November 2002 volume 18 number 11 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) 657-7517 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 Leading causes of death in Georgia Introduction Cause-of-death rankings show the most frequently occurring causes of death and their relative burden (1). We examined death data for Georgia residents who died in the years 1996 through 2000 to identify leading causes of death by age, sex, and race. Methods We examined death certificate data provided by physicians, coroners, medical examiners, and funeral directors for Georgia residents who died in 1996 through 2000. We categorized underlying causes of death according to lists published by the National Center for Health Statistics (NCHS) for tabulation of mortality statistics (2). We determined leading causes for all Georgia residents dying in the year 2000. For leading causes by age, sex, and race, we used a 5-year period (1996 through 2000) because of possible random variation by year. Since 1999, causes of death listed on death certificates have been coded according to the Tenth Revision of the International Classification of Diseases (ICD-10); deaths from 1996 to 1998 were coded using ICD-9 codes. To account for coding differences in ICD-9 and ICD-10, we multiplied the number of deaths in 1996 through 1998 by the appropriate comparability ratio to get the "comparability modified" number of deaths and added these to the actual number of deaths in 1999 and 2000 (3). Finally, we calculated age-adjusted mortality rates for the top 10 leading causes in Georgia in 2000 to compare state death rates to US rates, using the year 2000 projected population as the standard population. Results Death certificates were submitted for 63,657 Georgia residents who died in 2000. The two top causes, heart disease and cancer, accounted for 50% of all deaths (Figure 1). The 15 leading causes accounted for 82% of all deaths. Leading causes of death in 1996 through 2000 varied by age (Table 1). For age groups 1 to 4, 5 to 14, 15 to 24, and 25 to 34 years, unintentional injuries were the leading cause. Homicide was the second or third leading cause of death in each of these age groups; suicide ranked sixth, third, and fourth for the 5 to 14, 15 to 24, and 25 to 34 year age groups. Unintentional injuries, Figure 1: Leading causes of death, Georgia, 2000 (N=63,657) Heart disease Cancer S trok e Unintentional injury Chronic respiratory Diabetes Influenza/pneumonia Alzheimer's Kidney disease Septicemia S uicide HIV Hypertension Homicide Chronic liver 4534 3141 3043 1483 1426 1280 1279 1139 844 733 678 655 630 13628 18002 0 2000 4000 6000 8000 10000 12000 14000 16000 18000 20000 Number of deaths Source: Georgia death certificates Table 1: Leading causes of death in Georgia, by age group, 1996-2000* Rank <1 yr n=5,269** 1-4 yrs n=890 5-14 yrs n=1,321 15-24 yrs n=5,191 25-34 yrs n=7,822 35-44 yrs n=15,370 45-54 yrs n=25,014 55-64 yrs n=36,803 65-74 yrs n=60,338 75-84 yrs n=80,419 85+ yrs n=65,019 All ages N=303,456 Congenital 1 malformation Injury Injury 937 350 652 Short gestation/ 2 LBW Congenital Cancer 914 74 142 3 SIDS Homicide Homicide 559 59 73 4 Resp distress Cancer Heart 257 47 60 5 Maternal complic Heart Congenital 174 45 52 6 Injury 161 7 Bacterial sepsis 156 Septicemia 25 Anemia 17 Suicide 35 Benign tumor 20 8 Atelectasis Flu/Pneumonia 150 17 Necrotizing Stroke 14 9 enterocolitis 127 Neonatal 10 hemorrhage 124 HIV Chronic lung 17 14 Benign tumor Flu/Pneumonia 11 13 Placenta, cord, membrane Septicemia 124 13 Injury 2,382 Injury 2,060 Cancer 2,636 Cancer 6,959 Homicide 875 Suicide 605 Cancer 235 Heart 216 HIV 102 Congenital 58 Stroke 43 HIV 1,183 Homicide 876 Suicide 836 Cancer 683 Heart 619 Stroke 143 Diabetes 102 Heart 2,511 Injury 2,290 HIV 1,933 Suicide 939 Homicide 