The burden of asthma in Georgia 2003

The Burden of Asthma
in Georgia 2003
Prevalence Risk Factors Prevention

Acknowledgements
Georgia Department of Human Resources . . . . . . . . . . . . . . . . . . . . . . . . . .Maria Greene, Acting Commissioner Division of Public Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Kathleen E. Toomey, M.D., M.P.H., Director Chronic Disease Prevention and Health Promotion Branch . . . . . . . . . .Carol B. Steiner, R.N., M.N., Acting Director Epidemiology Branch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Paul Blake, M.D., M.P.H., Director Chronic Disease, Injury, and Environmental Epidemiology Section . .Kenneth E. Powell, M.D., M.P.H., Director Office of Health Information and Policy . . . . . . . . . . . . . . . . . . . . . . . . .Gordon R. Freymann, M.P.H., Director
Suggested Citation: Blackwell AD, Wu M, Mertz KJ, Powell KE, Williams CP, Chowdhury P. The Burden of Asthma in Georgia 2003. Georgia Department of Human Resources; Division of Public Health; Chronic Disease, Injury, and Environmental Epidemiology Section, December 2003. Publication number DPH03/127HW
Further information on this report may be obtained by contacting: Angela D. Blackwell, M.P.H. Georgia Department of Human Resources Division of Public Health Chronic Disease, Injury, and Environmental Epidemiology 2 Peachtree Street, 14.284 Atlanta, GA 30303-3142 (404) 463-3748 adblackwell@dhr.state.ga.us

Table of Contents
Highlights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Prevalence of Asthma in Georgia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
Prevalence of Asthma Among Public Middle and High School Students . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 Figure 1. Prevalence of current asthma among middle and high school students, Georgia, 2001 Figure 2. Prevalence of current asthma among middle and high school students by race and sex, Georgia, 2001 Figure 3. Prevalence of current asthma among middle and high school students by grade, Georgia, 2001 Prevalence of Asthma Among Public Middle and High School Students . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 Table 1. Prevalence of current asthma among middle and high school students by public health district,
Georgia, 2001 Risk Factors for Asthma Attacks Among Middle and High School Students . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 Figure 4. Prevalence of current smoking among middle and high school students by asthma status, Georgia, 2001 Figure 5. Prevalence of exposure to environmental tobacco smoke among middle and high school students by asthma
status, Georgia, 2001 Figure 6. Prevalence of overweight among middle and high school students by asthma status, Georgia, 2001 Prevalence of Asthma Among Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Figure 7. Prevalence of current asthma among adults 18 years and older by race and sex, Georgia, 2000-2001 Figure 8. Prevalence of current asthma among adults 18 years and older by age group, Georgia, 2000-2001 Figure 9. Prevalence of current asthma among adults 18 years and older by education, Georgia, 2000-2001 Figure 10. Prevalence of current asthma among adults 18 years and older by income, Georgia, 2000-2001 Table 2. Prevalence of current asthma among adults 18 years and older by public health district, Georgia, 2000-2001 Risk Factors and Preventive Behaviors for Asthma Attacks Among Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Figure 11. Prevalence of current smoking among adults 18 years and older by asthma status, Georgia, 2000-2001 Figure 12. Prevalence of overweight/obesity among adults 18 years and older by asthma status, Georgia, 2000-2001 Figure 13. Percentage of adults 18 years and older who received annual flu shot, Georgia, 2000-2001 Asthma and Adult Health Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Asthma Mortality in Georgia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
Deaths from Asthma in Georgia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Figure 14. Age-adjusted asthma death rates in Georgia and the United States, 1979-2000 Figure 15. Age-adjusted asthma death rates by race and sex, Georgia, 1996-2000 Figure 16. Asthma death rates by age group, Georgia, 1996-2000
Asthma Morbidity in Georgia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..11
Asthma Hospitalizations in Georgia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..11 Figure 17. Percentage of asthma hospitalizations by season, Georgia, 1999-2000 Figure 18. Age-adjusted asthma hospitalization rate by race and sex, Georgia, 1999-2000 Figure 19. Asthma hospitalization rates by age group, Georgia, 1999-2000 Asthma Hospitalizations by County . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Table 3. Number of hospitalizations for asthma, age-adjusted asthma hospitalization rates, and hospital charges per
year by county Georgia, 1999-2000 Map 1. Age-adjusted annual asthma hospitalization rates by county, Georgia, 1999-2000 Asthma Hospitalizations by Public Health District . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 Table 4. Age-adjusted annual asthma hospitalization rates and average charges per year by pubic health district,
Georgia, 1999-2000 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 Appendix. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

Highlights
In Georgia:
13.1% of public middle school students have asthma. 10.7% of public high school students have asthma. 6.7% of adults aged 18 years and older have asthma. Asthma causes approximately 9,400 hospitalizations every year. Hospital charges total approximately $59 million annually. Every year approximately 120 persons die because of asthma. Blacks and women are more likely than whites and men to be hospitalized or die
because of asthma. Despite the fact that cigarette smoking may trigger asthma attacks, 26.3% of adults
with asthma, 24.7% of high school students with asthma, and 11.6% of middle school students with asthma currently smoke. Exposure to environmental tobacco smoke (ETS) also may trigger an asthma attack. Middle school students with asthma (73.0%) are more likely than students without asthma (63.2%) to report exposure to ETS. A significant number of people with asthma (22.3%) were unable to see a doctor because of cost. About one-third of the adults with asthma in Georgia reported receiving a flu shot (34.4%) in the past year. A high percentage (21.4%) of high school students with asthma are overweight, compared to 9.0% of those without asthma. Sixty-seven percent of adults with asthma are currently overweight or obese compared to 58.9% of those without asthma.
2 The Burden of Asthma in Georgia

