January 2004 volume 20 number 1 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 January is Birth Defects Prevention Month ...but any month is the month to prevent birth defects Birth Defects -- Expanded Surveillance Activities in Georgia Birth defects are abnormal structural or functional/metabolic conditions that happen before or at the time of birth. Some are mild, like an extra finger or toe. Some are very serious, like a heart defect. They can cause physical, mental, or medical problems. Some, like Down syndrome or sickle cell anemia, are caused by genetic factors. Others are caused by certain drugs, medicines, or chemicals. The causes of most birth defects are still a mystery. Researchers are working hard to learn the causes of birth defects so we can find ways to prevent them.* About 120,000 babies born in the U.S. each year have birth defects. The overall prevalence and incidence of birth defects in Georgia is currently unknown. However, based on data from Vital Records and data provided by the Metropolitan Atlanta Congenital Defects Program (MACDP), it is estimated that approximately 3,000-3,500 children with birth defects are born each year in Georgia. Table 1 shows the top ten birth defects in Georgia from 2000-2002 as reported on birth and fetal death certificates. Over the three-year period there have been substantial increases in the rates of infants born with circulatory/respiratory anomalies, heart malformations, musculoskeletal anomalies, other chromosomal anomalies and Down syndrome. In an effort to improve surveillance outside of the metropolitan Atlanta area, which is home to the CDC's MACDP, we designed the Georgia Birth Defects Reporting and Information System (GBDRIS), a surveillance system to provide information on incidence, prevalence, trends and epidemiology of birth defects. The GBDRIS collects information on children from birth to six years of age. The system relies on existing data as well as hospital, laboratory and provider reporting. The GBDRIS is maintained by the Maternal and Child Health Section of the Epidemiology Branch, Division of Public Health, Department of Human Resources (DHR). A crucial source of information is the accurate and timely reporting of birth defects by medical providers and hospitals. To be able to provide reporters with assurances of confidentiality, birth defects have recently been added to the Notifiable Disease List in Georgia. The GBDRIS pilot project began in April 2003 and involves 17 hospitals, medical centers and laboratories. The two hospitals with the highest number of births from each perinatal region were selected. In addition, the Regional Perinatal Centers were also included if they were not one of the top two birthing hospitals. Birth defect reporting files and/or forms from pilot sites are collected monthly. Line listings of all cases in each district will be sent to the appropriate district's Children 1st Coordinator with the request for updates and 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. Did You Know?* Birth Defects are the leading cause of death in children less than 1 year of age--causing one in every five deaths. 18 babies die each day in the U.S. as the result of a birth defect. Defects of the heart and limbs are the most common kinds of birth defects. Millions of dollars are spent every year for the care and treatment of children with birth defects. follow up information. This will help to ensure that children identified through GBDRIS are receiving appropriate public health services. We have received over 3000 reports of birth defects and have identified 21 Neural Tube Defects (NTDs) in 2003. The NTD Enhanced Surveillance Project, another new GBDRIS activity, was initiated in 2003. The goal of this project is to collect more complete, accurate, and timely data on NTDs. These data will be used to help develop and evaluate folic acid promotion activities in the state. All NTD reports will be flagged during the pilot as well as after full implementation of the surveillance system and additional information will be collected on each case. This enhanced surveillance activity for NTDs will occur at all sites outside of the metropolitan Atlanta area. The CDC's MACDP is currently collecting extended data on all birth defects including NTDs in the metropolitan area. We will be collaborating with the MACDP to create a complete state file containing extended reports on all identified NTD cases. Table 1. Top Ten Birth Defects in Georgia, 2000-2002** Rate per Rate per Rate per 10,000 Live 10,000 Live 10,000 Live 2000 Births 2001 Births 2002 Births 1 Other circulatory/ 9.30 Heart malformations 9.59 Other circulatory/ 13.73 respiratory anomalies respiratory anomalies 2 Heart malformations 7.94 Other circulatory/ respiratory anomalies 9.52 Heart malformations 11.55 3 Cleft lip/palate 7.48 Other musculoskeletal anomalies 7.12 Other urogenital anomalies 6.98 4 Other urogenital anomalies 6.35 Cleft lip/palate 7.04 Other musculoskeletal anomalies 6.68 5 Polydactyl/syndactyl/adactyly 5.52 Other urogenital anomalies 6.97 Other gastrointestinal anomalies 6.08 6 Other musculoskeletal anomalies 4.91 Polydactyly/syndactyly/adactyly 6.07 Cleft lip/palate 6.23 7 Club foot 4.61 Other chromosomal anomalies 4.95 Other chromosomal anomalies 5.70 8 Other chromosomal anomalies 3.70 Down syndrome 4.05 Polydactyly/syndactyly/adactyly 5.63 9 Down syndrome 3.25 Club foot 3.67 Down syndrome 5.03 10 Hydrocephalus 2.80 Other gastrointestinal anomalies 3.22 Club foot 4.88 *(Source: National Birth Defects Prevention Network (NBDPN) pamphlet: Important Information about Preventing Birth Defects) **Based on birth and fetal death