Georgia epidemiology report, Vol. 25, no. 2 (Feb. 2009)

February 2009

volume 25 number 02

Tickborne Disease Surveillance in Georgia, 2008

JAN MAR MAY JUL SEP NOV JAN MAR MAY JUL SEP NOV JAN MAR MAY JUL SEP NOV JAN MAR MAY JUL SEP NOV JAN MAR MAY JUL SEP NOV

There are 6 tickborne diseases that are notifiable in Georgia: Rocky Mountain spotted fever (RMSF), human monocytic ehrlichiosis (HME), human granulocytic anaplasmosis (HGA), Lyme disease, Q fever, and tularemia. In 2008, the Georgia Division of Public Health (GDPH) began using the new national surveillance case definitions for all of these diseases except tularemia. The tularemia case definition has remained unchanged, and Georgia reported no cases of tularemia in 2008. The details of the new case definitions are listed in the March 2008 GER and can be found at http://www.health.state.ga.us/ pdfs/epi/gers/Mar08GER.pdf. A summary of the major changes is listed in box (right).

There were 10 confirmed, 66 probable, and 1 suspect cases of Rocky Mountain spotted fever (RMSF) reported to GDPH in 2008. All cases met laboratory and clinical criteria as required by the CDC national case definition. Fifty-five percent of cases were male, and the median age was 48 years (range 5-84 years). Of 58 cases where both race and ethnicity were known, 50 (86%) were non-Hispanic whites. Eighty-eight percent of cases had onsets during April-September (see graph). Health Districts with the most reported cases were Northwest (12), North Central (12),

Rocky Mountain Spotted Fever Cases by Month, Georgia, Rocky Mountain Spotted Fev2e0r0C4a-s2e0s0b8y Month, Georgia, 2004-2008
Probable Confirmed
30

25

20

15

10

5

0
2004

2005

2006 Month of Onset

2007

2008

LaGrange (10), and East Metro (9) (see map next page). Twenty (26%) cases were hospitalized, and there were no deaths. Surveillance for ehrlichiosis in 2008 detected 5 confirmed, 13

Summary of Case Definition Changes for Tickborne Diseases*
Rocky Mountain spotted fever: Change in the clinical criteria to make fever mandatory. Clarification of the laboratory criteria to specify that a
fourfold change in IFA IgG (not IgM) titer is required for confirmation of cases. Explanation of how ELISA tests and IFA IgM tests should (or should not) be used. Addition of a suspect case category.
Ehrlichiosis/Anaplasmosis: Updated nomenclature to reflect taxonomic changes
(i.e. Ehrlichia phagocytophila became Anaplasma phagocytophilum). Change in the clinical criteria to make fever mandatory. Clarification of the laboratory criteria to specify that a fourfold change in IFA IgG (not IgM) titer is required for confirmation of cases. Explanation of how ELISA tests and IFA IgM tests should (or should not) be used. Addition of a suspect case category.
Lyme disease: Clarification of what constitutes laboratory evidence for
surveillance purposes. Clarification of what constitutes exposure and endemic
county for surveillance purposes. Addition of a probable and a suspect case category.
Q fever: Established specific clinical and laboratory criteria for
acute vs. chronic Q fever. Established specific clinical criteria for surveillance
purposes. Clarification of the laboratory criteria to specify that a
fourfold change in IFA IgG (not IgM) titer is required for confirmation of cases. Explanation of how ELISA tests and IFA IgM tests should (or should not) be used.
*Surveillance case definitions are tools used by Public Health to capture actual cases of disease while excluding as many noncases 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.

The Georgia Epidemiology Report via e-mail is coming soon! Please visit, http://health.state.ga.us/epi/manuals/ger.asp for all current and past pdf issues of the GER.