690 Stroke 575 Chronic liver 411 Heart 6,234 Injury 1,781 Stroke 1,336 HIV 950 Chronic liver 771 Suicide 720 Diabetes 606 Diabetes 32 Septicemia 90 Diabetes 283 Chronic lung 533 Benign tumor Flu/pneumonia Flu/pneumonia Septicemia 30 77 210 350 Cancer 12,417 Cancer 18,632 Heart 25,997 Heart 24,464 Heart 88,671 Heart Heart Cancer Stroke Cancer 10,569 17,867 16,883 6,990 65,496 Stroke Chronic lung Stroke Cancer Stroke 1,912 4,250 7,178 6,856 22,195 Chronic lung Stroke Chronic lung Flu/pneumonia Injury 1,707 3,950 5,168 2,813 15,177 Injury Diabetes Flu/pneumonia Alzheimer's Chronic lung 1,171 1,727 2,235 2,622 14,168 Diabetes 1,083 Chronic liver 733 Injury 1,275 Chronic kidney 1,034 Alzheimer's 2,071 Diabetes 1,952 Chronic lung Flu/pneumonia 2,251 7,082 Chronic kidney Diabetes 1,486 6,933 Septicemia 562 Septicemia Chronic kidney Septicemia 1,027 1,695 1,441 Septicemia 5,391 Chronic kidney Flu/pneumonia 556 958 Injury 1,691 Injury 1,362 Chronic kidney 5,310 Suicide 422 Chronic liver Septicemia Atherosclerosis Alzheimer's 633 1,634 1,174 5,231 * Data reflect the actual number of deaths in 1999-2000 and the comparability-modified number of deaths for 1996-1998 | ** Actual number of deaths in age group, 1996-2000, including deaths that are not in the top 10 causes Chronic kidney=Nephritis, nephrotic syndrome and nephrosis Heart=Diseases of the heart Placenta, cord, membrane=Complications of placenta, cord, membrane Chronic liver=Chronic liver disease and cirrhosis Injury=Unintentional injury, including motor vehicle accidents Resp distress=Respiratory distress of newborn Chronic lung=Chronic lower respiratory diseases LBW=Low birth weight SIDS=Sudden infant death syndrome Congenital=Congenital malformation Maternal complic=Maternal complications of pregnancy homicide, and suicide accounted for 74% of deaths in the 15 to 24 year age group. Cancer and heart disease were the top two causes for all age groups from 35 to 44 years through 65 to 74 years. These two causes accounted for >50% of deaths in the 45 to 54, 55 to 64, 65 to 74, and 75 to 84 year age groups. Leading causes of death in 1996 through 2000 varied by sex (Table 2). Injury was the third leading cause in men but only the fifth leading cause in women. HIV, suicide, and homicide ranked sixth, seventh, and tenth for men but were not in the top 10 for women. Alzheimer's ranked eight for women but was not in the top 10 for men. For blacks who died in 1996 through 2000, HIV and homicide ranked fifth and eighth, respectively, but neither were in the top 10 for whites dying during this period (Table 3). Chronic lung disease (largely attributable to smoking) was fourth for whites but only tenth for blacks. Flu and pneumonia, Alzheimer's, and suicide were sixth, seventh, and ninth for whites but not in the top 10 for blacks. We compared age-adjusted mortality rates for the top 10 leading causes of death in Georgia in 2000 to age-adjusted rates for the US. For eight of the 10 leading causes, the age-adjusted rate was higher in Georgia than in the US (Figure 2). Discussion Cause-of-death rankings show the relative burden of causes of death among those causes eligible to be ranked (1). Most of the top 15 leading causes of death in year 2000 in Georgia were chronic diseases and injuries (unintentional and intentional). This scenario is very different from that in 1900, when the top three causes in the US were pneumonia and influenza, tuberculosis, and diarrhea (4). Grouping causes of death differently may produce different rankings (1). We used rankable causes published by NCHS to be consistent with national rankings. Some causes are not eligible to be ranked because they are subsumed in broader categories (e.g. motor vehicle accidents could be a leading cause but they are included in unintentional