Introduction
Asthma is a chronic inflammatory disorder of the lungs and airways that causes recurrent episodes of wheezing, breathlessness, chest tightness, and coughing. The cause or causes of asthma are not well understood and likely differ among individuals. Heredity, behaviors such as smoking, and environmental exposures such as viral infections all play a role. Once a person has asthma, a variety of things may trigger an attack. Respiratory infections, tobacco smoke (both from smoking and from secondhand smoke), pollen, molds, food, vigorous exercise, and air pollution are some of the things that trigger attacks in individuals. Being overweight may also be a risk factor for attacks. Asthma affects people of all ages, races, ethnic groups, and both sexes. Estimates from the 1998 National Health Interview Survey suggest that 26 million Americans have been diagnosed with asthma at some point in their life and nearly 11 million currently have asthma.1 Annually, asthma is responsible for more than 500,000 hospitalizations and 5,000 deaths nationwide.2,3 Georgia accounts for approximately 9,400 of the hospitalizations and 120 of the deaths. Asthma costs our nation approximately $11 billion a year.4 The 2000 Asthma in Georgia Report confirmed that asthma is a major public health problem in Georgia, as it is in the rest of the nation, especially for children.5 Based on data from the 2000 Georgia Childhood Asthma Survey, the report showed that an estimated 10.5% (210,000) of Georgia children from age 0 to 17 years have asthma and that asthma has a significant impact on their lives. Sixty-five percent (140,000) of the children with asthma had an attack in the past year and 30.0% (64,000) visited a hospital emergency department. Asthma also affects school attendance: 54.0% (88,000) of the children with asthma missed one or more days of school during the year because of asthma. In addition, parents and other caretakers of children with asthma are affected: 30.0% (64,000) missed one or more days of work or school due to the child's asthma. The Burden of Asthma in Georgia 2003 focuses on the prevalence of asthma in public middle and high school students and in adults. It provides information on risk factors associated with asthma, hospitalizations, and deaths from asthma in Georgia. The purpose of this report is to provide statewide, county, and district data to guide pulic health programs, policy makers, and other healthcare providers in their efforts to reduce the burden of asthma in Georgia.
The Burden of Asthma in Georgia 3

Prevalence of Asthma in Georgia

Source: GYTS

Source: GYTS

Prevalence of Asthma Among Public Middle and High School Students
In middle school and high school, 13.1% and 10.7% of students report they currently have asthma (Figure 1). In middle school and high school students there are no significant differences in the prevalence of asthma among the four major race/sex groups in Georgia (Figure 2). Asthma prevalence decreases as the grade level increases (Figure 3). Similar results have been reported in other studies that have shown asthma prevalence tends to decrease as children get older.5 Among the students with asthma, approximately half in middle school (54.0%) and in high school (48.0%) experienced an attack or episode of asthma in the past twelve months. The frequency of attacks can be reduced and controlled with proper treatment and modification of certain environmental factors, such as reduced exposure to tobacco smoke.
Prevalence of Asthma Among Public Middle and High School Students by Public Health District
District-specific data are available for middle schools from nine of 19 Public Heath Districts and for high schools from six Public Health Districts. In middle school, the prevalence of current asthma ranges from 10.4%-15.8% by district (Table 1). There is little variation among the six public health districts in the prevalence of current asthma among high school students (Table 1).
4 The Burden of Asthma in Georgia

Percent with Asthma

Percent with Asthma

Percent with Asthma

figure 1

Prevalence of current asthma among middle

and high school students, Georgia, 2001
20

18

16

14

13.1

12

10.7

10

8

6

4

2

0 Middle School

High School

figure 2

Prevalence of current asthma among

middle and high school students

by race and sex, Georgia, 2001

20

18

Males Females

16

15.0

14 13.4 12.7 13.6

12

14.0 12.3 11.3

10

8.9

8

6

4

2

0 Whites Blacks

Whites Blacks

MIDDLE SCHOOL

HIGH SCHOOL

figure 3

Prevalence of current asthma among

middle and high school students

by grade, Georgia, 2001

20

18

16

14 13.8 12.7 12.9

12 10

10.8 10.7 11.8 9.6

8

6

4

2

0

6

7

8

9 10 11 12

GRADE

Source: GYTS

Prevalence of Asthma continued. . .

Table 1. Prevalence of asthma among middle and high school students by public health district, Georgia, 2001

Districts

Percent with Asthma Middle School High School

GEORGIA

13.1

10.7

(1-1) Northwest (Rome)

N/A

N/A

(1-2) North Georgia (Dalton)

13.2

N/A

(2-0) North (Gainesville)

N/A

N/A

(3-1) Cobb/Douglas (Marietta)

N/A

N/A

(3-2) Fulton (Atlanta)

15.8

N/A

(3-3) Clayton (Morrow)

N/A

N/A

(3-4) East Metro (Lawrenceville)

N/A

N/A

(3-5) DeKalb (Decatur)

N/A

N/A

(4-0) LaGrange

11.3

N/A

(5-1) South Central (Dublin)

12.4

10.5

(5-2) North Central (Macon)

N/A

N/A

(6-0) East Central (Augusta)

10.5

10.2

(7-0) West Central (Columbus)

10.4

10.7

(8-1) South (Valdosta)

N/A

N/A

(8-2) Southwest (Albany)

13.7

10.0

(9-1) East (Savannah)

N/A

N/A

(9-2) Southeast (Waycross)

11.3

11.7

(9-3) Coastal (Brunswick)

12.5

10.3

(10-0) Northeast (Athens)

N/A

N/A

N/A=Not Available

Source: GYTS

The Burden of Asthma in Georgia 5

Prevalence of Asthma continued. . .

