December 2003 volume 19 number 12 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 Childhood Asthma in Georgia: Prevalence and Management Practices Introduction Asthma is a common chronic condition with significant impact on those who have it. Appropriate clinical management, including a written action plan, comprehensive pharmacologic therapy, and avoidance of allergens and other triggers, can reduce the burden of asthma. In a previous survey of asthma prevalence and impact among children in Georgia, conducted in 2000, 11% of children in Georgia were reported to have asthma, and 54% of children with asthma were reported to have missed an estimated 540,000 days of school because of asthma in the past year.1 The 2003 survey was conducted to assess changes in prevalence of childhood asthma and to collect more detailed information about severity, impact, and management to guide state asthma program planning. Methods A random-digit-dial telephone survey of primary caretakers of children in Georgia, representing 2,121 households with 3,896 children, was conducted from October 2002 through February 2003. The University of Georgia Survey Research Center in Athens, GA, collected the data. Asthma was defined according to a standard case classification of probable asthma: the child was ever diagnosed with asthma, and 1) has been told by a physician the child still has asthma, 2) takes prescription medicine for asthma, or 3) has had an asthma attack/wheeze episode in the last year. 2 Exposure to tobacco smoke was defined as "yes" if during the past week someone living in the household smoked cigarettes, cigars, or pipes inside or away from the house. Missed school days and missed work days were truncated to 31 days if the number of missed days was >31. Household and caretaker data were weighted according to the number of telephone lines in the household. Child data were weighted according to the number of telephone lines in the household and to the 2000 Georgia Census population. Of households participating in the survey, most (87%) had one telephone line. In Georgia, 8% of households do not have a telephone line.3 Results Disposition of Telephone Calls Of the 26,963 telephone calls placed, 6,648 (25%) were to eligible households (containing a child aged <17 years). Among the 6,648 households with children, 2,121 households (30% of calls) with 3,896 children completed the survey. Asthma Prevalence Approximately 10% (95% confidence interval [95% CI], 9%-11%) of children aged <17 years in Georgia (an estimated 212,000 children) have asthma. Among households with children, 16% (95% CI, 14%-17%) have at least one child with asthma. Asthma is more common among boys (11%; 95% CI, 10%-13%) than girls (8%; 95% CI, 7%-10%). The prevalence of asthma among non-Hispanic black children (12%; 95% CI, 9%-14%) is not significantly different from non-Hispanic white children (9%; 95% CI, 8%-10%) or children of other races/ethnicities (8%; 95% CI, 4%-12%). The prevalence of asthma is 9% (95% CI, 7%-11%) among those aged 0 to 4 years, 11% (95% CI, 9%-13%) among those 5 to 12 years, and 8% (95% CI, 7%10%) among those 13 to 17 years. Asthma prevalence is higher in children living in households with an annual household income <$20,000 (15%; 95% CI, 11%-19%) than in children living in households with a household income $75,000 (8%; 95% CI, 6%-10%). These estimates of the prevalence of asthma in 2002-2003 by sex, race, and household income are not significantly different from the estimates in 2000. The Georgia Epidemiology Report Via E-Mail To better serve our readers, we would like to know if you would prefer to receive the GER by e-mail as a readable PDF file starting in 2004. If yes, please send your name and e-mail address to Gaepinfo@dhr.state.ga.us. Percent Percent Reporting Trigger Viruses Pollen Tobacco Smoke Cold Weather Dust Mites Exercise Mold Pets Cockroaches Severity of Asthma Of children with asthma, 60% (95% CI, 54%- 66%) had an asthma attack or episode in the previous 12 months, and 19% (95% CI, 14%-24%) reported an Emergency Department (ED) visit in the past 12 months. The mean number of ED visits for children who reported at least one was 2.7, with a range of 1 to 12. Approximately 6% (95% CI, 3%-9%) of children with asthma reported being hospitalized overnight for at least one night, with a mean of 1.9 hospitalizations and a range of 1 to 6 hospitalizations per child among those hospitalized in the past 12 months (Figure 1). Figure 1. Asthma attacks and use of health services among children with asthma, Georgia, 2002-2003 Figure 2. Asthma triggers among children with asthma, Georgia, 2002-2003 100 85 80 74 69 60 60 55 48 42 40 34 20 10 0 70 60 60 50 40 30 19 20 10 6 0 Asthma Attack in ER Visit in last 12 Hospitalized