Georgia epidemiology report, Vol. 19, no. 5 (May 2003)

May 2003

volume 19 number 05

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

Knowledge and Use of Folic Acid Among Women in Georgia, 1999-2000

Seventy percent of neural tube defects, comprising defects of the brain and spinal cord, could be prevented by the daily consumption of 400 micrograms of folic acid before and during the early weeks of pregnancy. Since 1992 all women capable of becoming pregnant have been advised to consume 400 micrograms of folic acid per day to reduce the risk of having a pregnancy affected by neural tube defects (1). The Food and Drug Administration has required since 1998 that enriched cereal grain products (i.e. breakfast cereals, breads, and flour) be fortified at the level of 140 micrograms of folic acid per 100 grams of grain to increase consumption of folic acid through food. Serum folate levels for US women of reproductive age were higher in 1999-2000 (13.0 ng/mL) compared to 1988-1994 (4.8 ng/ mL), presumably due to consumption of fortified foods (2). However, serum folate levels among women in Georgia (8.9 ng/mL) are below the US average overall, and certain demographic groups are at greater risk than others (3).
Daily consumption of a multi-vitamin or folic acid supplement can benefit women who are not getting adequate folic acid thorough food. In 1995, a study by the Georgia Division of Public Health found that only 20% of women ages 15-44 took a daily multi-vitamin supplement, and 29% knew that folic acid can prevent birth defects (4). This report updates those results with findings from a similar study conducted in 1999 and 2000 among women ages 1844 which shows that 39% took a daily multivitamin or folic acid supplement and only 37% knew folic acid prevents birth defects.

Methods
We analyzed the responses of 2003 women ages 18 to 44 who participated in the 1999 or 2000 Georgia Behavioral Risk Factor Surveillance System (BRFSS), an on-going random digit dial telephone survey of the adult non-institutionalized population of Georgia (5). The survey included questions on a wide range of health conditions and risk behaviors, including consumption of folic acid in multi-vitamins or supplements and knowledge of the reason folic acid is recommended. Responses were weighted to adjust for selection probability and nonresponse to produce estimates representative of the population of adult women ages 18-44 in Georgia. Estimates and confidence intervals (CI) for folic acid supplement consumption and awareness of the health benefit of folic acid were calculated using SUDAAN, a statistical software for the analysis of complex survey data (6).

Results
Among Georgia women ages 18-44, 39.0% (95% CI 36.1-41.9) took a multivitamin or supplement containing folic acid at least once per day. Women with more than a high school

Projected Number of Children Born with Neural Tube Defects in Georgia

The number of cases actively ascertained by the Metropolitan Atlanta Congenital Defects Program (MACDP)* in the 5-county metropolitan Atlanta area was used to estimate the statewide number of cases (births and fetal deaths greater than or equal to 20 weeks) of Spina Bifida and Anencephaly by racial/ethnic group for the years 1994 through 2001.

Race/ Ethnicity White (NonHispanic) Black (NonHispanic)
Other**
Hispanic
Total

Defect 1994 1995 1996 1997 1998 1999 2000

Spina Bifida 55 33 38 69 42 18 18

Anencephaly 20 33 41 31

7 32 29

Spina Bifida 12

2 16

9 29

9

7

Anencephaly

7

9

9

7 13 16 18

Spina Bifida

0

0

2

7

0

3

0

Anencephaly

1

0

3

3

1

6

3

Spina Bifida

0

6

6

4

2

0 11

Anencephaly

0

6

4

0

1

6

3

Spina Bifida 67 41 62 89 73 30 36

Anencephaly 28 48 57 41 22 60 53

*MACDP10 is managed by the Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities ** Other includes Asian, American Indian or Alaska Native, Hawaiian or Other Pacific Islander, Multiracial and Unknown