Source: GYTS

Risk Factors for Asthma Attacks Among Middle and High School Students
Despite the fact that smoking may trigger asthma attacks, middle and high school students with asthma in Georgia are just as likely to smoke as students without asthma (Figure 4). Exposure to enviromental tabacco smoke (ETS) also may trigger an asthma attack.6-8 Middle school students with asthma are more likely to report exposure to ETS (73.0%) than students without asthma (63.2%). There are no significant differences in prevalence of ETS among high school students with asthma (76.1%) and those without asthma (77.0%) (Figure 5). In high school, the prevalence of students who are overweight (BMI for age 95th percentile) is higher among students with asthma (21.4%) than students without asthma (9.0%). There are no significant differences in overweight status detected among middle school students (Figure 6). Although the nature of the relationship between asthma and bodyweight requires more research, some evidence suggests that people with asthma who are overweight experience more symptoms than people with asthma who are not overweight.9-11 Therefore people with asthma have yet another reason to maintain proper bodyweight.
6 The Burden of Asthma in Georgia

Percent Overweight

Percent Exposed to Tobacco Smoke

Percent Who Smoke

figure 4

Prevalence of current smoking among middle and high school students by asthma status, Georgia, 2001
40

35

30

25

24.0

24.7

20

15

11.6

10 8.6

5

0 No Asthma Asthma

No Asthma Asthma

MIDDLE SCHOOL

HIGH SCHOOL

figure 5

Prevalence of exposure to environmental

tobacco smoke among middle and high school

students by asthma status, Georgia, 2001

100

90

80

73.0

77.0

76.1

70 63.2 60

50

40

30

20

10

0

No Asthma Asthma

No Asthma Asthma

MIDDLE SCHOOL

HIGH SCHOOL

figure 6

Prevalence of overweight among middle and high school students
by asthma status, Georgia, 2001
40

35

30

25

20

15.0

15 12.4

10

21.4 9.0

5

0 No Asthma Asthma

No Asthma Asthma

MIDDLE SCHOOL

HIGH SCHOOL

Source: GYTS

Source: GYTS

Prevalence of Asthma continued. . .

Prevalence of Asthma Among Adults

The prevalence of asthma among adults in Georgia in 2000-2001 was 6.7%, indicating that approximately 370,000 adults were affected. The prevalence of asthma among females (7.9%) was significantly higher than among males (5.5%). The prevalence among blacks (7.3%) was similar to whites (6.6%). The prevalence by race and sex ranged from 5.1% for white males to 8.1% for black females (Figure 7). There were no significant differences among age groups (Figure 8).
The asthma prevalence in adults with less than high school education (9.1%) is higher than in those with a college education (5.5%) (Figure 9). The prevalence is higher in adults with annual household incomes less than $15,000 than in adults with household incomes more than $15,000 (Figure 10). Reasons for these differences are unknown but may be related to environmental exposures more common in low socioeconomic populations.
Current asthma prevalence among adult Georgians in the 19 public health districts ranged from 5.1% to 8.5% in 2000-2001 (Table 2). There were no significant differences among the public health districts when compared to each other or to the state.

Percent with Asthma

figure 7

Prevalence of current asthma among

adults 18 years and older

by race and sex, Georgia, 2000-2001

10

Males Females

9

8.0

8.1

8

7

6.3

6

5.1

5

4

3

2

1

0 Whites

Blacks

Source: BRFSS
Percent with Asthma

Percent with Asthma

Percent with Asthma

Source: BRFSS

figure 8

Prevalence of current asthma among

adults 18 years and older

by age group, Georgia, 2000-2001

10

9 8.3 8

7

6.8

6

6.0 6.4

7.6 5.9

5

4

3

2

1

0 18-24 25-34 35-44 45-54 55-64 65+

AGE GROUP (YEARS)

figure 9

Prevalence of current asthma among

adults 18 years and older

by education, Georgia, 2000-2001
20

18

16

14

12

10

9.1

8

6.9

6.6

6

5.5

4

2

0 <High School HS Grad. Some College Grad Coll./Tech

figure 10

Prevalence of current asthma among

adults 18 years and older

by income, Georgia, 2000-2001

20

18

16

14 12.5

12

10

8

7.4 7.6

6.4

6

4.4 5.0

4

2

0

$0 -

$15,000- $25,000- $35,000- $50,000- >$75,000

15,000 24,999 34,999 49,999 74,999

Source: BRFSS

Source: BRFSS

The Burden of Asthma in Georgia 7

Prevalence of Asthma continued. . .

Table 2. Prevalence of asthma among adults 18 years and older by public health district, Georgia 2000-2001

Districts

Percent with Asthma

Georgia

6.7

(1-1) Northwest (Rome)

8.2

(1-2) North Georgia (Dalton)

8.5

(2-0) North (Gainesville)

6.6

(3-1) Cobb/Douglas (Marietta)

5.3

(3-2) Fulton (Atlanta)

7.6

(3-3) Clayton (Morrow)

7.6

(3-4) East Metro (Lawrenceville)

5.4

(3-5) DeKalb (Decatur)

7.6

(4-0) LaGrange

6.4

(5-1) South Central (Dublin)

6.9

(5-2) North Central (Macon)

6.1

(6-0) East Central (Augusta)

6.2

(7-0) West Central (Columbus)

6.3

(8-1) South (Valdosta)

7.9

(8-2) Southwest (Albany)

7.9

(9-1) East (Savannah)

5.4

(9-2) Southeast (Waycross)

7.7

(9-3) Coastal (Brunswick)

5.1

(10-0) Northeast (Athens)

6.1

Source: BRFSS

8 The Burden of Asthma in Georgia

Prevalence of Asthma continued. . .

