Georgia epidemiology report, Vol. 23, no. 10 (Oct. 2007)

October 2007

volume 23 number 10

Influenza

Epidemics of influenza occur during the winter months, 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, young children under two years of age, the elderly, pregnant women, and persons with certain chronic medical conditions are at higher risk for serious influenza-related complications. Most influenza-related deaths occur among the elderly. Prevention strategies are designed to prevent influenza in high-risk populations and those living with or in close contact with 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, influenza-related hospitalizations and deaths, otitis media in children, and work absenteeism. Annual influenza vaccination is recommended for persons at high risk of developing complications from influenza as well as their contacts (Table 1). However, all persons, including school-aged children and healthy adults, who want to reduce their risk of becoming ill with influenza or of transmitting influenza to others should be vaccinated.
During 2004-2005, the Advisory Committee on Immunization Practices (ACIP) recommended vaccination of all children aged 6 through 23 months. Beginning in 2006-2007, this recommendation was expanded to recommend vaccination of all children aged 6 through 59 months (i.e., 6 months through 4 years). These recommendations deserve emphasis because they are relatively new, and reported vaccination levels remain low among children. Children aged 6 months through 8 years who have not been previously vaccinated should receive 2 doses of vaccine the first year, followed by single dose vaccination in subsequent years. Children aged 6 months through 8 years who received only 1 dose in their first year of vaccination should receive 2 doses the following year (within the same season). To protect young children, especially those too young to be vaccinated (i.e. less than 6 months of age), vaccine is recommended for healthy household contacts and caregivers.
ACIP also emphasizes that healthcare personnel (HCP) and other persons who can transmit influenza to those at high risk should be vaccinated against influenza annually. Vaccination levels among HCP should be considered one measure of a patient safety quality program, for example, in hospitals or long term care facilities (LTCF), and healthcare administrators should implement policies to encourage HCP vaccination. Vaccination of HCP has been associated with reduced work absenteeism and with fewer deaths among LTCF residents and elderly hospitalized patients.
Four antiviral agents are approved for treatment or prophylaxis of

influenza. Due to recent widespread resistance to two of these medications among circulating influenza viruses, ACIP recommends that neither amantadine nor rimantadine be used for treatment or chemoprophylaxis. Until susceptibility to adamantanes has been re-established among circulating influenza A viruses, oseltamivir or zanamivir may be prescribed for influenza antiviral treatment or chemoprophylaxis (1).
Table 1. Persons for Whom Annual Influenza Vaccination is Recommended (1)
All persons, including school-aged children, who want to reduce the risk of becoming ill with influenza or of transmitting influenza to others.
All children aged 6 through 59 months (i.e., 6 months through 4 years);
Persons aged 50 years; Children and adolescents (aged 6 months through 18 years)
who are receiving long-term aspirin therapy and, therefore, might be at risk for experiencing Reye syndrome after influenza infection; Women who are, will be pregnant during the influenza season; Adults and children who have chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, hematological or metabolic disorders (including diabetes mellitus); Adults and children who have immunosuppression (including immunosuppression 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; Healthcare personnel; Healthy household contacts (including children) and caregivers of children aged <5 years and adults aged 50 years, with particular emphasis on vaccinating contacts of children aged <6 months; Healthy household contacts (including children) and caregivers of persons with medical conditions that put them at higher risk for severe complications from influenza.
2007-08 Influenza Vaccine Both the trivalent inactivated influenza vaccine (TIV) and the live, attenuated influenza vaccine (LAIV) prepared for the 2007-08 season will include influenza A/Solomon Islands/3/2006 (H1N1)like (new for this season), A/Wisconsin/67/2005 (H3N2)-like,

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and B/Malaysia/2506/2004-like antigens. TIV is given GDPH also monitors ILI activity through the syndromic surveillance component

by intramuscular injection, and may be used for any of the State Electronic Notifiable Diseases Surveillance System (SendSS). A

person aged 6 months, including those with high- growing number of hospital emergency departments participate in syndromic

risk conditions. LAIV is given by intranasal spray, and influenza surveillance (currently in 13 of 18 Health Districts), which monitors the

is licensed for use in healthy non-pregnant persons 5 number of patients presenting with respiratory syndromes or fever with flu-like

through 49 years of age.

