Georgia epidemiology report, Vol. 13, no. 2 (Feb. 1997)

Georgia

Epidemiology

Report
The Georgia Epidemiology Report is a publication of the Epidemiology Section of the Epidemiology and Prevention Branch, Division of Public Health, Department of Human Resources

February 1997
http://www.ph.dhr.state.ga.us
Division Of Public Health
Patrick J. Meehan, M.D. - Director Epidemiology and Prevention Branch State Epidemiologist
Kathleen E. Toomey, M.D., M.P.H.- Director Epidemiology Section Paul A. Blake, M.D., M.P.H.-Chief
Notifiable Diseases
Jeffrey D. Berschling, M.P.H.; Karen R. Horvat, M.P.H. ; Amri B. Johnson, M.P.H.; Jane E. Koehler, D.V.M, M.P.H.; Katherine GibbsMcCombs, M.P.H.; Preeti Pathela, M.P.H.; Sabrina Walton, M.S.P.H.
Chronic Disease
Nancy E. Stroup, Ph.D.-Program Manager Patricia M. Fox, M.P.H.; A. Rana Bayakly, M.P.H.; Edward E. Pledger, M.P.A.
Tuberculosis
Naomi Bock, M.D., M.S.
HIV/AIDS/Sexually Transmitted Diseases
Kim Cook, M.D., M.S.P.H.-Program Manager Stephanie Bock, M.P.H.; Mary Lynn Gaffield, M.P.H.; Andrew Margolis, M.P.H.
Perinatal Epidemiology
Mary D. Brantley, M.P.H.; Paul C Gangarosa, M.P.H.Raymond E. Gangarosa, M.D., M.P.H.; Leslie E. Lipscomb, M.P.H.; Mary P. Mathis, Ph.D., M.P.H.
Preventive Medicine Residents
Hussain R. Yusuf, M.B.B.S., M.P.H.;
EIS Officer
Michael S. Friedman, M.D.
Georgia Epidemiology Report Editorial Board
Editorial Executive Committee Paul A. Blake, M.D., M.P.H.- Editor Kathleen E. Toomey, M.D., M.P.H. Mary D. Brantley, M.P.H. Jeffrey D. Berschling, M.P.H.
Mailing List Edward E. Pledger, M.P.A.

Volume 13 Number 2
Population-Based Prevalence of Perinatal
Exposure to Cocaine in Georgia, 1994
Adapted from CDC's MMWR 1996:45(41):887-891
Maternal cocaine use during pregnancy is associated with adverse health effects for both mother and infant, including intrauterine growth retardation, placental abruption, preterm delivery, congenital anomalies, and cerebral injury1. Because cocaine use often occurs concurrently with use of other substances (e.g., cigarettes and alcohol) and because fear of prosecution may deter women from obtaining medical care, the occurrence of perinatal exposure to cocaine has not been well characterized. In Georgia, the routine collection of dried blood spots (DBS) from newborn heelsticks to screening for metabolic diseases enabled the Georgia Chapter of the March of Dimes Birth Defects Foundation, the Georgia Department of Human Resources (DHR), and Centers for Disease Control and Prevention (CDC) to collaborate on a feasibility study of the use of residual DBS for conducting population-based surveillance for perinatal cocaine exposure. This report presents the findings of the study, which indicate that in 1994 at least 0.5% of infants in Georgia had perinatal exposure to cocaine.
The sample for this study comprised all newborns whose DBS specimens were submitted to DHR during a 2-month period in 1994 and for whom an adequate specimen was available after completion of metabolic screening. Testing for cocaine metabolite was conducted with anonymous specimens--no linkage could be made back to identifiers. If more than one DBS specimen was obtained for a single newborn, only the results of the first specimen were included in this analysis. Newborns with gestations <31 weeks or birthweights <1500 g (<3 lbs, 5 oz) were excluded from the analysis because only half of these newborns were tested within 7 days after birth--a maximum time period for reliable detection of cocaine metabolite in the DBS specimen. Multiple births and all newborns tested after 7 days of age also were excluded. A total of 16,470 eligible infants were born during the 2-month period; of these, DBS specimens from 14,968 (91%) newborns were submitted to DHR and tested by CDC for cocaine metabolite.
For each specimen, a 1/4 inch punch (equivalent to a 12 L blood specimen) was obtained from one blood spot and was tested for benzoylecognine (BE)--a primary cocaine metabolite-- using a modified radioimmunoassay (RIA)2 Samples with BE measured at >0 ng/mL by RIA were then tested by liquid chromatography/tandem mass spectrometry for confirmation of BE at CDC3.
Data about maternal characteristics were collected from the birth certificate. Rigorous measures were employed to ensure anonymity of the final analysis database. In particular, personal identifying information and laboratory results were not present in the database simultaneously, and the analysis files precluded combination of attributes that potentially could permit inferential identification of any person.
Of the 14,968 newborns, specimens for 73 tested positive for BE, representing a statewide prevalence rate of 4.9 BE-positive per 1000 newborns. Demographic characteristics associated with high rates of BE in newborns included older age, education of <15 years, black race, being unmarrried and lacking a father's name on the birth certificate, and residing in a city within a large metropolitan statistical area (population >1,000,000). Mothers of BE-positive newborns resided in 17 of the 19 health districts in Georgia (Table 1).