Risk Factors and Preventive Behaviors for Asthma Attacks Among Adults
There are many conditions and risk factors that can affect adults with asthma. Despite the fact that smoking may trigger asthma attacks, 26.3% of adults who currently have asthma report cigarette smoking (Figure 11). Sixty-seven percent of adults with asthma are currently overweight or obese (Figure 12). This is significantly higher than for people without asthma (58.9%).
Influenza is associated with substantial adverse effects including time lost from work or school and hospitalization, especially among people who have asthma.12,13 Vaccination reduces morbidity in patients with asthma and immunization is recommended for all such patients.14,15 Unfortunately only about one-third of the adults with asthma in Georgia reported receiving a flu shot (34.4%) in the past year (Figure 13). The importance of flu shots in patients with asthma needs to be emphasized.
Asthma and Adult Health Status
Asthma has a considerable effect on how adult Georgians perceive their health status. Persons with asthma (33.5%) are more likely to report fair or poor health than those who do not have asthma (14.2%). Adults with asthma (19.2%) are also more likely to report mental distress than adults without asthma (10.4%). Adults with asthma (22.3%) are significantly more likely to be unable to see a doctor due to cost than those without asthma (10.8%).

Percent Overweight

Percent Who Smoke

Source: BRFSS

figure 11

Prevalence of current smoking among adults 18 years and older by
asthma status, Georgia, 2000-2001
40

35

30

26.3

25

23.3

20

15

10

5

0 No Asthma

Asthma

figure 12

Prevalence of overweight/obesity among

adults 18 years and older by

asthma status, Georgia, 2000-2001

100

90

80

70

67.0

60

58.9

50

40

30

20

10

0 No Asthma

Asthma

Source: BRFSS

figure 13
Percentage of adults 18 years and older with asthma who received flu shot, Georgia, 2000-2001
flu shot no flu shot
34.4%

Source: BRFSS

65.6%

The Burden of Asthma in Georgia 9

Source: Vital Statistics

Asthma Mortality in Georgia

Deaths from Asthma in Georgia
From 1996 through 2000 there were an average of 120 deaths per year from asthma (2.4 per 100,000). Age-adjusted asthma death rates in the United States and Georgia increased during the 1980's and early 1990's (Figure 14). In 1999, the classification system for cause of death coding changed from ICD-9 to ICD-10, making it difficult to interpret recent trends in asthma mortality, but the rate appears to be falling.
Asthma deaths affect all races and sexes but death rates disproportionately affect minority populations in the U.S. and Georgia. In Georgia, blacks are three times more likely to die from asthma than whites (3.6 per 100,000 vs. 1.2 per 100,000 population). Women are 1.3 times more likely to die from asthma than men (2.0 per 100,000 vs. 1.6 per 100,000 population). Death rates by race and sex ranged from 1.0 per 100,000 population for white males to 3.7 per 100,000 population for black females (Figure 15).
Deaths from asthma are more common among the elderly. Death rates are approximately 24 times higher for persons 65 years or older than for the youngest age groups (0-4 years and 5 to 24 years) (Figure 16).

Deaths per 100,000

figure 14

Age-adjusted asthma death rates in Georgia and United States, 1979-2000

3.0

*

GA
2.5

2.0

1.5

U.S.

1.0

0.5

0.0 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 *change from ICD-9 to ICD-10 coding

Source: Vital Statistics

Deaths per 100,000

figure 15

Age-adjusted asthma death rates by race and sex, Georgia, 1996-2000

10

9

Males Females

8

7 6

5

4

3.6

3.7

3

2

1.0

1.4

1

0 Whites

Blacks

Source: Vital Statistics

10 The Burden of Asthma in Georgia

Deaths per 100,000

figure 16

Asthma death rates by age group, Georgia, 1996-2000

10

9

8

7.1

7

6

5

4

3.4

3

2

1.2

1 0.3

0.3

0 0-4

5-24 25-54 55-64 65+

AGE GROUP (YEARS)

Asthma Morbidity in Georgia

Asthma Hospitalizations in Georgia
During 1999-2000 there were more than 9,400 hospitalizations per year in Georgia (120.5 per 100,000 population) with asthma as the primary diagnosis. Hospital charges total approximately $59 million dollars annually. Hospitalization rates in Georgia are 50 times higher than death rates. There are more hospitalizations in the fall and winter than spring and summer (Figure 17).
Blacks are 2.1 times more likely to be hospitalized with asthma than whites (195.7 vs. 93.3 per 100,000 population). Females are 1.5 times more likely to be hospitalized than males (142.4 vs. 93.4 per 100,000 population). Black females have the highest hospitalization rate (218.8 per 100,000 population) among the four major race/sex groups in Georgia (Figure 18).
Hospitalization rates are the highest for the young and the elderly (Figure 19). Rates are 2-4 times higher in the 0 to 4 year age group than for other age groups. A possible explanation is that asthma is often misdiagnosed and confused with other upper respiratory diseases in this age group.
Thirty-nine of Georgia's 159 counties had hospitalization rates in 1999-2000 that were significantly higher than the state rate (120.5 hospitalizations per 100,000 per year) (Table 3).
Counties with high rates are located throughout Georgia, but high rates are more common in the counties extending from Augusta to the southwest corner of the state (Map 1).
Seven of Georgia's 19 Public Health Districts had hospitalization rates 1999-2000 that were significantly higher than the state rate (Table 4).

Rate per 100,000

Rate per 100,000

Percentage

figure 17

Percentage of asthma hospitalizations

by season, Georgia, 2000

35%
30% 23.5%
25%
20%

17.0%

28.8%

30.8%

15%

10%

5%

0%

Spring Summer

Fall

Winter

SEASONS

figure 18

Age-adjusted asthma hospitalization

rates by race and sex,

Georgia, 1999-2000

400

350

Males Females

300

250

200

150

114.9

100

68.1

50

160.1

218.8

0 Whites

Blacks

figure 19

Age specific asthma hospitalization rates by age group, Georgia, 1999-2000
400 355.6 350

300

250

200

179.0

150

137.0

100

82.5

85.8

50

0 0 - 4 5 - 24 25 - 54 55 - 64 65+

AGE GROUP (YEARS)

The Burden of Asthma in Georgia 11

Asthma Morbidity in Georgia continued. . .

