Georgia epidemiology report, Vol. 17, no. 3 (Mar. 2001)

March 2001

volume 17 number 03

Division of Public Health http://health.state.ga.us
Kathleen E. Toomey, M.D., M.P.H. Director
State Health Officer
Epidemiology Branch http://health.state.ga.us/epi
Paul A. Blake, M.D., M.P.H. Director
State Epidemiologist
Mel Ralston Public Health Advisor
Georgia Epidemiology Report Editorial Board
Carol A. Hoban, M.S., M.P.H. - Editor Kathryn E. Arnold, M.D. Paul A. Blake, M.D., M.P.H.
Susan Lance-Parker, D.V.M., Ph.D. Kathleen E. Toomey, M.D., M.P.H.
Angela Alexander - Mailing List Jimmy Clanton, Jr. - Graphic Designer
Georgia Department of Human Resources
Division of Public Health Epidemiology Branch Two Peachtree St., N.W. Atlanta, GA 30303-3186 Phone: (404) 657-2588 Fax: (404) 657-2608
Please send comments to: Gaepinfo@dhr.state.ga.us
The Georgia Epidemiology Report is a publication of the Epidemiology Branch,
Division of Public Health, Georgia Department of Human Resources

Asthma in Georgia, 2000
Introduction Asthma is an obstructive lung disease with episodes of hyperreactivity and bronchoconstriction known as asthma attacks. The attacks usually occur in response to a viral infection such as a cold, or in response to other triggers such as allergens, irritants, and exercise. During an attack, the bronchial muscles tighten and the mucosa swells, causing bronchoconstriction and shortness of breath. Asthma is the third most common cause of hospitalization among children under the age of 15 and accounts for one in six of all pediatric emergency room visits in the U.S. The cause of asthma is not known, but it tends to run in families. In older people asthma may be confused with other chronic lung diseases such as emphysema or chronic bronchitis.
There is no cure for asthma. However, with proper management, asthma can be controlled and asthma attacks may be prevented. During the last 5-10 years several new pharmaceuticals have been released, and the understanding of how to manage asthma has changed dramatically1. The number and severity of asthma attacks can be reduced by avoiding allergens, irritants, and other triggers, and by taking prescribed long-term control medication daily. Examples of long-term control medications include anti-inflammatory medications such as inhaled steroids, and stabilizers such as cromolyns or leukotriene inhibitors. A written action plan outlining recommended control and quick-relief medications and detailing proper self-management steps can reduce the number of severe attacks.
For reasons unknown, asthma became more common during the 1980s and early 1990s. Few numbers are available about the prevalence and burden of asthma in Georgia because asthma is not a reportable disease, is usually not fatal, and even hospitalization data capture only the most severe disease episodes. This report describes the burden of asthma in Georgia. It contains information from three sources: 1) a descriptive cross-sectional random-digit-dial (RDD) telephone survey of asthma among Georgia children conducted in 2000, 2) Georgia hospital discharge data for 1998-1999, and 3) Georgia mortality data for 1982-1998. The survey of asthma among Georgia children was conducted by the American Lung Association of Georgia, Inc. and the Georgia Department of Human Resources, Division of Public Health.
Methods
Prevalence Survey A cross-sectional RDD telephone survey of a representative sample of all households in Georgia with children under 18 years of age was conducted to determine the prevalence and impact of asthma in Georgia children. Parents or other caretakers were questioned about the health of each child living in the home. Asthma was defined as 1) a current diagnosis of asthma, 2) a previous diagnosis of asthma and some indication of medical problems in the past 12 months due to asthma (such as an asthma attack, ER visit, or hospitalization due to asthma), or 3) use of medicine without a diagnosis of asthma and some indication of medical problems in the past 12 months due to asthma (such as an asthma attack, ER visit, or hospitalization due to asthma). If any adult in the household smoked more than 10 cigarettes in the house in the last month, that person was considered an in-house smoker. Analysis of household variables was performed with the SAS software package, and analysis of children's health was performed using the SUDAAN software package.

Hospitalization and Mortality Rates Analyses of hospitalization and mortality data were conducted for

Asthma Hospitalization and Death Rates

Georgians of all ages. Hospital discharge data were from the 1998 and 1999 Georgia Hospital In-patient Discharge Data, and mortality data for 1982-1998 were from the Office of Vital Records, Division of Public Health, Georgia Department of Human Resources. Georgia population estimates were from the U.S. Bureau of the Census estimates as of February, 2000. Asthma death and hospitalization rates were age-adjusted using the direct method and the 2000 U.S. standard population. Asthma was defined as an ICD-9 diagnosis code of 493. The source for national asthma death rates was the Centers for Disease Control and Prevention2.

