Georgia epidemiology report [Vol. 27, Issue 1 (Summer 2013)]

GEORGIA EPIDEMIOLOGY REPORT

SUMMER
2013
VOL 27 Number 01

Inside This Issue
Pg 1 Confirmed Measles in Two Metropolitan Atlanta Residents
Pg 2 State Epi Corner
Pg 5 Animal-Associated Transmission of Bacterial Enteric Illnesses in Georgia
Pg 6 Healthcare-Associated Infections are now Notifiable Diseases
GER
Brenda Fitzgerald, MD Commissioner State Health Officer
Patrick O'Neal, MD Director, Health Protection
Cherie Drenzek, DVM, MS State Epidemiologist
_________________________________
GER Editorial Board
Editor-in-Chief Melissa Ivey, MPH
Managing Editor Madhavi Vajani, MPH
Cherie L. Drenzek, DVM, MS, State Epidemiologist
Graphic Design Ginny Jacobs ______________________________
Georgia Department of Public Health Epidemiology Program Two Peachtree Steet, NW Atlanta, GA 30303 404-657-2588

Confirmed Measles in Two Metropolitan Atlanta Residents
Jessica Tuttle, MD
On June 19, 2012, a 32 year old male resident of Clayton County experienced the onset of mild congestion, fever, chills, and generalized body aches. Despite these symptoms, he reported to work at a restaurant located in the international concourse of Hartsfield-Jackson International Airport. On June 23, four days after initial symptoms began, he sought medical evaluation at a local emergency room after noting a maculopapular rash which began on his face the previous evening, and then spread to include areas of his trunk, forearms, and legs. Measles was suspected; the patient was isolated at the hospital and blood was obtained for serologic testing. The patient had no history of recent travel or known exposure to ill persons and an incomplete history of vaccination, having only received one measles vaccine at 1 year of age. He was discharged with instructions to stay home for the next four days, or the remainder of the eight-day infectious period of measles (four days preceding rash onset through the four days following rash onset).
The Georgia Department of Public Health (DPH) was notified of this case by the hospital on June 29, after a commercial laboratory reported a positive measles IgM antibody test. Because measles is spread by aerosolized droplets through the respiratory route and is highly infectious, a contact investigation was started immediately. The case-patient was interviewed by DPH and Health District epidemiologists to obtain a detailed history regarding his contacts and whereabouts during the infectious period of June 19-26 and identify persons who may have been exposed. Patients and employees present at the local emergency room during the case-patient's evaluation were also identified by hospital infection prevention personnel.
A total of 129 persons, including 41 restaurant employees, 83 hospital contacts, and 5 personal contacts, were identified as having had a potential exposure to the case-patient during his infectious period. All persons who may have been exposed while moving through the airport could not be identified. Over the subsequent 48 hours, Public Health and hospital personnel contacted each of the 129 exposed persons by phone to determine susceptibility and offer immunoprophylaxis to those identified to be at high risk of acquiring measles infection (i.e., persons who were unimmunized, pregnant, or immunocompromised). On June 30, immune globulin injections were administered to three such persons. DPH sent a measles alert to area physicians instructing them to consider measles in the differential diagnosis of patients with fever and rash in the Atlanta area throughout the 21-day measles incubation period, or until July 17, 2012. News media and the Centers for Disease Control and Prevention (CDC)'s Epi-X communication system were also used to reach medical providers.

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State Epi Corner
The Centers for Disease Control and Prevention (CDC) states that approximately 75% of recently emerging infectious diseases affecting humans are diseases of animal origin and that about 60% of all human pathogens are zoonotic. I would like to take this opportunity to briefly spotlight some zoonotic disease investigations in Georgia during 2012 that underscore the concept of interconnectedness, or "One Health", as an important component of the practice of infectious disease control and as a roadmap to improve both animal and human health.
During 2012, besides conducting enhanced surveillance for human infections with the swine variant influenza virus A H3N2v in Georgia (none have been identified to date), epidemiologists from the Georgia Department of Public Health led or collaborated in investigations of the following: 1) human occupational exposure to Brucella ceti from an infected bottlenose dolphin; 2) multi-state risk assessment of human exposures to Lymphocytic Choriomeningitis Virus (LCMV) from infected commercial feeder mice shipped to more than 450 pet stores; 3) evaluation of human exposures to Burkholderia pseudomallei (melioidosis) from infected research macaques shipped through a Georgia airport and recommendations for antimicrobial prophylaxis; 4) investigation of several Brucella suis infections among wild hog hunters exposed during field dressing or butchering; 5) evaluation of occupational exposures to Brucella organisms in diagnostic laboratories and recommendation for antimicrobial prophylaxis; and 6) investigation of human exposures to a rabid llama, a rabid domestic dog, rabid bats in an apartment dwelling, and a rabid horse hospitalized at a tertiary care facility.
We rely on existing partnerships with animal health officials, other state and federal agencies, animal diagnostic laboratories, and timely traditional disease reporting to detect these zoonotic disease situations warranting immediate investigation and implementation of control and prevention measures. Please continue to let us know about suspect situations via 1-866-PUBHEALTH or 404-657-2588.
Thank you, as always, for your trusted collaboration in our integrated mission to protect the health of Georgians.
Cherie L. Drenzek, DVM, MS State Epidemiologist