Table 3. Annual number of hospitalizations for asthma, age-adjusted asthma hospitalization rates, and hospital charges per year by county, Georgia, 1999-2000

County Number Rate Charges

County Number Rate Charges

Georgia Appling Atkinson Bacon Baker Baldwin Banks Barrow Bartow Ben Hill Berrien Bibb Bleckley Brantley Brooks Bryan Bulloch Burke Butts Calhoun Camden Candler Carroll Catoosa Charlton Chatham Chattahoochee Chattooga Cherokee Clarke Clay Clayton Clinch Cobb Coffee Colquitt Columbia Cook Coweta Crawford Crisp

9,403 41 11 9 2 40 20 61 69 45 49
217 18 19 35 28 66 47 18 28 19 26 108 17 12 214 5 24 77 125 4 229 17 541 66 55 40 61 92 6 45

120 239* 150
85 ## 100 140 136 89 243* 290* 141* 156 127 206* 136 142 200* 95 508* 60 276* 129 32 130 94 ## 99 56 166* ## 108 242* 96 177* 130 47 382* 109 54 209*

$58,800,000 190,000 60,000 50,000 5,000 210,000 125,000 425,000 390,000 220,000 220,000
1,680,000 60,000 80,000 145,000
270,000 515,000 220,000 130,000 90,000 90,000 135,000 575,000 105,000 70,000 1,250,000 35,000 155,000 470,000 830,000 20,000 1,400,000 80,000 3,940,000 365,000 285,000 430,000 270,000 625,000 40,000 220,000

Dade Dawson Decatur DeKalb Dodge Dooly Dougherty Douglas Early Echols Effingham Elbert Emanuel Evans Fannin Fayette Floyd Forsyth Franklin Fulton Gilmer Glascock Glynn Gordon Grady Greene Gwinnett Habersham Hall Hancock Haralson Harris Hart Heard Henry Houston Irwin Jackson Jasper Jeff Davis Jefferson

5 10 47 591 30 49 176 126 18 3 17 32 37 11 13 42 117 52 36 1,203 48 5 107 30 30 25 448 52 144 24 32 16 24 15 103 130 14 69 7 15 29

## 64 168* 101 158 440* 181* 142* 149 ## 49 162* 167* 108 65 49 136 55 184* 164* 216* ## 158* 69 131 175* 92 150 112* 257* 125 69 98 135 90 120 146 173* 62 109 165

$25,000 30,000 215,000
4,110,000 135,000 220,000 970,000 695,000 70,000 15,000 105,000 145,000 210,000 55,000 75,000 225,000 540,000 405,000 180,000
10,005,000 255,000 25,000 560,000 185,000 200,000 135,000
2,810,000 250,000 970,000 160,000 160,000 70,000 100,000 80,000 645,000 530,000 60,000 435,000 25,000 70,000 135,000

12 The Burden of Asthma in Georgia

Asthma Morbidity in Georgia continued. . .

Table 3. continued . . .

County Number Rate Charges

County Number Rate Charges

Jenkins

20

Johnson

12

Jones

15

Lamar

23

Lanier

10

Laurens

97

Lee

25

Liberty

76

Lincoln

11

Long

5

Lowndes

212

Lumpkin

13

McDuffie

47

McIntosh

15

Macon

26

Madison

47

Marion

6

Meriwether

32

Miller

11

Mitchell

30

Monroe

17

Montgomery

9

Morgan

21

Murray

29

Muscogee

164

Newton

55

Oconee

24

Oglethorpe

10

Paulding

44

Peach

39

Pickens

18

Pierce

20

Pike

19

Polk

44

Pulaski

29

Putnam

20

Quitman

1

Rabun

25

Randolph

15

Richmond

249

Rockdale

44

239* 133 65 151 147 214* 104 160* 136 55 245* 65 213* 146 184* 183* 78 136 181 134 80 120 130 76
91 88 90 82 52 159* 79 125 141 116 327* 109 ## 159 183 131 66

$95,000 55,000 90,000 135,000 75,000
580,000 115,000 385,000 60,000 15,000 905,000 35,000 205,000 90,000 110,000 300,000 30,000 160,000 65,000 135,000 100,000 55,000 115,000 155,000 1,115,000 260,000 125,000 60,000 215,000 210,000 130,000 145,000 100,000 180,000 95,000 75,000
5,000 120,000 50,000 2,260,000 245,000

Schley Screven Seminole Spalding Stephens Stewart Sumter Talbot Taliaferro Tattnall Taylor Telfair Terrell Thomas Tift Toombs Towns Treutlen Troup Turner Twiggs Union Upson Walker Walton Ware Warren Washington Wayne Webster Wheeler White Whitfield Wilcox Wilkes Wilkinson Worth

4

##

40

257*

28

289*

81

140

58

245*

9

155

49

151

6

88

4

199

32

160

11

120

21

181*

19

168

98

222*

86

213*

53

196*

7

52

9

126

124

210*

20

191*

10

98

22

119

33

120

54

86

37

64

48

133

11

181

22

105

36

138

4

##

7

130

14

74

75

91

25

313*

17

158

15

136

35

149

$20,000 200,000 135,000 585,000 230,000
70,000 285,000
45,000 15,000 140,000 45,000 85,000 130,000 520,000 315,000 280,000 35,000 70,000 585,000 70,000 75,000 110,000 150,000 375,000 200,000 335,000 40,000 110,000 185,000 15,000 35,000 100,000 500,000 100,000 95,000 95,000 185,000

Numbers, rates, and charges are annual.
*Hospitalization rate significantly higher than the Georgia rate Hospitalization rate significantly lower than the Georgia rate ## Rates are not calculated for counties with < 5 hospitalizations per year

The Burden of Asthma in Georgia 13

Asthma Morbidity in Georgia continued. . .
Map 1. Age-adjusted hospitalization rates for asthma by county, 1999-2000
County rate significantly higher than the state rate No difference between county and state rate County rate significantly lower than the state rate Less than ten hospitalizations - rate not calculated
14 The Burden of Asthma in Georgia

Asthma Morbidity in Georgia continued. . .

