Georgia epidemiology report, Vol. 24, no. 9 (Sept. 2008)

September 2008

volume 24 number 09

Influenza

Epidemics of influenza occur annually, causing an average of 226,000 hospitalizations and 36,000 deaths per year in the United States. Rates of influenza-related complications requiring hospitalization are highest among children under two years of age, the elderly, and persons with certain chronic medical conditions. Most influenza-related deaths occur among the elderly.
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 medical 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 beginning in September and continuing through May (Table 1).
Influenza Vaccination What is new for 2008 - 2009? The 2008 Advisory Committee on Immunization Practices (ACIP) recommends four major changes from last season: Annual vaccination of all children aged 5 18 years is
recommended beginning with the 2008-09 influenza season, if feasible. Annual vaccination of all children aged 6 months 4 years (59 months) and older children with conditions that place them at increased risk for complications from influenza should continue to be a primary focus of vaccination efforts. Either trivalent inactivated influenza vaccine (TIV) or live, attenuated influenza vaccine (LAIV) can be used when vaccinating healthy persons aged 2 49 years. Children aged 6 months 8 years should receive 2 doses (with the second dose given 4 or more weeks after the initial dose) of vaccine if they have not been vaccinated before at any time with either LAIV or TIV. Children aged 6 months 8 years who received only 1 dose in their first year of vaccinations should receive 2 doses (with the second dose given 4 or more weeks after the initial dose) the following year. LAIV should not be administered to children with reactive airways disease. Children with possible risk for influenza complications because of underlying medical conditions, children aged 6-23 months, and persons aged > 49 years should receive TIV. The 2008 2009 trivalent vaccine virus strains are A/ Brisbane/59/2007 (H1N1)-like, A/Brisbane/10/2007 (H3N2)-like, and B/Florida/4/2006-like antigens (1).

Table 1. Target Groups for Annual Influenza Vaccination 2008-2009
Children and adolescents All children aged 6 months--18 years, and especially those at
high risk for influenza complications, including those: Aged 6 months--4 years; Who have chronic pulmonary (including asthma) or
cardiovascular (except hypertension), renal, hepatic, hematological or metabolic disorders (including diabetes mellitus); Who are immunosuppressed (including immunosuppression caused by medications or by human immunodeficiency virus); Who have any condition (e.g., cognitive dysfunction, spinal cord injuries, seizure disorders, or other neuromuscular disorders) that can compromise secretions or that can increase the risk for aspiration; Who are receiving long-term aspirin therapy who therefore might be at risk for experiencing Reye syndrome after influenza virus infection; Who are residents of chronic-care facilities; and, Who will be pregnant during the influenza season.
Adults Persons aged 50 years; Women who will be pregnant during the influenza season; Persons who have chronic pulmonary (including asthma),
cardiovascular (except hypertension), renal, hepatic, hematological or metabolic disorders (including diabetes mellitus); Persons who have immunosuppression (including suppression caused by medications or by human immunodeficiency virus); Persons 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; Household contacts and caregivers of children aged <5 years and adults aged 50 years, with particular emphasis on vaccinating contacts of children aged <6 months; and, Household contacts and caregivers of persons with medical conditions that put them at high risk for severe complications from influenza.

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Other Infection Prevention Measures Influenza is spread primarily through droplets from the nose and throat, and sometimes through direct (person-to-person) or indirect (through inanimate objects) contact. To prevent the transmission of all respiratory infections, including influenza: Cover the nose/mouth with a tissue or sleeve when coughing or
sneezing; Use tissues to contain respiratory secretions and dispose of
them in a waste receptacle; Perform hand hygiene with soap and water or alcohol-based
hand rub after having contact with respiratory secretions and
contaminated objects/materials.
Antiviral Medications Antiviral medications with activity against influenza viruses are useful in preventing influenza and may be used for treatment early in the course of illness. However, only two of the four licensed antiviral agents are currently recommended (oseltamivir or zanamivir), because of widespread viral resistance to amantidine and rimantidine. In addition, low levels of oseltamivir-resistant influenza A (H1N1) strains were identified in the United States and some other countries during 2007-08. In the southern Hemisphere this August, 31% of influenza A (H1N1) viruses tested carried a mutation associated with oseltamivir resistance. No increase in oseltamivir resistance has been reported in influenza A (H3N2) and B.
Overview of Influenza Surveillance in Georgia Each year, the GDPH monitors influenza activity through a variety of surveillance methodologies. The cornerstone of these methodologies is the Sentinel Provider Network (SPN), part of a nationwide surveillance network coordinated by the Centers for Disease Control and Prevention (CDC). Volunteer sentinel healthcare providers throughout Georgia report the total number of patient visits and the number of those patients who present 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 three times during the season for testing at the Georgia Public Health Laboratory (GPHL). 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.