Epidemiology Section, Epidemiology & Prevention Branch, Two Peachtree St., N.W., Atlanta, GA 30303-3186

Phone: (404) 657-2588

FAX: (404) 657-2586

Table 1. Maternal Demographic Characteristics

Maternal Characteristic

Sample No. Rate 95% CI* Size Pos /1,000 Lo - Hi

Age Group

<20

2975

2

0.7 0.1 - 2.4

20-24

4168 15

3.6 2.0 - 5.9

25-29

3921 34

8.7 6.0 - 12.1

30 +

3903 22

5.6 3.5 - 8.5

Education (years)

<12

3449 25

7.2 4.7 - 10.7

12

5406 34

6.3 4.4 - 8.8

13-14

2482 12

4.8 2.5 - 8.4

15 +

3511

2

0.6 0.1 - 2.1

Race/ethnicity

Black

5049 61 12.1 9.2 -15.5

White non-Hispanic

9139 12

1.3 0.7 - 2.3

White Hispanic

491

0

0.0 0.0 - 7.5

Other****

287

0

0.0 0.0 - 12.9

Urban Residence

Large MSA**/ city

2766 39 14.1 10.0 - 19.3

Small MSA**/ city

1643

9

5.5 2.5 - 10.4

Non-MSA**/ city

1051

6

5.7 2.1 - 12.4

Large MSA**/ non-city

4705

9

1.9 0.9 - 3.6

Small MSA**/ non-city

1360

3

2.2 0.5 - 6.4

Non-MSA**/ non-city

3442

7

2.0 0.8 - 4.2

Marital Status and Father's name on Birth Certificate

Unmarried, father unknown 2437 34 14.0 9.7 - 19.5

Married, father unknown 170

7 41.2 16.6 - 84.8

Unmarried, father known 2679 20

7.5 4.6 - 11.5

Married, father known

9681 12

1.2 0.6 - 2.2

Total***

14968 73

4.9 3.8 - 6.1

Mothers of BE-positive newborns were more likely to reside in zipcodes which had 50 or more births during the study period than were mothers of BE-negative newborns (Map 1). Zipcodes with one or more BE-positive mothers were more likely to be in a large metropolitan statistical areas (MSA**) than were zipcodes with no BE-positive mothers.
Map 1. Perinatal exposure to Cocaine by Zipcode and MSA**

Test Results

Births/Zip # Pos Rate

50+

60 6.5

<50

13 2.3

Total

73 4.9

The mothers of BE-positive newborns were more likely to use tobacco and/or alcohol than BE-negative mothers. They were more likely to have inadequate weight gain during pregnancy, have 3 or more previous live births, and to have a short interpregnancy interval (less than 6 months) (Table 2).

Table 2. Maternal Risk during Pregnancy

Maternal

Sample No.

