Georgia epidemiology report, Vol. 19, no. 8 (Aug. 2003)

August 2003

volume 19 number 08

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

Melanoma and Sunburn Risk in Georgia
Nationally, an estimated 54,200 people will be diagnosed with melanoma in 2003, and 7,600 will die from melanoma, the most serious form of skin cancer.1 The lifetime probability of developing melanoma in the United States is one in 58 males and one in 82 females. According to the Georgia Comprehensive Cancer Registry (GCCR), in recent years more than 1,380 Georgians have been diagnosed with melanoma (annual incidence 14 per 100,000) and more than 170 have died of melanoma (annual mortality 2.7 per 100,000).
Between 1973-1999, both incidence and mortality increased. The rate of increase for both incidence and mortality was slightly higher for males than females, and has slowed since 1980 (Figure 1). The increase in incidence for both males and females was about 6% per year from 1973-1979; but was 4% per year for males and 2% per year for females from 1980-1999. The annual increase in mortality was 4% for males and 3% for females from 1973-1979; but was only 1% for males and near zero for women from 1980-1999.2
In Georgia melanoma is the seventh leading cause of cancer incidence. Men are more likely than women to be diagnosed with melanoma (average annual age-adjusted incidence rate of 18.3/100,000 vs. 11.4/100,000) (Table 1). Melanoma is primarily a disease of whites; nationally rates are more than 10 times higher in whites than in blacks. In Georgia, white males have the highest incidence and mortality from melanoma (Table 1). An average of 173 (age-adjusted rate 2.7/100,000) Georgians die of melanoma each year. White males are two times more likely than white females to die of melanoma (5/100,000 vs. 2.2/100,000 per year) (Table 1).
Melanoma metastasizes relatively quickly, but when detected at an early stage and treated properly, it is highly curable. Survival rates differ by stage of diagnosis. The five-year survival rate is 96% if melanoma is diagnosed early (localized stage), but only 60% with regional metastasis and 14% for distant metastasis. Eighty-three percent of Georgians are diagnosed at a localized stage, eight percent at a regional and four percent at a distant stage. The stage is unknown for 6%. Overall survival for whites (89%) is better than for blacks (66%).
Prevention
Most melanoma skin cancers are due to excessive exposure to ultraviolet (UV) light. Since 1985, the American Academy of Dermatology has developed and promoted extensive educational campaigns about the dangers of sun exposure in the United States.1 Sun protective behaviors can lead to significant reductions in sun exposure and subsequent reduction in risk for melanoma skin cancer.1 Particularly, sunburn during childhood and intense intermittent sun exposure have been shown to increase the risk of melanoma.1 Therefore the following measures should be taken to reduce exposure and prevent sunburn:
Avoid direct exposure to sun during the midday hours (10 a.m. 4 p.m.). When outdoors, wear a hat that shades the face, neck and ears and a long sleeved shirt and
long pants. Wear sunglasses to protect the skin around the eyes. Use sunscreen with a sun protection factor (SPF) of 15 or higher.
Despite their importance, few data about sun protective behaviors are available at the state and national level. Sun exposure data were collected as part of the 1999 Georgia Behavioral Risk Factor Surveillance System (BRFSS), an on-going population-based, telephone survey that collects information about health behaviors and preventive practices related to the leading causes of death and disability. According to the 1999 BRFSS, 27.0% [95% Confidence Interval (CI) 24.8-29.1] of Georgia adults 18 years and older had a sunburn during the past 12 months. Sunburn was defined as any time even a small part of the skin was red for more than 12 hours. Men were more likely than women (31.1%, 95% CI 27.7-34.6 vs. 23.1%, 95% CI 20.5-25.8) to have had a sunburn. One in three whites had a sunburn within the past year, but sunburn was very rare among black adults (36.1%, 95% CI 33.3-38.8 vs. 3.7%, 95% CI 1.9-5.5). The likelihood of sunburn decreased as age increased (p<0.05, Figure 2, see note in Data Sources) and the likelihood of sunburn increased as income increased (p<0.05, Figure 3).

Early Detection
Careful inspection of the skin can detect melanoma early so that it can be treated successfully. Recognition of changes in skin growths or the appearance of new growths is the best way to find early skin cancer. Adults should practice regular skin self examination. Suspicious lesions should be evaluated promptly by a physician. Melanomas often start as small, mole-like growths that increase in size and change color. A simple ABCD rule outlines the warning signals of melanoma. A is for asymmetry: one half of the mole does not match the other half; B is for border irregularity: the edge is ragged, notched, or blurred; C is for color: the pigmentation is not uniform, with variable degrees of tan, brown, or black; D is for diameter: greater than 6 millimeters. Any sudden or progressive increase in size is of concern.