Automated analysis of chief complaint data (syndromes) occurs daily and increases beyond expected counts trigger automatic alerts to key public health and hospital staff.
Georgia Influenza Activity - 2007-2008 Season Sentinel Provider Reports Influenza season peaked rapidly and intensely in Georgia in midFebruary. The proportion of ILI visits to the Georgia SPN rose to 10% (the highest percentage seen over 10 years of surveillance) during the third week of February and decreased to less than 1% by the third week in April (Figure 2).
Geographic Dispersion Influenza was geographically widespread from January 27, 2008 March 22, 2008. "Widespread" designation was based on reports of ILI activity from Sentinel Providers, syndromic surveillance, laboratory-confirmed influenza in more than half of Georgia's designated regions, and outbreaks.
Hospitalization Surveillance The Georgia Emerging Infections Program conducts surveillance for adults and children who are hospitalized for influenza in the eight county metropolitan Atlanta area. There were 263 adults and 70 children hospitalized with laboratory-confirmed influenza last season.
Influenza Virologic Surveillance The GPHL confirmed 87 influenza cultures for the 2007-08 season; 17 were subtyped as influenza A(H1), 56 as influenza A(H3) and 8 as influenza B.
Of 18 Georgia isolates further characterized by CDC: 6 H1 viruses were identified as A/Solomon Islands/03/2006-Like
(H1N1), (matched vaccine strain); 6 H3 viruses were identified as A/Wisconsin/67/2005-Like
(H3N2), (matched vaccine strain); 5 H3 viruses were identified as A/BRISBANE/10/2007-Like
(H3N2), (drift variant to vaccine strain); 1 B virus was identified as B/FLORIDA/ 04/2006, (mismatched
to vaccine strain).
Figure 1.

GDPH requires reporting of pediatric influenza-associated deaths and influenza outbreaks in schools, health care facilities, and other institutions. During 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 at http:// www.cdc.gov/flu/weekly/fluactivity.htm.

GDPH also monitors influenza-like illness (ILI) though syndromic surveillance in 36 Emergency Departments, using the State Electronic Notifiable Diseases Surveillance System (SendSS).

Oct Nov Nov week 1 week 1 week 5

Dec Jun week 4 week 4

Feb week 3

Mar Apr week 3 week 3
Week

May Jun Jul week 2 week 2 week 2

Aug Sep week 2 week1

Division of Public Health http://health.state.ga.us
S. Elizabeth Ford, M.D., M.B.A., F.A.A.P. Acting Director, State Health Officer
Martha N. Okafor, Ph.D., Deputy Director Health Information, Policy, Strategy, & Accountability

John M. Horan, M.D., M.P.H. State Epidemiologist
Director, Epidemiology Section http://health.state.ga.us/epi
Cherie Drenzek, D.V.M., M.S. Director, Acute Disease Epi Section

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. S. Elizabeth Ford, M.D., M.B.A., F.A.A.P. 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 Please send comments to:

Human Resources

gaepinfo@dhr.state.ga.us

Division of Public Health

Reports of Deaths among Children During the 2007-08 season, two influenza-associated pediatric deaths were reported to GDPH. One case also had a co-infection with methicillin-resistant Staphylococcus aureus (MRSA).
Influenza Outbreaks During 2007-08, 20 influenza outbreaks were reported to GDPH from institutional settings; 17 long-term care facilities, 2 schools and one place of business.

Georgia Influenza Sentinel Providers GDPH would like to thank the 2007-08 Influenza Sentinel Providers (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 Ariane Reeves, RN, BSN, MPH, CIC, Influenza Surveillance Coordinator, at 404-463-4625.

Table 2. Georgia Influenza Sentinel Provider Network participants who submitted reports for at least 50% of the 2007-2008 influenza season

Robert Benson, MD J. Dorland Brown, MD Annie Brown, RN, MSN, FNP-C Jean Chin, MD
Rita Collins, FNP
Warren Falo, MD Naomi Fehrle, C-FNP Jacqueline Fincher, MD Joel Fine, MD
Joi Fox, RN Curtis Hames, MD
Michelle Haney, RN Eric Hoffler, MD Patty Hopkins Michael Huey, MD
Gail Hurley MD
Brenda Jordan, MT Mary Key, RN, CIC Karen Kim, MD Laura Larson, MD William Manns, MD Dana McClure, RRT Tracy Middlebrooks, Jr., MD

