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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