June 1998 volume 14 number 5 Division of Public Health http://www.ph.dhr.state.ga.us Director Kathleen E. Toomey, MD, MPH 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 Summary of the 1998 Georgia Stroke Report Introduction Epidemiology and Prevention Branch State Epidemiologist Acting Director Kathleen E. Toomey, MD, MPH Epidemiology Section Chief Paul A. Blake, MD, MPH Public Health Advisor Mel Ralston Notifiable Diseases Jeffrey D. Berschling, MPH, Katherine Gibbs McCombs, MPH, Carol Hoban, MS, MPH, Jane E. Koehler, DVM, MPH, Laura Gilbert, MPH Amanda Reichert, RN Chronic Disease Ken Powell, MD,MPH- Program Manager, , Patricia M. Fox, MPH, Rana Bayakly, MPH, Mary P. Mathis, PhD, MPH, Alexander K. Rowe, MD, MPH Tuberculosis Rose Marie Sales, MD, MPH- Program Manager Naomi Bock, MD, MS, Beverly DeVoe, MS HIV/AIDS/Sexually Transmitted Diseases John F. Beltrami, MD, MPH- Program Manager Andrew Margolis, MPH, Lyle McCormick, MPH Ann Buckley, MPH, Amy Hephner, MPH, Laura Axelson, MPH Perinatal Epidemiology James W. Buehler, MD - Program Manager Leslie E. Lipscomb, MPH, Cheryl Silberman, PhD, MPH Hui Zhang, MD, MPH, Mohamed Qayad, MD, MPH Preventive Medicine Residents Mark E. Anderson, MD, MPH & Anthony Fiore, MD, MPH EIS Officers Julia Samuelson, RN, MPH, & Keoki Williams, MD Graphics Dept. Jimmy Clanton Jr. & Christopher Devoe Georgia Epidemiology Report Editorial Board Editorial Executive Committee Andrew Margolis, MPH - Editor Paul A. Blake, MD, MPH Jane E. Koehler, DVM, MPH Jeffrey D. Berschling, MPH Kathleen E. Toomey, MD, MPH Angela Alexander - Mailing List Christopher Devoe - Graphics Stroke is the third leading cause of death in Georgia, accounting for more than 4,200 deaths in 1996. Stroke is also a major cause of hospitalization and disability. In Georgia, there were over 21,000 hospitalizations for stroke in 1996. Nationally, stroke is the leading cause of serious, long-term disability. This report describes the burden of stroke in Georgia. Its purpose is to present a brief overview of stroke death rates in the past two decades and to report the approximate cost of stroke for 1996 in terms of hospitalizations. Methods Stroke was defined by the International Classification of Diseases, Ninth Revision, codes 430-438. The source of the number of deaths was the Georgia Division of Public Health. The source of stroke hospitalizations was the 1996 Georgia Hospital Inpatient Data System. The source of the population estimates was the US Bureau of the Census. Stroke death rates were age-adjusted using the direct method; the US 1990 population was used as the standard. Trends in Stroke Mortality in Georgia Throughout the 1980s and early 1990s, death rates from stroke declined dramatically in both Georgia and the US. In 1995, Georgias rate was 19 percent higher than the US rate. From 1981 to 1993, the average annual decrease of the Georgia stroke death rate was 3.9 percent per year (Figure 1). This decline is presumably due to improvements in medical care and healthier lifestyles. In the early 1990s, how- ever, the trend began to re- Fig. 1 - Stroke Death Rates in Georgia and the US, 1981-1996 verse direction. From 1993 to Deaths per 100,000 population 1996, the Georgia rate actu- 140 ally increased by an average of 0.7 percent per year. This dis- 120 turbing trend occurred in all 100 sex and race groups (Figure 2). This figure also reveals strik- 80 Georgia's death rate decreased by 3.9% per year Georgia Georgia's death rate increased by 0.7% per year ing differences between black 60 and white stroke death rates. United States In 1996, the risk of dying 40 from stroke was 37 percent 20 higher for black females than white females, and 60 percent higher for black males than 0 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 Year white males. Furthermore, Source: GA DPH. ICD9 codes f or stroke are 430-438. Rates are age-adjusted to the 1990 US population. these differences have not changed much over the past two decades. The reasons for these differences are not well understood, but may be a result of a higher percentage of blacks with high blood pressure, or factors related to poverty, such as poor