January 2007 volume 23 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 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, nutritional deficiencies, 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. Based on data from the Georgia Birth Defects Reporting and Information System (GBDRIS) and 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. Birth defects are a serious problem. The good news is that new ways of preventing and treating birth defects are being found. 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. 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 kinds of 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 GBDRIS/Publications (http://health.state.ga.us/epi/mch/birthdefects/ gbdris/publications.asp). The Birth Defects web page also provides general information about birth defects along with frequently asked questions and fact sheets for specific defects (http://health.state.ga.us/ epi/mch/birthdefects/index.asp). The GBDRIS is a statewide surveillance system designed to provide information on prevalence, trends and epidemiology of birth defects in Georgia. The GBDRIS collects information on children from birth to six years of age. The system relies on existing data along with passive case ascertainment, which means that cases of birth defects are identified and reported by hospitals, laboratories, and providers. The GBDRIS is maintained by the Maternal and Child Health (MCH) Section of the Epidemiology Branch, Division of Public Health, Georgia Department of Human Resources. Georgia is fortunate to be the site of the Centers for Disease Control and Prevention's Metropolitan Atlanta Congenital Defects Program (MACDP). MACDP is considered the gold standard for birth defects surveillance systems and utilizes active case ascertainment. MACDP conducts surveillance in the central five counties of metropolitan Atlanta (Clayton, Cobb, DeKalb, Fulton, Gwinnett). Table 1 (page 2) shows the rates of select birth defects for 2004 births based on GBDRIS data compared to baseline (1998-2002) rates provided by MACDP. Differences in rates may be attributable to the use of different ascertainment methods, incomplete reporting and lack of diagnostic verification in the GBDRIS. Varying demographics of women living in the metropolitan Atlanta area compared to the state as a whole may also contribute. For example, the birth rate for women 35 years or older in the five-county Atlanta area is 16.5% compared to 12.2% in Georgia. The GBDRIS Reporting Manual, reporting guidelines, and reporting forms can be found on the MCH Epidemiology Birth Defects web page under Questions related to the GBDRIS can be sent to GBDRIS@dhr.state. ga.us. Neural Tube Defects (NTDs)--Enhanced Surveillance As part of our increased efforts to decrease the number of NTDaffected pregnancies in Georgia, all reported NTD cases are flagged for diagnosis verification. Record reviews are conducted to collect additional information on each case. These additional data will be used to further develop prevention strategies and to evaluate ongoing folic acid awareness programs. In 1992 the U. S. Public Health Service (USPHS) published the recommendation that all women of childbearing age consume 0.4 mg (400 micrograms) of folic acid daily to prevent two common and serious birth defects, spina bifida and anencephaly NTDs. CDC estimates that 50-70% of these birth defects could be prevented if this recommendation were followed before and during early pregnancy. All women between 15 and 45 years of age should consume 0.4 mg of folic acid per day because half of U.S. pregnancies are unplanned and because these birth defects occur very early in pregnancy (3- 4 weeks after conception), before most women know they are pregnant. [Source: CDC Website] 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. | Please visit, http://health.state.ga.us/epi/manuals/ger.asp for all current and past pdf issues of the GER. (continued, from GBDRIS page 1) Table 1. Georgia Birth Defects Rates (per 10,000 Live Births) Rates* Defect GBDRIS MACDP (2004) (1998-2002) Anencephalus 0.11 3.17 Spina bifida w/o anencephalus 2.21 3.45 Hydrocephalus w/o spina bifida 9.38 8.10 Encephalocele 0.63 1.23 Ventricular septal defect 41.09 41.89 Gastroschisis/omphalocele 6.01 4.89 Trisomy 13 1.05 1.36 Down Syndrome 7.69 13.40 Trisomy 18 1.90 2.59 * Per 10,000 live births Recommendations Recommendation 1. Individual Responsibility Across the Lifespan. Each woman, man, and couple should be encouraged to have a reproductive life plan. A lifespan approach can be used to focus individual attention on reproductive health to reduce unintended pregnancies, agerelated infertility, fetal exposures to teratogens, and to improve women's health and pregnancy outcomes. Recommendation 2. Consumer Awareness Increase public awareness of the importance of preconception health behaviors and preconception care services by using information and tools appropriate across various ages, literacy and cultural/linguistic contexts. Consumer-friendly tools can help women self-assess risks, make plans, and take actions that will improve their health and the health of their children. Preconception Health Childbearing is a common experience among women in the United States and approximately 50 percent of pregnancies are unplanned. Therefore, improving the health of women in their reproductive years before they become pregnant continues to be an important strategy to reduce all adverse pregnancy outcomes, inculding birth defects. In 2006, CDC published recommendations to improve preconception health and health care in