certificates. Data from the Office of Health Information and Policy, Division of Public Health, GA Department of Human Resources. This article was written by Debra L. Hersh, M.P.H. and Hema Joshi, M.Med.Sci. Neural Tube Defects Neural tube defects are a group of disorders caused by failure of development of the structures that form and enclose the spinal cord and brain. Fifty seven percent of these defects are openings in the spine (spina bifida), which lead to a loss of sensation and muscle control below the opening. In the remainder of cases, the top of the brain and skull do not develop. This condition, called anencephaly, invariably leads to death of the infant. The Role of Folic Acid in Prevention Folic acid plays a large role in preventing neural tube defects. Studies have shown that addition of folic acid to the diet of women of childbearing age may reduce the incidence of neural tube defects by 50-70%. 1,2,3 In 1992, the U.S. Public Health Service recommended that "women of childbearing age (15- 44) who are capable of becoming pregnant should consume 400 micrograms of folic acid per day to reduce the risk of spina bifida or other NTDs". Women who have already had a pregnancy affected by a NTD are urged to consume at least 4000 micrograms of folic acid each day. These guidelines should be followed regardless of whether they are planning to become pregnant, as most pregnancies are unplanned. Folic acid, or folate as it is called in its naturally occurring state, is a member of the B complex group of vitamins. In 1998 the Food and Drug Administration required all enriched grain products to be fortified with 140 mcg of synthetic folic acid per 100g of food. 4 Enriched grains include breads, cereals and pasta. Some breakfast cereals contain the daily recommendation of 400 mcg of folic acid in a single serving, including Smart Start, Multigrain Cheerios, Total -2 - and Product 19. Check the food label on the side of the box to determine the level in your favorite cereal. Natural food does contain folate but in smaller amounts. Natural sources of folate include: orange juice and other citrus juices, green leafy vegetables, avocados, dried beans and peas, lentils, okra, broccoli, and asparagus. Since many women of childbearing age do not receive the recommended daily allowance through diet alone, multivitamins are the most effective way of obtaining the recommended amount of folic acid. In Georgia Neural tube defects are among the most common birth defects, affecting about 1 in 1,400 infants born in Georgia or about 100 cases per year. Sixty percent of neural tube defect cases occur among White mothers, 30% among African-American women, 8% Hispanic and 2% other races/ethnicities, similar to the population proportions in the state. A higher proportion of mothers over 20 years of age had babies with NTDs. The data for Georgia suggests that after the mandatory fortification in 1998, the rates for NTDs decreased. However, the rates remain higher than the national average (1 per 2,500 babies), so awareness and education efforts need to continue. This article was written by Hema Joshi, M. Med. Sci. and Debra L. Hersh, M.P.H. References: 1. Mulinare J, Cordero JF, Erickson JD et al. Periconceptional use of multivitamins and the occurrence of neural tube defects. JAMA 1988, 260; 3141-5. 2. Mulinsky A, Jick H, Jickss et al. Multivitamin/folic acid supplementation in early pregnancy reduces the prevalence of neural tube defects JAMA 1989, 262: 2847-52. 3. MRC vitamin study research group. Prevention of neural tube defects: results of the Medical Research Council vitamin study. Lancet 1991, 338:131-7. 4. Federal register March 5th 1996; 61:8781-97. What Steps Can Women Take for Healthier Babies? * Not all birth defects can be prevented. But, a woman can increase her own chance of having a healthy baby. Many birth defects happen very early in pregnancy, sometimes before a woman even knows she is pregnant. Remember that about half of all pregnancies are unplanned. Threrefore, every woman should: Take a multivitamin that has 400 mcg of folic acid in it every day. Have regular medical check-ups. Talk to her health care provider about any medical problems and medicine use (both over-the-counter and prescription). Ask about avoiding any substances at work or at home that might be harmful to a developing baby. Keep vaccinations up-to-date. Eat a healthy, balanced diet. Avoid eating raw or undercooked meat. Avoid alcohol, tobacco, and street drugs. While pregnant: Keep up these healthy habits. Get early prenatal care and go to every appointment. *(Source: National Birth Defects Prevention Network (NBDPN) pamphlet: Important Information about Preventing Birth Defects) -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 January 2004 Volume 20 Number 1 Reported Cases of Selected Notifiable Diseases in Georgia Profile* for October 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 October 2003 2003 38 641 9 2 81 370 1 108 59 1 0 2 0 0 0 257 83 9 20 24 27 0 35 Previous 3 Months Total Ending in October 2001 2002 2003 171 198 155 8734 9345 6256 69 42 32 21 9 8 300 304 262 5096 5157 3293 19 13 9 304 105 388 151 103 199 2 10 10 1 2 1 10 5 6 1 0 2 3 8 3 0 0 0 670 817 832 232 664 220 25 28 29 74 111 66 159 201 109 213 195 120 5 3 0 137 144 108 Previous 12 Months Total Ending in October 2001 2002 2003 642 625 655 32745 34522 32677 165 124 116 44 48 30 1021 907 854 18580 19008 16456 104 97 67 903 522 801 451 447 662 12 18 32 1 5 13 53 40 32 8 3 3 23 29 21 0 0 0 1683 1957 1982 455 1757 1484 96 111 111 297 321 392 613 742 683 856 787 704 24 16 10 583 599 481 * 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 -