education or higher household income were more likely to consume folic acid supplements. Unemployed women were significantly less likely than employed women or homemakers to take daily folic acid supplementation (Table 1).
Just over one-third of women of reproductive age (36.7%, 95% CI 33.9-39.5) correctly identified "birth defects prevention" as the reason that folic acid is recommended (Figure 1). Women ages 25-34 were the most likely age group to know folic acid was recommended to prevent birth defects. Women with higher education and higher household income were also more likely to correctly identify the reason that folic acid is recommended. Women with a spouse or partner were more likely than divorced, separated, or widowed women and never married women to know that folic acid prevents birth defects, and homemakers were more knowledgeable than employed women or students (Table 1).
Among women who were aware of the health benefit of folic acid almost half consumed daily folic acid supplements (45.4%, 95% CI 40.6-50.2). However, among women who were not aware of the health benefit only about one-third took folic acid daily (35.1%, 95% CI 31.6-38.7).
Discussion
These findings indicate that most women of reproductive age do not take a daily folic acid supplement (61%) and are not aware that folic acid is recommended to prevent birth defects (63%). One of the Healthy People 2010 goals is for 80% of all non-pregnant women ages 15-44 to consume 400 micrograms of folic acid each day from fortified foods or dietary supplements. Women who were knowledgeable about the benefit of folic acid were more likely to consume daily folic acid supplements, suggesting that increasing awareness of the benefit will result in more women of childbearing age consuming adequate folic acid through supplementation.
Although the survey was limited to self-report data among households with telephones and included few non-black minority households, the findings confirm similar national surveys that found an increase in folic acid awareness from 64% to 73% between 1996 and 1998 among women who had a recent pregnancy (7) and an increase in consumption from 25% to 31% between 1995 and 2002 (8).
In the decade since the Public Health Service recommendations, many efforts have been undertaken to increase knowledge and awareness of folic acid consumption and reduce the incidence of neural tube birth defects in Georgia, including the creation of the Georgia Folic Acid Task Force (See box). Our results suggest that particular attention should be focused on socio-demographic groups with low income and low education. Pregnancy planning to decrease the incidence of unintended pregnancy; increased consumption of foods naturally rich in folates (e.g. fruits, green leafy vegetables, and dried beans and le-

Table 1. Percent of Women 18-44 who Consume Daily Folic Acid Supplement and Know Folic Acid is Recommended to Prevent Birth Defects, Georgia, 1999-2000

Take a Folic Acid Supplement Daily

Know That Folic Acid is Recommended to Prevent Birth Defects

N

% 95% CI % 95% CI

Total Age

1874 39.0 36.1-41.9 36.7 33.9-39.5

18-24

275

36.4 28.8-44.0 31.5 24.5-38.5

25-34

732

40.6 36.2-45.0 43.9 39.5-48.3

35-44

867

39.2 35.3-43.1 33.3 29.4-37.2

Race/Ethnicity

White, non-Hispanic

1149 41.1 37.5-44.7 40.8 37.2-44.3

Black, non-Hispanic

611

35.3 30.2-40.4 29.5 24.5-34.5

Hispanic

69

34.6 21.1-48.1 31.0 17.5-44.4

Other, non-Hispanic

35

33.4 16.4-50.4 28.0 11.7-44.3

Education

High School or Less

756

29.0 24.9-33.0 25.8 21.8-29.8

Some College/Tech School

521

40.3 34.5-46.0 33.6 28.3-38.9

College, 4 years or more

597

51.0 46.0-55.9 54.1 49.2-59.0

Household Income

Less than $25,000

522

33.5 27.5-39.5 25.9 20.7-31.1

$25,000 - $50,000

637

37.4 32.9-41.9 38.7 34.1-43.3

$50,000 - $75,000

295

41.1 34.2-48.0 40.8 34.1-47.5

More than $75,000

249

55.5 48.1-62.9 52.8 45.3-60.3

Marital Status

Never married

462

34.7 28.4-41.0 31.4 25.6-37.2

Married/Unmarried Couple 1022 41.9 38.3-45.5 41.3 37.7-44.9

Divorced/separated/widowed 387

36.5 30.5-42.5 27.8 22.5-33.1

Employment Status

Employed

1383 38.7 35.4-42.0 34.3 31.2-37.4

Unemployed

105

23.6 14.7-32.5 34.7 22.0-47.4

Homemaker

240

44.5 36.8-52.2 53.8 46.4-61.2

Student

82

45.6 29.5-61.7 30.7 17.9-43.5

Retired/Unable to work

58

37.3 19.9-54.7 30.4 13.3-47.6

gumes); consumption of folate fortified foods; and daily consumption of multivitamins or folic acid supplements are all strategies that will improve blood folate levels among women of reproductive ages and reduce the incidence of related birth defects.

References

1. CDC. Recommendations for the use of folic acid to reduce the number of cases of spina bifida and other

neural tube defects. MMWR 1992;41 (No. RR-14).

2.

CDC. Folate status in women of childbearing age, by race/ethnicity--United States, 1999-2000. MMWR

2002:51 (No. 36).

3. CDC. Serum folate levels among women attending family planning clinics--Georgia, 2000. MMWR

2002:51 (No. RR-13).

4. CDC. Knowledge about folic acid and use of multivitamins containing folic acid among reproductive-aged

women--Georgia 1995. MMWR 1996:45(No. 37).

5. http://www.cdc.gov/brfss/usersguide.htm

6. Research Triangle Institute (2001). SUDAAN User's Manual, Release 8.0Research Triangle Park, NC:

Research Triangle Institute.

