Georgia epidemiology report, Vol. 24, no. 1 (Jan. 2008)

January 2008

volume 24 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, 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. **
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.
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 United States 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.
Birth Defects Monitoring in Georgia: GBDRIS Background and Update
The Georgia Birth Defects Reporting and Information System (GBDRIS) is a statewide surveillance system designed to: 1) provide information on the epidemiology of birth defects in Georgia; 2) identify and refer eligible children for public health services; and 3) collect data on children from birth to age six. The GBDRIS is a passive surveillance system, meaning that it relies on reports from hospitals and other providers rather than actively ascertaining cases at all facilities. Passive ascertainment also means that reported diagnoses are considered probable since they are not verified through active case reviews. The GBDRIS is maintained by the

Maternal and Child Health (MCH) Epidemiology Section of the Epidemiology Branch, Division of Public Health, Department of Human Resources.
Reports of birth defects have been received by special request for over 30 years from the 5-county metro Atlanta area. However, in 2002, birth defects were added to the List of Notifiable Conditions under state laws and Notifiable Disease Reporting Regulations OCGA 31-12-2, OCGA 31-1-3.2, DHR Rules 290-5-5.02, and DHR Rules 290-5-24. While birth defects on this list are to be reported within 7 days, hospitals are asked to report to the GBDRIS on a monthly basis.
The following groups of conditions are reportable upon diagnosis in any child younger than 6 years: congenital anomalies, genetic and metabolic conditions, sickle-cell anemia and other hemoglobinopathies, Fetal Alcohol Syndrome, cerebral palsy, autism, and mental retardation. The specific list of conditions can be found in an appendix of the GBDRIS Reporting Manual (see link below).
The pilot phase for GBDRIS was conducted in 2003 with 15 hospitals. In subsequent years, GBDRIS has been expanded. Currently, 79 of the 94 facilities that provide obstetric services in Georgia report to the GBDRIS. The GBDRIS received 32,700 records in 2005 and over 23,000 records in 2006. Multiple records may be received by GBDRIS for one child due to possible testing at different hospitals in Georgia.
The Metropolitan Atlanta Congenital Defects Program (MACDP), maintained by the Centers for Disease Control and Prevention, is also involved in identifying birth defects in Georgia. MACDP uses active case ascertainment to conduct birth defects surveillance in five metropolitan Atlanta counties Clayton, Cobb, DeKalb, Fulton and Gwinnett. It is considered the gold standard for birth defects surveillance. Table 1 compares rates of select birth defects from 2005-2006 GBDRIS data to baseline 1998-2002 MACDP data. Because MACDP conducts active surveillance and GBDRIS does not verify birth defects through passive surveillance, there may be discrepancies in birth defect rates between MACDP and GBDRIS. Incomplete reporting from hospitals and medical facilities, as well as demographic differences between women living in the Metropolitan Atlanta area and those residing in other areas of Georgia may also contribute to the variation among rates.
General information, fact sheets, and frequently asked questions about birth defects can be found on the Birth Defects web page (http://health.state.ga.us/epi/mch/birthdefects/index.asp). Specific information about the GBDRIS, including the GBDRIS Reporting Manual, forms, and guidelines can be located on the Birth Defects web page by clicking "GBDRIS" (http://health.state.ga.us/epi/mch/ birthdefects/gbdris/index.asp).

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.

Table 1. Georgia Birth Defects Rates (per 10,000 Live Births)

Rates*

Defect

GBDRIS MACDP (2005-2006) (1998-2002)