Confirmed Measles in Two Metropolitan Atlanta Residents (continued)
Repeat specimens from the case-patient collected on June 30 were tested at the Georgia Public Health Laboratory (GPHL) and CDC, confirming the measles diagnosis through antibody and genetic material testing (reverse transcriptase polymerase chain reaction, or RT-PCR). Viral genotyping showed the measles virus strain to be D8, which has most recently been circulating in the United Kingdom (UK). However, the casepatient had not travelled in the 21 days prior to his illness onset and reported minimal contacts aside from his daily work routine. He could have been exposed to an ill traveler at his workplace on the international concourse.
A secondary measles case was identified in a Clayton County infant on July 13, 2012. This 10 month-old infant had been exposed to the index case in the emergency room on June 23 and had received prophylactic immune globulin seven days after exposure. He developed a low grade fever and mild maculopapular rash on July 13 which progressed from the face to the trunk and extremities. The infant tested negative for measles IgM antibodies at GPHL, but this result was considered to be false and attributed to probable immune globulin suppression of measles antibody response. Based on clinical findings and epidemiologic linkage, this infant was confirmed as a secondary measles case (Figure 1).
Measles is spread via airborne droplets from the respiratory tract and is highly infectious, with the potential for severe clinical complications, including death. Although endemic measles was declared eliminated from the U.S. in 2000, sporadic cases and outbreaks continue to occur. These are primarily linked with international travel from measles-endemic areas of the world such as Africa, Asia, and certain countries in Europe, where there has been a recent resurgence of disease1. Imported cases brought in by unvaccinated or undervaccinated foreign visitors and U.S. travelers and the existence of susceptible unimmunized residents in U.S. communities remain the two key factors contributing to domestic measles outbreaks in recent years2. Confirmed measles cases occurring in Georgia during the past decade are described in Table 1.
The most effective prevention measure against measles outbreaks and sustained measles transmission continues to be the maintenance of high vaccination rates. The recommended schedule of two doses of measles-mumps-rubella (MMR) vaccine is highly effective (>95%) in preventing measles. The first dose is routinely given to children at age 12-15 months, followed by a booster dose at age 4-6 years3.
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Confirmed Measles in Two Metropolitan Atlanta Residents (continued)

All U.S. residents six months of age or older planning to travel abroad should be protected from measles and receive MMR vaccine before departure, if indicated. Infants as young as six months should get an early dose of the vaccine if traveling internationally, though they would still require the two scheduled MMR vaccines at the appropriate ages to be fully protected4. Children 12 months of age and older should have two doses of MMR separated by at least 28 days. Teens and adults should have documentation of two doses of MMR or other evidence of measles immunity.

To report a suspect measles case, contact your local health department or call 1-866-PUB-HLTH (1-866-782-4584) immediately.
Acknowledgements
We thank Ebony Thomas, Vaccine Preventable Disease Epidemiologist at DPH; Olatanwa Adewale, District Epidemiologist for Clayton County; and hospital infection prevention personnel for their assistance with this investigation.

The association of recent measles outbreaks in the U.S. with unvaccinated, infectious international travelers has been well documented5. International airports can serve as a major port of measles virus entry, processing millions of international travelers each year. CDC recommends that measles be considered in the differential diagnosis of any patient with a febrile rash illness and a history of recent international travel.

References
1. Katz SL, Hinman AR. Summary and conclusions: Measles elimination meeting, 16-17 March 2000. J Infect Dis 2004;189 (Suppl 1):S43-7.
2. Centers for Disease Control and Prevention. Measles - United States, 2011. MMWR 2012;61:253-7.