Table 4. Age-adjusted annual asthma hospitalization rates and average charges per year by public health district, Georgia, 1999-2000

Districts

Hospitalizations
Number Rate

Charges

GEORGIA

9,403 120 $58,800,000

(1-1) Northwest (Rome)

435

85 $2,320,000

(1-2) North Georgia (Dalton)

258

81 $1,580,000

(2-0) North (Gainesville)

473 107 $2,695,000

(3-1) Cobb/Douglas (Marietta)

666 102 $4,635,000

(3-2) Fulton (Atlanta)

1203 164 * $10,005,000

(3-3) Clayton (Morrow)

229 108 $1,400,000

(3-4) East Metro (Lawrenceville) 545

88 $3,315,000

(3-5) DeKalb (Decatur)

591

101 $4,110,000

(4-0) LaGrange

686 114 $3,995,000

(5-1) South Central (Dublin)

255 193 * $1,265,000

(5-2) North Central (Macon)

560 121 $3,395,000

(6-0) East Central (Augusta)

554 132 * $3,995,000

(7-0) West Central (Columbus)

411 119 $2,355,000

(8-1) South (Valdosta)

533 237 * $2,295,000

(8-2) Southwest (Albany)

599 170 * $3,120,000

(9-1) East (Savannah)

231

87 $1,355,000

(9-2) Southeast (Waycross)

477 155 * $2,770,000

(9-3) Coastal (Brunswick)

249 119 $1,415,000

(10-0) Northeast (Athens)

448 133 * $2,765,000

* Hospitalization rate significantly higher than the Georgia rate

Hospitalization rate significantly lower than the Georgia rate

The Burden of Asthma in Georgia 15

Discussion

16 The Burden of Asthma in Georgia

Asthma is a major public health issue in Georgia as it is in the United States. Approximately 13.1% of Georgia's public middle school students, 10.7% of Georgia's high school students, and 6.7% of adult Georgians report currently having asthma. This report shows that asthma affects all age, race, and sex groups. Blacks and women are more likely to be hospitalized and die from asthma than whites and men. Asthma hospitalizations are highest among the older and younger age groups. Death rates are 24 times higher for the elderly (65 years of age and older) than for the younger age groups (0 to 4 years and 5 to 24 years).
Findings presented in this report suggest at least four ways by which the burden of asthma in Georgia can be reduced:
1) Reduce cigarette smoking and exposure to environmental
tobacco smoke (ETS).
2) Improve access to quality healthcare.
3) Increase receipt of annual flu shot.
4) Increase physical activity and improve diet to reduce overweight
and obesity.
Reduce smoking and exposure to environmental
tobacco smoke
1Despite the fact that cigarette smoking may trigger asthma attacks, 26.3%
of adults with asthma, 24.7% of high school students with asthma, and 11.6% of middle school students with asthma currently smoke. Approximately 3 in 4 middle school students and high school students with asthma are exposed to environmental tobacco smoke. Smoking and exposure to environmental tobacco smoke have been shown to increase the frequency and severity of asthma attacks. Stopping smoking and limiting exposure to ETS can help reduce the frequency and severity of asthma attacks. Policies against smoking in public places also will help prevent asthma attacks.

2Improve access to quality healthcare
A significant number of adults with asthma (22.3%) were unable to see a doctor because of cost. Lack of access to adequate healthcare can make it difficult for individuals to keep their asthma under control. Asthma is a disease that can be controlled with proper treatment and management. Therefore, programs which provide education regarding proper treatment and self-management need to be made available.
3Increase receipt annual flu shot
Respiratory infections are a common trigger of asthma attacks. Annual flu shots for people with asthma will reduce the incidence of asthma attacks or their severity. However, only about one-third of adults with asthma have received the annual flu shot (34.4%).
Increase physical activity and
4improve diet
A high percentage (21.4%) of high school students with asthma are overweight, compared to 9.0% of those without asthma. Sixty-seven percent of adults with asthma are currently overweight or obese. The relationship between asthma and obesity is not well understood, but overweight or obese individuals tend to experience more symptoms than people of normal weight. Asthma is a disease that should not limit an individual's normal activities. Participation in physical activities and eating a healthy diet can help reduce asthma symptoms.
Education, policy changes, and modification of risk factors will help reduce frequency and severity of attacks in individuals with asthma and possibly delay or prevent the development of asthma in individuals without asthma. These actions will ultimately reduce the burden of asthma in Georgia and improve the quality of life of Georgians with asthma.

