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-