the United States. Prevention efforts offer hope for reducing the number of children born with a birth defect in Georgia. Ten recommendations were developed to improve preconception health through changes in consumer knowledge, clinical practice, public health programs, health care financing, and data and research activities. The recommendations are aimed at achieving four goals, based on personal health outcomes. Goal 1. Improve the knowledge and attitudes and behaviors of men and women related to preconception health. Goal 2. Assure that all women of childbearing age in the United States receive preconception care services that will enable them to enter pregnancy in optimal health. Goal 3. Reduce risks indicated by a previous adverse pregnancy outcome through interventions during the interconception period, which can prevent or minimize health problems for a mother and her future children. Goal 4. Reduce the disparities in adverse pregnancy outcomes. The recommendations are part of a national strategic plan to improve the health of women, their children, and their families and are based on existing knowledge and evidence-based practice. Recommendation 3. Preventive Visits As part of primary care visits, provide risk assessment and health promotion counseling to all women of childbearing age to reduce reproductive risks and improve pregnancy outcomes. Professional guidelines for clinicians who provide primary care to women should include routine risk assessment. Different guidelines recommend eight to 10 specific areas for preconception risk assessment, including: Reproductive history Environmental hazards and toxins Medications that are known teratogens Nutrition, folic acid intake, and weight management Genetic conditions and family history Substance use, including tobacco and alcohol Chronic diseases (e.g., diabetes and hypertension) Infectious diseases and vaccinations Family planning Social and mental health concerns Recommendation 4. Interventions for Identified Risks Increase the proportion of women who receive interventions as follow-up to preconception risk screening, focusing on high priority interventions (i.e., those with evidence of effectiveness and greatest potential impact). Integrating childbearing with the management of chronic health problems and infectious diseases reduces unnecessary risks for women, their future pregnancies, and their future children. Recommendation 5. Interconception Care Use the interconception period to provide additional intensive interventions to women who have had a previous pregnancy that ended in an adverse outcome (i.e., infant death, fetal loss, birth defects, low birthweight, or preterm birth). Postpartum visits are an opportunity to link women to interventions designed to reduce risks to them and their future children. Recommendation 6. Pre-Pregnancy Checkup Offer, as a component of maternity care, one prepregnancy visit for women planning pregnancy. Adoption of the prepregnancy visit as a standard of care can help to reinforce the importance of pregnancy planning and preparedness among women and men. 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 -2 - 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 Recommendation 7. Health Insurance Coverage for Women with Low Incomes Increase public and private health insurance coverage for women with low incomes to improve access to preventive women's health and preconception and interconception care. Medicaid is the primary mechanism for extending health coverage to women with low incomes who do not have health insurance. As states seek to expand Medicaid coverage to persons with low incomes and adults who do not have health insurance, women of childbearing age should receive priority for qualifying for Medicaid coverage. Recommendation 8. Public Health Programs and Strategies Integrate components of preconception health into existing local public health and related programs, including emphasis on interconception interventions for women with previous adverse outcomes. Public health practice collaboratives that link local public health programs can promote development and dissemination of community-based best practices. Recommendation 9. Research Increase the evidence base and promote the use of the evidence to improve preconception health. Additional evidence is needed regarding the effectiveness of interventions, the value of better service integration, and the potential cost benefit of preconception care for the general population and for women at high risk for poor pregnancy outcomes. Recommendation 10. Monitoring Improvements Maximize public health surveillance and related research mechanisms to monitor preconception health. Community health data are used for public health surveillance to evaluate and improve health, health programs, and health policy. Surveillance includes monitoring the frequency of conditions, risk factors, services, and outcomes. The CDC Report also gives specific action steps for each recommendation. To view the full report, please go to www.cdc.gov/mmwr/preview/ mmwrhtml/rr5506a1.htm. Improving preconception health will require changes in the knowledge, attitudes, and behaviors of persons, families, communities, and institutions (e.g., government and health-care settings). The purpose of preconception care is to improve the health of each woman before any pregnancy and thereby affect the future health of the woman, her child, and her family. [Sources: NBDPN Birth Defects Prevention Month Information Packet-2007 and CDC's Recommendation to Improve Preconception Health and Health Care--United States: A Report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care] Achieve optimal preconception health by: Consuming 400 micrograms of folic acid daily; Knowing one's family history; Having a check-up from a health care provider prior to conception; Seeking reproductive genetic counseling, if appropriate; Managing chronic maternal illnesses and conditions such as diabetes, seizure disorders, lupus or phenylketonuria (PKU); Avoiding alcohol, nicotine, and illicit drugs; Ensuring that prescription medication and herbal supplements are safe at the time of conception and during early pregnancy; Avoiding harmful occupational and environmental exposures In addition, avoiding infections and ensuring protection against domestic violence are important elements of preconception health. Spotlight On: Diabetes and Pregnancy Background The most common hormone condition that affects pregnancy is diabetes mellitus (DM). Over 700,000 people in Georgia have DM. Women with DM have the disease before they get pregnant unlike gestational diabetes, which develops during pregnancy. Strict control of blood sugar levels is very important before and during pregnancy. Careful control lowers the risk of birth defects, miscarriage, and stillbirth. Under the guidance of their healthcare providers, women can learn to monitor their own blood glucose levels. They can change the amount of insulin and modify their diets and activity to keep their blood sugar levels in the normal range. Studies have shown that women who maintain normal blood sugar levels before and throughout pregnancy have the best chance of having a healthy child. How Pregnancy Affects Diabetes Pregnancy makes controlling blood sugar difficult. Normal changes in pregnancy seem to disturb a woman's blood glucose. Nausea and vomiting upset blood sugar levels as do infections. During labor, a lack of food and physical exertion may upset blood sugar levels. How Diabetes Affects Pregnancy Diabetes may make it more difficult to become pregnant and to keep the pregnancy. Diabetes may affect the health of both the woman and her infant. Some of the effects for the woman are toxemia, infections, and extra fluid around the baby. Some of the effects for the infant are difficulty controlling the infant's blood sugar levels in the first few hours after birth, preterm birth, birth defects, and an increased chance of developing diabetes. Women with poorly controlled diabetes in the early weeks of pregnancy have an increased risk of miscarriage and stillbirth as well as increased risk of having a very large baby (10 pounds or more), which makes vaginal delivery more difficult and puts the baby at risk for injuries during birth. Does Maternal Diabetes Cause Birth Defects? High blood sugar levels during pregnancy increase the chance that a baby will be born with birth defects. High sugar levels have the most effect early in pregnancy, possibly before a woman knows she is pregnant. For pregnant women with poor diabetic control, the risk for a baby to be born with birth defects is about 6-10%; this is about twice the chance for birth defects if the mother's diabetes is well controlled. For those with extremely poor control in the first trimester, there may be up to a 20% risk for birth defects. Some of the associated birth defects include spinal cord defects (spina bifida), heart defects, skeletal defects, and defects in the urinary, reproductive, and digestive systems. Finally, babies born to women with diabetes also have an increased chance of having breathing difficulties, low blood sugar (hypoglycemia) and jaundice (yellowish skin) at birth. Studies have shown that women who have well-controlled diabetes before becoming pregnant and who maintain low sugar levels throughout pregnancy are not at increased risk for having a baby born with birth defects. [*Sources: WI Association for Perinatal Care and the Organization of Teratology Information Services (OTIS)] These articles were written by Debra Thompson, M.P.H. -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 2007 Volume 23 Number 01 Reported Cases of Selected Notifiable Diseases in Georgia Profile* for October 2006 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 2006 2006 58 3160 43 4 75 1622 8 3 11 2 0 1 0 3 0 207 247 3 12 6 34 0 39 Previous 3 Months Total Ending in October 2004 2005 2006 160 165 159 8680 8741 9608 84 60 127 4 17 17 282 226 240 4210 4447 5170 15 21 17 85 42 15 97 48 44 8 13 9 1 2 1 4 0 4 2 0 0 4 12 10 0 0 0 747 839 755 158 269 501 19 44 20 108 147 86 82 103 50 222 242 159 2 1 0 111 136 122 Previous 12 Months Total Ending in October 2004 2005 2006 561 616 565 34214 33037 37102 191 140 274 21 34 43 883 773 695 15921 15844 18379 112 117 109 371 145 62 450 255 180 40 36 31 12 6 7 23 16 18 2 1 5 26 54 29 1 0 0 1977 1946 1866 663 637 1190 124 135 108 473 545 397 437 380 331 851 975 862 6 3 6 521 514 505 * 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**: 11/05-10/06 Five Years Ago: 11/01-10/02 Cumulative: 07/81-10/06 Total Cases Reported* <13yrs >=13yrs Total 5 1,305 1,310 1 1,543 1,544 231 30,261 30,492 Percent Female AIDS Profile Update Risk Group Distribution (%) MSM IDU MSM&IDU HS Blood Unknown 26.7 31.8 6.6 2.4 9.3 0.2 49.2 26.6 38.1 7.6 2.9 18.9 0.8 31.7 19.8 44.3 15.3 4.9 14 0.9 19.8 Race Distribution (%) White Black Other 18.9 75.8 5.3 17.5 77.2 5.3 30.9 66.1 3 MSM - Men having sex with men * Case totals are accumulated by date of report to the Epidemiology Section IDU - Injection drug users HS - Heterosexual ** Due to a change in the surveillance system, case counts may be artificially low during this time period - 4 -