The Burden of Asthma in Georgia 17

References
1. American Lung Association. Prevalence based on revised National Health Interview Survey. Available at: http://www.lungusa.org/data/data_102000.html.
2. American Lung Association. Epidemiology and Statistics Unit, Best Practices and Programs Services. Trends in Asthma Morbidity and Mortality. February 2002.
3. National Center of Health Statistics. 2000 National Hospital Discharge Survey, Advanced Data No. 329, June 2002.
4. National Heart, Lung, and Blood Institute. Morbidity and Mortality: 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases. May 2002.
5. Mellinger-Birdsong AK, Powell KE, Iatridis T. 2000 Georgia Asthma Report. Georgia Department of Human Resources, Division of Public Health, Chronic Disease, Injury, and Environmental Epidemiology Section, December, 2000. Publication number DPH00.65H.
6. Mannino DM, Moorman JE, Kingsley B, et al. Health effects related to environmental tobacco smoke exposure in children in the United States: data from the Third National Health and Nutrition Examination Survey. Arch Pediatr Adolesc Med 2001; 155:36-41.
7. Strachan DP, Cook DG. Health effects of passive smoking. 6. Parental smoking and childhood asthma: longitudinal and case-control studies. Thorax 1998 Mar; 53:(3): 204-212.
8. Forastiere F, Corbo GM, Michelozzi P, et al. Effects of environment and passive smoking on the respiratory health of children. Int J Epidemiol 1992; 21:66-73.
9. Kemp JP, Kemp JA. Management of asthma in children. Am Fam Physician 2001; 63:13411348.
10. von Mutius E, Schwartz J, Neas LM, et al. Relation of body mass index to asthma and atopy in children: the National Health and Nutrition Examination Study III. Thorax 2001; 56:835838.
11. Gennuso et al. The relationship between asthma and obesity in urban minority children and adolescents. Archives of Pediatrics and Adolescent Medicine 1998; n 152(12); 1197-1202.
12. Baker WH. Excess pneumonia and influenza associated hospitalization during influenza epidemics in the United States, 1970-78. Am J Public Health 1986; 76:761-765.
13. Sullivan KM, Monto AS, Longini IM Jr. Estimates of the US health impact of influenza. Am J Public Health 1993; 83:17121716.
14. National Asthma Education and Prevention Program. Expert Panel report 2: guidelines for the diagnoses and management of asthma. Bethesda Md.: National Heart, Lung, and Blood Institute, 1998. (NIH publication no. 98-4051).
15. National Health Interview Survey: receiving influenza vaccine. Hyattsville, MD. National Center for Health Statistics, 2000: 22-4. Available at www.cdc.gov/nchs/about/major/nhis/nhis2htm.
18 The Burden of Asthma in Georgia

Appendix 1: Acknowledgements
Georgia Department of Human Resources . . . . . . . . . . . . . . . . . . . . . . . . . .Maria Greene, Acting Commissioner Division of Public Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Kathleen E. Toomey, M.D., M.P.H., Director Chronic Disease Prevention and Health Promotion Branch . . . . . . . . . .Carol B. Steiner, R.N., M.N., Acting Director Epidemiology Branch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Paul Blake, M.D., M.P.H., Director Chronic Disease, Injury, and Environmental Epidemiology Section . .Kenneth E. Powell, M.D., M.P.H., Director Office of Health Information and Policy . . . . . . . . . . . . . . . . . . . . . . . . .Gordon R. Freymann, M.P.H., Director
We would like to thank Susan Enete for her assistance with editing and layout, Dafna Kanny and Linda Martin for their help with data from the Youth Tobacco Survey and BRFSS, respectively, and Gloria Chen, Judy Griffith and Jeff Gary for suggestions and edits.
Suggested Citation: Blackwell AD, Wu M, Mertz KJ, Powell KE, Williams CP, Chowdhury P. The Burden of Asthma in Georgia 2003. Georgia Department of Human Resources; Division of Public Health; Chronic Disease, Injury, and Environmental Epidemiology Section, December 2003. Publication number DPH03/127HW
Further information on this report may be obtained by contacting: Angela D. Blackwell, M.P.H. Georgia Department of Human Resources Division of Public Health Chronic Disease, Injury, and Environmental Epidemiology 2 Peachtree Street, 14.284 Atlanta, GA 30303-3142 (404) 463-3748 adblackwell@dhr.state.ga.us
The Burden of Asthma in Georgia 19

Appendix 2: About the Data
There are four data sources discussed in the 2002 Georgia Asthma Report: 1) the Georgia Youth Tobacco Survey for public middle and high school students, 2) the Behavioral Risk Factor Surveillance System for adults 18 years and older, 3) the Georgia vital statistics data, and 4) the Georgia hospital inpatient discharge data.
The Georgia Youth Tobacco Survey (GYTS) is a self-administered pencil and paper survey. This survey was last administered to Georgia public middle and high school students in fall 2001. The main focus of this survey was tobacco but two questions on height and weight were included to calculate BMI and three questions concerning asthma were included: 1) Have you ever been told by a doctor or nurse that you have asthma? 2) Do you still have asthma? 3) Have you had an episode or attack of asthma in the past twelve months? Current asthma was defined as a "yes" answer to the first two questions. For both middle school and high school data, a weight variable was calculated for each record to reflect the likelihood of sampling each student and to reduce bias by compensating for differing patterns of non-response. SUDAAN was used to compute the 95% confidence intervals, which were used to determine the differences between subgroups. Differences between prevalence estimates were considered statistically significant if the 95% confidence intervals did not overlap. This survey does not include students who do not attend public middle school and high school, were home schooled, or those who do not attend school at all.
The Behavioral Risk Factor Surveillance System (BRFSS) is conducted in cooperation with Centers for Disease Control and Prevention (CDC). Georgia residents 18 years and older are interviewed by telephone about health conditions, behaviors, and the use of preventive services. Asthma was one of the topics included in 2000 and 2001. The questions were 1) Have you ever been told that you have asthma? 2) Do you still have asthma? Current asthma was classified by a "yes" answer to both questions. Prevalence for 2000-2001 combined were estimated using SAS and SUDAAN, which take into account the stratified sample design of the BRFSS. People without a telephone are not included in the survey.
Mortality data are based on deaths of Georgia residents whose underlying cause of death was asthma. Deaths from 1996 to 1998 with ICD-9 code 493 and deaths in 1999 and 2000 with ICD-10 codes J45-J46 were selected. To combine the data from 1996-2000 the estimated comparability ratio 0.8938 was used to calculate the "comparability modified" number of deaths in 1996-1998, which was added to actual number of deaths in 1999-2000. Death rates were age adjusted to the 2000 US standard population via the direct method. Recent trends in mortality are difficult to interpret because of the change from ICD-9 to ICD-10 coding of deaths in 1999.
Hospitalization data in the report are based on hospital discharge data for Georgia residents who were hospitalized in 1999 or 2000 with asthma as the primary diagnosis. The ICD-9 codes used to select hospitalizations were 493.0-493.9. Hospitalization data only included information reported by non-federal acute care hospitals in Georgia. Rates were age-adjusted to the 2000 US standard population via the direct method. Hospitalization charges may differ from costs. Charges are based upon the hospital's full-established rates. The amount a hospital is reimbursed is usually less than what is charged.
Death and hospitalization rates are expressed per 100,000 population throughout the report.
20 The Burden of Asthma in Georgia