Anencephalus

0.24

3.17

Spina Bifida w/o anencephalus 4.18

3.45

Hydrocephalus w/o spina bifida 5.88

8.10

Encephalocele

0.38

1.23

Ventricular septal defect

38.02

41.89

Gastroschisis/omphalocele

5.05

4.89

Trisomy 13

0.55

1.36

Down Syndrome

8.64

13.40

Trisomy 18

0.83

2.59

* Per 10,000 live births

identified 80% of these 1167 potential cases, approximately 20% of the cases would not have been contacted at all.
For these and other reasons, GBDRIS will consider adding active case verification to its activities. The analyses of referral patterns by type of defect/condition will further delineate the best candidates for active case verification. Major heart defects may be the first candidate for consideration, as 2 of the most common types of birth defects in each Health District are heart-related.
*The Children 1st data presented for this article are from 2006 follow-up reports submitted from District 1-1, District 3-1, District 4, District 5-2, and District 6.
Article by Jennifer Smith, M.S.P.H and Debra Thompson, M.P.H.

Feedback from Monthly Reports of Potential Birth Defects Cases: An Assessment of Passive Reporting and Referral to Services within Five Public Health Districts
GBDRIS works in conjunction with many public health programs. These programs target women and children and are administered through the 18 Public Health Districts in Georgia. Children 1st is the program serving as the single point of entry to this statewide collaborative system of public health and other prevention-based programs and services. This system operates through five core functions identification, screening, assessment, linkage and/or referral, and monitoring.
Monthly reports listing suspected birth defect cases (based on GBDRIS data) are generated for each Public Health District. These reports are given to Children 1st Coordinators with requests for feedback on those cases, which is essential to the linking of Georgia families with early intervention programs and this feedback is also used to evaluate existing services, as well as, track the use of services within the public health system. In 2006, feedback was received from five Districts, in response to the distributed reports. This feedback provided information for 1167 of 1386 (84%) potential birth defects. Noting that children may be enrolled in multiple programs, percentages of referrals were as follows: Children 1st: 57% WIC: 24% Babies Can't Wait: 8% Children's Medical Services: 5% Other: 4% High Risk Infant Follow Up: 1%
Because information for this report was based on GBDRIS reports submitted by hospitals and diagnoses were not confirmed by case reviews, initial contact with parents was not based solely on a GBDRIS report. While other sources would have eventually

SENDSS Newborn Data System
In November 2007, the Epidemiology Branch and the Family Health Branch (FHB), Division of Public Health, piloted the first release of SENDSS (State Electronic Notifiable Disease Surveillance System) Newborn, Georgia's web-based child health information system. SENDSS Newborn is a population-based surveillance and tracking system to identify and monitor at risk children throughout Georgia. A critical function of this new system is to create unique child-based records by integrating electronic interfaces from diverse sources, including electronic records from the Vital Events Information System Birth Registry, the Public Health Laboratory Newborn Screening Information System and electronic interfaces with hospital hearing screening equipment. SENDSS Newborn will become accessible in 2008 to all hospitals, Health District offices, audiologists and primary care providers in Georgia. SENDSS Newborn will also be expanded to include the Georgia Birth Defects Reporting and Information System, and a module to capture childhood and adult blood lead surveillance and tracking. The lead module will replace the CDC STELLAR data system currently used by the Georgia Childhood Lead Poisoning Prevention Program.
SENDSS Newborn addresses the Children 1st Program's information needs by flagging records of children with medical and socio-environmental risk factors, creating prompts for timely referrals to both public and private services for followup, and triggering prompts for routine monitoring by private providers. In addition, newborn hearing, metabolic and genetic screening tests and results are linked to each electronic birth certificate, providing population-based newborn screening rates and missed opportunities for screening. Records of children who have positive metabolic screens or fail the initial or follow-up hearing screen are flagged for tracking to follow-up screening, confirmatory testing, diagnostic evaluation, and ultimately for treatment and intervention services. Electronic interfaces for routine transmissions of hearing screening results will allow hospitals to upload hearing screening results for linkage to birth certificates. Records of infants who did not pass the in-hospital

Division of Public Health http://health.state.ga.us
Stuart T. Brown, M.D. Director |State Health Officer
Martha N. Okafor, Ph.D. Deputy Director

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

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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Georgia Department of Human Resources
Division of Public Health

