton, and Rockdale coun-

Figure 4. Counties in the top three categories have greater incidences of RMSF than the national average.

ties), and Macon (serving Baldwin, Bibb, Crawford, Hancock, Houston, Jasper, Jones, Monroe, Peach, Putnam, Twiggs, Washington, and Wilkinson counties). Eighty-three percent of cases resided north of the Piedmont Fall Line (the dividing line between the Piedmont and the Coastal Plain stretching across the state roughly from Columbus to Macon to Augusta). See Figure 4.

case confirmation. Alternatively, complete a Notifiable Disease Report Form (form 3095) and mail to your District Health Office. Be sure to include clinical signs and symptoms in addition to laboratory results, as clinical compatibility is required by the surveillance case definitions. For more immediate notification, for example reporting a cluster of disease or a case of tularemia,

Other tick-borne diseases reported to GDPH during 2005 included human monocytic ehrlichiosis (HME), human granulocytic anaplasmosis (HGA), and Lyme disease. Enhanced passive sur-

please call your County Health Department, District Health Office, or Georgia Division of Public Health. After hours, call 1866-PUB-HLTH statewide.

veillance for ehrlichiosis detected two confirmed and six probable Tick-borne Disease Education Materials Available from the

cases of HME, two probable cases of HGA, and one confirmed case of human illness caused by another species of Ehrlichia. All HME cases occurred during the summer (June through the first week in September), while the HGA cases occurred during the fall (September and the first week in November). All ehrlichiosis cases except for two HME cases resided north of the Piedmont Fall Line. It is unclear whether this phenomenon represents the

Division of Public Health Mosquitoes and Ticks and the Diseases They Spread (public
information brochure) Tick-borne Diseases Poster (for physician's offices and hospitals) Tick-borne Diseases website http://www.health.state.ga.us/epi/
vbd/tick.asp - Disease fact sheets - Pictures of common ticks in Georgia

distribution of the tick vectors, lack of access to health care, or

- Information about tick identification and testing

less diagnostic testing (and perhaps less case identification) south To order education materials, contact your district Public Health

of the Fall Line. There were six cases of Lyme disease that fit the CDC surveillance case definition reported to GDPH during 2005.

Liaison or the Division of Public Health at 404-657-2588 or gaepinfo@dhr.state.ga.us.

Three cases had recent tick exposure outside of Georgia and

likely acquired their infections out of state.

Recommended Reading (includes Continuing Education Ex-

amination):

Centers for Disease Control and Prevention. Diagnosis and man-

How to Report to Public Health To report a case of tick-borne illness electronically, log on to Georgia's State Electronic Notifiable Disease Surveillance System (SENDSS) at http://sendss.state.ga.us. Enhanced screens for tick-borne diseases now collect complete information needed for

agement of tickborne rickettsial diseases: Rocky Mountain spotted fever, ehrlichioses, and anaplasmosis--United States: a practical guide for physicians and other health-care and public health professionals. MMWR 2006;55 (No. RR-4).

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Article written by Laurel E. Garrison, M.P.H.

1-866-PUB-HLTH Georgia's Notifiable Disease Emergency Reporting System
Information for Healthcare Providers
What is 1-866-PUB-HLTH? 1-866-PUB-HLTH, also called the Notifiable Disease Emergency Reporting System, is a statewide service that facilitates better communication among Georgia health care providers, health departments, and emergency response personnel. This telephone number is used to report public health emergencies and immediately notifiable diseases. This includes clusters of illness as well as diseases that could result from a bioterrorism event. The Notifiable Disease Emergency Reporting System is available 24 hours a day, 7 days a week through the combined efforts of the Georgia Department of Human Resources Division of Public Health (GDPH), the Georgia Poison Center (GPC), and District Public Health Offices.
Who should use 1-866-PUB-HLTH? Clinicians, laboratory personnel, and public health professionals should use the number to report immediately notifiable diseases or other public health emergencies. Private citizens should NOT use this number.
How does it work? When you call 1-866-PUB-HLTH, a specially trained poison center employee answers the phone. The poison center employee fills out a report, and then contacts the District Health Office of the patient's residence either by phone or fax, depending on the disease reported. You can request that someone from the health department return your call 24 hours a day, 7 days a week. The poison center employee has no clinical or formal public health training and cannot answer questions directly, but will put you in contact with someone who can.
When should I use 1-866-PUB-HLTH versus other methods of reporting? When you recognize a public health emergency or diagnose an immediately notifiable disease, including clusters of any illness, disease outbreaks and potential agents of bioterrorism. To report other notifiable diseases, you may: call your County or District Health Office, OR report cases electronically through the State Electronic Notifiable Disease Surveillance System (SENDSS) at http://sendss.state.ga.us, OR complete a Notifiable Disease Report Form (#3095) and mail in an envelope marked CONFIDENTIAL to your County, District, or State Health Department.
If I report a case using 1-866-PUB-HLTH, should I also report using additional (redundant) mechanisms? No. There is no need to report a case through multiple channels.