Appendix 3: Definitions
Age-adjusted rate: A rate calculated in a manner that allows comparison of populations with different age structures Comparability ratio (CR): The ratio used to compare number of deaths using ICD-9 codes for years 1998 and ICD-10 codes for years 1999; the comparability ratio for asthma is 0.8938 Current smoking (adults): Smoked at least 100 cigarettes in their lifetime and who currently smoke Current smoking (students): Smoked cigarettes on one or more days of the past 30 days Exposure to environmental tobacco smoke: Exposure to tobacco smoke in the home, a room, or in a car in the past seven days Fair or poor health: Self-reported health status as fair or poor Flu shot: Flu shot received in the past twelve months Income: Annual household income from all sources Mental distress: Mental health not good on 14 or more of the past 30 days; may be caused by stress, depression, or problems with emotions Overweight or obese (adults): A body mass index (BMI) equal to or greater than 25.0; BMI is weight in kilograms divided by height in meters squared Overweight (students): BMI for age 95th percentile based on the CDC's growth chart for BMI determined by age and sex Prevalence: The percentage of persons who have a disease or a risk factor at a given time Risk factor: A habit, characteristic, or finding on clinical examination that is associated with an increased probability of disease Seasons: Winter = December-February; Spring = March-May; Summer = June-August; and Fall = September-November Statistically significant: In this report, a p-value <0.05 is considered statistically significant; observed results are probably different from what might have occurred as a result of chance alone
The Burden of Asthma in Georgia 21

Appendix 4: Abbreviations
BMI: Body mass index BRFSS: Behavioral Risk Factor Surveillance System CDC: Centers for Disease Control and Prevention ETS: Environmental tobacco smoke GYTS: Georgia Youth Tobacco Survey ICD-9: International Classification of Diseases, 9th Revision ICD-10: International Classification of Diseases, 10th Revision
22 The Burden of Asthma in Georgia

Appendix 5: Georgia Public Health Districts

1-1 Northwest (Rome)

Dade Catoosa

Fannin

Murray

Whitfield 1-2

Walker

Gilmer

Towns Rabun
Union 2-0
White Lumpkin Habersham

Chattooga Gordon Pickens

Stephens

1-1

Dawson

Banks Franklin

Floyd Polk

Bartow Cherokee

Hall

Hart

Cobb Paulding

Forsyth Jackson Madison

Fulton Gwinnett

10-0

Elbert

3-4 Barrow Clarke

1-2 North Georgia (Dalton) 2-0 North (Gainesville) 3-1 Cobb-Douglas 3-2 Fulton 3-3 Clayton (Morrow) 3-4 East Metro (Lawrenceville) 3-5 DeKalb 4-0 LaGrange 5-1 South Central (Dublin) 5-2 North Central (Macon) 6-0 East Central (Augusta)

Haralson Carroll

3-1
Douglas
3-2

DeKalb
3-5

Oconee

Walton

Oglethorpe

3-3
Clayton

Rockdale Newton

Morgan Greene

Wilkes Tallaferro

Lincoln Columbia

Heard

Fayette Henry

Coweta
4-0

Spadling Butts Jasper Putnam

Wilkes

Warren

Richmond

Hancock Glascock

6-0

7-0 West Central (Columbus) 8-1 South (Valdosta) 8-2 Southwest (Albany) 9-1 East (Savannah) 9-2 Southeast (Waycross) 9-3 Coastal (Brunswick) 10-0 Northeast (Athens)

Troup

Pike Lamar

Meriwether

MonroeJones

Baldwin

Jefferson

Washington

Burke

Harris

Upson

5-2

Bibb

Wilkinson

Talbot

Crawford

Johnson

Jenkins Screven

Twiggs

Emanuel

Muscogee

Taylor

Peach

Laurens

Marion
Chattahoochee 7-0

Houston Bleckley

Macon

5-1

Treutlen

Effingham Candler Bulloch
9-1

Schley

Pulaski

Stewart Webster Sumter

Quitman

Terrell Lee

Randolph

Dooley

Dodge Wheeler

Crisp Wilcox

Telfair

Turner

Ben Hill

Jeff Davis

Toombs

Evans Bryan Chatham

Tattnall

Liberty

Appling

Long
9-3

Clay Calhoun Dougherty Worth

Early

8-2
Baker

Irwin Tift
Berrien

Miller

Mitchell Colquitt Cooks

Bacon Coffee

Wayne

Atkinson

Pierce
9-2
Brantley Ware

McIntosh Glynn

Lanier

Seminole

8-1

Camden

Decatur

Thomas Brooks

Lowndes

Grady

Clinch

Charlton

Echols

The Burden of Asthma in Georgia 23