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. 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. 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 -2 - 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] -3 - 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 - 4 -