December 1998 volume 14 number 12 Division of Public Health The Georgia Epidemiology Report is a publication of the Epidemiology Section of the Epidemiology and Prevention Branch, Division of Public Health, Georgia Department of Human Resources http://www.ph.dhr.state.ga.us Director Summary of the 1998 Georgia State of the Kathleen E. Toomey, M.D., M.P.H. Heart Report Epidemiology and Prevention Branch State Epidemiologist Introduction Acting Director Kathleen E. Toomey, M.D., M.P.H. Epidemiology Section Chief Paul A. Blake, M.D., M.P.H. Public Health Advisor Mel Ralston Notifiable Diseases Jeffrey D. Berschling, M.P.H., Carol Hoban, M.S., M.P.H. Katherine Gibbs McCombs, M.P.H. Jane E. Koehler, D.V.M., M.P.H. Laura Gilbert, M.P.H., Kathryn E. Arnold, M.D. Amanda Reichert, R.N., M.S. Susan E. Lance-Parker, D.V.M., Ph.D. Chronic Disease and Injury Ken Powell, M.D., M.P.H.- Program Manager, Patricia M. Fox, M.P.H., Rana Bayakly, M.P.H., Mary P. Mathis, Ph.D., M.P.H., Alexander K. Rowe, M.D., M.P.H. Linda M. Martin, M.S. Tuberculosis Rose Marie Sales, M.D., M.P.H.- Program Manager Naomi Bock, M.D., M.S., Beverly DeVoe, M.S. HIV/AIDS/Sexually Transmitted Diseases John F. Beltrami, M.D., M.P.H.&T.M.- Program Manager Andrew Margolis, M.P.H., Lyle McCormick, M.P.H. Ann Buckley, M.P.H., Amy Hephner, M.P.H. Perinatal Epidemiology James W. Buehler, M.D. - Program Manager Leslie E. Lipscomb, M.P.H., Cheryl Silberman, Ph.D.,M.P.H. Hui Zhang, M.D., M.P.H. Mohamed Qayad, M.D., M.P.H. Corliss Heath, M.P.H. Preventive Medicine Residents Mark E. Anderson, M.D., M.P.H. Anthony Fiore, M.D., M.P.H. EIS Officers Julia Samuelson, R.N., M.P.H. & Keoki Williams, M.D. Graphics Dept. Jimmy Clanton Jr. & Christopher Devoe Georgia Epidemiology Report Editorial Board Editorial Executive Committee Andrew Margolis, M.P.H. - Editor Paul A. Blake, M.D., M.P.H. Jane E. Koehler, D.V.M., M.P.H. Jeffrey D. Berschling, M.P.H. Kathleen E. Toomey, M.D., M.P.H. Angela Alexander - Mailing List Christopher Devoe - Graphics Cardiovascular disease (CVD) is the leading cause of death in Georgia, accounting for 23,366 deaths, or nearly 40 percent of all deaths in the state. Mortality rates from CVD have been declining in the past two decades, although a perceptible leveling off of these rates has occurred in the last five years. This observable new trend may be the result of changes in the prevalence of risk factors contributing to CVD, as well as an increase in the number of CVD survivors who have a particularly high risk of dying from these conditions. This article is a summary of the 1998 Georgia State of the Heart Report1 ; it presents a brief overview of CVD mortality rates in the past 2 decades and reports the prevalence of modifiable CVD risk factors in Georgia. CVD Trends in Georgia CVD mortality rates have declined in both Georgia and the U.S. over the past 17 years, but rates in Georgia have remained approximately 10% above the national average during this period (Figure 1). The decline is presumably due to improvements in medical care and healthier lifestyles. Although the Georgia CVD mortality rate continues to decline, the rate of decline is slowing. From 1980-1992, the CVD mortality rate declined by an average of 2.4% per year. However, from 1992-1996, the rate of decline had slowed to only 0.4% per year. The rate of decline in CVD deaths has slowed for all age groups; however, the change has been most striking among older Georgians. For 45-64 year olds, the CVD mortality rate declined by 3.7% per year for 1980-1992, but by only 1.5% per year for 1992-1996. In contrast, for those 85 and older, the rate declined by 1.1% per year for 1980-1992, but actually increased by 0.7% per year for 1992-1996. CVD is not just a disease of old age. Although atherosclerosis may begin in the teenage years, the age at which it