Georgia epidemiology report, Vol. 22, no. 01 (Jan. 2006)

January 2006

volume 22 number 01

January is Birth Defects Prevention Month

. . . but any month is the month to prevent birth defects.

Birth defects are abnormal structural or functional/metabolic conditions that are present at 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 birth defects are caused by genetic factors like Down syndrome or sickle cell anemia. Others are caused by certain drugs, medicines, or chemicals. The causes of most birth defects are still unknown. Researchers are working hard to learn the causes of birth defects so we can find ways to prevent them. **
The good news is that new ways of preventing and treating birth defects are being found. Folic acid is a B vitaimin that can help prevent birth defects of the brain and spinal cord called neural tube defects (NTDs). Genes that may cause birth defects are being discovered every day, providing hope for new treatments and cures. Genetic counseling can provide parents with information about their risks based on family history, age, ethnic or racial background,

or other factors. Better health care for mothers with problems like diabetes or seizures can improve their chances of having healthy babies. In addition, immunization prevents infections like German measles (rubella) that can harm unborn babies.**
Did You Know? Birth defects are the leading cause of death in children less than one 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 birth defects. Millions of dollars are spent every year for the care and treatment of children with birth defects.**
**Source: National Birth Defects Prevention Network (NBDPN) pamphlet: Important Information about Preventing Birth Defects

The Georgia Birth Defects Reporting and Information System (GBDRIS) was designed to provide information about the epidemiology of birth defects in Georgia. The GBDRIS is a statewide surveillance system with passive case ascertainment, which means that cases are identified and reported by hospitals, medical centers, and
Number of Hospitals/Medical Centers Reporting from each Public Health District
12

other providers. The system was implemented during 2003 as a pilot project in 15 hospitals and medical centers. Due to the success of the pilot project, the surveillance system was expanded statewide to all the birthing hospitals and medical centers. The system now captures a total of 92 facilities (91%) of all birthing hospitals that are currently reporting on a regular basis.
The chart below illustrates the number of hospitals that are reporting from each of the public health districts in Georgia.
Neural Tube Defects--Enhanced Surveillance As part of our increased efforts to prevent neural tube defects (NTDs) we are flagging all NTD cases and are collecting additional information on each case on a monthly basis. The additional data will help us to further develop prevention strategies.

No. of Hospitals/Medical Centers Rome Dalton Gainsville Cobb Fulton Clayton Gwinnett Dekalb La Grange Dublin Macon Augusta Columbus Valdosta Albany Savannah Waycross Athens

10 8 6 4 2 0
Public Health Districts

Newborn Surveillance and Tracking System (NSTS) The NSTS is a web-based newborn surveillance and tracking system for the collection, management and analysis of newborn and child health and case management information. It will provide secure access for approved private and public health care providers and local, district and state level program managers. The purpose of the NSTS is to:
Provide rapid identification of every newborn Assure follow up and referrals through tracking Establish a unified child health profile over time Assess the burden of health conditions and risk
factors through surveillance Evaluate programs

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. If yes, please send your name and e-mail address to Gaepinfo@dhr.state.ga.us.

The NSTS will collect and integrate information for five programs that help address problems associated with infant morbidity/mortality and poor health outcomes of young children. The following programs will be integrated in the final system:
Children 1st Hearing Screening, Diagnosis and Intervention Newborn Blood Spot Screening Georgia Birth Defects Reporting and Information Sys-
tem (GBDRIS) Georgia Childhood Lead Poisoning Prevention Pro-
gram (GCLPPP) Vital Events Registration (birth, death and fetal death
certificates)
INFORMATION ON BIRTH DEFECTS AND RELATED LINKS http://health.state.ga.us/epi/mch/birthdefects/index.asp http://health.state.ga.us/epi/mch/birthdefects/gbdris/links.asp

INFORMATION ON THE GBDRIS http://health.state.ga.us/epi/mch/birthdefects/gbdris/index.asp Written by: Debra L. Thompson, MPH and Hema Joshi, M.Med.Sci
FOLIC ACID: Helps prevent birth defects; Reduces the risk of other birth defects such as cleft lip, cleft palate and heart defects; May reduce the risk of cardiovascular disease and colon, cervical and breast cancer; and may even help prevent Alzheimer's disease.

Obesity, Diabetes and Birth Defects

Obesity and diabetes are intimately related. Both of these conditions have similar metabolic abnormalities which include insulin resistance and hyperinsulinemia.1 These conditions occur both alone and in combination. They are also risk factors for birth defects, more specifically, neural tube defects. This section focuses on both obesity
and diabetes.