symptoms. These symptoms are reported daily, and increases beyond expected

counts prompt automatic alerts to key public health and hospital staff. The

The optimal time to receive influenza vaccine is October number of patients admitted or who die with these symptoms is also available to

or November, prior to influenza virus exposure; public health and hospital staff.

however, in Georgia, influenza activity typically peaks

after December, so influenza vaccination should continue GDPH requires reporting of pediatric influenza-associated deaths and influenza

throughout the influenza season as long as vaccine is outbreaks in schools, health care facilities, long term care facilities and other

available. ACIP encourages immunization providers institutions. During the influenza season, Georgia influenza activity is posted

to offer influenza vaccine and schedule immunization weekly on the GDPH website, at http://health.state.ga.us/epi/flu, with links

clinics throughout the influenza season. Healthcare provided to nationwide data from CDC.

providers who have vaccine available may post this

information on the flu clinic locator website (http:// Georgia Influenza Surveillance, 2006-07 Season

www.immunizeadultga.org/), which helps Georgians The Georgia Public Health Laboratory (GPHL) confirmed the start of the 2006-

seeking vaccine to find providers in their community. 07 influenza season by identifying the virus in a Georgia resident whose illness

If uncertainties arise related to vaccine supply, ACIP began on November 5, 2006. During the 2006-07 season, GPHL identified 93

may recommend that certain groups defer vaccination influenza viruses. Of the 93 influenza isolates, 38 were subtyped as influenza A

with TIV to ensure access for the highest risk groups, (H1), three were subtyped as influenza A (H3), and 52 were subtyped as influenza

however no such problems are anticipated for the coming B. Thirty-one of the influenza isolates were then sent to CDC for antigenic

influenza season. Since high-risk groups do not receive characterization: 12 were characterized as A/NEW CALEDONIA/20/99

LAIV, no such restrictions would apply for this vaccine. (H1N1)-like (one of the two influenza A components of the 2006-07 influenza

vaccine), nine were characterized as B/OHIO/1/2005-like, (the B component of

Overview of Influenza Surveillance in Georgia the 2006-07 influenza vaccine), one was characterized as B/FLORIDA/07/2004-

The Georgia Division of Public Health (GDPH) like and one was characterized as B/HongKong/330/2001 (neither of which

monitors influenza activity via a sentinel provider were a component of the 2006-07 influenza vaccine, although the vaccine would

network, part of a nationwide surveillance network be expected to have conferred some cross-protection).

coordinated by the Centers for Disease Control and

Prevention (CDC). Weekly during influenza season, Two distinct peaks of influenza activity were observed during the 2006-07 season

volunteer sentinel healthcare providers throughout in both the sentinel and syndromic surveillance systems (Fig. 1). This pattern

Georgia report the total number of patient visits, and may have resulted from social distancing with school or work closures, and/or

the number of those patients with influenza-like illness from altered patterns of healthcare-seeking behaviors during winter breaks.

(ILI). ILI is defined as fever 1000 F AND cough and/ Overall, influenza activity peaked in Georgia in mid-February, consistent with

or sore throat. Sentinel providers also submit throat four of the last five influenza seasons. The proportion of ILI visits to Georgia

or nasopharyngeal swabs from representative patients Influenza Sentinel Providers peaked at 5.1% during the second week of February

with ILI several times during the season for viral culture and decreased to less than 1% by early April.

at the Georgia Public Health Laboratory (GPHL).

Because ILI may be caused by pathogens other than Figure 1. Percent of Visits for Influenza-like illness Reported by Sentinel

influenza, and many cases of influenza are not medically Provider Network in Georgia

evaluated, confirmed by laboratory testing, or reported,

10.0

the sentinel surveillance network cannot be used to

determine the number of influenza illnesses during a

8.0

% of Visits

given season. However, ILI data coupled with the results

6.0

of viral cultures from GPHL and from a network of

4.0

hospital laboratories throughout the state that report

to the CDC's National Respiratory and Enteric Virus

2.0

Surveillance System (NREVSS) help to characterize

0.0

1 3 1 3 5 2 4 2 4 2 4 2 4 1 3 1 3 5 2 4 2 4 2 4 1 3

influenza disease activity and distribution. Sentinel

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Oct Oct Nov Nov Nov Dec Dec Jan Jan Feb Feb Mar Mar Apr Apr May May May Jun Jun Jul Jul Aug Aug Sep Sep

surveillance plays a critical role by providing specimens

for influenza virus testing and allows strain selection for

Month and w eek

next year's influenza vaccine.