diet or decreased access to health care. Males have a higher risk than females of dying from a stroke. However, in terms of absolute numbers, there are actually 50 percent more deaths due to stroke among females than males. In 1996, there were 1,704 stroke deaths among males, but 2,548 stroke deaths among females. This difference exists because women live to older ages when strokes are more common. Females also die in greater numbers than men each year from other cardiovascular diseases, such as heart disease. However, stroke is not just a disease of old age: One in five Georgians who died from stroke in 1996 was younger than 65 years of age. 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 Hospitalizations for Stroke in Georgia Conclusions Each year there are more nonfatal than fatal strokes. Stroke survi- After years of steady decline, the death rate for stroke is on the vors are often left with permanent, severe disabilities. We can estimate rise. Black Georgians should be especially concerned because their the burden of non-fatal strokes in Georgia by examining hospital ad- risk of dying from stroke is particularly high. All Georgians should missions. In 1996, there were 21,601 hospitalizations1 for stroke be concerned by the discrepancy between the death rates of stroke among Georgia residents, or a hospitalization for stroke every 24 min- among blacks and whites. It is not possible to explain conclusively utes. Of these stroke victims, 92.4 percent were discharged alive from reasons for the change in stroke death rates, but two factors are prob- hospitals. However, after excluding those who were institutionalized ably important contributing causes. First there is either a leveling off before their stroke, more than one-third of stroke survivors were left or an increase in the percentage of Georgians with unhealthy behav- unable to care for themselves without assistance. Most of these people iors that put them at risk for a stroke. Second, owing to advances in required care in a skilled nursing facility or other institution. medical care, the population of Georgians who have already had a Hospitalizations for stroke consume considerable health and finan- previous heart attack or stroke is growing. These cardiovascular dis- cial resources. In 1996, Georgia residents spent 137,931 days in the ease survivors are at particularly high risk for dying from stroke, and hospital because of stroke, and the charges for these admissions totaled thus contribute to the growing number of stroke deaths. almost $265 million. The average charge for a hospital stay was $12,264. Fig. 2 - Stroke Death Rates in Georgia by Sex and Race, 1981-96 The practical implications of these Reducing the Risk of Stroke Deaths per 100,000 population 200 150 Black males From 1981 to 1993, From 1993 to 1996, Sex-race group death rate changed by death rate changed by Black males Black females White males White females - 4.1% per year - 3.9% per year - 4.1% per year - 3.6% per year + 2.0% per year + 0.5% per year + 1.4% per year + 0.2% per year findings are clear. Because most strokes result from a process of arterial blockage that begins at an early age, a greater effort should be made to reduce the preva- The increase in stroke death rates should alert Georgians to the importance of modifying their personal lifestyles to re- 100 Black females White males lence of risk factors among all Georgians. Reducing stroke risk factors involves not smoking, eating a healthy duce the rate of stroke. The following risk White females diet, engaging in regular physical activ- factors can be modified to reduce the risk 50 of stroke: Death rates decreasing Death rates increasing ity, controlling high blood pressure, and reducing blood cholesterol. Hypertension is a leading risk factor for stroke. The National Institutes of Health have updated their guidelines for diagnosing and treating hypertension. 