Georgia epidemiology report, Vol. 15, no. 5 (May 1999)

May 1999

volume 15 number 5

Division of Public Health
http://health.state.ga.us

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

Director Kathleen E. Toomey, M.D., M.P.H.
Epidemiology and Prevention Branch Acting Director
Kathleen E. Toomey, M.D.,M.P.H.

Stroke in Georgia: Defining the Problem and Finding Solutions
Introduction

Acting State Epidemiologist Paul A. Blake, 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.
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.
Graphics Dept.
Jimmy Clanton Jr.
Georgia Epidemiology Report Editorial Board
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 Jimmy Clanton, Jr. - Graphics

Stroke is the third leading cause of death in Georgia, accounting for 4,276 deaths in 1997 (Figure 1). Stroke is also a major cause of hospitalization and disability. In Georgia, there were nearly 25,000 hospitalizations for stroke in 1997. Nationally, stroke is the leading cause of serious, long-term disability. Despite this burden, the impact of stroke can be reduced by the actions of individuals and policies throughout the state. This report presents a brief overview of stroke death rates in the past two decades, the approximate cost of stroke for 1997 in terms of hospitalizations, and recommendations for reducing the impact of stroke in Georgia.
Methods
Stroke was defined by the International Classification of Diseases, Ninth Revision, codes 430-438. The source of the number of deaths in Georgia was the Georgia Division of Public Health. The source of stroke hospitalizations was the 1997 Georgia Hospital Inpatient Data System. The source of the population estimates was the United States (U.S.) Bureau of the Census. The source of national stroke death rates was the National Center for Health Statistics. Stroke death rates were age-adjusted using the direct method; the U.S. 1990 population was used as the standard.
Trends in Stroke Mortality
Georgias stroke death rate is the sixth highest in the country, and in 1996, Georgias rate was 24 percent higher than the U.S. rate. Throughout the 1980s and early 1990s, death rates from stroke declined dramatically in both Georgia and the U.S. (Figure 2). From 1981 to 1992, the average annual decrease of the Georgia stroke death rate was 4.4 percent per year. This decline is presumably due to improvements in medical care and healthier lifestyles.
In the early 1990s, however, the trend began to reverse direction. From 1992 to 1997, the Georgia rate leveled off and the curve may be increasing. This disturbing trend occurred in all sex and race groups (Figure 3).
Figure 3 also reveals striking differences between black and white stroke death rates. In 1997, the risk for dying from stroke was 32 percent higher for black females than white females and 54 percent higher for black males than white males. Furthermore, 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 for dying from a stroke. However, in terms of absolute numbers, there are actually 53 percent more deaths among females than males. In 1997, there were 1,688 deaths among males, but 2,588 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 1997 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

Recognition of Stroke Warning Signs

Each year there are more nonfatal than fatal strokes. Stroke survivors are often left with permanent, severe disabilities. We can estimate the burden of non-fatal strokes in Georgia by examining hospital admissions. In 1997, there were 24,553 hospitalizations for stroke among Georgia residents, or on average, a hospitalization for stroke every 21 minutes.
Hospitalizations for stroke consume considerable health and financial resources. In 1997, Georgians spent 153,656 days in the hospital because of stroke, and charges for these admissions totaled more than $300 million. The average charge for a hospital stay was $12,253.

5) Support a statewide multi-media public awareness campaign to educate Georgians about stroke risk factors, stroke warning signs, and the need to call 911 when a stroke is suspected. Such a campaign should include direct mailings, television and radio announcements, and the creation of a stroke information hotline. 6) Officially recognize that stroke is a treatable disease that, like a heart attack, should be considered a medical emergency; and recognize May as Stroke Awareness Month in Georgia.
Transport, Treatment, and Rehabilitation of Stroke Victims