kills varies greatly, and death often occurs before old age. In 1996, one in five Georgians who died of CVD was younger than 65 years of age. CVD mortality rates also differ by gender and race. Men have higher rates than women, and AfricanAmericans have higher rates than Whites. This pattern is also seen in national CVD mortality rates. Prevalence of CVD Risk Factors The leveling off of CVD mortality rates may be caused by the changing pattern of risk factors for heart disease and stroke, such as smoking, hypertension, hyperlipidemia, obesity and physical inactivity. The prevalence of the following risk factors was estimated by a telephone survey of a representative sample of Georgians 18 years of age and older (Georgia Behavioral Risk Factor Surveillance System). Physical Inactivity & Being Overweight. In this study, physical inactivity is defined as the lack of regular activity, or participation in activities for less than 20 minutes at least 3 times per week, and overweight is defined as being at or above 120% of ideal body weight. There has been a steady increase in the percentage of overweight Georgians; between 1984 and 1996, the percentage increased from 19 to 30 percent. Since the 1980s, about two-thirds of Georgians reported they were not physically active on a regular basis (Figure 2). Losing weight and being physically active can improve blood pressure and cholesterol levels and can decrease the chance of developing diabetes, another risk factor for heart disease. Georgia Department of Human Resources Division of Public Health Epidemiology & Prevention Branch, Epidemiology Section Two Peachtree St., N.W., Atlanta, GA 30303 - 3186 Phone: (404) 657-2588 Fax: (404) 657-2586 Figure 2 Figure 1 Figure 1. Cardiovascular Disease Death Rates in Georgia and the United States, 1980-1996 Deaths per 100,000 people per year 600 500 Georgia 400 United States 300 200 100 0 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 Year Source: Georgia Division of Public Health, US Census Bureau, and the National Cente r for Health Statistics. Figure 2. Percent of Georgians Who are Physically Inactive and Percent who are Percent 80 Overweight, 1984-1996 Sedentary Lifestyle 60 40 Obesity 20 0 84 85 86 87 88 89 90 91 92 93 94 95 96 Year Source: Georgia Division of Public He alth. Current Smoking. Current smoking is defined as someone who has smoked at least 100 cigarettes in their lifetime and who smokes now. The percentage of Georgians who smoke regularly declined from 31% in 1984 to 19% in 1992 (Figure 3). Since then the rate has not changed. In 1996, 20% of Georgians reported they smoked cigarettes regularly. Lowering smoking rates is a fundamental public health priority. In addition to its well-known association with cancer, smoking is a major CVD risk factor. In fact, each year smoking causes more deaths from heart attacks than from cancer. The good news is that giving up smoking quickly reduces the chance of developing cardiovascular disease. Within five years, the chances of having a heart attack are 50% to 70% lower for former smokers, compared to current smokers. Beyond getting current smokers to quit, it is equally important to prevent people from starting to smoke. For example, people who begin smoking before their eighteenth birthday have more trouble quitting. Hypertension. Uncontrolled high blood pressure (>140/90) is a leading risk factor for stroke, the third leading cause of death in Georgia. The percentage of Georgians who reported having been told they had high blood pressure has remained in the 19%-24% range since the 1980s, although the percentage of those who have been treated successfully is not known. Some people can control their blood pressure by losing weight and engaging in regular physical activity. tion of Georgians who have already had a heart attack or stroke is