0 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 Year Source: GA DPH. ICD9 codes f or stroke are 430-438. Rates are age-adjusted to the 1990 US population. Sustained behavioral changes are often difficult to make, even for highly motivated individuals. Therefore, it is crucial to engage entire communities in According to these new guidelines, blood pressure should be main- a process to encourage policy and environmental changes that make it tained at less than 130/85. The following lifestyle modifications can easier for people to change their behavior. Physicians, community help keep blood pressure under control and even prevent hypertension leaders and parents can act as role models. Additionally, local envi- from developing in the first place: 1) Stay active; 2) Eat less fat; 3) Use ronments, such as schools and workplaces, can be changed to facilitate less salt; and 4) Dont drink too much alcohol. healthy behaviors. Tobacco Use. Tobacco is a major preventable cause of stroke. The message is simple: if you use tobacco, stop; if you dont use tobacco, dont start. Diabetes. Having diabetes can seriously increase the risk of stroke and heart disease. Diabetics can prevent or delay heart and blood vessel disease by controlling their weight, cholesterol, and blood pressure. Elevated cholesterol. A person with a normal cholesterol level (less than 200 mg/dl), should get their level checked every five years. Eating foods that contain no cholesterol, such as fruits and vegetables, and staying physically active are two easy ways to keep cholesterol low. 1In 1996, data were reported for 75 percent of acute care hospital beds in Georgia. Thus, these statistics represent only about 75 percent of the total number and cost of hospitalizations for stroke. Hospitals with acute care beds which did not report data in 1996 were probably similar to those which did. Much of the death and disability from stroke in Georgia is preventable. If we focus attention on realistic ways of reducing risk, we can renew the decline in stroke death rates that Georgia has experienced in much of the past two decades. Georgians can work together to reduce the number of individuals who suffer and die from strokes. For More Information The complete 1998 Georgia Stroke Report is available from the Georgia Division of Public Health (404-657-2588) and the American Heart Association, Southeast Affiliate (770-952-1316). The report can also be accessed via the Internet at www.ph.dhr.state.ga.us. Contributors This article was contributed by Tim Dignam, MPH and Alex Rowe, MD, MPH, Chronic Disease and Injury Epidemiology Unit, Epidemiology and Prevention Branch, Division of Public Health, Georgia Department of Human Resources. Outbreak of Gastrointestinal Illness at Rome Middle School Background By Preeti Pathela, MPH & Debbie Abercrombie, RN Notifiable Disease Unit, Epidemiology and Prevention Branch Georgia Division of Public Health, DHR. On Wednesday, April 29, 1998, a Communicable Disease Specialist, reported to the Georgia Epidemiology and Prevention Branch (EPB) that approximately 40 students at Rome Middle School in Rome, Georgia, had been ill with symptoms of nausea, headache, malaise, vomiting, and diarrhea. The ill persons were part of a group of 64 students and 27 adult chaperones that had traveled to Washington, D.C., on a school trip on April 24-26. Most reported illnesses occurred late Sunday, April 26, with others occurring in the subsequent few days. The symptoms and suspected incubation period were suggestive of illness caused by Norwalk virus. Suspect meals consumed by the group included dinner on Saturday at a dinner theater in Virginia, and breakfast on Sunday at the hotel. - 2 - Methods Discussion On April 30, investigators interviewed approximately 30 students at Rome Middle School who had experienced illness about their clinical symptoms as well as food and drinks consumed at the dinner theater. The students were asked to provide stool samples for bacterial and viral testing in order to determine the potential etiologic agent. Laboratory testing for bacterial pathogens was arranged with the Georgia Public Health Laboratory in Atlanta. Laboratory testing for Norwalk virus was arranged with the Division of Viral Diseases of the Centers for Disease Control and Prevention. The laboratory investigation showed that the outbreak was caused by a Norwalk-like virus. The symptoms