OBESITY Obesity is defined as an abnormal accumulation of body fat in proportion to body size. It is typically measured using the height and weight of an individual to calculate the Body Mass Index. It is the most commonly used indicator of obesity.2,3
BMI = [WEIGHT (KG)] [HEIGHT (M)]2

The Institute of Medicine has set the following cut off points to determine categories of weight status

Underweight Normal weight Overweight Obese

BMI
< 19.8 19.8-26.0 26.0-29.0
> 29.0

Obesity has become a major public health issue all over the world.4
The increased prevalence of obesity in the U.S among women of reproductive age raises concerns about the effect of obesity on pregnancy outcomes.2
About 10% of pregnant women are obese.5
Risks Associated With Obesity During Pregnancy Obesity increases the risk of gestational diabetes, pre-ec-
lampsia, delivery complications such as macrosomia, shoulder dystocia, higher rates of cesarean sections and infections.4
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Several independent studies have shown an association between obesity and neural tube defects.6-10
Other defects possibly associated with obesity include heart defects, orofacial clefts and multiple congenital anomalies.10
No association between obesity and the following defects have been documented. - Gastroschisis* *Low BMI has been shown to be associated with increased rates. - Isolated cleft lip/palate
How is Obesity Linked to Birth Defects? The biological mechanisms linking obesity and neural tube
defects are unknown. Obese women may have a metabolic abnormality or nutri-
tional deficiency that disrupts the development of the embryo early in pregnancy.3
Recommendations Weight loss during pregnancy is not recommended; how-
ever, women of reproductive age should make efforts before conception to lose weight to achieve healthy pregnancy outcomes.11 Obese women should be informed of the risks associated with pregnancy and receive appropriate dietary counseling.11 Obese women should be screened for hypertension and glucose intolerance.11 Pregnant women should be encouraged to perform physical activity unless told otherwise by their physician.11
DIABETES MELLITUS Diabetes mellitus is a chronic disease caused by inherited and/or acquired deficiency in production of insulin by the pancreas, or by the ineffectiveness of the insulin produced. Such deficiencies result in increased concentrations of glucose in the blood, which in turn damage many of the body's systems, in particular the blood vessels and nerves.12

Diabetes mellitus is one of the most common medical complications of pregnancy. Women with this condition can be separated into those who have diabetes before pregnancy (pre-gestational) and those diagnosed during pregnancy (gestational).13
Gestational Diabetes Gestational diabetes is defined as glucose intolerance of varying severity that begins or is first recognized during pregnancy.2
Gestational diabetes results from decreased maternal insulin sensitivity. This may increase nutrient availability to the fetus, possibly accounting for an increased risk of fetal overgrowth and adiposity.14
What Are The Risks to the Infant? Infants of diabetic mothers are at increased risk of the following conditions:
Macrosomia Neonatal hypoglycemia Neonatal hypocalcemia Hyperbilirubinemia Respiratory distress syndrome Long term obesity and glucose intolerance15
Pre-existing Diabetes Women with poorly controlled diabetes at conception are at increased risk of delivering an infant with congenital malformations, particularly neural tube defects.13
How is Diabetes Linked to Birth Defects? The underlying mechanisms linking diabetes and birth defects are unknown. However,
It is postulated that the increased risk of birth defects may be due to the result of metabolic abnormalities early in pregnancy1.
An increased risk for birth defects associated with hyperinsulinemia could be the result of an adverse event such as hyperglycemia early in pregnancy1.
Gestational diabetes occurs later in pregnancy and may be associated with pre-existing factors that are directly associated with the development of birth defects.3
Recommendations for pregnant diabetic women Glycemic control - Glycemic control, defined as maintaining blood sugar levels at an acceptable level, before conception and throughout pregnancy is necessary for optimal maternal and fetal outcomes.16 Monitoring - Self monitoring of blood glucose is essential during pregnancy. Preprandial and postprandial testing are recommended.16

