February 2002 volume 18 number 02 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 Cardiovascular disease: Georgia's biggest killer Introduction Cardiovascular disease (CVD), which includes all diseases of the heart and blood vessels, is the number one killer in the United States and in Georgia. Almost 40% of all deaths in Georgia in 1999 were caused by CVD. Although the CVD death rate has been declining during the past few decades, the CVD mortality rate in Georgia remains above the US rate. The purpose of this report is to describe trends in CVD, differences in mortality rates by demographic characteristics, the burden of CVD-related hospitalizations, and risk behaviors associated with CVD in Georgia. Methods We analyzed data from 1999 death certificates filed on residents of Georgia with an underlying cause of death coded as cardiovascular disease (ICD-10 codes I00-I78, further classified as ischemic heart disease, I20-I25, or stroke, I60-I69). To calculate mortality rates, we used the 1999 United States Bureau of Census estimates for Georgia as the population denominator; we used the direct method of calculating age-adjusted rates based on the year 2000 standard population. Using the hospital discharge database compiled by the Georgia Hospital Association for nonfederal acute-care hospitals in Georgia, we selected hospitalization records with principal discharge diagnosis of CVD (ICD-9 codes 390-448, further classified as ischemic heart disease, 410-414, stroke, 430-438, or heart failure, 428). Charges associated with these hospitalizations were totaled.1 Information about smoking, hypertension, hypercholesterolemia, overweight, and physical inactivity was obtained from the 1999 Behavioral Risk Factor Surveillance System, a survey of a representative sample of the non-institutionalized adult population of Georgia. Results CVD Mortality In Georgia, 24,274 persons died of CVD in 1999. The age-adjusted CVD mortality rate for Georgia of 399 per 100,000 population was 14% higher than the US rate of 351 per 100,000 (Figure 1). Ischemic heart disease, also known as coronary heart disease, is the leading form of CVD in Georgia. In 1999, of all CVD deaths, 10,502 (43%) were caused by ischemic heart disease and 4,277 (18%) were caused by stroke. Georgia's stroke rate is one of the nation's highest. In 1999, Georgia had an age-adjusted stroke mortality rate of 71 per 100,000 population, 15% above the US rate of 62 per 100,000. CVD mortality rates are higher for blacks than for whites in Georgia. In 1999, black males had an age-adjusted CVD mortality rate 23% higher than that of white males, and black females had a rate 26% higher than that of white females (Figure 2). CVD mortality rates are higher for men than for women. In terms of absolute numbers, however, more women than men die from CVD in Georgia each year because women live to older ages when CVD is more common. In 1999, there were 13,050 female deaths and 11,223 male deaths from CVD. Although CVD death rates increase with age, approximately 22% of all CVD deaths in Georgia occur in persons < 65 years of age. The percentage of deaths that were premature (<65 years) in 1999 was highest for black males (42%) and lowest for white females (10%) (Table 1). Figure 3 shows the variation in the annual average age-adjusted CVD death rates by county from 1995 to 1999. 2 Counties in the state's southeastern region and along the western border have the highest CVD death rates. Hospitalizations from CVD In 1999, there were 128,386 hospitalizations in Georgia due to CVD, more than five times the number of deaths. Total charges from those hospitalizations were more than $1.9 billion.1 Approximately 37% of the CVD hospitalizations were attributed to ischemic heart disease, 18% to stroke, and 17% to heart failure. More information on stroke hospitalizations will be available from the pilot stroke registry developed by Emory University and the Georgia Medical Care Foundation with funding from the Centers for Disease Control and Prevention (see box page 3). Risk factors for CVD Smoking, lack of regular physical activity, overweight, hypertension, and hypercholesterolemia are all associated with increased risk for CVD. In 1999, 24% of Georgia adults (>18 years) reported that they currently smoke (Figure 4). Approximately 74% reported that they do not get regular physical activity,3 26% reported ever having been told they have high blood pressure, 29% reported ever having been told they have high blood cholesterol, and 58% were overweight or obese.4 The percentage of Georgians who were overweight or obese has increased significantly from 37% in 1984, the first year of available data. Physician advice In 1998, of Georgians >18 years who were current smokers, 76% reported that a doctor or other health professional had ever advised them to quit smoking (Table 2). Of adults overweight or obese, 44% reported that a doctor or other health professional had ever talked to them about diet or eating habits. Of adults not getting regular physical activity, 42% reported that a doctor or other health professional had ever talked to them about physical activity. Among all adults in Georgia, regardless of weight and activity level, only 38% reported ever discussing diet or eating habits and only 41% reported ever discussing physical activity with a doctor or other health professional. The percentage of persons reporting discussion of smoking cessation, diet, or regular physical activity within the past year was much smaller (Table 2). Figure 1. Cardiovascular disease death rates in Georgia and the United States, 1980-1999 Figure 2. Cardiovascular disease death rates in Georgia by race and sex, 1999 Table 1. Premature cardiovascular disease deaths by race and sex, Georgia, 1999 Figure 3. Cardiovascular disease death rates by county, Georgia, 1995 - 1999 Age-adjusted death rates Significantly above the state rate Not Significantly different from the state rate Significantly below the state rate -2 - Figure 4. Prevalence of CVD risk factors