Georgia Department of Human Resources, Division of Public Health, in collaboration with the CDC. Data were weighted to the age, sex, and race distribution of the adult population in Georgia. Confidence intervals and test of linear trend were calculated using SUDAAN.
Definitions
Age-adjusted rate: A rate calculated in a manner that allows for the comparison of rates derived from populations with different age structures.
Cancer incidence rate: The number of new cancer cases occurring in a population during a specified period of time. Often expressed per 100,000 population.

Clinical Intervention
Although there is insufficient evidence to recommend routine total-body skin examination, clinicians should remain alert for skin lesions with malignant features (i.e. asymmetry, border irregularity, color variability, diameter >6 mm, or rapidly changing lesions) when examining patients for other reasons, particularly patients with established risk factors. Such risk factors include clinical evidence of melanocytic precursor or marker lesions (e.g., atypical moles, certain congenital moles), large numbers of common moles, immunosuppression, a family or personal history of skin cancer, substantial cumulative lifetime sun exposure, intermittent intense sun exposure or severe sunburns in childhood, freckles, poor tanning ability, and light skin, hair, and eye color. Appropriate specimens should be taken to evaluate suspicious lesions.4
Data Sources
The number of cases and incidence rates for the state of Georgia were obtained from the Georgia Department of Human Resources, Division of Public Health, Georgia Comprehensive Cancer Registry (GCCR). The GCCR is a population-based cancer registry that includes all cancer cases diagnosed in Georgia residents since January 1, 1995. GCCR collects, analyzes, utilizes and disseminates cancer incidence. This information is used to assist state agencies, health care providers, and Georgia citizens to monitor cancer incidence trends; plan and implement cancer control and prevention activities; develop public and professional education programs; and stimulate scientific cancer research.
The number of deaths and death rates for the state of Georgia were obtained from the Georgia Department of Human Resources, Division of Public Health, Vital Records Branch.
Behavioral risk factor data were obtained from the Behavioral Risk Factor Surveillance System, a state-based surveillance system administered by the

Cancer mortality rate: The number of cancer deaths occurring in a population during a specified period of time. Often expressed per 100,000 population.
Risk factor: A behavior, characteristic or physical finding that is consistently associated with increased probability of a disease or complications from the disease.
Cancer Stages
Local: an invasive malignant cancer confined entirely to the organ of origin. Regional: A malignant cancer that 1) has extended beyond the limits of the organ of origin directly into surrounding organs or tissue; 2) involves regional lymph nodes by way of lymphatic system; 3) has both regional extension and involvement of regional lymph nodes. Distant: A malignant cancer that has spread to parts of the body remote from the primary tumor either by direct extension or by discontinuous metastasis to distant organs, tissues or via the lymphatic system to distant lymph nodes.
References
1. Cancer Facts and Figures 2003, American Cancer Society, Inc, Atlanta, GA.
2. SEER Cancer Statistics Review 1973-1999, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD 2002.
3. What You Need to Know about Melanoma, National Cancer Institute, HIH Publication number 99-1563.
4. Guide to Clinical Preventive Services, Second Edition, Report of the U.S. Preventive Services Task Force, International Medical Publishing, Inc., April 1996.
This article was written by Rana Bayakly, M.P.H., Linda Martin, M.S., Chrissy McNamara, Ms.P.H., Pranesh Chowdhury, M.P.H., and Kenneth Powell, M.D., M.P.H.

Table 1 Age-adjusted melanoma incidence and mortality, by sex and race, Georgia

Incidence (1999-2000)

Mortality (1997-2001)

Both(95% CI)

Male (95% CI)

Female (95% CI)

All White Black

14 (13.6 -14.8) 16.2(15.5 - 17) 1.2 (0.8 - 1.7)

18.3(17.2-19.4) 20.6(19.2-21.9) 1.5 (0.7 - 2.3)

11.4 (10.6-12.0) 13.3 (12.4-14.0) 1.0 (0.6 - 1.6)

_ _ _ Rates are not calculated for number of events <20.