2003-2004

2004-2005

2005-2006

2006-2007

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

Influenza activity in Georgia was characterized as regional from November 5 December 9, 2006, and widespread from December 10 December 30, 2006. Activity decreased to regional from December 31, 2006 January 27, 2007 and returned to widespread from January 28 March 10, 2007.
Reports of Influenza-Associated Deaths among Children, Georgia, 2006-07 Since August 2004, influenza-associated deaths in children <18 years of age have been notifiable in Georgia. During the 200607 influenza season, five such cases were reported to GDPH. All had severe pneumonia and four of five had bacterial coinfections in addition to influenza; two with methicillin-resistant Staphylococcus aureus (MRSA), one with S. aureus documented by immunohistochemical staining, and one with invasive group A streptococcal infection. The fifth case was pregnant and had severe primary viral pneumonia.

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.
Thank you, Georgia Influenza Sentinel Providers GDPH would like to thank the 2006-07 Influenza Sentinel Providers, especially those who continued to report through the summer (Table 2). These generous volunteers provide essential information on statewide disease trends and circulating influenza strains. If you are a healthcare provider interested in conducting influenza surveillance, contact Ariane Reeves, R.N., B.S.N., M.P.H., CIC, Influenza Surveillance Coordinator, at 404-657-2588.

Influenza Outbreaks, Georgia, 2006-07 During 2006-07, four influenza outbreaks were reported to GDPH from institutional settings (three schools and one correctional facility). All four were confirmed influenza B outbreaks.

Vaccination Rates among High Risk Persons, Georgia, 2006 While most influenza vaccine is purchased directly by private providers, Public Health also distributes influenza vaccine. During the 2006-07 season, the Vaccines for Children Program distributed 244,200 doses of vaccine to Georgia providers for administration to uninsured and under-insured children. County and District Health Departments distributed 362,040 doses of vaccine.

Data from the Behavioral Risk Factor Surveillance System (BRFSS) indicate that influenza and pneumococcal vaccination rates have improved among Georgians aged 65 years during the past decade (Figure 2). However, influenza and pneumococcal vaccination rates are still far below the Healthy People 2010 goal of 90% vaccination for both vaccines among persons aged 65 years.

Figure 2. Influenza and Pneumococcal Vaccination Rates among Persons Aged>=65 Years, Georgia, 1995-2006

Vaccination rate (%)

100

90

80

70

60

50

40

30

20

10

Source: BRFSS

0

1995 1996 1997 1999 2000 2001 2002 2003 2004 2005 2006

Influenza

Pneum ococcal

Healthy People 2010 G oal

Resources Many illnesses have signs and symptoms similar to those of influenza infection, making a clinical diagnosis difficult. Knowing when influenza virus is circulating in the community can help

Table 2. Georgia Influenza Sentinel Providers who submitted reports for at least half of the 34 weeks during the 2006-07 influenza season

Newnan Hospital Wellstar Urgent Care Wellstar Urgent Care Wellstar Urgent Care Sandy Springs Pediatrics Tanner Medical Center The Pediatric Center Mountain Medical Valdosta State University Immediate Medical Care University of West Georgia Columbus State University Colquitt Complete Care Georgia Institute of Technology Northeast Georgia Medical Center Medical College of Georgia Fine and Associates Internal Medicine LaVista Primary Care Athens Neighborhood Health Center Upson Regional Medical Center Northwest Georgia Family Practice Gilbert Health Center, University of Georgia Henry Medical Center Archibald Urgent Care Emory University Student Health Services Tracy Middlebrooks, Jr. MD Community Care Center Ronny Sayers MD Lee Medical Arts Center East Albany Medical Center Trojan Battery Co. Medical Services Dept, Coca-Cola Company Lakeside Pediatrics, LLC Lockheed Martin Medical Dept. LaGrange Pediatrics Cornerstone Medical Associates Family Health Center Macon Volunteer Clinic Cagle Inc. Flint River Community Hospital Louis Smith Memorial Hospital Tift Regional Medical Center Georgia Southern University Health Services