among adults (>18 years) in Georgia Table 2. Percentage of adults (>18) in Georgia reporting that a doctor or health professional talked to them about healthy lifestyles Current smoker Overweight/ No regular obese exercise Hypertension (ever) High cholesterol (ever) Editorial Note CVD mortality rates in Georgia are higher than in the U.S. The state's most frequent killer not only claims thousands of lives each year, but also accounts for billions in health care expenditures. CVD is preventable, but not without lifestyle changes on the part of Georgians. We need to stop smoking, keep youth from starting to smoke, increase regular physical activity, lose weight, and eat less fat and more fruits and vegetables. To facilitate behavior change in communities where healthy lifestyles are not the norm, environmental and policy changes that require or encourage behavior change are needed. State and local laws that limit smoking in public places and increase cigarette taxes, community decisions to build sidewalks and open school athletic facilities to the public, and business decisions to encourage walking programs in indoor shopping malls are all examples of policy changes which promote healthy lifestyles, thereby decreasing risk for CVD. Health care providers can also help to reduce risk for CVD. Screening for hypertension and hypercholesterolemia with appropriate management for those affected is important in reducing CVD mortality. Routine discussions about the benefits of smoking cessation, increased physical activity, low-fat diets, and weight loss may encourage individuals to adopt healthier lifestyles. For more information More detailed information on deaths, hospitalizations, and risk factors related to CVD in Georgia will be published in February 2002 by the Georgia Division of Public Health (404-657-3103) and the American Heart Association, SE Affiliate (678-385-2075). For more information on the stroke registry, contact Dr. Michael Frankel or Michelle Manzo (404-616-8741). Footnotes 1 Hospital charges do not represent actual costs and do not include physician fees or medication costs. 2 Age-adjusted mortality rates for counties were calculated using data from death certificates provided by the Vital Statistics Branch and Office of Health Information and Policy. The number of deaths from CVD in 1999 was determined by selecting deaths with an ICD-10 code of I00-I78 for underlying cause. The number of deaths for 1995-1998 was determined by selecting ICD-9 codes that correspond to the new ICD-10 codes. The number of deaths for 1995-1998 was multiplied by the "comparability ratio" provided by NCHS (National Vital Statistics Reports, Vol 49, No. 3) for CVD (0.9981) before calculating age-adjusted mortality rates. The "comparability ratio" compensates for the change in coding systems. Age-adjusted mortality rates were calculated using county population estimates from the US Bureau of Census (release date: August 30, 2000) and the year 2000 standard population. The z-test was used to compare county rates to the state rate with significance at p<0.05. The source of the formula for the z-test and the standard error for an age-adjusted rate was the National Center for Health Statistics, National Vital Statistics Report, volume 48, number 11, July 24, 2000, page 104. 3 Regular physical activity or exercise is defined as at least 30 minutes of moderate-intensity physical activity 5 or more days per week or at least 20 minutes of vigorous physical activity 3 or more days per week. 4 Overweight is defined as body mass index 25.0 - 29.9; obese is defined as body mass index >30.0. The Paul Coverdell National Acute Stroke Registry Emory University, in collaboration with the Georgia Medical Care Foundation, received a grant from the Centers for Disease Control and Prevention to participate in "The Paul Coverdell National Acute Stroke Registry." Georgia is one of four states participating in the project. The objective of the stroke registry is to improve the quality of care for patients with stroke. The project involves collecting information on all persons admitted to participating hospitals with a diagnosis of stroke. The data will be used to identify strengths in patient management and opportunities for improved care so as to provide education to clinicians and multidisciplinary teams. The registry gives Georgia the opportunity to impact national health care policy and at the same time improve stroke management in our communities. Over 40 acute care hospitals in the state will be participating in the project. This article was written by Kristen Mertz, M.D., Nkenge Jones, M.P.H., and Ken Powell, M.D., M.P.H. -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 February 2002 Volume 18 Number 02 Reported Cases of Selected Notifiable Diseases in Georgia Profile* for November 2001 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 Nov 2001 2001 17 2444 2 3 43 1349 10 62 1 0 0 7 0 0 0 92 71 8 19 35 31 0 33 Previous 3 Months Total Ending in Nov 1999 2000 2001 175 125 89 6124 7330 7990 38 41 43 12 5 17 432 301 202 4812 5268 4557 17 18 24 101 116 232 69 111 84 4 4 0 0 0 0 13 11 13 1 0 0 12 5 1 0 0 0 652 470 496 66 92 235 32 28 16 62 69 59 136 120 128 165 180 133 7 3 2 149 151 146 Previous 12 Months Total Ending in Nov 1999 2000 2001 747 615 586 30344 28775 31534 164 192 145 41 47 42 1330 1224 955 21328 19190 17429 83 78 104 519 351 927 231 330 386 5 10 9 0 0 0 67 59 52 4 2 7 50 54 18 0 1 0 2002 1721 1648 322 323 471 141 125 90 280 293 279 708 546 559 769 724 717 19 20 19 623 665 576 * 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: 12/00 - 11/01 Five Years Ago: 12/95 - 11/96 Cumulative: 7/81 - 11/01 Total Cases Reported* <13yrs >=13yrs Total Percent Female AIDS Profile Update Risk Group Distribution (%) MSM IDU MSM&IDU HS Blood Unknown 2 1622 1624 25.1 32.8 9.2 2.3 11.4 1.2 43.0 19 2382 2401 19.1 46.2 17.9 5.2 18.0 1.4 11.3 210 23913 24123 17.2 48.0 18.0 5.5 13.2 1.9 13.5 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 19.9 75.2 4.9 33.2 64.5 2.4 34.9 62.8 2.3