Diet - Women should receive nutritional assessments throughout pregnancy to make sure they are receiving adequate nutrition to promote euglycemia, appropriate weight gain and adequate nutritional intake.2
Physical activity - Pregnant women should be encouraged to perform physical activity unless told otherwise by their physician .16
References 1. Anderson JL, Waller K, Canfield MA, Shaw GM, Watkins
ML,Werler MM. Maternal Obesity, Gestational Diabetes, and Central Nervous System Birth effects. Epidemiology 2005;16: 87-92) 2. WebMD Inc 2005 http://www.medscape.com/viewarticle/ 501298_2 3. Worthington-Roberts B, Williams SR Nutrition in Pregnancy and Lactation. Fifth Edition (1993) p267. 4. Maternal obesity and complications during pregnancy. Dietl J. J. Perint Med 2005;33(2):100-5 5. California Birth Defects Monitoring Program. Neural tube defects and obesity. 6. Shaw GM, Todoroff K, Finnell RH, Lammer EJ. Spina bifida phenotypes in infants or fetuses of obese mothers. Teratology 2000 May; 61(5):376-81. 7. Werler MM, Louik C, Shapiro S, Mitchell AA. Prepregnant weight in relation to risk of neural tube defects. JAMA. 1996 Apr 10; 275(14): 1089-92. 8. Kallen K. Maternal smoking, body mass index and neural tube defects. Am J Epidemiol 1998 Jun 15;147(12):1103-11 9. Ray JG, Wyatt PR, Vermeulen MJ, Meier C, Cole DE. Greater maternal weight and the ongoing risk of neural tube defects after folic acid flour fortification. Obstet Gynecol. 2005 Feb; 105(2):2615. 10. Waller, K. Maternal obesity and the risk of congenital anomalies. Canadian Congenital Anomalies Surveillance Network Fourth Scientific Meeting. November 20-22, 2005 Ottawa, Ontario. 11. Galtier-Dereure F, Boegner C, Bringer J. Obesity and pregnancy: complications and cost. Am J Clin Nutr Vol 71 No.5 1242S-1248S May 2000. 12. Diabetes mellitus http://www.who.int/mediacentre/factsheets/ fs138/en/ 13. Sheffield J.S, Butler-Koster E. L, Casey B.M, McIntire D.D, Leveno K.J. Maternal Diabetes Mellitus and Infant malformations. Obstets and Gyne nov 2002 vol 100 No.5 part 1. 14. Catalano PM, Kirwan JP, Haugel-de Mouzon S, King J. Gestational diabetes and insulin resistance: role in short- and long-term implications for mother and fetus. J Nutr. 2003 May;133(5 Suppl 2):1674S-1683S. 15. Gestational Diabetes Mellitus. Canadian Diabetes Association. Clinical Practice Guidelines Expert Committee. 16. Pre-existing Diabetes and Pregnancy. Canadian Diabetes Association. Clinical Practice Guidelines Expert Committee.
Written by: Hema Joshi, M.Med. Sci. and Debra L. Thompson, MPH

Division of Public Health http://health.state.ga.us
Stuart T. Brown, M.D. Director
State Health Officer

Epidemiology Branch http://health.state.ga.us/epi
Susan Lance, D.V.M., Ph.D. Director
State Epidemiologist

Georgia Epidemiology Report
Editorial Board Carol A. Hoban, M.S., M.P.H. Editor
Kathryn E. Arnold, M.D. Cherie Drenzek, D.V.M., M.S. Susan Lance, D.V.M., Ph.D.
Stuart T. Brown, M.D. Angela Alexander - Mailing List Jimmy Clanton, Jr. - Graphic Designer
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Two Peachtree St., N.W. Atlanta, GA 30303-3186 Phone: (404) 657-2588
Fax: (404) 657-7517

Georgia Department of Human Resources
Division of Public Health

Please send comments to: Gaepinfo@dhr.state.ga.us

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 2006

Volume 22 Number 01

Reported Cases of Selected Notifiable Diseases in Georgia Profile* for October 2005

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 2005
2005 46
1837 13 6 60 917 6 8 11 5 1 0 0 2 0 299 118 0 0 0 0 0 30

Previous 3 Months Total

Ending in October

2003

2004 2005

166

158

163

9499

8692

7638

32

80

58

9

4

17

273

279

191

4791

4212

3687

20

15

18

373

86

33

177

102

33

12

8

11

0

1

2

6

4

0

2

2

0

9

4

11

0

0

0

854

747

841

229

156

269

38

19

6

119

100

23

166

76

8

241

201

40

0

2

0

135

112

107

Previous 12 Months Total

Ending in October

2003

2004

2005

670

558

613

36219

34218

31624

112

186

133

31

21

33

859

871

681

18021

15915

14874

82

112

113

784

373

130

618

474

223

35

40

34

10

12

6

31

23

17

3

2

1

32

26

51

0

1

0

1997

1974

1978

1498

657

639

123

121

85

458

463

353

766

421

220

882

807

678

11

6

2

519

523

476

* 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: 01/05-12/05 Five Years Ago: 01/01-12/01 Cumulative: 07/81-12/05

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

3

1,902 1,905

2

1,616 1,618

224

29,492 29,716

Percent Female

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

26.3

32.1

5.6

1.9

9.5

1.2

49.7

27.0

33.5

9.3

2.7

18.4

1.7

34.3

19.6

45.1

15.6

4.9

14.2

1.9

18.5

Race Distribution (%) White Black Other

24.1 73.8

2.1

18.7 76.9

4.3

31.7 65.8

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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