Georgia epidemiology report, Vol. 24, no. 3 (Mar. 2008)

March 2008

volume 24 number 03

Tickborne Disease Surveillance in Georgia, 2007

Six tickborne diseases are notifiable in Georgia: Rocky Mountain spotted fever (RMSF), human monocytic ehrlichiosis (HME), human granulocytic anaplasmosis (HGA), Lyme disease, Q fever, and tularemia.
Eleven confirmed and 49 probable cases of RMSF were reported to the Georgia Division of Public Health in 2007. All cases met laboratory and clinical criteria, as required by the CDC national case definition. Of the 60 cases of probable and confirmed RMSF in Georgia during 2007, one probable case, in an 8 year old boy from north Georgia, was fatal. Seventy-seven percent of cases were in males, and the median age was 45 years (range 6-76 years). Of 43 cases where both race and ethnicity were known, 39 (91%) were in non-Hispanic whites. Eightyseven percent of cases had onsets during April-September. Health Districts with the most confirmed and probable cases were East Metro (13), LaGrange (11), North Central (9), and Northwest (8). Eighty-nine percent of cases were in persons who 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).

a range of 16-84 years. Six of the 13 cases (46%) were in males. Of 10 cases for which both race and ethnicity were known, 9 (90%) were in non-Hispanic whites. Of the 18 Georgia Health Districts, the LaGrange District reported the most cases (3). The HGA case was in a resident of Gwinnett County, who was exposed while hiking in western Georgia.
Eleven cases of Lyme disease were reported to GDPH in 2007 that fit the CDC surveillance case definition. The median age of persons with cases was 32 (range 4-66) and 6 (55%) cases were in females. For the 7 cases where both race and ethnicity were known, 6 were in nonHispanic whites. None were hospitalized, and there were no deaths. Of 9 persons with a known exposure history, 5 (56%) were exposed outside of Georgia in a Lyme-endemic state.
Two cases of Q fever were reported to GDPH in 2007. One case of confirmed chronic Q fever was in a Pierce County resident, and one case of probable acute Q fever was in a Cobb County resident. No cases of tularemia were reported to GDPH in 2007.

Surveillance for ehrlichiosis in 2007 detected 4 confirmed and 9 probable cases of HME, and 1 confirmed case of HGA, all of which met CDC's national case definition. There were no deaths. All HME cases occurred during April-October, and the HGA case occurred in September. The median age of persons with HME cases was 55 years, with

Personal prevention measures such as wearing tick repellent, long pants, and long sleeves, as well as performing full body tick checks can help prevent tickborne diseases. For more information about prevention, see our website at http://www.health.state.ga.us/epi/vbd/ tick.asp.

Changes in the National Surveillance Case Definitions for Tickborne Diseases

The Council of State and Territorial Epidemiologists (CSTE) and the Centers for Disease Control and Prevention (CDC) have updated the national surveillance case definitions for certain notifiable tickborne diseases. These new case definitions went into effect on January 1, 2008. Surveillance case definitions are tools used by Public Health to capture actual cases of disease while excluding as many non-cases as possible. Reported cases that meet the surveillance case definitions are included in Public Health case counts and statistics, which serve to

educate healthcare providers and the general public alike regarding the incidence of notifiable diseases. Surveillance case definitions establish uniform criteria for disease reporting and are not intended to be used as the sole criteria for making clinical diagnoses or determining the care necessary for a particular patient. Use of additional clinical, epidemiologic, and laboratory data may enable a physician to diagnose a disease even though the formal surveillance case definition may not be met.

Rocky Mountain spotted fever (Rickettsia rickettsii infection)

Clinical Criteria: Any reported fever PLUS one or more of the following: rash, headache, myalgia, anemia, thrombocytopenia, or any hepatic transaminase elevation.

Confirmed

Probable

Suspect

A confirmed case meets the clinical criteria and the following laboratory criteria: Serologic evidence of a fourfold change in immunoglobulin G (IgG)-specific anti-
body titer reactive with Rickettsia rickettsii antigen by IFA between paired serum specimens (one taken in the first week of illness and a second 2-4 weeks later), or Detection of R. rickettsii DNA in a clinical specimen by PCR assay, or Demonstration of spotted fever group antigen in a skin lesion (biopsy) or organ tissue (autopsy) specimen by IHC, or Isolation of R. rickettsii from a clinical specimen in cell culture.

