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 - 2 - 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 - 3 - 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 - 4-