Georgia epidemiology report, Vol. 15, no. 2 (Feb. 1999)

February 1999

volume 15 number 02

Division of Public Health
http://www.ph.dhr.state.ga.us Director
Kathleen E. Toomey, M.D., M.P.H.

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 1999 Georgia State of the
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 A. 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 Lyle McCormick, M.P.H., Ann Buckley, M.P.H.

Cardiovascular disease (CVD) is the leading cause of death and serious disability in Georgia. The recently published 1999 Georgia State of the Heart Report1,2 describes the burden of CVD mortality in Georgia, the economic cost of CVD in terms of hospitalizations, and the prevalence of modifiable CVD risk factors. This article summarizes the findings of that report.
Trends in Cardiovascular Disease in Georgia
In 1997, CVD accounted for 23,461 deaths, or 40 percent of all deaths in the state. Mortality rates from CVD have declined in both Georgia and the U.S. over the past 18 years, but Georgias rates have remained approximately 10 percent above the national average during this period. The decline is presumably due to improvements in medical care and to healthier lifestyles. Although the Georgia CVD death rate continues to decline, the rate is leveling off (Figure 1). From 1980-1992, the rate decreased by an average of 2.5 percent per year; in contrast, from 1992-1997, the rate of decline had slowed to only 0.7 percent per year. This disturbing 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.
Another key finding is that premature CVD death (as defined by the percentage of CVD deaths occurring among individuals younger than 65 years of age) is considerably greater among blacks than whites (Table 1). Black men have approximately 60 percent more premature CVD death than white men, and black women have over twice the burden of premature CVD death as white women. The reasons for the racial disparity are not well understood, but may be a result of a higher prevalence of hypertension among blacks, or factors related to poverty, such as poor diet, or decreased access to health care.
Hospitalizations for Cardiovascular Disease

Perinatal Epidemiology
James W. Buehler, M.D. - Program Manager Leslie E. Lipscomb, 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.

In 1997, there were 133,000 hospitalizations for CVD among Georgia residents, or an average of one hospitalization every 4 minutes. These hospitalizations were expensive. Georgia residents spent 666,000 days in the hospital because of CVD, and the charges for these admissions totaled $1.8 billion. Excluding uncomplicated deliveries, CVD accounted for 17 percent of all hospitalizations and 22 percent of all hospital charges. The average charge for a hospital stay was $13,350. In addition to hospital charges, other costs associated with CVD include long-term care and rehabilitation, lost wages of patients, and resources used by family members caring for patients. These other costs are greater than the hospital charges.

Graphics Dept.
Jimmy Clanton Jr. & Christopher Devoe
Georgia Epidemiology Report Editorial Board
Editorial Executive Committee
Carol A. Hoban, M.S., M.P.H. - Editor Kathryn E. Arnold, M.D.
Jeffrey D. Berschling, M.P.H. Paul A. Blake, M.D., M.P.H. Jane E. Koehler, D.V.M., M.P.H. Kathleen E. Toomey, M.D., M.P.H. Angela Alexander - Mailing List Christopher Devoe - Graphics

Cardiovascular Disease Risk Factors
The leveling off of CVD mortality rates may be caused by an increase in modifiable risk factors for myocardial infarction and stroke.
Physical Inactivity and Being Overweight. Many Georgians are overweight and are not physically active on a regular basis (Figure 2). Four out of every five Georgia adults do not engage in regular physical activity (at least 30 minutes per day of moderately intense activity, such as walking at a brisk pace, on 5 or more days a week), and the prevalence appears to be increasing. There has also been a steady increase in the prevalence of overweight3
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

F ig u re 1 - Ag e-Ad ju sted * C ard iovascu lar D isease D eath R ates in G eorg ia, 1980-97
600

Death rate per 100,000 population

500

400

300

200

Death rate dec reased by an average

100

of 2.5% per year

Death rate decreased by an average of 0.7% per year

Year

0 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97

* Age adjusted to the U.S. 1990 population.