Botulism Information for Clinicians

Botulism is a neurological illness caused by a toxin produced by the bacterium Clostridium botulinum. In addition to recent concerns about the potential use of botulism toxin for bioterrorism, there are three naturally occurring types of botulism: 1. Wound botulism occurs when a wound is infected by C. botulinum that produces toxin. 2. Foodborne botulism occurs when toxin is ingested, often from home-canned foods of low acid content. 3. Infant botulism occurs when the bacterial spores are ingested by a baby under the age of 1 year. Botulism is characterized by an incubation period ranging from 2 hours to 8 days and symptoms of a descending paralysis. Stool, serum, and epidemiologically implicated food may be tested for both the presence of the bacteria and the toxin. CDC performs testing for most cases of suspected botulism, but specimens should be submitted through the Georgia Public Health Laboratory. CDC requires consultation with a medical epidemiologist in order to ap-

prove both testing and the release of antitoxin for patient treatment. Consultation for cases of suspected infant botulism is done in conjunction with the California Department of Health Services, Infant Botulism Treatment and Prevention Program. The Division of Public Health, Epidemiology Branch, Notifiable Diseases Epidemiology Section is available to discuss suspect cases with clinicians, and refer to the appropriate place--CDC or California Department of Health Services. We also facilitate submission of laboratory specimens. If you suspect a case of botulism, please contact us immediately at 404-657-2588, 1-866-PUBHLTH, or call your District Health Office. For more information, please refer to the following sites: http://health.state.ga.us/epi/disease/botulism.asp http://www.cdc.gov/ncidod/dbmd/diseaseinfo/botulism_g.htm
http://www.dhs.ca.gov/ps/dcdc/InfantBot/ibtindex.htm

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

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 2006

Volume 22 Number 03

Reported Cases of Selected Notifiable Diseases in Georgia Profile* for December 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 December 2005
2005 29 2215 8 0 50 968 6 4 5 2 0 1 1 1 0 96 52 0 2 7 16 0 48

Previous 3 Months Total

Ending in December

2003

2004 2005

100

129

114

8278

8070

7401

34

38

40

4

8

7

200

234

150

4152

4043

3417

23

26

18

187

43

16

141

119

22

5

7

14

0

0

1

12

3

3

0

1

1

8

10

7

0

0

0

554

456

560

198

169

257

38

27

4

136

108

31

137

70

32

220

214

98

1

2

0

133

152

140

Previous 12 Months Total

Ending in December

2003

2004

2005

619

589

593

35846

34476

32315

122

179

149

27

23

30

844

903

669

17749

16063

15019

81

117

104

771

320

113

598

469

157

35

43

39

10

12

6

37

15

18

3

2

2

36

29

47

0

1

0

2041

1942

1990

1159

655

672

126

117

93

476

476

381

740

395

282

896

837

774

11

6

1

523

539

509

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

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

3

1,836 1,839

2

1,619 1,621

226

29,567 29,793

Percent Female

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

25.8

32.4

5.6

2.0

9.0

1.3

49.7

26.9

33.6

9.1

2.8

18.7

2.0

33.8

19.6

45.1

15.6

4.9

14.1

1.9

18.5

Race Distribution (%) White Black Other

24.4 73.6

2.0

18.6 77.1

4.3

31.7 65.8

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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