In addition, DPH would like to remind health care providers in Georgia to consider measles in persons with clinically compatible illness and a history of international travel, exposure to international travelers, or an exposure to a confirmed measles case in the preceding 21 days. Suspect measles cases should be isolated promptly (in a negative pressure room, if available) and DPH should be notified immediately. MMR can be an effective preventative measure for susceptible contacts (i.e., infants, pregnant women, and immunocompromised persons) but only if administered within 72 hours after exposure6. Prophylactic immune globulin can be administered up to 96 hours after exposure. The delay in reporting this suspect case precluded the timely use of vaccine as a preventative. The immune globulin that was administered was done so 24 hours beyond the recommended interval, possibly allowing for the development of a secondary case, although clinically less severe than if no immune globulin had been given. Immediate reporting of suspect cases to health officials can limit the extent of exposure to measles in the community, enable the provision of prophylactic immunization, and allow for more timely enhanced surveillance.

3. Centers for Disease Control and Prevention. Measles, mumps, and rubella vaccine use and strategies for elimination of measles, rubella, and congenital rubella syndrome and control of mumps: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1998;47:(No. RR-8).
4. Centers for Disease Control and Prevention. Measles imported by returning U.S. travelers aged 6-23 months, 20012011. MMWR 2011;60:397-400.
5. Centers for Disease Control and Prevention. Measles outbreak associated with an arriving refugee Los Angeles County, California, August-September 2011. MMWR 2012;61:385-9.
6. American Academy of Pediatrics. Measles. In: Pickering LK, et al [editors]. Red Book: 2012 Report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; 2012:489-99.

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Figure 1. Timeline Associated with EpidemiologicallyLinked Confirmed Measles Cases, Georgia, 2012

May 29

June 12

June 27 June 23

June 30

June 19

June 26 June 28

July 13

INCUBATION PERIOD OF CASE 1

INFECTIOUS PERIOD OF CASE 1

HEALTH ALERT TO PHYSICIANS INCUBATION PERIOD OF CASE 2

July 17

Case 1 develops fever, cough, coryza, conjunctivitis

Case 1 returns to work

Case 1 confirmed; Immune globulin administered to contacts

Case 1 serology results

Case 1 notices rash; initial are positive; DPH

specimen collected in ER (Case 2 present)

notified

Case 2 develops fever, rash; confirmed through epidemiologic linkage

Table 1. Confirmed Measles Cases, Georgia, 2002-2012

Case Number Year Reporting County Age History of MCV*

Exposure History

1

2002

2

2002

3

2002

4

2003

5

2004

6

2008

7

2009

8

2010

9

2012

10

2012

*Measles-containing vaccine

Dade DeKalb
Fulton
DeKalb Douglas Fulton Fulton DeKalb Clayton Clayton

22 years 41 years
31 years
12 years 40 years 54 years 7 months 22 years 32 years 10 months

None None
Unknown
Unknown None
Unknown None
Unknown 1 MMR None

U.S. resident returning from Nigeria Foreign visitor from Soviet Union Epidemiologic linkage to 10 month old resident of Alabama who recently returned from Philippines Emigrated from Nigeria prior to symptom onset Foreign visitor from Republic of Georgia U.S. resident returning from Pakistan Visited international airport Emigrated from Ethiopia prior to symptom onset Worked on international concourse of airport Epidemiologic linkage to case number 9

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Animal-Associated Transmission of Bacterial Enteric Illnesses in Georgia
Hope Dishman, MPH and Melissa Tobin-D'Angelo, MD, MPH

Salmonella is the most commonly reported cause of bacterial enteric illness in Georgia (2,806 cases in 2010), Campylobacter is the third most often reported (598 cases in 2010), and shiga toxin-producing E. coli (STEC) is the fourth (85 cases in 2010). Infections with Salmonella, Campylobacter, and STEC cause diarrhea, abdominal cramps, and fever, and can sometimes lead to severe complications, such as hemolytic uremic syndrome (HUS). In 2011, the Centers for Disease Control and Prevention (CDC) estimated that 9.4 million cases, 55,961 hospitalizations, and 1,351 deaths from foodborne illness associated with 31 major pathogens occur annually in the United States1.
Although enteric infections may come from a variety of food, water, or environmental sources, contact with animals - either ill or asymptomatically colonized - may also lead to infection. A 2012 analysis using Foodborne Diseases Active Surveillance Network (FoodNet) data and outbreak data collected by the CDC estimated the percentage of bacterial enteric disease cases attributable to animal contact2, shown in Table 1.
Contact with animals at home or in public settings can lead to bacterial infections with Salmonella, Campylobacter, or STEC. The Georgia Department of Public Health has been tracking enteric illness outbreaks due to animal transmission since 2002. We reviewed our database for all outbreaks associated with animal contact caused by the above enteric bacteria (Figure 1).
Baby poultry (primarily chicks) and turtles, were the most common sources of animal-associated outbreaks in Georgia over the last 9 years. Outbreaks were due to Salmonella (n=17) and Campylobacter (n=1). No STEC outbreaks were identified. Forty-seven illnesses occurred during these 18 outbreaks and 7 (15%) of those 47 case-patients were hospitalized for their illnesses; zero deaths were reported. Each outbreak included a median of 2 people (range 1-7) and a median of 0 hospitalizations (range 0-2). Case-patient age was known in 14 outbreaks; in 10 (71%) of those outbreaks, at least 50% of cases were under 10 years old. In 7 (50%) of those 14 outbreaks, at least 50% of cases were under 5 years old.
Figure 1. Enteric Illness Outbreaks due to Animal Transmission by Source, Georgia, 2002-2012 (n=18)