growing. These CVD survivors are at particularly high risk for dying from CVD, and thus contribute to a growing number of CVD deaths. The practical implications of these findings are clear. Because heart attacks and strokes result from a process of arterial blockage that begins at an early age, a greater effort should be made to reduce the prevalence of CVD risk factors among all Georgians. These risk factors are primarily behavioral: quitting smoking, changing diet, engaging in regular physical activity, controlling hypertension, and reducing blood cholesterol. Sustained behavioral changes are often difficult to makeeven for highly motivated individuals. Therefore, it is crucial to engage entire communities in a process to change societal norms of behavior. Community leaders and parents can act as role models; and local environments, such as schools and workplaces, can be changed to facilitate healthy behaviors. Much of CVD in Georgia is preventable. If we focus our attention on realistic ways of reducing risk, we can renew the decline in CVD mortality rates that Georgia has experienced over most of the past two decades. Georgians can work together to reduce the number of individuals in our state with unhealthy CVD behaviors. Technical Notes Conclusions Cardiovascular disease is defined by the International Classification The steady decline in CVD mortality rates over the past two decades of Diseases, Ninth Revision, codes 390-448. The source of the numis slowing. A particularly disturbing facet of this change is seen ber of deaths was Vital Records. The source of the population estiamong elderly Georgians for whom the rate is actually increasing. It mates was the US Bureau of the Census. Cardiovascular disease is not possible to explain conclusively the change in CVD mortality mortality rates were age-adjusted using the direct method; the US rates, but two factors are probably important contributing causes. 1990 population was used as the standard. The source of the CVD First, there is either a leveling off or an increase in the percentage of risk factors was the Georgia Behavioral Risk Factor Surveillance SysGeorgians with unhealthy behaviors that put them at risk for a heart tem (BRFSS). attack or stroke. Second, due to advances in medical care, the popula- - 2 - Figure 3. Percent of Georgians Reporting Current Smoking, 1984-1996 Percent 35 30 25 20 15 10 5 0 % Smokers 84 85 86 87 88 89 90 91 92 93 94 95 96 31.2 29.6 27.7 25.9 25.9 23.7 24.3 21.9 19.4 23.9 22.8 20.5 20.3 Year Source: Georgia Division of Public Health. (MMWR) Morbidity & Mortality Weekly Reports You May Have Missed December 11, 1998 / Vol. 47 / No. 48 Lead Poisoning Associated with Imported Candy and Powdered Food Coloring -- California and Michigan. Progress Toward Global Measles Control and Regional Elimination, 1990-1997 Notice to Readers: Alcohol Involvement in Fatal Motor-Vehicle Crashes -- United States, 1996-1997. Notice to Readers: Federal Register Notice on the Draft Guidelines for HIV Case Surveillance, Including Monitoring HIV Infection and AIDS. December 4, 1998 /Vol. 47 / No. 47 Impact of the Sequential IPV/OPV Schedule on Vaccination Coverage Levels -- United Sates, 1997 A 1999 edition of the Georgia State of the Heart Report will be available in early 1999. This report and the 1998 Georgia State of the Heart Report are available from the Georgia Division of Public Health (404-657-2588) and from the American Heart Association, Southeast Affiliate (770-952-1316). Fatal Car Trunk Entrapment Involving Children -- United States, 1987-1998. Forecasted State-Specific Estimates of Self-Reported Asthma Prevalence -- United States, 1998. November 27, 1998 / Vol. 47 / No. 46 References 1998 Georgia State of the Heart Report. Georgia Department of Human Resources, Division of Public Health, and The American