Tab le 1 - P rem atu re Card iovascu lar Disease (C VD) Death s in G eorg ia b y R ace an d Sex, 1997

Black m ales W hite m ales Black fem ales W hite fem ales

Percent of CVD deaths before age 65 years
44.1% 27.0% 23.9%
9.7%

adults. Between 1984 and 1997, the percentage of overweight Georgians increased from 37 percent to 58 percent. In spite of the growing knowledge of the ill effects of being overweight, over half of all Georgians are overweight. Losing weight and being physically active on a regular basis can improve blood pressure and cholesterol levels and can decrease the chances of developing diabetes, another risk factor for heart disease.
Current Smoking. The percentage of Georgians who are current smokers declined from 31 percent in 1984 to 19 percent in 1992; since then the rate has been increasing (Figure 3). In 1997, 22 percent of Georgians reported they smoked cigarettes. Lowering smoking rates is a fundamental public health priority for Georgia: Each year smoking causes more deaths from heart attacks than from cancer.
Hypertension and hyperlipidemia. The percentage of Georgia adults who reported having been told they had high blood pressure has remained in the 19 percent to 24 percent range since the 1980s, although the percentage of these who have been treated successfully is not known. Similarly, approximately one in six Georgia adults reported having been told they had high cholesterol.
Conclusions

Much of the 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
CVD is defined by the International Classification of Diseases, Ninth Revision, codes 390-448. The source of the number of deaths was the Georgia Division of Public Health. The source of the population estimates was the U.S. Bureau of the Census. CVD mortality rates were age-adjusted using the direct method; the U.S. 1990 population was used as the standard. The source of the CVD risk factors was the Georgia Behavioral Risk Factor Surveillance Survey.
F igure 2 - P e rc e nt o f G e o rgia ns re po rting no re gula r physical activity and being overweight, 1984-97
Percent 100

The steady decline in CVD mortality rates over the past two decades is slowing. It is not possible to explain conclusively the change in CVD mortality rates, but two factors are probably important contributing causes. First, there is either a leveling off or an increase in the percentage of Georgians with unhealthy behaviors that put them at risk for heart disease or stroke. Second, due to advances in medical care, the population of Georgians who have already had a myocardial infarction 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 most CVD results from arteriosclerosis that begins at an early age, a greater effort should be made to reduce the prevalence of CVD risk factors among all Georgians. These changes are primarily behavioral: quitting smoking, changing diet, engaging in regular physical activity, controlling high blood pressure, 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. In addition, it is particularly important for clinicians to screen their patients for CVD risk factors and then play an active role in helping to control those risk factors that are identified.

80

No regular activity increased by an

average of 1.9% per y ear

60

(black line)

40
Overweight increased by an average of 3.7% per year (gray line)
20

0 Year 84 85 86 87 88 89 90 91 92 93 94 95 96 97
Footnotes
1. Rowe AK, Powell KE, and Hall V. The 1999 Georgia State of the Heart Report. Georgia Department of Human Resources, Division of Public Health, Cardiovascular Health Section, and the American Heart Association, Southeast Affiliate, February 1999. Publication number DPH99.3HW
2. Copies of The 1999 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 (770-9521316).

- 2 -

Figure 3 - Percent of Georgians Reporting Current
Smoking, 1984-1997
Percent 35

30

25

20

15

10

Smoking rate decreased by an

Smoking rate increased

average of 5.7% per year

by an average of 3.6%

5

per year

0 Year 84 85 86 87 88 89 90 91 92 93 94 95 96 97

(MMWR) Morbidity & Mortality Weekly Reports
You May Have Missed January 29, 1999 /Vol. 48 / No. 3 Outbreak of Vibrio parahemolyticus Infection Associated with
Eating Raw Oysters and Clams Harvested from Long Island Sound - Connecticut, New Jersey, and New York, 1998.
HIV Testing - United States, 1996.
Evaluation of Varicella Reporting to the National Notifiable Disease Surveillance System - United States, 1972-1997.
January 22, 1999 / Vol. 48 / No. 2 Update: Influenza Activity - United States, 1998-99 Season.
Final Stages of Poliomyelitis Eradication - Western Pacific Region, 1997-1998.

3. Overweight is defined as a body mass index [BMI] greater than 25.0 kg/m2. Using weight (in kilograms) and height (in meters), BMI equals weight divided by the square of the height. Using weight (in pounds) and height (in inches), BMI equals 705 times weight divided by the square of the height.
Contributors

January 15, 1999 / Vol. 48 / No. 1 False-Positive Laboratory Tests for Cryptosporidium
Involving an Enzyme-Linked Immunosorbent Assay United States, November 1997 - March 1998.
Recommended Childhood Immunization Schedule - United States, 1999.

This article was contributed by Alex Rowe, M.D., M.P.H., and Trish Fox, M.P.H., of the Chronic Disease and Injury Epidemiology Unit, Division of Public Health, Georgia Department of Human Resources.
Overview of Nofifiable Diseases

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.