A probable case meets the clinical criteria and has serologic evidence of elevated IgG or IgM antibody reactive with R. rickettsii antigen by IFA, ELISA, dot-ELISA, or latex agglutination.

A suspect case has laboratory evidence of past or present infection but no clinical information available (e.g. a laboratory report).

Comments: For a detailed description of diagnostic testing for RMSF, please see: Garrison, L.E. and Nicholson, W.L. Diagnostic testing for Rocky Mountain spotted fever: unraveling the uncertainty. Georgia Epidemiology Report, April 2007. Available at http://www.health.state. ga.us/pdfs/epi/gers/Apr07GER.pdf.

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Ehrlichia chaffeensis infection (i.e. human monocytic ehrlichiosis, or HME)

Clinical Criteria: Any reported fever PLUS one or more of the following: rash, headache, myalgia, anemia, leukopenia, thrombocytopenia, or any hepatic transaminase elevation.

Confirmed

Probable

Suspect

A confirmed case meets the clinical criteria and the following laboratory criteria: Serologic evidence of a fourfold change in immunoglobulin G
(IgG)-specific antibody titer to E. chaffeensis antigen by IFA between paired serum specimens (one taken in the first week of illness and a second 2-4 weeks later), or Detection of E. chaffeensis DNA in a clinical specimen by PCR assay, or Demonstration of ehrlichial antigen in a skin lesion (biopsy) or organ tissue (autopsy) specimen by IHC, or Isolation of E. chaffeensis from a clinical specimen in cell culture.

A probable case meets the clinical criteria and the following laboratory criteria: Serologic evidence of elevated
IgG or IgM antibody reactive with E. chaffeensis antigen by IFA, ELISA, dot-ELISA, or assays in other formats, or Identification of morulae in the cytoplasm of monocytes or macrophages by microscopic examination.

A suspect case has laboratory evidence of past or present infection but no clinical information available (e.g. a laboratory report).

Anaplasma phagocytophilum infection (i.e. human granulocytic anaplasmosis, or HGA)

Clinical Criteria: Any reported fever PLUS one or more of the following: rash, headache, myalgia, anemia, leucopenia, thrombocytopenia, or any hepatic transaminase elevation.

Confirmed

Probable

Suspect

A confirmed case meets the clinical criteria and the following laboratory criteria: Serologic evidence of a fourfold change in immunoglobulin G
(IgG)-specific antibody titer to A. phagocytophilum antigen by IFA between paired serum specimens (one taken in the first week of illness and a second 2-4 weeks later), or Detection of A. phagocytophilum DNA in a clinical specimen by PCR assay, or . Demonstration of anaplasmal antigen in a skin lesion (biopsy) or organ tissue (autopsy) specimen by IHC, or Isolation of A. phagocytophilum from a clinical specimen in cell culture.

A probable case meets the clinical criteria and the following laboratory criteria: Serologic evidence of elevated
IgG or IgM antibody reactive with A. phagocytophilum antigen by IFA, ELISA, dot-ELISA, or assays in other formats, or Identification of morulae in the cytoplasm of neutrophils or eosinophils by microscopic examination.

A suspect case has laboratory evidence of past or present infection but no clinical information available (e.g. a laboratory report).

Lyme disease (Borrelia burgdorferi infection)

Erythema migrans (EM): For surveillance purposes, EM is defined as a skin lesion that typically begins as a red macule or papule and expands over a period of days to weeks to form a large round lesion, often with partial central clearing. A single primary lesion must reach greater than or equal to 5 cm in size across its largest diameter. Secondary lesions also may occur. Annular erythematous lesions occurring within several hours of a tick bite represent hypersensitivity reactions and do not qualify as EM. For most patients, the expanding EM lesion is accompanied by other acute symptoms, particularly fatigue, fever, headache, mildly stiff neck, arthralgia, or myalgia. These symptoms are typically intermittent. The diagnosis of EM must be made by a physician.