Heart Association, Southeast Affiliate, 1998. Pub No. DPH97.71HW. This article was contributed by Trish Fox, M.P.H., Alex Rowe, M.D., M.P.H., and Ken Powell, M.D., M.P.H. Progress Toward Eliminating Haemophilus influenzae Type b Disease Among Infants and Children -- United States, 1987-1997 Coronary Heart Disease Mortality Trends Among Whites and Blacks, Appalachia and United States, 1980-1993 November 20, 1998 / Vol. 47 / No. 45 Risks for HIV Infection Among Persons Residing in Rural Areas and Small Cities -- Selected Sites, Southern United States, 1995-1996 Update: Influenza Activity -- United States, 1998-1999 Season Laboratory-Based Surveillance for Rotavirus -- United States, July 1997-June 1998 November 13, 1998 / Vol. 47 / No.44 African Tick-Bite Fever Among International Travelers -- Oregon, 1998 Vaccination Coverage by Race/Ethnicity and Poverty Level Among Children aged 19-35 Months -- United States, 1997 Notice to Readers: Epi Info 2000: A Course for Practitioners and Teachers of Epidemiologic Computing November 6, 1998 / Vol. 47 / No.43 The "Father" of Modern Epidemiology Dr. John Snow (1813-1858) Dr. John Snow is renowned worldwide for leadership in two medical disciplines. He was the first physician to practice full-time as an anesthetist, and actually delivered several of Queen Victoria's babies using chloroform. He is also recognized for using modern epidemiologic methods to interrupt the 1854 cholera epidemic in London. Dr. Snow mapped deaths from cholera and showed that the majority occurred within 250 yards of a water pump located at the intersection of Cambridge and Broad Streets. Suspecting the Broad Street pump as the source of disease, Dr. Snow had the water pump handle removed, thus ending the epidemic. - 3 - State-Specific Prevalence Among Adults of Current Cigarette Smoking and Smokeless Tobacco Use Risk Factors for Short Interpregnancy Interval -- Utah, June 1996June 1997 Notice to Readers: FDA Approval of a Fourth Acellular Pertussis Vaccine for Use Among Infants and Young Children The Morbidity and Mortality Weekly Report (MMWR) series is produced by the Centers for Disease Control and Prevention (CDC). Publications are available on the World-Wide Web at http://www.cdc.gov or by calling 202.512.1800 for paper copy. The Georgia Epidemiology Report Epidemiology and Prevention Branch Two Peachtree St., NW Atlanta, GA 30303-3186 December 1998 Volume 14 Number 12 Reported Cases of Selected Notifiable Diseases in Georgia Profile* for September 1998 Selected Notifiable Diseases Campylobacteriosis Chlamydia genital infection 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 September 1998 1998 64 2335 20 8 161 1875 3 72 0 0 0 4 0 2 0 265 77 9 9 47 41 0 40 Previous 3 Months Total Ending in September 1996 1997 1998 260 283 242 3646 3513 5584 44 41 53 21 12 33 306 311 412 5264 4232 5558 6 7 11 126 220 187 33 92 1 0 0 5 0 5 1 22 24 16 4 0 0 8 6 9 0 0 0 523 504 823 345 299 323 57 39 17 134 98 41 351 261 158 252 299 165 3 6 2 170 156 144 Previous 12 Months Total Ending in September 1996 1997 1998 844 694 806 12872 15412 21512 101 68 119 43 43 71 735 834 1178 21839 18479 19766 43 44 51 322 645 742 54 186 180 5 2 12 1 6 8 162 113 97 10 12 2 32 24 27 0 0 0 1542 1413 1709 823 1195 1430 227 168 114 542 412 225 1373 1201 818 1031 1316 822 44 26 11 756 731 608 * 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 Latest 12 Months: 12/97 to 11/98 Five Years Ago: 12/92 to 11/93 Cumulative: 7/81 to 11/98 Total Cases Reported * 1326 1900 19851 AIDS Profile Update Percent Female Risk Group Distribution (%) MSM IDU MSM&IDU HS Blood Unknown 18.3 39.2 17.6 4.9 13.3 0.8 24.3 15.2 45.7 22.5 6.0 13.1 1.5 11.3 15.2 50.9 19.3 5.9 12.1 1.9 10.0 Race Distribution (%) White Black Other 24.5 72.8 2.7 33.7 64.5 1.8 38.4 59.5 2.1 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-