Table 1: State of Georgia Official List of Notifiable Diseases All Georgia physicians, laboratories and other health care providers are required by law to report patients with the following conditions to their County Public Health Department or District Public Health office. Cases may also be reported to the Notifiable Disease Unit of the Epidemiology and Prevention Branch. Both lab-confirmed and clinical diagnoses are reportable within the time interval specified below. Reporting enables appropriate public health follow-up for your patients, helps identify outbreaks, and provides a better understanding of disease trends in Georgia. For the latest information from the Division of Public Health, visit our web site at www.ph.dhr.state.ga.us. To go directly to the Epidemiology and Prevention Branch page go to:www.ph.dhr.state.ga.us/epi/epistart.htm.

Immediately
any cluster of illnesses animal bites anthrax botulism cholera diphtheria E. coli O157:H7 encephalitis (arboviral)
*Haemophilus influenzae (invasive)
hepatitis A (acute) hantavirus hemolytic uremic syndrome measles (rubeola) meningitis (specify agent)
*meningococcal disease (invasive)
pertussis
*** plague
poliomyelitis rabies (human and animal)
***S. aureus (with vancomycin MIC > 4
mcg/ml) syphilis (congenital & adult)

Within 7 days
AIDS aseptic meningitis brucellosis campylobacteriosis cancer treated as an outpatient chancroid Chlamydia trachomatis (genital infection) cryptosporidiosis
***cyclosporiasis ***ehrlichiosis
giardiasis gonorrhea
^HIV * HBsAg+ pregnant women
hepatitiis B & C (acute)
** newly identified HBsAg + carriers
lead blood level > 10ug/dl legionellosis leptospirosis
* listeriosis (invasive)

lymphogranuloma venereum Lyme disease malaria mumps psittacosis Rocky Mountain spotted fever rubella (including congenital) salmonellosis shigellosis
*streptococcal disease,
Group A or B (invasive)
*Streptococcus pneumoniae,
drug resistant (invasive) tetanus toxic shock syndrome typhoid Vibrio infections
*** yersiniosis

tuberculosis

*** tularemia *** Q fever
*Invasive= bacteria isolated from blood, bone, cerebral spinal fluid (CSF), joint, pericardial fluid, peritoneal fluid, or pleural fluid. ^HIV is reportable without personal identifiers

**Hepatitis B surface antigen positive

Infant mortality is reportable to Vital Records

***Pending approval for implementation 7/99

Mail a completed form in an envelope marked CONFIDENTIAL to your County Public Health Department or District Public Health office OR to the Notifiable Disease Unit, Suite 6-325 (for AIDS, 6-407), 2 Peachtree St. NW, Atlanta,GA 30303-3142.
- 3 -

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

Bulk Rate U.S. Postage
Paid Atlanta, Ga Permit No. 4528

February 1999

Volume 15 Number 02

Reported Cases of Selected Notifiable Diseases in Georgia Profile* for November 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 November 1998
1998 57 2143 15 4 118 1463 8 62 13 0 0 10 1 2 0 130 60 10 16 34 20 2 39

Previous 3 Months Total

Ending in November

1996

1997

1998

196

259

194

3906

3204

6914

41

28

57

8

8

20

299

358

427

4707

3852

4918

13

11

18

126

238

218

27

68

31

0

2

0

0

4

0

24

18

21

4

0

1

10

2

9

0

0

0

442

405

616

497

455

222

46

49

36

134

81

51

353

244

146

281

229

108

10

5

3

178

164

140

Previous 12 Months Total

Ending in November

1996

1997

1998

799

742

771

13901

15189

23728

92

74

137

39

45

79

792

896

1213

20846

18039

20044

48

44

59

388

735

721

60

208

210

4

4

10

1

9

5

156

107

103

9

11

3

36

18

34

0

0

0

1443

1407

1812

1007

1196

1223

199

172

109

516

379

211

1361

1137

755

1033

1265

759

38

24

9

784

719

594

* 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: 2/98 - 1/99 Five Years Ago: 2/93 - 1/94 Cumulative: 7/81 - 1/99

Total Cases Reported *

AIDS Profile Update

Percent

Risk Group Distribution (%)

Female

MSM IDU MSM&IDU

HS Blood

Unknown

Race Distribution (%) White Black Other

1319

18.9

39

16.1

4.8

13.4

0.7

26

23.8 73.8

2.4

2089

15.1

44.6

23

5.9

13.1

1.3

12

32.3

66

1.7

20088

15.3

50.7

19.2

5.8

12.1

1.9

10.2

38.3 59.7

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-