Late manifestations: For surveillance purposes, late manifestations include any of the following when an alternate explanation is not found: Musculoskeletal system. Recurrent, brief attacks (weeks or months) of objective joint swelling in one or a few joints, sometimes followed
by chronic arthritis in one or a few joints. Manifestations not considered as criteria for diagnosis include chronic progressive arthritis not preceded by brief attacks and chronic symmetrical polyarthritis. Additionally, arthralgia, myalgia, or fibromyalgia syndromes alone are not criteria for musculoskeletal involvement. Nervous system. Any of the following, alone or in combination: lymphocytic meningitis; cranial neuritis, particularly facial palsy (may be bilateral); radiculoneurophathy; or, rarely, encephalomyelitis. Encephalomyelitis must be confirmed by demonstration of antibody production against Borrelia burgdorferi in the cerebrospinal fluid (CSF), evidenced by a higher titer of antibody in CSF than in serum. Headache, fatigue, paresthesia, or mildly stiff neck alone are not criteria for neurologic involvement. Cardiovascular system. Acute onset of high-grade (2nd-degree or 3rd-degree) atrioventricular conduction defects that resolve in days to weeks and are sometimes associated with myocarditis. Palpitations, bradycardia, bundle branch block, or myocarditis alone are not criteria for cardiovascular involvement.

Laboratory evidence is defined as follows for surveillance purposes: Positive two-tier testing using a sensitive EIA or IFA followed by a Western immunoblot, or A positive IgG Western immunoblot, or A positive culture for B. burgdorferi.

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Confirmed

Probable

Suspect

A confirmed case of Lyme disease with exposure in Georgia or another nonendemic area is defined as: A case of EM with laboratory evi-
dence of infection, or A case with at least one late manifes-
tation that has laboratory evidence of infection.

A probable case is any other case of physiciandiagnosed Lyme disease that has laboratory evidence of infection.

A suspect case with exposure in Georgia or another nonendemic area is defined as: A case of EM with no laboratory evidence of infection, or A case with laboratory evidence of infection but no clini-
cal information available (e.g. a laboratory report).

Comments: Cases with exposure to tick habitats in an endemic area (i.e. the Northeast, upper Midwest, or California) can be confirmed by clinical diagnosis of EM only (no laboratory evidence is needed). Please report exposure county and state.

Q fever (Coxiella burnetii infection)

Acute Q fever clinical criteria: Acute fever PLUS one or more of the following: rigors, severe retrobulbar headache, acute hepatitis, pneumonia, or elevated liver enzyme levels.

Confirmed Acute

Probable Acute

A confirmed case of acute Q fever is defined as a case that: a.) meets the clinical criteria of acute Q fever or is epidemiologically linked to a lab confirmed case; and b.) meets the following laboratory criteria: Serologic evidence of a fourfold change in IgG-specific antibody titer to
Coxiella burnetii phase II antigen by IFA between paired serum specimens (one taken in the first week of illness and a second 3-6 weeks later, phase I titers may be elevated as well), or Detection of C. burnetii DNA in a clinical specimen by PCR assay, or Demonstration of C. burnetii antigen in a clinical specimen by IHC, or Isolation of C. burnetii from a clinical specimen by culture.

A probable case of acute Q fever is defined as a case that: a.) meets the clinical criteria of acute Q fever and b.) meets the following laboratory criteria: Has a single supportive IFA IgG titer of >=1:128 to
phase II antigen (phase I titers may be elevated as well), or Has serologic evidence of elevated IgG or IgM antibody reactive with C. burnetii antigen by ELISA, dotELISA, or latex agglutination.

Chronic Q fever clinical criteria: Newly recognized, culture-negative endocarditis, particularly in a patient with previous valvulopathy or compromised immune system, suspected infection of a vascular aneurysm or vascular prosthesis, or chronic hepatitis, osteomyelitis, osteoarthritis, or pneumonitis in the absence of other known etiology.