injuries). Table 2: Leading causes of death, Georgia residents, 1996-2000, by sex Males Females Leading causes All causes 1. Disease of the heart 2. Cancer 3. Injury 4. Stroke 5. Chronic lung 6. HIV 7. Suicide 8. Flu/pneumonia 9. Diabetes 10. Homicide No. Leading causes deaths 151,351 All causes 42,994 34,910 9,737 8,675 7,588 3,581 3,448 3,180 2,987 2,452 1. Disease of the heart 2. Cancer 3. Stroke 4. Chronic lung 5. Injury 6. Diabetes 7. Flu/pneumonia 8. Alzheimer's 9. Septicemia 10. Chronic kidney No. deaths 152,105 45,672 30,586 13,519 6,579 5,440 3,946 3,900 3,736 3,157 2,973 Table 3: Leading causes of death, Georgia residents, 1996-2000, by race Whites Blacks Leading causes All causes 1. Disease of the heart 2. Cancer 3. Stroke 4. Chronic lung 5. Injury 6. Flu/pneumonia 7. Alzheimer's 8. Diabetes 9. Suicide 10. Septicemia No. Leading causes deaths 219,163 All causes 66,161 48,807 15,870 12,238 10,907 5,495 4,568 4,362 3,633 3,331 1. Disease of the heart 2. Cancer 3. Stroke 4. Injury 5. HIV 6. Diabetes 7. Chronic kidney 8. Homicide 9. Septicemia 10. Chronic lung No. deaths 82,573 22,292 16,458 6,229 4,180 3,393 2,551 2,197 2,089 2,054 1,900 -2 - Figure 2: Age-adjusted death rates, Georgia and the US, 2000 Heart disease Cancer Stroke Unintentional injury Chronic resp iratory Diabetes Influenza/p neumonia Alzheimer's Kidney disease Sep t icemia 60.8 73.4 35.5 41.6 44.3 48.4 25.2 22.8 23.7 23.5 18.0 22.0 13.5 20.3 11.4 18.0 201.0 205.8 257.9 286.0 US GA References 1. Anderson RN. Deaths: Leading causes for 2000. National vital statistics reports; vol 50 no. 16. Hyattsville, Maryland: National Center for Health Statistics. 2002. 2. National Center for Health Statistics. ICD-10 Causeof-death lists for tabulating mortality statistics, effective 1999. NCHS instruction manual, part 9. Hyattsville, Maryland: National Center for Health Statistics. 1997. 3. Anderson RN, Minino AM, Hoyert DL, Rosenberg HM. Comparability of cause of death between ICD-9 and ICD-10: Preliminary estimates. National vital statistics reports; vol 49, no. 2, Hyattsville, Maryland: National Center for Health Statistics. 2001. 4. Leading causes of death, 1900-1990. NCHS DataWarehouse, Historical data, NCHS website: http://www.cdc.gov/nchs/ datawh/statab/unpubd/mortabs/hist-tabs.htm. 0 50 100 150 200 250 300 350 400 Age-adjusted death rate (per 100,000 population) Data sources for Georgia rates: Georgia death certificates (deaths) and US Census Bureau (population) US rates taken from National Vital Statistics Reports 2002;50(15):8 A combination of frequency, ages of those affected, and preventability of the leading causes of death must all be considered when determining priorities for intervention. Most of Georgia's top 15 causes in 2000 have agreed-upon prevention strategies. Legislators and public health programs must work together to reduce deaths from leading causes in Georgia. This article was written by Kristen Mertz, M.D., M.P.H., Manxia Wu, M.D., M.P.H., and Ken Powell, M.D., M.P.H. The authors thank the Vital Records Office and the Office of Health Information and Policy for compiling mortality data for Georgia. For information on leading causes of death in the United States, see CDC's website ( http://www.cdc.gov/nchs/releases/02facts/ final2000.htm ) Addendum: months. Influenza vaccination for children, including healthy young children age 6-23 The September 2002 (Vol.18, no.9) issue of the Georgia Epidemiology Report discussed Influenza Surveillance in Georgia and included recommendations for influenza vaccination for the 2002-2003 influenza season. In that issue, Table 1 lists target groups for annual influenza vaccination, including children aged >6 months who have certain medical conditions. In addition to these high-risk children, for whom annual vaccination is strongly