Prevention of illness attributed to animal contact in public settings, such as petting zoos or agricultural fairs, is important to avoid large numbers of ill people. A 2011 compendium of recommendations to prevent animal-borne diseases in public settings is available at http://www.cdc.gov/mmwr/preview/ mmwrhtml/rr6004a1.htm?s_cid=rr6004a1_w. However, most animal-associated outbreaks (94%) reported in Georgia occurred in private homes.
The Georgia Department of Public Health recommends the following steps to prevent enteric illness associated with animal contact3:
Wash hands with soap and water after touching or petting animals or touching their environments, especially before eating or putting hands in the mouth.
Young children should be closely supervised around animals.
Children under 5 should not have contact with reptiles and amphibians and their cages or tanks.
Pet owners should wash hands with soap and water and clean the area carefully after cleaning an animal's tank or cage, changing bedding, or feeding the animal.
People should not eat, drink, or prepare food while touching animals or their environments.
References
1. Scallan E, Hoekstra R, Angulo F, Tauxe R, Widdowson M, Roy S, Jones J, Griffin P. (2011). Foodborne Illness Acquired in the United States Major Pathogens. Emerging Infectious Diseases, 17(1):7-15. doi: 10.3201/eid1701.P11101
2. Hale C, Scallan E, Cronquist A, Dunn J, Smith K, Robinson T, Lathrop S, Tobin-D'Angelo M, Clogher P. (2012). Estimates of Enteric Illness Attributable to Contact with Animals and their Environments in the United States. Clinical Infections Diseases, 54(S5):S4729. doi: 10.1093/cid/cis051
3. CDC. Healthy Pets, Healthy People. Centers for Disease Control and Prevention. Accessed on: 28 December 2012 from http://www.cdc.gov/healthypets/.

Table 1. Estimated Cases, Hospitalizations, and Percent Cases due to Animal-Associated Transmission of Enteric Bacteria, United States

Bacteria

Estimated Cases*

Estimated Hospitalizations*

Estimated Percent Illnesses
Animal-Borne^

Campylobacter spp.

845,024 (337,0311,611,083)

8,463 (4,30015,227)

17% (9-29%)

STEC O157

63,153 (17,587149,631)

2,138 (5494,614)

6% (3-11%)

STEC nonO157

112,752 (11,467287,321)

271 (0971)

8% (4-15%)

Salmonella spp., nontyphoidal

1,027,561 (644,7861,679,667)

19,336 (8,54537,490)

11% (6-20%)

*Adapted from Scallan et al, 2011 ^Adapted from Hale et al, 2012

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Georgia Epidemiology Report
Georgia Department of Public Health Epidemiology Program Two Peachtree Steet, NW Atlanta, GA 30303 404-657-2588
To subscribe to GER or to share questions and comments, please email GER@dhr.state.ga.us
GER is also available online at http://health.state.ga.us/epi/ manuals/ger

Healthcare-Associated Infections are now Notifiable Diseases
Beginning in January 2013, healthcare-associated infections (HAIs) should be reported to the Georgia Department of Public Health (DPH), in accordance with the notifiable disease law. This applies only to facilities required to report HAI data to the Center for Medicare and Medicaid Services (CMS) via the National Healthcare Safety Network (NHSN). Reporting facilities will need to join the State HAIs group in NHSN and confer rights to the State for select HAIs reported to CMS. Data will remain confidential. For more information, please contact Jeanne Negley, State HAIs Coordinator, at jenegley@dhr.state.ga.us or 404-657-2593.

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