in last last 12 months months 12 months Exposure to Tobacco Smoke Environmental tobacco smoke (ETS) is the third most common asthma trigger, affecting more than two-thirds of children with asthma, an estimated 145,000 children statewide. ETS is the most common of the potentially modifiable triggers. Children with asthma for whom tobacco smoke was a reported trigger are just as likely to be exposed to tobacco smoke at home (35%; 95% CI, 28%-42%) as are children with asthma for whom tobacco smoke was not reported as a trigger (32%; 95% CI, 21%44%) and children without asthma (31%; 95% CI, 29%-34%). Impact on School and other Activities Among children aged 5 to 17 years with asthma, 48% (95% CI, 42%-55%), about 75,000 children, were reported to have missed an estimated 470,000 days of school because of asthma in the past year. Among children who missed school, the mean number of days missed was 6.3 days. Among adults in households of children with asthma, 33% (95% CI, 27%-38%), an estimated 69,000 adults, missed work or school due to the child's asthma; the mean number of work days missed was 6.1. Caretakers reported that they restricted the child's activity on ozone alert days for 48% (95% CI, 42%-54%) of children with asthma (an estimated 100,000 children). In addition, 23% (95% CI, 18%-27%) of children with asthma (about 48,000 children), were reported to have "moderate" or "a lot" of limitation to their activities over their whole life when compared to their friends. Triggers According to caretakers, factors that cause asthma attacks or aggravate asthma for their child include viruses (85%; 95% CI, 81%89%), pollen (74%; 95% CI, 69%-79%), tobacco smoke (69%; 95% CI, 63%-74%), cold weather (60%; 95% CI, 55%-66%), dust mites (55%; 95% CI, 49%-61%), exercise (48%; 95% CI, 43%-54%), mold (42%; 95% CI, 36%-48%), pets (34%; 95% CI, 29%-40%), and cockroaches (10%; 95% CI, 6%-13%) (Figure 2); many of these triggers are potentially modifiable. Disease Management Among children with asthma, 84% (95% CI, 79%-88%) use prescription medicine, including 36% (95% CI, 30%-42%) with prescriptions for both control and quick-relief medicine, 14% (95% CI, 10%-18%) with a prescription only for control medicine, and 34% (95% CI, 28%-39%) with a prescription only for quick relief medicine (Figure 3). National, Heart, Lung and Blood Institute (NHLBI) Guidelines state that use of >2 quickrelief treatments per week or about 2 prescriptions per year may indicate need for control medicine to reduce inflammation and prevent exacerbations. 4 Among children with asthma who have a prescription only for quick relief medicine, 55% (95% CI, 46%-65%), or 17% (95% CI, 13%21%) of all children with asthma, use >2 prescriptions per year. Figure 3. Use of asthma prescription medicines among children with asthma, Georgia, 2002-2003 Percent using medicine 40 35 30 25 20 16 15 10 5 0 No Prescription Medicine 34 Quick Relief Only 14 Control Only 36 Quick Relief and Control Control medicine: medicine designed to control airway inflammation and prevent attacks from occurring Quick-relief medicine: medicine designed to provide quick relief of asthma symptoms during an attack or exacerbation -2 - Table 1. Disease management practices and training for children with asthma, Georgia, 2002-2003 Management practice/training No routine check-ups for asthma No written asthma management plan 2 or more quick-relief prescriptions per year but no control medicine No training on how to manage asthma* No training to recognize signs and symptoms of an attack * No training about things that can trigger asthma attacks* No training on use of peak flow meter * No training on use of inhaler (among those with inhaler)* No training on use of a spacer (among those with inhaler)* % (95% CI) 30 (25,35) 65 (59,70) 17 (13,21) 18 (14,23) 28 (23,33) 23 (20,25) 13 (09,18) 06 (02,09) 30 (24,37) The NHLBI Guidelines also recommend that patients receive periodic assessments and be given a written plan by their health care provider. 4 In Georgia, 30% of children with asthma do not have regular asthma checkups and 65% do not have a written plan to help them manage their asthma (Table 1). Training caretakers and children to help manage the disease may also reduce the frequency and severity of attacks. In Georgia, for 18% of children with asthma, neither the caretaker nor the child has been taught to manage the child's asthma, for 28% neither caretaker nor child has been taught to recognize signs and symptoms of an asthma attack, and for 23% neither caretaker nor child has been taught about triggers for an asthma attack for that particular child. For 13% of children with asthma who have a peak flow meter, neither caretaker nor child has been trained on how to use the peak flow meter. For 