7. CDC. Are Women with recent live births aware of the benefits of folic acid? MMWR 2001:50(No. RR6).

8. March of Dimes. Folic acid and the prevention of birth defects. A national survey of pre-pregnancy

awareness and behavior among women of childbearing age. 1995-2000. White Plains, NY: March of

Dimes, June 2000, publication no. 31-1404-00.

9. Edmonds LD, Layde PM, James LM, et al. Congenital malformations surveillance: two American systems.

Int J Epidemiol 1981;10:247-52.

Article written by Linda M. Martin, M.S. and Bina Jayapaul-Philip, Ph.D.

Figure 1. Knowledge of Reason Health Professionals Recommend Folic Acid, Women 18-44, Georgia, 1999-2000

To make strong bones 18%

Don't know/not sure 28%

To prevent birth defects 35%

Some other reason 13%
To prevent high blood pressure 5%

The Georgia Folic Acid Task Force
The Georgia Folic Acid Task Force (GFATF) includes members from public and private health agencies, professional medical associations, non-profit organizations, and consumer representatives who are committed to promoting the consumption of folic acid to prevent birth defects. Since its inception in 1997, the GFATF has been involved with increasing public knowledge about folic acid and encouraging its use to prevent neural tube defect births. In 2003, one of the GFATF's major goals will be to target the Hispanic female population with awareness and education activities. In addition, the Task Force will seek to create partnerships with pharmacies to distribute the folic acid message. For more information on the GFATF contact Eddie Towson, Georgia Division of Public Health, 404-463-0406 or email at eltowson@dhr.state.ga.us.
-2 -

Revised Guidelines Recommend Prenatal Screening for Perinatal GBS Disease Prevention

Despite a marked reduction during the 1990's, Group B streptococcal (GBS) disease remains the leading cause of invasive bacterial infection in newborns less than a week old in the United States. This "early-onset" GBS disease is thought to occur as a result of infant exposure to GBS during labor, following bacterial ascent through the ruptured membranes and aspiration of amniotic fluid. Provided that maternal GBS colonization can be identified, early-onset GBS cases are largely preventable with the use of intrapartum antibiotics1. New perinatal GBS prevention guidelines were issued by the Centers for Disease Control and Prevention (CDC) in 2002, and are endorsed by the American College of Obstetrics and Gynecology and the American Association of Pediatrics2. The new guidelines recommend universal screening of pregnant women for GBS colonization by vaginalrectal culture at 35 to 37 weeks gestation. If the screening culture is positive for GBS, antibiotics are offered during labor to reduce the risk of infant GBS exposure during birth. Previous guidelines (1996) allowed a choice of the above "screening-based approach" or a "risk-based approach" which offered intrapartum antibiotics to women with certain obstetric risk factors during labor. The screeningbased approach was recently shown to be at least 50% more effective than the risk-based approach, leading to the new recommendations for universal screening.3 Under the new guidelines: 1) Universal screening is recommended (Figure 1): whenever pos-
sible, a prenatal screening culture is obtained at 35 to 37 weeks' gestation to identify maternal colonization with GBS. The screening culture is taken from both vaginal and rectal sources, and cultures are processed in selective broth culture medium to increase detection of GBS by inhibiting competing bacterial flora. If the culture is positive for GBS, antibiotics are offered during labor to reduce the risk of infant GBS exposure during birth. 2) Women whose culture results are unknown at delivery are to be managed according to the risk-based approach; the obstetric risk factors remain unchanged (i.e.: preterm labor <37 weeks' gestation, membrane rupture >18 hours, or intrapartum temperature > 100.4 F (>38.0 C)). Women with these risk factors and unknown GBS screening culture results at the time of delivery should be offered intrapartum antibiotics. 3) Women with negative vaginal and rectal GBS screening cultures within 5 weeks before delivery do not require intrapartum antibiotics for GBS prevention, even if they develop obstetric risk factors. 4) As before, women with GBS bacteriuria during the current pregnancy or who previously gave birth to an infant with

