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 March 1997 Volume 13 Number 3 Infant Mortality in Georgia during Rapid Service Expansion, 1989 through 1992 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. In 1990, Georgia's overall infant mortality rate (IMR) was ranked 50th among states. However, the state had already initiated innovative programs designed to improve infant health, and by 1992, Georgia had improved its national ranking to 46th--improving faster than the national average: q In Georgia, overall IMR declined from 12.3 in 1989 to 10.1 in 1992, an 18% improvement q In the US, overall IMR declined from 9.8 in 1989 to 8.5 in 1992, a 13% improvement Despite this unfavorable overall ranking, Georgia ranked better in racespecific infant mortality--26th among 49 states reporting for whites, and 9th of 37 reporting for blacks. Georgia's IMR ranking reflects the state's relatively large black population, as well as the nation's large and widening gap between black and white IMR. From 1989 to 1992, IMR for white Georgians improved 21% (from 9.0 to 7.1), and IMR for white Americans improved 15% (from 8.1 to 6.9). During the same time period, IMR for black Georgians improved 15% (from 18.3 to 15.5), and IMR for black Americans improved 10% (from 18.6 to 16.8). The very low birth weight (VLBW) rate--births weighing under 1500g per 1,000 livebirths--changed little in Georgia during this time. VLBW rate for whites started at 9.5 in 1989, rose to 10.6 in 1990, and then declined to 9.8 in 1992. For blacks, VLBW rate started at 28.9 in 1989 and had declined only slightly to 28.6 in 1992. This report examined the state's expansion of pregnancy-related outreach programs during this period, and focuses on the relationship of WIC and Medicaid services with infant mortality. Changes in Pregnancy-related Outreach Programs in Georgia Between 1989-1992, Georgia began a number of coordinated outreach pro- grams directed at improving pregnancy outcomes. It became simpler and easier for any woman receiving Medicaid (an antipoverty health insurance program) to en- Epidemiology Section, Epidemiology & Prevention Branch, Two Peachtree St., N.W., Atlanta, GA 30303-3186 Phone: (404) 657-2588 FAX: (404) 657-2586 roll in WIC (a nutritional program for women, infants, and children)--as WIC started using Medicaid status as proof of WIC income eligibility ("presumptive eligibility", starting 1989) and began services at the client's first visit without waiting for administrative details ("adjunctive eligibility", starting 1991). Medicaid introduced outreach workers into communities ("Right from the Start" Medicaid workers, starting 1989), coordinated support services (Perinatal Case Management, starting 1990), increased prenatal care reimbursement (starting 1991), and provided postpartum home visitation nurses (Pregnancy Related Services, starting 1991). Accordingly, the number of pregnant women receiving both WIC and Medicaid increased between 1989-1992, particularly among high-risk groups (See Figure 1). However, the number of pregnant women receiving only Medicaid also increased from 7200 (7%) to 13,500 (12%) overall, and 4300 (11%) to 7000 (17%) for blacks. Figure 1. Percent of Pregnant Women Receiving both WIC and Medicaid, by Risk Group, Georgia 1989-1992 WIC and Medicaid records were linked to birth and death records to see how publicly funded program support during pregnancy related to infant mortality. The analysis considered 24 groups formed by: category of support (no public support, WIC only, Medicaid only, and WIC+Medicaid), race (black or white), and age of mother (10-19 years, 20-34 years, 35 years or older). Trends for 1989-1992 were considered. The effect on infant mortality of very low birth weight was also examined. Data from the Georgia Pregnancy Risk Assessment Monitoring System (PRAMS) were used to estimate the relationship between publicly funded program support and income. How did changes in infant mortality relate to public support? In each of the study years, approximately 110,000 infants were born to mothers who were Georgia residents. Each year, approximately 1800-1950 infants were of very low birth weight, and 1150-1350 infants died in the first year of life. Infants whose mothers had received only Medicaid had the highest IMRs. Infants whose mothers had received WIC, with or without Medicaid, had substantially lower IMRs. Black infants whose mothers had received no support had among the highest IMRs. By contrast, white infants whose mothers had received no support had the lowest IMR (see Figure 2). Figure 2. Infant Mortality Rate by Type of Public Support and Race, Georgia 1989-1992 The number of pregnant women receiving prenatal care in the first trimester increased from 54,700 (78%) to 56,200 (83%) for the white population, and 23,500 (60%) to 25,800 (64%) for the black population. Since outreach policies encourage all women on Medicaid to enroll in WIC, the number and outcomes of pregnant women who receive both WIC and Medicaid provide a new assessment of the impact of barriers to care. Such barriers to care may include different locations for program enrollment, transportation problems, long waiting times, administrative delays, work conflicts with clinic hours, and appointment scheduling. In every comparison, blacks had higher IMRs than whites. Over the whole state, black infants were 2.9 times as likely to die as white infants. By comparison, the blackwhite IMR ratio was: q lowest for WIC+Medicaid support (1.6) q highest for no public support (3.6) - 2 - For all types of public support, infants of mothers age 10-19 years usually had the highest IMRs. However, for mothers receiving Medicaid, with or without WIC, maternal age 35 years or older was associated with highest IMR. Statewide, black infants were 2.2 times as likely to be VLBW as white infants. Over the 4-year period, only one group showed substantial change in IMR--black teenagers