Number of Cases

probable, and 1 suspect case of Ehrlichia chaffeensis infection. Seventeen cases (89%) occurred during AprilSeptember. The median age was 59 years, with a range of 15-74 years. Fifty-three percent of cases were female. Of 15 cases for which both race and ethnicity were known, all were nonHispanic whites. Of the 18 Georgia Health Districts, East Metro (6) and LaGrange (4) reported the most cases. Among the 17 cases for which it was known, 14 (82%) were hospitalized, and there were no deaths. There was also 1 probable case of HGA reported from the LaGrange Health District.
There were 21 confirmed, 8 probable, and 5 suspect cases of Lyme disease reported to GDPH in 2008. This is a 5-fold increase over the ten year average (1997-2007) of 6.7 cases per year. This is at least partially due to the change in the case definition, which allowed for the counting of probable and suspect cases. If the case definition had not changed, we would have counted only 17 cases, but that is still an increase over the 10 or 12 cases we have seen in recent years. It is possible this is due to other changes in surveillance, reporting, or testing, or it may reflect an actual increase in the incidence of Lyme disease in Georgia. The median age of cases was 38 (range 7-75) and 56% of cases were female. Among the 25 cases where race and ethnicity were known, all were nonHispanic whites except for one Asian. Four (12%) were hospitalized, and there were no deaths. Of 29 cases with a known exposure history, 6 (21%) were exposed outside of Georgia in a Lymeendemic state (see table). This finding differs from previous years' surveillance data which has indicated that about half of Georgia cases were exposed in Lymeendemic states. This may be due to the counting of probable and suspect cases and incomplete exposure information

Rocky Mountain Spotted Fever Cases by County of Residence, 2008

Dade

Catoosa

Walker

Whitfield Murray

Chattooga

Gordon

Floyd

Bartow

Fannin

Towns Union

Rabun

Gilmer Pickens Cherokee

Lumpkin Dawson
Forsyth

White Habersham Stephens

Hall

Banks Franklin

Jackson Madison

Hart Elbert

Risk per 100,000 population
3.49 - 8.69 1.66 - 3.48 0.50 - 1.65 0.00 - 0.49 No reported cases

Polk Paulding Cobb

Gwinnett Barrow

Clarke Oglethorpe

Haralson Carroll Heard

Douglas Coweta

DeKalb Fulton

Walton

Oconee

Wilkes Lincoln

Rockdale

Clayton Henry

Newton

Morgan

Greene Taliaferro

Columbia McDuffie

Fayette Spalding

Butts Jasper Putnam

Warren Hancock Glascock

Richmond

Troup

Meriwether

Pike Lamar Monroe

Baldwin Jones

Jefferson Washington

Burke

Harris

Upson

Bibb

Wilkinson

Talbot

Crawford

Twiggs

Johnson

Jenkins

Muscogee Chattahoochee Marion

Taylor

Peach Houston

Macon

Bleckley

Laurens

Emanuel

Treutlen

Candler

Screven Bulloch

Effingham

Schley

Stewart Webster

Sumter

Quitman

Randolph Terrell

Lee

Dooly

Pulaski

Wilcox Crisp

Turner

Dodge Ben Hill

Montgomery

Wheeler

Toombs

Evans

Tattnall

Telfair

Jeff Davis Appling

Long

Bryan Liberty

Chatham

Clay Calhoun

Dougherty

Worth

Irwin Tift

Coffee

Early

Baker

Miller Seminole
Decatur

Mitchell

Colquitt

Berrien Atkinson Cook
Lanier

Grady

Thomas Brooks

Lowndes

Clinch

Echols

Bacon

Wayne

McIntosh

Pierce Brantley

Glynn

Ware

Charlton

Camden

Created: April 2009

Georgia Department of Human Resources

Classification: Equal Interval

Division of Public Health Office of Strategy & Systems Development

30

Health Planning & Assessment Unit

0

30 Miles

Source: Division of Public Health Projection: Georgia Statewide
Lambert Conformal Conic

Count of Lyme Disease Cases, Georgia, 2008

Case Category
Confirmed Probable Suspect Total

Exposure Location (State)