Most asthma attacks are successfully managed without hospitalization. However, hospitalization is sometimes required. During 1998-1999, there were more than 9,000 hospitalizations per year in Georgia (122 per 100,000 population per year) with asthma as the primary diagnosis. Death from asthma is uncommon. In the 17 years from 1982 through 1998, there were 1,990 deaths from asthma in Georgia, an average of 117 per year (adjusted rate of 2.2 per 100,000 population). Asthma hospitalizations and deaths are highest in the winter.

Mortality rates for Georgia were calculated as three-year rolling averages. A mortality rate for a given year included deaths and populations from the preceding and following years. Analysis of hospitalization and mortality rates was performed with the SAS software package.

The age-adjusted death rate for asthma in Georgia is similar to the rate for the United States2. During the 1980s and early 1990s, death rates in Georgia were slightly higher than U.S. rates and both were rising (Figure 1). Since 1993, the rates for Georgia and the U.S. have been similar and

Results

stable. Hospitalization rates for asthma are about 100 times higher in Georgia than death rates. Hospitalization rates are highest for both

Prevalence of Asthma in Children, 2000 The random digit dial telephone survey of households in Georgia with children indicates that approximately 11% (210,000) of children 0-17 years of age have asthma. Among households with children, one in six (16%)

young and old people, whereas death rates are low for young people and highest for older people (Figure 2). Both hospitalizations and deaths are more common among black Georgians than white Georgians. Black Georgians were 2.0 times more likely to be hospitalized

has a child with asthma. Among Georgia children, asthma is slightly

more common among boys (13%) than girls (8%), and among blacks (12%) than whites (10%). These are not statistically significant differences,

Figure 1. Age-Adjusted* Asthma Death Rate, Georgia** and United States, 1982-98

Deaths* per 100,000

but similar results have been reported in other surveys. Among children with asthma, about two-thirds (65%, 140,000) have had an attack or episode of asthma in the last year. Almost one-third of Georgia children with asthma (30%, 64,000) have been to an emergency room because of asthma in the last year (Table 1).

3

2.5

Georgia

2
U.S.
1.5

1

0.5

In the past year, more than half (54%) of Georgia children 5-17 years of

0 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98

age with asthma missed one or more days of school due to asthma.

Year

Based on this report, about 88,000 children age 5-17 years of age with asthma missed an estimated 540,000 days of school due to asthma.

* Age-adjusted to the 2000 US standard population ** Age-Adjusted Asthma Death Rates for Georgia are 3-year rolling averages

These 540,000 school days are about 5% of the total number of days

Figure 2. Asthma Hospitalization and Death

missed by all students for any reason. Parents or other caretakers may

Rates by Age Group, Georgia, 1998-99

miss work or school because their child is having an asthma attack. In the

past year, 30% (about 63,000) of parents of children with asthma missed an estimated 390,000 days of work or school because of the child's asthma (Table 1).
Patient education is important to teach patients and their families to recognize and avoid triggers and how to respond when an attack begins.

Rate per 100,000

250

200 163.4

150

100

50

0.3

0

0-19

63.1 0.7

117.0 2.4

179.9 8.4

20-39 40-64

65+

Patient and family education may include individual instruction from

Age Group

physicians or office staff, information from the American Lung Associa-

Hospitalization Rate Death Rate

tion (ALA) or other national organizations, or a course or class on how

Hospitalization rates are for 1998-1999, death rates are for 1994-1998

to manage asthma. Although some individuals may have

learned how to manage their or their child's asthma through other means, over half of Georgia children with asthma (56%, 120,000) live in a household where neither parent nor child has taken a course or class in managing asthma (Table 1).

Table 1.

Asthma among Georgia Children, 0-17 Years of Age, 2000.

Percent

Estimated Number of

Among all Children 0-17 years

Children in Georgia

Asthma

11%

210,000

Avoiding tobacco smoke is another way to reduce the

Among Children with Asthma Asthma attack in past 12 months

65%

frequency of attacks. Tobacco smoke is known to be a

Emergency Room visit in past 12 months

30%

trigger for many people with asthma. More than one-

Child missed school

54%

quarter (29%, about 61,000) of children with asthma live Parent missed school/work

30%

in a household where at least one person smokes inside

Lives in households where neither parent nor child has taken a class in managing asthma

56%

the house (Table 1).