were consistent with this etiologic agent. The incubation period and the occurrence of similar illnesses in the 5 other groups from other states incriminated the evening meal served at the Dinner Theater on April 25. The reports of onset of illness during the evening of April 25, within a few hours after the meal, probably reflect errors in completion of questionnaires or poor recall by the children. The specific food that caused the outbreak was probably the salad. It could have been contaminated by a food handler in the restaurant, Results or one of the ingredients may have been contaminated before it reached the restaurant. Because of the El Nino-associated flooding in Sixty-four children and 27 adults participated in the school trip to Washington, D.C. Of these, 62 (97%) students and 16 (59%) adults were interviewed. All 78 ate dinner at the Dinner Theater on the evening of April 25. Fifty-one (65%) reported having had at least one symptom after the event. Illnesses were reported to have begun on California, lettuce was both difficult to obtain and expensive at that time. It is possible that the lettuce came from an unusual source, or that it was flooded and contaminated in the field. Investigation of the restaurant has not found any ill food handlers who helped prepare the suspect meal. April 25, with the largest numbers occurring during the evening of April 26 and on April 27 (Table 1). The symptoms were headache (88%), nausea (63%), vomiting (55%), cramps (51%), diarrhea (41%), There are several key elements to consider when conducting a foodborne outbreak investigation. fever (41%), and chills (37%). A case was defined as an illness in a person 12 to 14 years of age who experienced vomiting (since it is a memorable and unmistakable symptom) OR who experienced at least two of the following 3 symptoms: nausea, headache, and diarrhea (>3 stools in 24 hours). Thirty- Questionnaire - Before constructing a questionnaire, general hypothesis-generating interviews should be conducted. These will give enough information about what unique questions need to be put on the questionnaire in addition to demographics, illness onset dates and times, symptom complex, food/drink consumption, treatment, etc. Ideally, questions should two of these 51 persons met the case definition. The median incubation period for symptoms among the cases was 28 hours and 30 minutes, and the median duration of illness was about 56 hours. be asked and forms should be filled out by members of the investigating team to maintain uniformity and minimize misinterpretation of the questions. Interviews need to be conducted with both ill and well participants, in order to have a comparison group and thus effectively implicate a source of illness. Table 1. Date and Time of Onset of Illness in Participants of the Specimen collection - A specimen or culture is valuable if it is collected soon in the investigation, kept in the proper container and at the Rome Middle School Washington D.C. Trip. April 24-May 1, 1998. right temperature, and transported appropriately. The Georgia Public Laboratory should be consulted. The laboratory can be reached at 404/327-7900 Case definition - Before data analysis, it is important to define a case Number of Cases 20 CASES ANY SYMPTOM of illness, as all people with symptoms may not have illnesses relating to the outbreak. For instance, some people report symptoms that are too subjective, or occur too early or too late in the outbreak, and it must be decided if they are truly cases or not. In this investigation, an age restriction was 15 included in the definition, as students had different food exposures than the adults. Rapid investigation - Interview affected persons while events are 10 fresh and collect laboratory specimens quickly while they still harbor the pathogen. Accurate epidemiologic data can effectively guide an environmen- 5 tal investigation. If all phases of the investigation are successful, a source of disease or vehicle of transmission will be identified, and the mission of public health (to interrupt disease transmission and/or prevent similar outbreaks in 0 the future) will be accomplished. Investigators