Total

GA

Out of State Unknown

12

6

3

21

7

0

1

8

4

0

1

5

23

6

5

34

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
Acting 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.P.H., Ph.D. 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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Georgia Department of Human Resources
Division of Public Health

Two Peachtree St., N.W. Atlanta, GA 30303-3186 Phone: (404) 657-2588
Fax: (404) 657-7517
Please send comments to: gaepinfo@dhr.state.ga.us

among confirmed cases, or it may represent an actual increase in exposures in Georgia. There is a need for surveillance in ticks and wildlife in order to determine risk of human exposure to B. burgdorferi throughout the state. Thus far, no infected ticks have been found outside the barrier islands. Among the 22 confirmed, probable, and suspect cases whose exposure was in Georgia and for which a county of exposure was known, 11 (50%) were exposed in the LaGrange Health District (see map). Due to the increase in diagnosis and reporting of Lyme disease in the state, GDPH is conducting a Lyme Disease Laboratory Report Survey in 2009 (see box).
Notice: Lyme Disease Laboratory Report Survey
In 2009, GDPH will follow up on every laboratory report that is positive for Borrelia burgdorferi by calling the healthcare provider and asking him/her to complete an online survey. It may be completed by the treating physician, nurse, or other designee. Providers should enter all patients who test positive for Lyme disease, regardless of clinical signs and symptoms, final diagnosis, or treatment given. This survey is part of the SendSS platform, ensuring confidentiality and familiarity for the provider. This surveillance tool will collect all relevant demographic, clinical, and laboratory data for each patient who tests positive for Lyme disease. If you or your staff receives a phone call from GDPH regarding a positive laboratory report, please cooperate by completing the online survey. Thank you in advance for your support of Public Health!
There were 2 cases of Q fever reported to GDPH in 2008. A probable acute case of Q fever occurred in a dairy farmer from South Georgia, who had exposure to cattle including assisting cows during calving. The second case was a confirmed case of acute Q fever in a soldier who was exposed in Iraq.

Count of Lyme Disease Cases by County of Exposure, Georgia, 2008

Dade

Catoosa Whitfield

Fannin

Walker

Nor(tDhaGlteoonr)gia

Murray

Gilmer

Chattooga
No(Rrtohmwee)st Floyd

Gordon Bartow

Pickens Cherokee

Towns Union

Rabun

Lumpkin

White

Habersham

North (Gainesville) Dawson

Stephens Banks

Forsyth Hall

Jackson

Franklin Madison

Hart Elbert

Polk

Cobb

Gwinnett

Barrow

Clarke

N(Aortthheenass)t

Haralson Carroll

Paulding CobbDouglas
Douglas Fulton

(LEawasrtenMceetvroille) DDeKeKalablb
Rockdale

Walton

Fulton

Clayton (JoCnlaeystboonro) Henry

Fayette

Newton

Oconee Morgan

Oglethorpe

Wilkes

Lincoln

Greene

Taliaferro

McDuffie Columbia

Warren

Heard

Coweta LaGrange
Meriwether

Troup Harris

Talbot

Spalding

Butts

Jasper

Putnam

Hancock

Glascock

Richmond

Lamar Pike
Monroe

Jones

Baldwin

Washington

Jefferson

Burke

Ea(Asut gCuesnttara) l

Upson

Crawford

North Central (Macon) Wilkinson

Bibb

Twiggs

Johnson

Jenkins

Muscogee

Taylor

Peach

Houston

Emanuel

Number of Cases
Status
CONFIRMED CONFIRMED or PROBABLE CONFIRMED or SUSPECT PROBABLE PROBABLE or SUSPECT SUSPECT
Public Health Districts
5 cases with unknown exposure locations were mapped to county of residence
6 cases with out of state exposure not shown
Screven