Rate

95% CI*

Characteristic

Size Pos /1,000

Lo - Hi

Smoking tobacco and/or drinking alcohol

Both

106 13 122.6 65.3 - 209.7

Tobacco only

1584 28

17.7 11.7 - 25.5

Alcohol only

111

3

27.0 5.6 - 79.0

Neither

13117 29

2.2

1.5 - 3.2

Weight gain (lbs)

Less than 15

996 13

13.1 6.9 - 22.3

15-24

3001 18

6.0

3.6 - 9.5

25 or more

9955 35

3.5

2.4 - 4.9

Missing

1016

7

6.9 2.8 - 14.2

Previous births

None

6520

6

0.9

0.3 - 2.0

1

5015 14

2.8

1.5 - 4.7

2

2262 16

7.1 4.0 - 11.5

3 or more

1171 37

31.6 22.2 - 43.6

Interpregnancy interval (months)

No previous birth

6520

6

0.9

0.3 - 2.0

0-6

675 15

22.2 12.4 - 36.7

7 or more

7542 44

5.8

4.2 - 7.8

Unknown

231

8

34.6 15.0 - 68.2

Total***

14968 73

4.9

3.8 - 6.1

The mothers of BE-positive newborns were more likely than those of BE-negative newborns to have received no or inadequate prenatal care or to lack information about timing of prenatal care on the birth certificate (Table 3). However, 74% of the mothers of BE-positive newborns had received some prenatal care, and 34% had initiated prenatal care during the first trimester. Mothers of BE-positive newborns were more likely to have given birth either in a place with no obstetric services or a perinatal regional center than in hospitals which offer standard obstetric services.

Table 3. Health Care Information

Maternal Characteristic

Sample Size

#

Rate

+ /1,000

95% CI* Lo - Hi

Adequacy of prenatal care (Kotelchuck index)

None

167 15

89.8 50.3 - 148.1

Inadequate

1702 27

15.9 10.5 - 23.1

Intermediate Adequate

2236

3

6780 12

1.3

0.3 - 3.9

1.8

0.9 - 3.1

Adequate plus

3920 12

Missing

163

4

Perinatal hospital service level

3.1 24.5

1.6 - 5.3 6.7 - 62.8

None Minimal (L I)

149

6

2817 10

40.3 14.8 - 87.6

3.5

1.7 - 6.5

Intermediate (L II) Specialized (L III) Perinatal center

4844 12 4649 16 2503 29

2.5 3.4 11.6

1.3 - 4.3 2.0 - 5.6 7.8 - 16.6

Teaching hospital

Yes

3719 36

9.7 6.8 - 13.4

No

11243 37

3.3

2.3 - 4.5

Trimester prenatal care began

1st (1-3 mo)

12080 25

2.1

1.3 - 3.1

2nd (4-6 mo)

2139 21

9.8 6.1 - 15.0

3rd (after 6 mo)

447

8

17.9 7.7 - 35.3

None

167 15

89.8 50.3 - 148.1

Unknown

135

4

29.6 8.1 - 75.9

Total***

14968 73

4.9

3.8 - 6.1

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The infants born to BE-positive mothers were more likely to have a low birthweight (less than 2500 grams) and to be premature (less than 37 weeks gestation) than were infants born to BE-negative mothers (Table 4).

Table 4. Pregnancy Outcome Rates

Pregnancy Outcome

Sample No.