Lives in a house with adult smoker(s)

29%

Takes medicine for asthma

90%

Takes medicine for asthma daily

26%

-2 -

140,000 64,000 88,000 (540,000 days) 63,000 (390,000 days)
120,000 61,000
189,000 56,000

with asthma and 2.6 times more likely to die from asthma than white Georgians.
Forty-seven of Georgia's 159 counties had asthma hospitalization rates in 1998-1999 that were significantly higher than the state rate of 122 hospitalizations per 100,000 population per year. Although located in all parts of Georgia, counties with high rates are more common in a band extending from Augusta to the southwest corner of the state (Figure 3).
Editorial Note
This report confirms that asthma is a major health problem in Georgia, as it is in the rest of the nation. The report shows that an estimated 11% of Georgia children from 0-17 years of age have asthma and that asthma has a significant impact on their lives, including attacks, visits to hospital emergency departments, missing school because of asthma, and causing parents and other caretakers of children with asthma to miss work or school due to the child's asthma.
Findings presented in this report suggest at least two ways by which the burden of asthma in Georgia could be reduced:
1) reduce the exposure of people with asthma to tobacco smoke, and
2) improve training in asthma management for parents and older children.
Reducing Smoking More than one-quarter of Georgia children with asthma live in a household where someone smokes inside the house. Exposure to tobacco smoke has been shown to make asthma more severe, and even the smoke that remains on a person's clothing can trigger an attack in a sensitive person. Stopping smoking or at least not smoking in the house will reduce the frequency and severity of asthma attacks. Efforts

to reduce smoking among the entire population and limit smoking in public places also will help prevent asthma attacks.
Improving Training More than half of Georgia children with asthma live in homes where neither parent nor child has taken a course or class on how to manage asthma. Additionally, starting asthma education at the time of asthma diagnosis, integrating that education into every step of clinical asthma care, and tailoring the education specifically to the needs of each patient can reduce the frequency and severity of asthma attacks. To reduce the frequency and severity of asthma attacks, it is important to:
Learn to recognize and avoid asthma triggers. Learn to recognize early symptoms of an asthma attack. Have a step-by-step plan to use as indicated by symptoms.
Improving the quality of life of Georgians with asthma is the goal of the Division of Public Health and the American Lung Association of Georgia, Inc. If you need further information, please contact one of the resources listed below.
This article was written by: Anne K. Mellinger-Birdsong, M.D., M.P.H. and Kenneth E. Powell, M.D., M.P.H.
References: 1. National Heart, Lung, and Blood Institute. Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. NIH Publication No. 97-4051, July 1997. 2. Centers for Disease Control and Prevention. Surveillance for Asthma United States, 1960-1995. MMWR, 1998; 47(SS-1):1-28.
Further information for clinicians about the NIH National Asthma Education and Prevention Program Guidelines for the Diagnosis and Management of Asthma may be obtained at: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Figure 3. Georgia Counties with High Asthma Hospitalization Rates, 1998-1999

County Rate Compared to State Rate County Rate Significantly Higher County Rate Similar to State Rate County Rate Unreliable Due to Small Numbers

-3 -

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

PRESORTED STANDARD U.S. POSTAGE
PAID ATLANTA, GA PERMIT NO. 4528

March 2001

Volume 17 Number 03

Reported Cases of Selected Notifiable Diseases in Georgia Profile* for September 2000

Selected Notifiable Diseases

Total Reported for November 2000
2000

Previous 3 Months Total

Ending in November

1998

1999 2000

Previous 12 Months Total

Ending in November

1998

1999

2000

Campylobacteriosis Chlamydia trachomatis 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

24 3219
9 3 85 2054 11 39 33 0 0 4 0 3 0 93 33 9 25 61 114 2 141

189 7857
47 18 337 5433 24 233 38
0 0 22 1 8 0 500 204 46 82 249 256 6 173

148 8707
38 14 358 6497 21 77 65
3 0 19 0 12 0 487 52 54 99 233 319 5 213

116 8430
38 6
269 5710
24 106
96 3 0
12 0 5 0
392 94 32 66
128 242
4 225

769 25552
152 85
1215 20869
69 879 213
8 5 103 2 38 0 1838 1138 126 237 825 838 16 630

724 31439
166 42
1357 21989
80 482 231
5 0 72 4 52 0 1976 283 145 290 742 832 21 670

605 30883
191 44
1200 19795
82 371 310
10 0
54 2
46 0
1711 342 114 278 516 650 16 704

* 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: 01/00 - 12/00 Five Years Ago: 01/95 - 12/95 Cumulative: 7/81 - 12/00

Total Cases Reported*

Percent Female

AIDS Profile Update
Risk Group Distribution (%) MSM IDU MSM&IDU HS Blood

Unknown

1207

27.2

28.2

10.4

2.2

13.0

2.3

43.9

2256

18.9

46.8

20.5

5.6

16.4

1.5

9.3

22651

16.7

48.8

18.4

5.6

13.1

1.9

12.2

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 -

Race Distribution (%) White Black Other

19.2 77.0

3.8

35.0 62.0

3.0

35.9 61.9

2.1