East Georgia Urgent Care Wellstar Urgent Care Georgia Southwestern State University Health Center University Health Center, University of Georgia Farber Student Health at Valdosta State University Wellstar Urgent Care Sutter Family Practice McDuffie Medical Association Fine and Associates Internal Medicine Specialists PC Rockdale Medical Center Georgia Southern University Health Services Trojan Battery Co. ABC Pediatrics The Pediatric Center Thomasville Emory University Student Health Services Athens Neighborhood Health Center Louis Smith Memorial Hospital Tift Regional Medical Center Pooler Pediatrics Tanner Medical Center Georgia Institute of Technology Flint River Community Hospital Tracy Middlebrooks, Jr. MD

Jo Middlebrooks, RN

Henry Medical Center

Ann Nichols, FNP

Kennesaw State University Health Clinic

Ilona Orlich, LPN

Cagle Inc.

Johnny Peeples, MD

Eastman Pediatrics

Johnnie Pollard, RN

University of West Georgia Health Services

Nancy Rowell, MD

Community Care Center

Philip Saleeby, MD

Philip R. Saleeby MDPC

Ronny Sayers, MD

Sardis Medical Center

Suzanne Schuessler, MD LaGrange Pediatrics

Minkailu Sesay, MD

Memorial Family Practice

Debra Spavone, RN

Newnan Hospital

Herman Spivey, MD

Northwest Georgia Family Practice

William Swofford, MD Colquitt Complete Care

Debbie Tarno, RNC

Columbus Regional Urgent Care Center

Becky Tew, BSN, MS

Columbus State University

Raymond Tidman, MD Mountain Medical

Wes Ulrich, MD

Macon Volunteer Clinic

Glenda Van Houten, RN Upson Regional Medical Center

Tulasi Vanapalli, MD

Immediate Medical Care

Julia Weeks, MD

Archbold Urgent Care

Lisa Wheatley, FNP

Northeast Georgia Medical Center, Employee Health

Mary Whitaker, RN

Gwinnett Medical Center

Mark Wood, MD

Lockheed Martin Medical Department

William Yang, MD, MPH Medical Services Department, CocaCola Company

This article was written by Kathryn Arnold, M.D. and Ariane Reeves, R.N., B.S.N., M.P.H., C.I.C.
Reference: 1. Centers for Disease Control and Prevention. Prevention and Control of Influenza; Recommendations of the Advisory Committee on Immunization Practices (ACIP) 2008.MMWR 2008; 57 (No. RR-7)[pp: 1-60]
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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

September 2008

Volume24Number09

Reported Cases of Selected Notifiable Diseases in Georgia, Profile* for June 2008

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 June 2008
2008 82 179 12 12 51 152 12 1 17 3 4 3 0 3 0 247 107 6 49 32 70 0 46

Previous 3 Months Total Ending in June

2006 2007 2008

140

195

203

10125

10863

4415

54

42

52

12

4

16

145

143

132

4994

4569

1675

27

34

30

15

25

11

62

35

39

9

11

7

3

4

10

6

4

7

4

0

2

5

5

4

0

0

0

361

362

549

260

628

401

42

26

24

105

133

134

98

109

94

263

314

283

3

3

2

124

138

140

Previous 12 Months Total Ending in June

2006 2007 2008

577

626

699

37455

41787

35181

201

264

266

38

33

56

690

692

665

18268

19489

14286

111

128

140

87

76

48

185

173

153

36

48

39

8

8

17

17

19

26

5

0

2

34

28

15

0

0

0

1903

1931

2145

889

1789

1488

147

104

102

487

535

633

402

416

426

997

1093

1188

7

10

9

502

519

476

* 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

Disease

Total Cases Reported*

Classification <13yrs

>=13yrs Total

HIV, non-AIDS 22

2,689

2,711

Percent Female MSM

29

24

Risk Group Distribution %

IDU

MSM&IDU HS

Unknown Perinatal White

2

1

5

67

1

18

Race Distribution %

Black

Hispanic Other

77

4

1

8/07-7/08

AIDS

5

1,892

1,897

29

28

3

1

8

59

<1

17

77

5

1

Five Years Ago:**

HIV, non-AIDS -

-

-

-

-

-

-

-

-

-

-

-

-

-

8/03-7/04

AIDS

11

1,712

1,723

29

34

7

2

16

39

<1

18

75

5

1

Cumulative: HIV, non-AIDS 219

11,937

12,156

32

28

6

2

10

52

2

21

74

4

1

07/81-7/08 AIDS

239

32,785

33,024

20

43

14

5

14

23

1

30

67

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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