Reducing the Risk of Stroke
The increase in stroke death rates should alert Georgians to the importance of modifying their personal lifestyles to reduce the rate of stroke.
The following risk factors can be modified to reduce the risk of stroke:
Hypertension is a leading risk factor for stroke. The National Institutes of Health have updated their guidelines for diagnosing and treating hypertension. According to these new guidelines, blood pressure should be maintained at less than 130/85. The following lifestyle modifications can help keep blood pressure under control and even prevent hypertension from developing in the first place: 1) Stay active; 2) Eat less fat; 3) Use less salt; and 4) Dont drink too much alcohol.
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.
Policies for Reducing the Impact of Stroke in Georgia
In March 1999, a state legislative committee chaired by Representative Barbara Mobley published The Final Report of the Joint Study Committee on the Impact of Stroke on Georgias Citizens. In this report, a comprehensive policy agenda is proposed for reducing the impact of stroke in Georgia. The report emphasizes: 1) Preventing strokes by reducing risk factors for stroke and heart disease; 2) Improving the ability of Georgians to recognize stroke warning signs and call 911 immediately when a stroke is suspected; 3) Improving the transport, treatment, and rehabilitation of stroke victims; and 4) Systematically evaluating the preceding three components to identify areas of strength and weakness, and to plan improvements. The report concluded with the following 12 recommendations.
Prevention
1) Support the primary prevention efforts of the Georgia Division of Public Health. Primary prevention for stroke includes lowering rates of smoking and obesity and improving levels of physical activity. 2) Authorize an expert study committee to determine which policies and environmental features could be changed to make it easier for Georgians to be physically active and to eat healthy diets. 3) Support the use of all tobacco settlement funds for health. 4) Create a policy requiring annual renewal of the license to sell tobacco products and collect a fee for the license renewal to pay for the enforcement of laws prohibiting tobacco sales to minors.

7) Recommend that local Emergency Medical Services (EMS) directors amend their protocols to designate stroke calls as priority one. Such a recommendation will facilitate the swift transport of patients to hospitals where appropriate treatment can be delivered and underscore the importance of treating stroke as a medical emergency. 8) Authorize an expert committee to develop acute stroke treatment guidelines for Georgia. 9) Support an educational program to train health providers (emergency medical technicians, emergency department physicians and nurses, and others) on the appropriate care of patients having an acute stroke. 10) Acknowledge the leadership and work of the Collaborative Quality Improvement Partnership (a partnership of the Georgia Hospital Association, Georgia Medical Care Foundation, and the Medical Association of Georgia) and encourage collaboration with other organizations working to reduce the impact of stroke in Georgia, such as EMS. One potentially useful product of such a collaboration is a directory of hospitals capable of treating stroke with t-PA (tissue plasminogen activator) for local EMS directors and ambulance dispatchers. 11) Authorize an expert committee to develop guidelines for the rehabilitation of stroke victims in Georgia.
Evaluation
12) Create a Georgia Center for Public Health Partnership on Stroke. The Center should help coordinate the efforts of other organizations throughout the state working to reduce the impact of stroke in Georgia and should be a resource for current scientific knowledge on stroke prevention, treatment, and rehabilitation. The purpose of the Center should be to evaluate the three preceding components of stroke reduction in Georgia, identify strengths and weaknesses, and make recommendations for improvements.
Conclusions
After years of steady decline, the death rate for stroke has leveled off and may be increasing. Black Georgians should be especially concerned because their risk for dying from stroke is particularly high. All Georgians should be concerned by the disparity between the death rates of stroke among blacks and whites. It is not possible to explain conclusively reasons for the change in stroke death 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 a stroke. Second, owing to advances in medical care, the population of Georgians who have already had a previous heart attack or stroke is growing. These cardiovascular disease survivors are at particularly high risk for dying from stroke, and thus contribute to a growing number of stroke deaths.
The practical implications of these 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 prevalence of risk factors among all Georgians. Reducing stroke risk factors involves not smoking, eating a healthy diet, engaging in regular physical

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activity, controlling high blood pressure, and reducing blood cholesterol.

Fig 3.

Age-adjusted Stroke Death Rates in Georgia by race-sex groups, 1981 - 1997

Sustained behavioral changes are often difficult to make, even for highly motivated individuals. Therefore, it is crucial to engage entire communities in a process to encourage policy and environmental changes that make it easier for people to change their behavior. Physicians, community leaders, and parents can act as role models. Additionally, local environments, such as schools and workplaces, can be changed to facilitate healthy behaviors.
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 latest comprehensive report on stroke in Georgia is the 1998 Georgia Stroke Report. This 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.health.state.ga.us/manuals/stroke/. The final report of the Joint Study Committee on the Impact of Stroke on Georgias Citizens can be obtained from Representative Mobleys legislative office (404-656-0126).
Contributor
This article was contributed by Alex Rowe, M.D., M.P.H., Chronic Disease, Injury, and Environmental Epidemiology Unit, Epidemiology and Prevention Branch, Division of Public Health, Georgia Department of Human Resources.
Fig 1. Leading Causes of Death in Georgia, 1997

Deaths per 100,000 population 200

Black males
150

Black females

100

White males

White females

50

Death rates decreasing

Death rates leveling off

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

<HDU

Notice to Readers: Changes in Hepatitis
Serology Panel Testing
During the past year, many State and District public health staff have noticed that reference laboratories no longer include IgM tests for hepatitis A and B as part of their hepatitis panel. Instead, total antibody (a combination of IgM and/or IgG) is being tested. As a result, diagnosis of acute hepatitis A or B is delayed until a second test specifically for IgM is ordered and results received. Also, since many clinicians are unaware of this change, a positive antibody test for hepatitis A is sometimes being interpreted as evidence of acute hepatitis A in a jaundiced person, when the positive total antibody may, in fact, only indicate presence of IgG from a distant infection with hepatitis A.