Both (95% CI) 2.7 (2.5 - 2.9) 3.4(3.2 - 3.6) 0.5(0.3 - 0.7)

Male(95% CI) 4.0 (3.7 - 4.3) 5.0 (5.5 - 4.6) _ _ _

Female(95% CI) 1.8 (1.6 - 2.0) 2.2 (2.0 - 2.5) 0.6 (0.4 - 0.8)

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Figure 1 Melanoma of the skin Surveillance Epidemiology & End Results age-adjusted incidence and mortality rate, 1973-1999
25

Incidence and Mortality per 100,000

20
Incidence
15

10
Mortality
5

0 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

Percent Percent

Figure 2. Percent of adults (age 18 and older) who had a sunburn in the last 12 months, by age, Georgia 1999

50

45

40

35

30

25

20

15

10

5

0

1 8 -2 4

2 5 -3 4

3 5 -4 4

4 5 -5 4

5 5 -6 4

65 and o ld e r

A g e Y e a rs

Figure 3. Percent of adults (age 18 and older) who had a sunburn in the last 12 months, by income, Georgia 1999

50

45

40

35

30

25

20

15

10

5

0

L e s s th a n

$ 1 5 ,0 0 0 -

$ 2 5 ,0 0 0 -

$ 5 0 ,0 0 0 -

$ 7 5 ,0 0 0 o r

$ 1 5 ,0 0 0

$ 2 4 ,9 9 9

$ 4 9 ,9 9 9

$ 7 4 ,9 9 9

m o re

A n n u a l H o u s e h o ld In c o m e

GEORGIA TRACKS ASEPTIC MENINGITIS OUTBREAK

In April 2003, the Georgia Division of Public Health (GDPH) became aware of an outbreak of aseptic (viral) meningitis in Augusta. The outbreak has subsequently spread to other parts of Georgia, including Atlanta, Gainesville, and Athens, and may spread further. The cause of the outbreak appears to be Echovirus 9, an enterovirus that is spread by fecal and oral routes. Most infections with Echovirus 9 do not cause illness, while approximately 1 in 1000 infections leads to meningitis. Thorough and frequent handwashing is the best way to prevent spread of this virus.

From January through June 2003, more than 200 cases of aseptic meningitis have been reported to GDPH. The majority of cases associated with this outbreak have occurred among children under age 18 years and their caregivers. No deaths associated with this outbreak have been reported. Healthcare providers who identify an increase in aseptic meningitis cases should alert their district public health office, or contact GDPH at 404-657-2588. Aseptic meningitis is a notifiable disease and cases must be reported to public health within seven days. More information about aseptic meningitis may be found on the GDPH website at http://health.state.ga.us.

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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

August 2003

Volume 19 Number 08

Reported Cases of Selected Notifiable Diseases in Georgia Profile* for May 2003

Selected Notifiable Diseases

Total Reported for May 2003
2003

Previous 3 Months Total

Ending in May

2001

2002

2003

Previous 12 Months Total

Ending in May

2001

2002

2003

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

51

147

160

126

611

645

627

2359

7990

8487

8040

31987

33854

34445

3

25

21

20

176

156

109

1

4

12

3

42

56

36

48

232

206

159

1143

903

894

1170

4111

4570

3794

19644

18943

17947

4

35

24

18

96

101

71

29

239

147

115

608

834

448

21

87

115

107

409

440

468

2

3

4

6

11

13

24

2

0

0

3

0

2

10

3

14

12

8

53

42

34

0

5

2

1

7

4

1

3

7

9

6

35

26

26

0

0

0

0

1

0

0

94

236

315

225

1668

1785

1857

131

70

313

322

323

1129

1902

3

18

21

14

105

106

97

17

74

70

73

286

293

360

34

176

150

132

568

678

656

21

251

178

123

836

790

678

0

7

4

0

23

22

6

23

121

158

96

636

572

506

* 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: 07/02-06/03 Five Years Ago: 07/98-06/99 Cumulative: 07/81-06/03

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

0

1,332 1,332

11

1,618 1,629

211

26,355 26,566

Percent Female

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

25.8

32.9

7.5

1.8

12.9

1.3

43.6

23.6

37.0

15.8

4.2

19.0

1.5

22.4

18.0

47.2

17.0

5.4

13.7

1.9

14.8

Race Distribution (%) White Black Other

17.6 77.3

5.1

21.1 76.8

2.1

33.4 64.1

2.5

MSM - Men having sex with men

IDU - Injection drug users

HS - Heterosexual

* Case totals are accumulated by date of report to the Epidemiology Section

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