who received no public support. This group had among the highest IMRs, 31.7, in 1989 and experienced a large and steady increase over each year. By 1992, black teenagers receiving no public support had an IMR of 82.9--the largest by far of any group at any time. This group was also unique in having a VLBW rate almost as large as its IMR throughout the period (ranging from 33.1 to 77.7). These trends are hard to interpret. As WIC and Medicaid services expanded--and since teenagers are automatically eligible for both--this group substantially decreased in size, from 694 births in 1989 to 193 births in 1992. The number of infant deaths each year in this group was small and changed relatively little, ranging from 13-22. Thus this category was not a major contributor to infant mortality in Georgia. Since 1992, WIC and Medicaid coverage among teenagers has increased even further, from 79% to 93%. There are several possible explanations for increasing risk in a shrinking population that does not receive services despite outreach efforts: q The population might contain a growing subpopulation at high risk (e.g., deficient parenting skills). q Risks may be increasing for such a subpopulation. q Outreach programs might fail to serve expanding high risk subpopulations (e.g., the homeless?). q Services may draw off relatively low risk people as the population shrinks "unmasking" large preexisting risks (e.g., expanding outreach may be less successful in reaching addicts). q Inadequate data, including failure to link records across databases, might be concentrated among higher-risk individuals. q Statistical variation might give rise to a spurious positive result (especially with multiple tests performed). The relatively high VLBW rate suggests that prenatal care, rather than neonatal intensive care, is the larger problem for this group. Table 1 summarizes this study, along with self-reported income obtained from PRAMS interviews of recent mothers. WIC services, with or without Medicaid, appear to mitigate the effects of poverty. For example, the WIC+Medicaid group had even higher poverty rates than that receiving only Medicaid, yet its infant mortality was remarkably lower. Among black mothers, the comparison is most striking: the WIC+Medicaid group had the lowest infant mortality (12.8) and the Medicaid-only group had the highest (26.5). Table 1. Infant Mortality Rate Compared with Percent Population Below 100% Poverty Level, by Race, Georgia 1992 % Below 100% Poverty ( PRAMS) Black White WIC and Medicaid Medicaid only WIC only No public support 90 80 85 73 54 45 15 6 Infant Mortality (This study) Black White 12.8 9.4 26.5 17.1 16.1 7.1 23.7 6.8 This observational, descriptive, ecological, retrospective investigation is limited in its ability to infer causal relationships by its basic design--since it observed natural outcomes rather than a well-defined intervention, applied only limited controls for extraneous factors, examined primarily characteristics of groups instead of individuals, and examined trends in preexisting data. However, its findings agree with other scientific studies showing infant mortality depends on: q appropriate public services q barriers to care q income q conditions involving race Better care after birth may have played a major role in reducing the infant mortality rate. Rapid advances in neonatal intensive care during the study period (e.g., surfactant therapy) seem likely to slow down, so Georgia's improvement in IMR could stall. Further research is needed to determine why VLBW rate responded so little to prenatal care outreach. Although expanding services were generally associated with improving infant mortality, barriers to care in one selected subpopulation appeared to be correlated with very high infant mortality. In the current era of planned budget cutbacks, these findings may be important to prevent reversal of Georgia's gains following a period of service outreach. This report was contributed by Raymond Gangarosa, M.D., M.P.H. - 3 - The Georgia Epidemiology Report Epidemiology and Prevention Branch Two Peachtree St., NW Atlanta, GA 30303-3186 March 1997 Volume 13 Number 3 Reported Cases of Selected Notifiable Diseases in Georgia Profile* for December 1996 Selected Notifiable Diseases Total Reported for December 1996 Previous 3 Months Total Ending in December 1994 1995 1996 Previous 12 Months Total Ending in December 1994 1995 1996 Campylobacteriosis 36 267 212 150 1080 1049 792 Chlamydia genital infection 729 na 2667 3368 na 11439 13333 Cryptosporidiosis 4 na na 17 na na 92 E. coli O157:H7 1 12 8 4 26 29 39 Giardiasis 49 111 146 221 463 572 812 Gonorrhea 1254 0 6438 4421 0 21465 19810 Haemophilis influenzae (invasive) 2 8 5 8 67 37 47 Hepatitis A (acute) 26 17 14 107 43 84 412 Hepatitis B (acute) 2 37 7 7 555 103 47 Blood Lead Level > 10 g/dL (cap) 119 na 759 578 na 2955 2985 Blood Lead Level > 10 g/dL (ven) 25 na 135 118 na 604 617 Legionellosis 0 13 2 0 118 19 3 Lyme Disease 0 15 0 0 127 14 1 Meningococcal Disease (invasive) 7 15 35 22 82 106 146 Mumps 0 4 3 1 18 11 8 Pertussis 1 8 6 6 37 31 30 Rubella 0 0 0 0 7 0 0 Salmonellosis 131 402 471 388 1584 1662 1467 Shigellosis 128 604 181 479 1887 1359 1134 Syphilis - Primary 10 62 87 38 262 291 187 Syphilis - Secondary 37 136 164 125 620 630 495 Syphilis - Early Latent 90 433 365 317 1806 1663 1287 Syphilis - Other** 90 208 291 242 862 1152 913 Syphilis - Congenital 2 13 17 6 54 59 35 Tuberculosis 74 212 175 206 740 742 790 * 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 Total Cases Reported * Percent Female Risk Group Distribution (%) MSM IDU MSM&IDU HS Blood Unknown Last 12 Mos 03/96 to 02/97 5 Yrs Ago 03/91 to 02/92 Cumulative 01/80 to 02/97 2342 1695 17331 19.2 42.1 17.7 4.5 12.8 54.7 22.8 6.3 14.5 52.1 19.0 6.0 16.7 1.2 17.7 9.1 1.8 5.2 11.1 2.1 9.8 Race Distribution (%) White Black Other 31.3 66.1 2.6 43.2 54.9 1.9 40.6 57.4 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-