Rate

Size Pos /1,000

95% CI* Lo - Hi

Birthweight Normal
Low Gestational age Term Preterm Total***

14265 57 703 16

12946 38

2003

29

14968 73

4.0

3.0 - 5.2

22.8 13.0 - 37.0

2.9

2.1 - 4.0

14.5

9.7 - 20.8

4.9

3.8 - 6.1

Editorial Note: This study in Georgia is the first to use newborn DBS to deter-
mine perinatal exposure to cocaine. Statewide prevalence of perinatal cocaine exposure have been estimated previously by testing maternal urine samples obtained at delivery from women in California4, Missouri5, Rhode Island6, South Carolina7, and Utah8. In Alabama, statewide prevalence was estimated by testing maternal urine specimens at delivery from pregnant women attending public health clinics9. Although these studies employed different methodologies, the characteristics of women in Georgia who used cocaine during pregnancy were consistent with patterns in previous reports1,8. In addition, in Georgia, evidence of antepartum cocaine exposure was present among newborns in areas throughout the state and in diverse population groups.
To reduce cocaine use during pregnancy, in 1990 the Georgia General Assembly convened a Conference on Children of Cocaine and Substance Abuse (CCCSA), which recommended that cocaine-using pregnant women be treated and not prosecuted.
Public policy recommendations from the Georgia General Assembly Conference on Children of Cocaine
q Base public health policy on valid research
q Legislate comprehensive, holistic approaches to control the substance abuse crisis
q Declare a moratorium on legislation which could prosecute drug dependent pregnant women
q Appropriate substance abuse treatment facilities for pregnant women should be developed and funded.
Acknowledging these recommendations in 1992, the Georgia Court of Appeals established that mothers who prenatally pass cocaine to their infants may not be prosecuted under Georgia law. In addition, CCCSA recommended the feasibility study detailed in this report.
The findings in this report underestimate the true prevalence of cocaine exposure during pregnancy in Georgia for two reasons. First, screening of newborns provides information about cocaine exposure only near the time of delivery and not about exposures that may have occurred earlier10. Second, because cocaine metabolite is excreted from the body, testing must occur soon after birth. DBS samples are not collected for fetal deaths and may not be collected routinely during the interval of detection of BE for early neonatal deaths and for newborns in intensive care, especially infants with very low birthweight and infants born prematurely. Finally, the association of cocaine with low birthweight and prematurity cannot be inferred as causal without the
* CI - Poisson confidence interval. ** MSA - Standard metropolitan statistical area. Large MSAs have populations >=1,000,000. *** Some numbers do not total to 14,968 because of missing data **** Numbers for racial/ethnic groups other than blacks, whites, and Hispanics were too small for
meaningful analysis.

analytical ability to control for other causes of these adverse outcomes, such as smoking cigarettes during pregnancy--which is also common among cocaine users.
This study illustrates that DBS screening can be an important tool to estimate the population-based prevalence of perinatal cocaine exposure. As a result of technological improvements associated with this effort in Georgia, the immunoassay for BE in DBS can be used for screening with laboratory confirmation of positive values by liquid chromatography/tandem mass spectrometry2. This methodology also can be used to detect other substances (e.g., tetrahydrocannabinol and nicotine) and their metabolites. When measures for ensuring anonymity and legal protection against prosecution are provided, this approach can assist states or large communities in designing and evaluating population-wide prevention and intervention activities to reduce cocaine and other substance use among pregnant women. In addition, efforts are needed to increase public support for such studies and for programs to prevent cocaine use during pregnancy.
References
1. Holzman C, Paneth N. Maternal cocaine use during pregnancy and perinatal outcomes. Epidemiol Rev 1994;16:315-34.
2. Henderson LO, Powell MK, Hannon WH, et al. Radioimmunoassay screening of dried blood spot materials for benzoylecgonine. J Anal Toxicol 1993;17:42-7
3. Sosnoff CS, Ann Q, Bernert JT, et al. Analysis of benzoylecgonine in dried blood spots by liquid chromatography/atmospheric pressure chemical ionization tandem mass spectrometry. J Anal Toxicol 1996;20:179-84.
4. Vega WA, Kolody B, Hwang J, Noble A. Prevalence and magnitude of perinatal substance exposures in California. N Engl J Med 1993;329:850-4.
5. Dempsey ME, Schlechte T, Stockbauer JW, Schramm WF, Cary PC. Prevalence and implications of perinatal substance use in Missouri. Missouri Medicine 1996;93:292-9.
6. Hollinshead WH, Griffin JF, Scott HD, Burke ME, Coustan DR, Vest TA. Statewide prevalence of illicit drug use by pregnant women-Rhode Island. MMWR 1990;39:225-7.
7. Nalty D. 1991 South Carolina prevalence study of drug use among women giving birth: report of the South Carolina Commission of Alcohol and Drug Abuse. Columbia, South Carolina: South Carolina Commission on Alcohol and Drug Abuse, 1991.
8. Buchi KF, Varner MW, Chase RA. The prevalence of substance abuse among pregnant women in Utah. Obstet Gynecol 1993;81:239-42.
9. Pegues DA, Engelgau MM, Woernle CH. Prevalence of illicit drugs detected in the urine of women of childbearing age in Alabama public health clinics. Public Health Rep 1994;109:530-8.
10. Casanova OQ, Lombardero N, Behnke M, Eyler FD, Conlon M, Bertholf RL. Detection of cocaine exposure in the neonate: analyses of urine, meconium, and amniotic fluid from mothers and infants exposed to cocaine. Arch Pathol Lab Med 1994;118:988-93.
This report was contributed by R Rochat, M Brantley, Perinatal Epidemiology, EPB; V Floyd, D Norris, MCH Branch; E Franko, Public Health Laboratory; P Blake, K Toomey, EPB, DPH, GA DHR. P Fernhoff, B Ziegler, L Mayer, Georgia Chapter, March of Dimes Birth Defects Foundation. O Henderson, H Hannon, Clinical Biochemistry Br, Div of Environmental Health Laboratory Sciences, L Martin Birth Defects and Genetic Diseases Br, Div of Birth Defects and Developmental Disabilities, National Center for Environmental Health; C Ferre, Pregnancy and Infant Health Br, Div of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.
A Georgia Perspective: Infant health & maternal behaviors during pregnancy that may adversely affect the fetus
Infant health
1:50 Are very low birthweight infants (less than 3 lbs 5 oz) 1:33 Have a major birth defect 1:200 Have perinatal exposure to cocaine 1:500 Test positive for HIV (maternal antibody)--and an estimated
15-20% of these will develop AIDS 1:4000 Are born with Fetal Alcohol Syndrome
Maternal behaviors
1:2 Are not taking multivitamins with folate during pregnancy 1:6 Smoke tobacco during their pregnancy 1:10 Consume alcohol during their pregnancy 1:100 Receive no prenatal care 1:200 Use cocaine shortly before the end of their pregnancy