Heart/Other CVD Cancer Stroke
Unintentional injuries Chronic Lung Disease Pneumonia/Influenzae
Suicide/Homicide

All deaths = 59,232 Stroke deaths = 4,276

This change has also had a profound effect on public health follow-up of acute hepatitis cases. By the time the additional confirmatory IgM tests results have been ordered and received, the window for preventive treatment of hepatitis A contacts has passed, resulting in additional, preventable cases. Further, if the confirmatory IgM test is not ordered, the total IgG result will not meet national case definitions for reporting hepatitis and cases will be grossly underestimated in state and national surveillance systems.

Diabetes

AIDS

Other

0

5000

10000

CVD = Cardiovascular disease AIDS = Acquired immunodeficiency syndrome

Iirsqrhu

15000

20000

Fig 2.

Age-adjusted Stroke Death Rates in Georgia and the United States, 1981 - 1997

Deaths per 100,000 population 140

120

Georgia's death rate

Georgia's death

decreased by 4.4% per year

rate increased by

100

0.4% per year

80

Georgia

60
United States
40

20

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

The Centers for Disease Control and Prevention (CDC) has investigated the situation, and concluded that this change resulted from modifications to Current Procedural Terminal (CPT) codes. CPT codes are standardized codes developed and maintained by the CPT Board of the American Medical Association for reporting medical services. The Health Care Financing Administration requires use of these codes when services are reported for Medicare and Medicaid reimbursement. Effective January 1, 1998, the CPT Board changed the hepatitis serology panel to exclude the tests for hepatitis A IgM and IgM anti-hepatitis B core.
Upon being notified by the CDC of the clinical and public health difficulties created by the change, the CPT Board agreed to revise the hepatitis serology panel to include both of the IgM tests that were deleted. However, these modification will not be implemented until the next CPT code manual is issued on January 1, 2000. Until then clinicians attempting to diagnose patients with signs and symptoms of acute viral hepatitis should continue to order the additional IgM tests at the time the hepatitis serology panel is ordered. If you have further questions about interpreting tests for acute hepatitis, please contact the Epidemiology and Prevention Branch at (404) 657-2588.

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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

May 1999

Volume 15 Number 5

Reported Cases of Selected Notifiable Diseases in Georgia Profile* for February 1999

Selected Notifiable Diseases Campylobacteriosis

Total Reported for February 1999
1999 65

Previous 3 Months Total

Ending in February

1997

1998

1999

117

154

168

Previous 12 Months Total

Ending in February

1997

1998

1999

778

779

797

Chlamydia genital infection

2051

2891

5495

6101

13415

17793

24325

Cryptosporidiosis

17

11

22

40

92

85

166

E. coli O157:H7

0

14

4

5

50

35

81

Giardiasis

92

208

215

275

878

903

1276

Gonorrhea

1573

4229

4926

4726

18960

18736

19837

Haemophilus influenzae (invasive)

8

20

22

24

53

46

66

Hepatitis A (acute)

34

99

174

141

453

810

855

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

14

23

70

44

77

255

186

0

0

2

0

3

6

8

0

1

2

0

2

10

3

10

27

42

19

133

122

80

0

4

1

0

11

8

2

2

9

4

5

38

13

38

0

0

0

0

0

0

0

77

304

259

342

1439

1362

1897

18

306

291

102

1208

1181

1046

9

50

24

28

197

146

116

19

91

51

69

458

340

237

52

306

226

184

1321

1062

747

29

350

213

113

1121

1133

722

2

7

0

6

29

17

15

35

192

142

145

772

669

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: 3/98 - 2/99 Five Years Ago: 3/93 - 2/94 Cumulative: 7/81 - 2/99

Total Cases Reported *

AIDS Profile Update

Percent

Risk Group Distribution (%)

Female

MSM IDU MSM&IDU

HS Blood

Unknown

Race Distribution (%) White Black Other

1301

19.3

38.3

16.1

4.6

13.1

0.8

27.1

23.8 73.7

2.5

1963

15

44.9

22.5

5.5

12.9

1.3

12.9

32.3 65.8

1.9

20189

15.3

50.7

19.2

5.8

12.1

1.9

10.2

38.1 59.8

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

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