Confirmed Chronic

Probable Chronic

A confirmed case of chronic Q fever is defined as a case that: a.) meets the clinical criteria of chronic Q fever; and b.) meets the following laboratory criteria: Serologic evidence of IgG antibody to C. burnetii phase I antigen
>=1:800 by IFA (while phase II IgG titer will be elevated as well, phase I titer is higher than the phase II titer), or Detection of C. burnetii DNA in a clinical specimen via amplification of a specific target by PCR assay, or Demonstration of C. burnetii antigen in a clinical specimen by IHC, or Isolation of C. burnetii from a clinical specimen by culture.

A probable case of chronic Q fever is defined as a case that: a.) meets the clinical criteria of chronic Q fever and b.) meets the following laboratory criteria: Has an antibody titer to C. burnetii phase I IgG antigen
>=1:128 and <1:800 by IFA.

Abbreviations: IFA--indirect immunofluorescence assay, PCR--polymerase chain reaction, EIA--enzyme-linked immunosorbent assay. Adapted from: CDC. Case definitions for infectious diseases under public health surveillance. Available at: http://www.cdc.gov/ncphi/disss/ nndss/casedef/case_definitions.htm.

The case definition for tularemia is unchanged and can be found at http://www.cdc.gov/ncphi/disss/nndss/casedef/tularemia_current.htm.

Recommended Reading
1.) Garrison, L.E. and Nicholson, W.L. Diagnostic testing for Rocky Mountain spotted fever: unraveling the uncertainty. Georgia Epidemiology Report, April 2007. Available at: http://www.health.state.ga.us/ pdfs/epi/gers/Apr07GER.pdf. 2.) CDC. Case definitions for infectious diseases under public health surveillance. Available at: http://www.cdc.gov/ncphi/disss/nndss/ casedef/case_definitions.htm.

3.) CDC. Diagnosis and management 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).
This article was written by Laurel Garrison, M.P.H.

Division of Public Health http://health.state.ga.us

Epidemiology Branch http://health.state.ga.us/epi

Stuart T. Brown, M.D. Director |State Health Officer
Martha N. Okafor, Ph.D. Deputy Director

John M. Horan, MD, MPH State Epidemiologist Director | Epidemiology Branch

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. John M. Horan, M.D., M.P.H.
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 2008

Volume24Number03

Reported Cases of Selected Notifiable Diseases in Georgia, Profile* for December 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 December 2007
2007 37 14 14 2 46 6 14 3 15 5 1 1 0 1 0 129 135 1 29 17 43 0 40

Previous 3 Months Total

Ending in December

2005

2006

2007

110

129

143

8180

9270

90

46

81

52

7

6

12

209

173

187

3974

4611

38

26

35

30

20

12

12

42

45

33

14

14

16

1

1

3

4

6

5

1

0

0

7

7

3

0

0

0

551

458

617

258

597

455

35

30

12

137

130

102

110

93

60

223

236

164

1

3

0

135

126

116

Previous 12 Months Total

Ending in December

2005

2006

2007

591

579

692

33276

40010

31946

155

281

248

31

43

47

757

677

688

15707

20402

13173

113

123

122

124

56

67

202

202

140

39

38

43

6

8

11

18

20

24

2

4

0

48

31

15

0

0

0

1936

1839

2048

675

1382

1657

137

124

85

539

482

515

411

385

352

973

1019

976

2

10

8

502

507

473

* 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

32

3,134

3,166

AIDS

7

1,520

1,527

HIV,

-

non-AIDS

AIDS

7

1,805

1,812

Percent Risk Group Distribution

Female MSM

IDU

MSM&IDU HS

Unknown

Perinatal

Race Distribution

White Black

Hispanic

26

21

2

1

5

71

<1

22

72

4

26

25

3

1

7

64

<1

21

70

6

-

-

-

-

-

-

-

-

-

-

27

36

7

2

16

38

<1

19

75

5

Other 2 3 1

Cumulative: HIV, non-AIDS 218

11,219

11,437

32

27

6

2

11

52

2

21

74

3

2

07/81-1/07 AIDS

239

32,047

32,286

20

44

15

5

14

22

<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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