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 -2 - 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. -3 - 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 - 4 -