recommended, vaccination of healthy children 6 months-23 months is encouraged when feasible because they are at increased risk for influenza-related hospitalization. Hospitalization rates among children aged 0-1 years are comparable to rates among persons aged >65 years. The current influenza vaccine is not approved by the U.S. Food and Drug Administration (FDA) for use among children aged <6 months, the pediatric group at greatest risk for influenza-related complications. Vaccinating household contacts and out-of-home caretakers of children 0-23 months might decrease the probability of influenza among these children, and is encouraged, particularly for contacts of children aged 0-5 months. For children aged <9 years who have not been immunized previously, two doses should be administered >1 month apart for satisfactory antibody responses. If possible, the second dose should be administered before December. To this end, vaccination should begin in October for children with certain medical conditions, household contacts of infants aged <6 months who are not eligible for influenza vaccine, healthy children aged 6-23 months, and children aged 6 months to <9 years receiving influenza vaccine for the first time. For more vaccine information, please go to http://www.health.state.ga.us/programs/immunization For information about the Vaccines for Children Program, please go to http://www.health.state.ga.us/programs/immunization/vfc/index.shtml. For ACIP Recommendations for Prevention and Control of Influenza, please go to MMWR 2002 No. 51 (RR-03), 1-31, http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5103a1.htm#tab3 Table: Influenza vaccine* dosage, by age group--United States, 2002-2003 season Age group 6-35 months 3-8 years >9 years Dose 0.25 mL 0.50 mL 0.50 mL Number of doses 1 or 2 1 or 2 1 Route Intramuscular Intramuscular Intramuscular *Vaccines manufactured by Aventis Pasteur (Fluzone split) and Wyeth Lederle (Flushield split) are FDA approved for use among persons aged >6 months. Vaccine manufactured by Evans Vaccines, Ltd. (Fluvirin purified surface antigen vaccine) is approved for use among persons aged >4 years. Two doses administered >1 month apart are recommended for children aged <9 years who are receiving influenza vaccine for the first time. -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 November 2002 Volume 18 Number 11 Reported Cases of Selected Notifiable Diseases in Georgia Profile* for August 2002 Selected Notifiable Diseases 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 Total Reported for August 2002 2002 54 1723 8 4 101 1017 1 26 1 1 0 0 0 1 0 186 79 3 23 37 11 0 30 Previous 3 Months Total Ending in August 2000 2001 2002 234 260 182 7851 8742 7094 76 51 30 27 17 19 369 277 252 5384 5110 4077 12 13 12 108 311 95 94 107 76 2 4 2 0 1 0 7 5 5 0 1 0 18 8 3 1 0 0 710 650 616 86 98 321 33 35 22 80 93 68 132 141 125 197 193 82 7 6 0 172 116 125 Previous 12 Months Total Ending in August 2000 2001 2002 665 637 567 27594 31631 32008 189 151 134 54 32 56 1355 1051 871 18746 18736 17802 77 97 100 336 811 616 288 422 396 10 13 11 0 1 1 61 51 42 3 8 3 61 25 16 1 0 0 1903 1608 1763 297 335 1354 131 106 84 287 298 253 570 569 612 716 818 627 24 22 13 661 581 566 * 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. AIDS Profile Update Report Period Latest 12 Months: 10/01-09/02 Five Years Ago: 10/97-09/98 Cumulative: 07/81-09/02 Total Cases Reported* <13yrs >=13yrs Total 2 1,778 1,780 5 1,312 1,317 212 25,273 25,485 Percent Female 25.3 18.8 17.7 MSM 40.4 41.5 47.6 IDU 7.1 19.3 17.4 Risk Group Distribution (%) MSM&IDU HS Blood 2.4 13.7 2.0 5.8 16.4 1.0 5.4 13.4 1.9 Unknown 34.4 16.1 14.3 Race Distribution (%) White Black Other 18.6 76.4 5.0 23.5 74.2 2.4 34.1 63.5 2.4 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 -