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