6% of children with asthma who use an inhaler, neither caretaker nor child has been taught to use their inhaler and for 30%, neither has been taught to use a spacer. Conclusions Asthma continues to be a significant problem among children in Georgia, affecting one in ten (212,000 children). Asthma has a significant impact on their lives; an estimated 75,000 children miss 470,000 days of school, an estimated 100,000 children face activity restrictions during ozone alerts, and an estimated 48,000 children have limited activities compared to friends without asthma. Although most caretakers report that they or the child have been taught to manage the child's asthma, 65% do not have a written asthma management plan. In addition, 17% of children with asthma use two or more quickrelief prescriptions per year but do not have a prescription for control medicine. This may put the children at risk for more attacks, more missed school, and more limited activity compared to children without asthma. Recommendations Children with asthma should have a written management plan to help self-mange their asthma. Children with asthma who use greater than two quick-relief medication refills per year should be evaluated for control medication. Exposure to tobacco smoke should be eliminated for all children with asthma. References 1. Mellinger-Birdsong AK, Powell KE, Iatridis T, Bason J. Prevalence and impact of asthma in children, Georgia, 2000. Am J Prev Med 2003; 24:242-248 2. CSTE position statement 1998-EH/CD1, Asthma surveillance and case definition. 3. March 2001 Current Population Survey, U.S. Census Bureau. Data provided by Marketing Systems Group (GENESYS). Accessed September 12, 2003: www.cdc.gov/brfss/technical_infodata/ surveydata/2000/table3_00.htm 4. National Asthma Education and Prevention Program. NAEPP Expert Panel Report 2: Guidelines for the diagnosis and management of asthma. Bethesda, MD: National Institutes of Health, National Heart, Lung, and Blood Institute, 1997. This article was written by Anne Mellinger-Birdsong, M.D., M.P.H., Angela Blackwell, M.P.H., Manxia Wu, M.D., M.P.H., Kristen Mertz, M.D., M.P.H., and Kenneth Powell, M.D., M.P.H. Exposure to tobacco smoke is common among children with asthma, even though it is reported to be a trigger for asthma attacks for most children with asthma. More than one third of children with asthma who have tobacco smoke as a reported trigger are exposed to tobacco smoke in the household. This can lead to increased asthma attacks, increased use of medicine, and increased school absences and activity restrictions. Optimal management of asthma can reduce the burden of asthma on children, their caretakers, and society in general. The Division of Public Health's asthma program plans to promote education for providers, patients and their families to improve clinical management and increase avoidance of exacerbating environmental exposures. The Cancer and ALS Legal Initiative of the Atlanta Legal Aid Society works closely with social workers, doctors, nurses, and administrators in the healthcare community to address the need of patients for legal services. Many patients need help to get and protect the benefits to which they are entitled (such as Social Security, SSI, Medicaid, and Medicare), to defend against job, housing, and insurance discrimination, and to prepare wills and advance directives for their health care. The Initiative provides free legal services to low-income residents of Fulton, Dekalb, Cobb, Gwinnett, and Clayton Counties who are living with cancer or ALS. The Initiative may be reached at (404) 614-3969. -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 December 2003 Volume 19 Number 12 Reported Cases of Selected Notifiable Diseases in Georgia Profile* for August 2003 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 2003 2003 30 2059 13 3 78 1089 4 139 18 3 0 1 0 0 0 274 67 3 17 28 14 0 22 Previous 3 Months Total Ending in August 2001 2002 2003 220 211 209 8570 9018 8076 61 39 36 13 14 11 305 306 241 5081 5224 4173 17 14 9 289 90 234 128 119 51 2 6 9 1 2 2 8 7 6 1 0 0 6 11 2 0 0 0 717 847 866 145 438 209 32 27 21 81 95 75 140 190 115 205 190 91 6 3 1 121 164 99 Previous 12 Months Total Ending in August 2001 2002 2003 657 609 646 32309 34376 34510 160 130 117 35 56 30 1032 905 841 18724 18989 17433 102 99 68 850 559 647 427 454 406 13 15 32 1 5 10 52 41 33 8 3 1 25 27 21 0 0 0 1678 1892 1937 367 1529 1720 105 105 102 285 309 383 589 744 688 843 778 682 22 18 6 558 621 477 * 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 Total Cases Reported* <13yrs >=13yrs Total Percent Female Risk Group Distribution (%) MSM IDU MSM&IDU HS Blood Unknown Race Distribution (%) White Black Other 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 -