early-onset GBS disease should receive intrapartum antibiotic prophylaxis. The complete guidelines also include: Updated intrapartum antibiotic regimens for women with penicillin allergy, in light of emerging clindamycin and erythromycinresistant GBS isolates; Instructions on antimicrobial susceptibility testing for clindamycin and erythromycin for penicillin-allergic patients; Algorithm for management of patients with threatened preterm delivery; Recommendation against routine intrapartum antibiotics for GBS-colonized women undergoing planned Cesarean delivery who have not begun labor or had rupture of membranes; Expanded instructions on specimen collection and culture methods; Updated algorithm for management of newborns exposed to intrapartum antibiotic prophylaxis. The success of the screening-based approach is enhanced by best practices for specimen collection and handling, laboratory culture methods, timely reporting of results, and familiarity with the new guidelines by a complex team of healthcare professionals. We encourage obstetric and pediatric providers, other prenatal care providers, infection control practitioners, laboratorians, and hospital maternity staff to review and discuss the revised guidelines, which can be found at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5111a1.htm. In addition, CDC has developed a GBS prevention website, with useful educational print materials and slidesets at http://www.cdc.gov/groupBstrep/default.htm.
Rates of early-onset GBS disease in Georgia have been consistently higher than the national average, and remain higher than Healthy People 2010 goals (Table 1). Widespread adoption of the newly issued GBS prevention guidelines could improve this situation.
References: 1) CDC. Early-onset Group B Streptococcal disease--United States, 1998-1999.
MMWR 2000; 49: 793-796. 2) Centers for Disease Control and Prevention. Prevention of perinatal group
B streptococcal disease: revised guidelines from CDC. MMWR 2002; 51(RR11): 1-23. 3) Schrag SJ, Zell ER, Lynfield R, et al. A population-based comparison of strategies to prevent early-onset group B streptococcal disease in neonates. NEJM 2002; 347: 233-239.
Article written by Kathryn E. Arnold, M.D.

Figure 1. Indications for intrapartum antibiotic prophlyaxis to prevent pernatal GBS disease under a universal prenatal screening strategy based on combined vaginal and rectal cultures collected at 35 - 37 weeks' gestation from all pregnant women
Vaginal and rectal GBS screening cultures at 35-37 weeks' gestatation for ALL pregnant women (unless patient had GBS bacteriuria during the current pregnancy or a previous infant with invasive GBS disease)

Intrapartum prophylaxis indicated Previous infant with invasive GBS disease GBS bacteriuria during current pregnancy Positive GBS screening culture during current pregnancy (unless a planned cesarean delivery, in the absence of labor or amniotic membrane rupture, is performed) Unknown GBS status (culture not done, incomplete, or results unknown) and any of the following:
Delivery at <37 weeks' gestation Amniotic membrance rupture>18 hours Intrapartum temperature>100.40F (>38.00C)*

Intrapartum prophylaxis not indicated Previous pregnancy with a positive
GBS screening culture (unless a culture was also positive during the current pregnancy) Planned cesarean delivery performed in the absence of labor or membrane rupture (regardless of maternal GBS culture status) Negative vaginal and rectal GBS screening culture in late gestation during the current pregnancy, regardless of intrapartum risk factors

Table 1. Emergining Infections Program data regarding the incidence of early-onset GBS disease for the Atlanta Metropolitian Area compared to the national average, 1998-2001.

POPULATION
Metro Atlanta National Average Healthy People 2010 Goal

INCIDENCE RATE

1998

1999

2000

2001

0.92* 0.74* 0.67* 0.63*

0.6+

0.4+

0.6+

0.5V

0.5 cases per 1,000 live births

* Cases per 1,000 live births in the Atlanta Metropolitan Area + Cases per 1,000 live births V Cases per 1,000 persons <1 year of age

*If amnionitis is suspected, broad-spectrum antibiotic therapy that includes an agent known to be active against GBS should replace GBS prophylaxis.

-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

May 2003

Volume 19 Number 05

Reported Cases of Selected Notifiable Diseases in Georgia Profile* for February 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 February 2002
2002 18
2105 4 2 25
1007 2 21 10 1 1 5 0 0 0 21 43 7 18 25 14 0 19

Previous 3 Months Total

Ending in February

2000

2001 2002

105

106

97

7769

8329

7709

34

33

15

5

6

7

241

161

176

4352

4539

3869

31

38

13

145

142

94

116

87

82

2

3

4

0

1

1

21

9

13

2

0

0

5

3

2

0

0

0

252

265

190

75

365

379

24

29

22

62

56

65

134

203

97

195

200

104

6

5

0

191

149

88

Previous 12 Months Total

Ending in February

2000

2001 2002

622

632

647

30254

33117

33839

182

160

110

45

48

46

1169

925

912

19429

18356

18224

85

112

73

438

926

458

390

412

456

11

12

21

0

2

2

52

44

39

3

7

2

39

24

26

1

0

0

1694

1711

1935

331

887

1853

121

99

100

281

296

319

550

697

608

756

851

626

21

24

6

687

535

536

* 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: 04/02-03/03 Five Years Ago: 04/98-03/99 Cumulative: 07/81-03/03

Total Cases Reported* <13yrs >=13yrs Total

1

1,371 1,372

11

1,265 1,276

211

25,928 26,139

Percent Female
26.6
20.8
17.8

MSM
34.6 39.2 47.3

Risk Group Distribution (%) IDU MSM&IDU HS Blood Unknown

7.1

2.0

13.1

1.5

41.7

17.0

5.5

17.9

1.1

19.2

17.2

5.4

13.5

1.9

14.8

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

18.7 75.9

5.4

22.6 74.9

2.4

33.7 63.8

2.5