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

screen are flagged and displayed in the SENDSS Newborn user "to-do list". Each hospital, pediatrician, Newborn Hearing Screening or Children 1st staff has their own "to-do list" of children needing follow-up services. When a child's record is updated with the requested information (e.g., follow-up screening results), that child is removed from the "to-do list" or a new prompt is created requesting completion of the next activity for that child (e.g., referral to a diagnostic evaluation).
In-house development of SENDSS Newborn began in February 2007. The technical platform is an Oracle database and Java front end. Incoming records are processed through a robust probabilistic de-duplication and matching software application to create linkages between existing child records and incoming data from each electronic interface or to create new child records. Also, each incoming record containing an address for a child will be assigned a latitude and longitude for geo-spatial analysis after processing by enterprise level geo-coding software. Development and testing of SENDSS Newborn is well underway. User acceptance testing of the system began in November 2007, with the assistance of the Dalton Health District office, PedsCare, a pediatric clinic serving Dalton's population, T.C. Thompson's Audiology Clinic, a clinic serving children with special needs; and Hamilton Hospital, the primary birthing hospital serving the Dalton Health District. SENDSS Newborn was piloted in the Dalton Health District and at Northside Hospital, Georgia's largest birthing hospital (with over 18,000 births annually) in December. Phased implementation to all Health Districts, hospitals, and private providers will take place in 2008.
SENDSS Newborn will allow users to collect and share information regarding the health status of each child receiving public health services. Most importantly, Health District staff will be able to access individual child health records, view lists of children with abnormal results, provide timely contact to the provider and family, and ensure the child is referred to the appropriate public health services. This centralized system will serve as a virtual medical home for children receiving public health services as well as for those children diagnosed with a health condition regulated under Georgia's notifiable disease law (i.e., hearing impairment, birth defects, etc). Since SENDSS Newborn will be accessible to all birthing hospitals, pediatricians and other primary care providers, a child's record can be updated with more current contact information. Also if the child's record was flagged for any reason, any provider that checks that, child's record will receive notice that the child is due for a repeat screening, diagnosis or other services. Thus, SENDSS Newborn should help fill a gap in locating children considered lost to follow-up as well as improve the efficiency and effectiveness of Health District staff.
Article written by Siobhan Gilchrist, J.D., M.P.H, M.S. and Debra Thompson, M.P.H.
Infections and Pregnancy
During pregnancy, a woman may be exposed to various infectious diseases, some of which have the ability to infect the placenta and seriously harm a fetus, resulting in deafness, vision loss, neurological and behavioral disorders, or other birth defects. Toxoplasmosis, cytomegalovirus (CMV), varicella, and rubella are among the infectious diseases with potential to cause birth defects