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The Georgia Epidemiology Report Epidemiology and Prevention Branch Two Peachtree St., NW Atlanta, GA 30303-3186

February 1997

Volume 13 Number 2

Reported Cases of Selected Notifiable Diseases in Georgia Profile for November 1996

Selected Notifiable Diseases

Total Reported for November 1996

Previous 3 Months Total

Ending in November

1994

1995

1996

Previous 12 Months Total

Ending in November

1994

1995

1996

Campylobacteriosis

53

281

279

192

992

1094

803

Chlamydia genital infection

666

na

2607

3911

na

10330

13713

Cryptosporidiosis

6

na

na

41

na

na

88

E. coli O157:H7

2

16

9

8

25

29

39

Giardiasis

80

134

195

301

454

566

795

Gonorrhea

1134

NA

5841

4666

NA

19227

20794

Haemophilis influenzae (invasive)

2

7

3

12

65

38

47

Hepatitis A (acute)

45

16

17

127

52

85

387

Hepatitis B (acute)

4

36

14

13

608

109

46

Blood Lead Level > 10 g/dL (cap)

211

Blood Lead Level > 10 g/dL (ven)

40

Legionellosis

0

na

914

753

na

176

158

15

1

0

na

2776

3045

na

581

615

112

24

4

Lyme Disease

0

15

0

0

121

20

1

Meningococcal Disease (invasive)

7

11

29

22

77

100

151

Mumps

0

6

3

4

18

10

9

Pertussis

1

11

7

8

37

28

33

Rubella

0

0

0

0

7

0

0

Salmonellosis

121

489

664

444

1496

1681

1451

Shigellosis

191

569

289

502

1681

1555

1019

Syphilis - Primary

14

65

87

49

253

288

203

Syphilis - Secondary

38

146

195

125

613

635

498

Syphilis - Early Latent

89

452

373

324

1779

1699

1318

Syphilis - Other==

74

165

282

213

812

1143

922

Syphilis - Congenital

2

16

16

6

53

56

40

Tuberculosis

58

129

172

177

713

811

784

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.

Report Period

Total Cases Reported *

AIDS Profile Update

Percent

Risk Group Distribution (%)

Race Distribution (%)

Female

MSM IDU MSM&IDU HS Blood Unknown White Black Other

Last 12 Mos 02/96 to 01/97 5 Yrs Ago 02/91 to 01/92 Cumulative 01/80 to 01/97

2361 1636 17131

19.1

42.7 17.2

4.3

12.9

55.7 22.1

6.0

14.4

52.1 19.0

6.0

15.7 1.2

18.9

8.9 1.7

5.5

10.9 2.1

10.0

32.3 65.4 2.3 44.4 53.9 1.7 40.7 57.3 2.0

MSM - Men having sex with men IDU - Injection drug users HS - Heterosexual * Case totals are accumulated by date of report to the Epidemiology Section

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