in the Epidemiology and Prevention Branch of the 4/25 AM 4/25 PM 4/26 AM 4/26 PM 4/27 AM 4/27 PM 4/28 AM 4/28 PM 4/29 AM 4/29 PM 4/30 AM 4/30 PM Georgia Division of Public Health are always willing to assist district and Date and Time local health authorities in investigations. The EPB is available 24 hours a day to provide consultation by phone and fax regarding epidemiologic and labo- ratory aspects of an investigation; the contact number is 404/657-2588. The association of illness with foods eaten was examined for the 32 persons with illnesses which met the case definition (cases), and the 17 persons 12-14 years of age who did not have any symptoms (con- trols) Three items were significantly associated with illness: salad (odds ratio [OR]=10.50, p=0.009), spaghetti and meatballs (OR=7.15, p=0.007), and ice in drinks (OR=10.50, p=0.009). However, both the EPIDEMIOLOGY 101 lettuce and the ice could account for 30 of 32 cases, while the spaghetti could account for only 22 of 32. To further weaken the spaghetti as an implicated vehicle, it was discovered that for the four adults who met the case definition (except for the age limitation), all 4 ate salad, 3 Public Health Surveillance is the on-going, systematic collection, management, analysis, interpretation, and dissemination of data for the purpose of evaluating a public health concern. There are two types of public health surveillance. consumed ice, and none ate spaghetti. In the laboratory investigation, no Salmonella, Shigella, Campylobacter, E. coli O157:H7, or Aeromonas bacteria were detected Passive Surveillance: (provider/lab initiated) The form of data collection where health care providers and laboratories send reports to a health department based upon a known set of rules and regulations. in the 10 stools cultured for bacterial pathogens. On May 6, CDC reported that electron microscopic examination of 6 stool specimens had detected small round structured viruses (SRSV, or Norwalk-like viruses) in 5 of 6 stool samples tested, and the sixth stool had equivocal Active Surveillance: (health department initiated) The form of data collection where health departments solicit reports from providers and laboratories that would probably otherwise not have been reported. Active surveillance is usually limited to specific diseases over a defined time period. results. - 3 - The Georgia Epidemiology Report Epidemiology and Prevention Branch Two Peachtree St., NW Atlanta, GA 30303-3186 June 1998 Volume 14 Number 5 Reported Cases of Selected Notifiable Diseases in Georgia Profile* for March 1998 Selected Notifiable Diseases Total Reported for March 1998 1998 Previous 3 Months Total Ending in March 1996 1997 1998 Previous 12 Months Total Ending in March 1996 1997 1998 Campylobacteriosis 28 161 113 116 1019 745 769 Chlamydia genital infection 2411 3257 3284 6120 12113 13631 19029 Cryptosporidiosis 7 13 8 18 118 88 84 E. coli 0157:H7 0 4 14 2 31 49 34 Giardiasis 69 161 214 203 614 873 905 Gonorrhea 1856 5377 4342 4969 21954 18907 19164 Haemophilus influenzae (invasive) 1 21 18 18 40 49 42 Hepatitis A (acute) 58 55 112 148 101 471 801 Hepatitis B (acute) 23 8 31 71 60 84 266 Legionellosis 0 1 0 0 10 2 6 Lyme Disease 0 0 1 2 9 2 10 Meningococcal Disease (invasive) 8 58 36 43 129 125 115 Mumps 0 1 5 0 9 13 6 Pertussis 1 6 8 2 30 37 12 Rubella 0 0 0 0 0 0 0 Salmonellosis 57 261 244 201 1708 1452 1340 Shigellosis 73 132 254 219 1083 1247 1171 Syphilis - Primary 12 55 43 33 287 187 149 Syphilis - Secondary 18 147 97 55 627 453 316 Syphilis - Early Latent 77 369 330 233 1542 1303 1014 Syphilis - Other 74 277 376 211 1138 1154 1048 Syphilis - Congenital 2 14 8 3 65 28 17 Tuberculosis 44 219 189 132 813 761 638 * 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 Female Risk Group Distribution (%) MSM IDU MSM&IDU HS Blood Unknown Race Distribution (%) White Black Other Latest 12 Months: 06/97 to 05/98 Five Years Ago: 05/92 to 05/93 Cumulative: 7/81 to 05/98 1465 1825 19263 19.2 14.1 15.0 39.8 18.1 3.7 16.0 1.2 21.3 48.5 21.6 6.2 11.8 2.2 9.6 51.1 19.2 5.8 11.9 2.0 10.0 23.5 73.8 2.7 36.1 62.1 1.8 38.9 59.0 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-