Marion Chattahoochee

Macon

Stewart

W(CeostluCmebnutrsa)l Webster

Schley Sumter

Quitman

Lee

Randolph

Terrell

Clay

Calhoun

Dougherty

Dooly Crisp

Bleckley

Treutlen

Laurens

Pulaski Wilcox

Dodge

Montgomery Wheeler

Sou(DthuCbleinnt)ral Telfair

Toombs

Candler Tattnall

Bulloch Evans

Effingham
Chatham Bryan

Turner

Ben Hill

Jeff Davis

Appling

Long

Liberty (SCaovaasntnaal h)

Worth

Irwin

Coffee

Bacon

Wayne

McIntosh

Early

Baker

Miller

So(AultbhMawniteycsh) tell

Seminole

Decatur

Grady

Tift

Berrien

Atkinson

Colquitt

Thomas

Cook Brooks (VSaolduotshta)

Lanier

Clinch

Pierce

(SWoauythcreoassst ) Ware

Brantley

Charlton

Glynn Camden

Lowndes

Echols

30

0

30

Miles

Georgia Department of Human Resources
Division of Public Health Health Planning & Assessment Unit



Created: March 2009
Source: GA DHR/DPH Projection: Georgia Statewide
Lambert Conformal Conic
Map originally printed in color

The following tickborne disease education materials are available: Mosquitoes and Ticks and the Diseases They Spread (public information brochure) Tickborne Diseases Poster (for physician's offices and hospitals) Tickborne Diseases website http://www.health.state.ga.us/epi/vbd/tick.asp o Disease fact sheets o Pictures of common ticks in Georgia o Information about tick identification o Surveillance data and statistics
To order education materials, contact your district Public Health Liaison or the Georgia Division of Public Health at 404-657-2588 or gaepinfo@dhr.state.ga.us.

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.

This article was written by Laurel Garrison, M.P.H.

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The Georgia Epidemiology Report Epidemiology Branch Two Peachtree St., NW Atlanta, GA 30303-3186
Providers can contact Public Health IMMEDIATELY 24 hours a day, 7 days a week, by calling: 1-866-PUB-HLTH (1-866-782-4584) to report immediately notifiable diseases and public health emergencies

PRESORTED STANDARD U.S. POSTAGE
PAID ATLANTA, GA PERMIT NO. 4528

February 2009

Volume25Number02

Reported Cases of Selected Notifiable Diseases in Georgia, Profile* for November 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 November 2008
2008 32 330 25 3 35 220 7 4 15 3 1 2 0 4 0 164 94 6 55 31 81 0 23

Previous 3 Months Total Ending in November

2006

2007

2008

155

163

132

9314

10289

4050

114

78

81

14

23

12

218

233

153

4950

4424

1773

25

27

24

11

13

18

49

36

49

14

13

13

1

2

4

5

7

4

0

0

0

10

3

9

0

0

0

632

789

734

605

428

255

26

32

23

144

156

177

86

82

116

258

277

256

3

1

1

127

109

109

Previous 12 Months Total Ending in November

2006

2007

2008

583

677

692

39726

43779

36059

279

238

255

43

47

46

706

705

655

20299

18286

13928

118

125

146

58

69

56

194

155

174

36

42

43

8

10

36

17

27

19

5

0

2

30

16

27

0

0

0

1824

2018

2294

1304

1640

1202

124

107

127

479

575

716

379

432

520

1027

1163

1304

10

9

9

513

473

484

* 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 15

2,998

3,013

Percent Female MSM

26

30

Risk Group Distribution %

IDU

MSM&IDU HS

Unknown Perinatal White

2

1

4

63

1

21

Race Distribution %

Black

Hispanic Other

73

4

1

1/08-12/08 AIDS

2

1,957

1,959

25

31

3

1

6

60

<1

18

71

5

<1

Five Years Ago:**

HIV, non-AIDS 79

1,794

1,875

36

29

9

3

15

39

4

20

76

3

1

1/04-12/04 AIDS

6

1,504

1,510

28

33

7

3

14

42

<1

18

76

5

<1

Cumulative: HIV, non-AIDS 224

13,380

13,604

31

28

5

2

10

53

2

21

74

4

1

07/81-12/08 AIDS

239

33,723

33,962

20

43

14

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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