Amna Khan-Hickman, RN J. Dorland Brown MD Warren Falo MD Rodger Chapman MD Kytia Balcarek MD Laura Larson MD Patty Hopkins Raymond Tidman MD Rita Collins Tulasi Vanapalli MD Johnnie Pollard RN Becky Tew RN, MSN Bill Swafford, MD William Manns MD Stratton Kearns MD James Wilde MD

Newnan Kennesaw Marietta Marietta Atlanta Villa Rica Thomasville Blue Ridge Valdosta Morrow Carrollton Columbus Colquitt Atlanta Gainesville Augusta

Joel Fine MD Snellville Dich Van Nguyen MD Tucker

Gail Hurley MD Athens Glenda van Houten RN Thomaston Herman Spivey MD Summerville

Jean Chin MD Athens Jo Middlebrooks RN Stockbridge Julia Weeks MD Thomasville

Michael Huey MD Tracy Middlebrooks, Jr., MD Nancy Rowell MD, FNP Ronny Sayers, MD Susan Green RN Susan Green RN Michelle Haney RN

Atlanta Augusta Riverdale Sardis Leesburg Albany Lithonia

William Yang MD, MPH Bob Bagheri, MD Mark Wood MD Suzanne Schuessler MD Nina Courchesne LPN Roberta Weintraut MD Lynn Denny MD Oneal Shaw Kim Driver RN Brenda Jordan MT Daniel Goff RN, CIC, ICP

Atlanta Cumming Marietta La Grange Warner Robins Macon Macon Pine Mtn Valley Montezuma Lakeland Tifton

Curtis Hames MD

Statesboro

healthcare providers diagnose influenza infections among patients This article was written by James R. Cope, M.P.H., Shani Thompson, M.P.H., Ben presenting with ILI. During influenza season, GDPH sends Sloat, M.P.H., and Kathryn Arnold, M.D.

email updates on influenza activity in Georgia to those who are

interested. If you would like to receive these updates, send an References

email to flu@dhr.state.ga.us with the word "subscribe" in the

1. CDC. Prevention and Control of Influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2007. MMWR 2007;56(No. RR-6).

subject line.

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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 2007

Volume23Number10

Reported Cases of Selected Notifiable Diseases in Georgia, Profile* for July 2007

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 2007
2007 96 30 19 5 46 7 1 4 6 3 3 1 0 2 0 214 125 1 8 5 9 0 29

Previous 3 Months Total Ending in July

2005 2006 2007

215

169

241

8082

10280

2154

27

54

48

7

17

8

175

165

149

3874

5460

807

18

27

22

38

19

19

38

57

24

13

13

8

3

5

6

7

2

4

0

3

0

19

8

5

0

0

0

562

546

484

130

290

639

29

28

10

134

112

58

106

112

40

262

244

117

0

1

0

130

143

108

Previous 12 Months Total Ending in July

2005 2006 2007

611

572

649

32977

38119

33241

164

202

258

21

43

32

829

690

677

15606

18908

15105

111

116

120

186

85

66

300

190

154

31

36

43

5

8

8

20

15

20

3

5

0

46

32

25

0

0

0

1854

1913

1886

526

947

1839

110

136

82

507

472

431

361

402

305

956

984

822

4

8

3

489

523

472

* 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**:
2/06-1/07
Five Years Ago:
2/02-1/03

Disease

Total Cases Reported*

Classification <13yrs

>=13yrs Total

HIV, non-AIDS

41

3,694

3,735

AIDS

14

2,089

2,103

HIV,

-

non-AIDS

AIDS

1

1,790

1,791

Percent Risk Group Distribution

Female MSM

IDU

MSM&IDU HS

Unknown

Perinatal

Race Distribution

White Black

Hispanic

27

28

4

1

10

56

1

23

71

5

27

29

6

1

10

54

<1

24

69

6

-

-

-

-

-

-

-

-

-

-

25

37

9

3

15

36

-

20

73

6

Other 1 1 1

Cumulative: HIV, non-AIDS 271

11,952

12,223

32

28

7

2

11

50

2

22

73

4

1

07/81-1/07 AIDS

282

37,359

37,641

20

44

15

5

13

23

<1

30

66

3

1

Yrs - Age at diagnosis in years

MSM - Men having sex with men

IDU - Injection drug users

HS - Heterosexual

* Case totals are accumulated by date of report to the Epidemiology Section ** Due to a change in the surveillance system, case counts may be artificially low during this time period

***HIV, non-AIDS was not collected until 12/31/2003

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