in a developing fetus. Additionally, while some infectious diseases may not be transmitted from an infected mother to her baby, they may have a serious impact on pregnancy, such as uterine infection, miscarriage, premature labor, or stillbirth.
Toxoplasmosis is a parasitic illness that usually causes no symptoms. It can affect the fetus if the mother develops infection during pregnancy. Although the rate of fetal infection is highest if the mother is infected during the third trimester, the outcome for the baby is most severe if the maternal infection occurs during the first trimester.
Cytomegalovirus (CMV) is a common virus that infects 50-85 percent of adults in the United States. The virus is transmitted by sexual contact or other close contact with an infected person's saliva, urine, or other body fluids. Transmission is higher in households with young children and in day care centers.
CMV infection may cause few symptoms in the pregnant woman, or may result in mild illness with a low-grade fever. If a woman has a CMV infection during pregnancy, she may pass CMV to her fetus during pregnancy or delivery, or to her infant through breast milk. Fetuses infected with CMV may or may not have symptoms at birth. Some infected fetuses with no symptoms at birth develop hearing, vision, and neurologic problems later in childhood.
Varicella (chickenpox) infections can cause problems throughout a pregnancy. If a woman has chickenpox during the first 20 weeks of pregnancy, there is a small risk (2 percent) that her infant will develop varicella syndrome, which includes abnormally small limbs and head, mental retardation, scarring of the skin, and eye defects. If a mother becomes infected around the time of delivery, the infection can be passed to the newborn.
Rubella (German measles) is associated with an increased risk of miscarriage and can also cause a congenital syndrome in the newborn that may include deafness, visual problems, cardiac defects, neurologic abnormalities, and mental retardation.
Listeriosis is a form of food poisoning caused by bacteria. If a pregnant woman has listeriosis, she may have a miscarriage, premature birth or stillbirth, or her baby may become very ill or even die. (http://health.state.ga.us/pdfs/epi/notifiable/ EnglishVer_6_ 28_04.pdf ).
The following simple steps can help women protect themselves and her unborn child from these and other infections during pregnancy: Wash your hands often with soap and water Do not share food or utensils with young children Cook your meat until it is well done Do not consume unpasteurized (raw) milk or byproducts,
such as soft cheese Do not touch or change dirty cat litter Avoid wild or pet rodents and their droppings Get tested for sexually transmitted diseases and protect
yourself from them Speak with your physician about vaccinations Stay away from people you know who are sick Ask your doctor for a Group B Strep test
This article was written by Debra Thompson, M.P.H.

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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

January 2008

Volume24Number01

Reported Cases of Selected Notifiable Diseases in Georgia, Profile* for October 2007

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 2007
2007 48 30 16 6 65 13 9 5 11 6 1 2 0 2 0 301 152 4 26 15 42 0 33

Previous 3 Months Total Ending in October

2005 2006 2007

165

166

167

8742

10132

850

60

133

104

17

16

27

226

252

203

4448

5563

379

21

19

27

42

16

14

50

56

43

13

13

9

2

1

1

0

4

10

0

0

0

12

11

3

0

0

0

840

756

837

271

492

368

44

31

25

147

153

119

106

91

59

245

261

158

1

1

0

137

129

105

Previous 12 Months Total Ending in October

2005 2006 2007

616

573

666

33039

39509

32539

140

275

248

34

42

43

773

718

652

15844

20022

13650

117

114

129

142

59

68

254

195

148

36

36

41

6

7

10

16

19

26

1

5

0

54

31

18

0

0

0

1947

1830

1989

639

1169

1727

135

123

89

546

479

491

385

388

366

979

1006

916

3

8

8

515

516

459

* 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
12/06-11/07
Five Years Ago:**
12/02-11/03
Cumulative:
07/81-11/07

Disease Classification HIV, non-AIDS
AIDS HIV, non-AIDS
AIDS HIV, non-AIDS AIDS

Total Cases Reported*

<13yrs >=13yrs Total

26

2,910

2,936

7

1,119

1,126

-

-

-

0

1,686

1,686

208

10,522

10,730

238

31,589

31,827

Percent Risk Group Distribution (%)

Female MSM

IDU

MSM&IDU HS

26

26

3

1

8

25

24

3

1

7

-

-

-

-

-

26

37

7

2

15

32

28

7

2

11

20

44

15

5

14

Unknown 62

Perinatal <1

Race Distribution (%)

White Black

Hispanic

23

70

5

Other 2

65

<1

21

70

6

3

-

-

-

-

-

-

39

-

19

75

5

1

50

2

22

73

3

2

21

<1

31

66

3

<1

Yrs - Age at diagnosis in years

MSM - Men having sex with men

IDU - Injection drug users

HS - Heterosexual

* Counted as Georgia casesonly when the individual resided in Georgia at the time of earliest diagnosis of HIV or AIDS. NOTE: Previous reports may not have been restricted by this

methodology. This month's report includes only those cases, in order to avoid duplication with other states. For this reason an apparentdecrease in Georgia case counts may be noted in some

instances. All future reports will be based on the more restricted methodology.

** HIV (non-AIDS) data was not collected until 12/31/2003.

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