2007 Georgia asthma surveillance report [Feb. 2007]

Georgia
Asthma
Surveillance Report 2007
2007 Georgia Asthma Surveillance Report | 1

Acknowledgments
Georgia Department of Human Resources B.J. Walker, Commissioner
Division of Public Health Stuart T. Brown, M.D., Director
Chronic Disease Prevention and Health Promotion Branch Kimberly Redding, M.D., M.P.H., Director
Asthma Prevention Program Carolyn P. Williams, Manager Epidemiology Branch Susan Lance, D.V.M., Ph.D., Director Chronic Disease, Injury, and Environmental Epidemiology Section John Horan, M.D., M.P.H., Chief For more information on asthma surveillance in Georgia, please contact: Asthma Epidemiologist Chronic Disease, Injury, and Environmental Epidemiology Section Division of Public Health Georgia Department of Human Resources 2 Peachtree Street, 14th Floor Atlanta, GA 30303-3142 (404) 657-3103 http://health.state.ga.us/epi/cdiee/asthma.asp
Graphic Design: Jimmy Clanton Jr. Suggested Citation: Blackwell A, Kanny D, 2007 Georgia Asthma Surveillance Report. Georgia Department of Human Resources, Division of Public Health, Chronic Disease, Injury, and Environmental Epidemiology Section, February 2007. Publication Number: DPH07/049HW
2 | 2007 Georgia Asthma Surveillance Report

Table of Contents
Highlights.................................................................................................................................................... 4 Introduction ................................................................................................................................................. 5 Prevalence of Asthma in Georgia .............................................................................................................6
Prevalence of Asthma among Children Ages 0-10 .......................................................................6 Prevalence of Asthma among Middle and High school Students ...............................................8 Prevalence of Asthma among Adults.............................................................................................10 Work-related Asthma Prevalence among Adults ........................................................................12 Asthma Morbidity in Georgia ...................................................................................................................13 Asthma Emergency Room (ER) Visits in Georgia ......................................................................13 Asthma Hospitalizations in Georgia..............................................................................................15 Asthma Mortality in Georgia ....................................................................................................................17 Asthma Severity and Impact in Georgia ..................................................................................................18 Asthma Management in Georgia..............................................................................................................20 Conclusions .................................................................................................................................................. 22 References ....................................................................................................................................................24 Appendix I:Data Tables..............................................................................................................................25 Appendix II: Data Sources for Asthma.....................................................................................................31 Appendix III:Definitions and Abbreviations............................................................................................33
2007 Georgia Asthma Surveillance Report | 3

Highlights
In Georgia,
More than 100,000 (10%) children ages 0-10 have asthma. Approximately 56,000 (15%) middle school students have asthma. Approximately 70,000 (16%) high school students have asthma Approximately 480,000 (7%) adults have asthma. There are more than 47,000 emergency room (ER) visits per year with asthma as the
primary diagnosis, and ER charges are approximately $35 million. There are more than 11,000 hospitalizations per year with asthma as the primary
diagnosis, and hospital charges total more than $107 million. Approximately 117 persons die every year from asthma. Blacks are more likely than Whites and women are more likely than men to visit the ER,
be hospitalized or die because of asthma. Despite the fact that cigarette smoking may trigger asthma attacks, approximately 4,500
(8%) middle school students 14,000 (20%) high school students, and one in four (25%) adults with asthma smoke cigarettes. More than 30% of children ages 0-10, two-thirds of middle school students and threefourths of high school students are exposed to secondhand smoke regardless of their asthma status. Appropriate disease management can reduce the burden of asthma, including avoidance of triggers, proper treatment regime, following an asthma management plan created by you and your doctor, and knowing when to seek medical help.
4 | 2007 Georgia Asthma Surveillance Report

Introduction
Asthma is a chronic inflammatory disorder of the lungs and airways that can include recurrent episodes of wheezing, coughing, shortness of breath, and chest pain or tightness. The cause or causes of asthma are not well understood and likely differ among individuals. Heredity, behaviors such as smoking and environmental exposures, and viral infections all play a role. Once a person has asthma a variety of things can trigger an attack such as allergens (e.g. pollen, dust mites, animal dander etc.), infections, exercise, changes in the weather, and exposure to airway irritants (e.g. tobacco smoke, secondhand smoke, industrial chemicals, etc.) Being obese may also be a risk factor for asthma attacks. Asthma attacks differ in severity for each individual and can be life-threatening. With appropriate clinical management including a written management plan, comprehensive pharmacologic therapy, and avoidance of allergens and other triggers asthma can be controlled, people with asthma in Georgia can lead normal lives.
According to a 2005 report from the National Center for Health Statistics, an estimated 33 million Americans have been diagnosed with asthma at some point in their life and nearly 22 million currently have asthma. 1 In 2004, asthma was responsible for 2 million emergency room (ER) visits, 500,000 hospitalizations, and nearly 5,000 deaths nationwide. 1, 2 Georgia accounts for approximately 47,000 ER visits, 11,000 hospitalizations, and 117 deaths.2, 3 The economic burden of asthma annually (direct and indirect) totaled more than $16 billion nationwide.4 Asthma affects people of all ages, sexes, races, and ethnic groups, but certain subpopulations are disproportionately affected. Blacks and females are more likely to visit the ER, be hospitalized, and die from asthma than Whites and males. 5, 6 Children are also disproportionately affected. This disparity is seen mostly in health care utilization, with ER visit rates and hospitalization rates for children 2 to 3 times higher than for adults. 5, 6
In 2000, the Georgia Department of Human Resource (DHR) and the American Lung Association (ALA) of Georgia jointly produced the first Georgia asthma report, which provided insight into the problem of asthma. Findings highlighted the need for a statewide systematic approach to address the problem of asthma in Georgia. 7 In 2001, the Centers for Disease Control and Prevention (CDC) awarded a grant to DHR to create and implement a statewide plan to address asthma in Georgia. Surveillance was considered a key component to guide the program in its efforts, and the 2003 Burden of Asthma in Georgia report was developed. 8 This report focused on prevalence and risk factors for middle and high school students and adults, morbidity, and mortality. The 2003 report further confirmed that asthma was a major public health problem in Georgia.
The 2007 Georgia Asthma Surveillance Report presents data on asthma prevalence and risk factors for asthma, work-related asthma prevalence, healthcare utilization, deaths, asthma severity, and management practices for all age groups. This report is the third and most comprehensive report available to describe the burden of asthma in Georgia. The purpose of this report is to increase awareness of the burden of asthma on Georgia and to guide public health programs, policy makers, and healthcare providers in the planning, implementation, and evaluation of interventions and programs to reduce the burden of asthma in Georgia.
2007 Georgia Asthma Surveillance Report | 5

Source: Georgia Childhood Asthma Survey

Prevalence of Asthma in Georgia

Prevalence of Asthma among Children Ages 0-10

Figure 1: Prevalence of current asthma

among children ages 0-10 by sex,

An estimated 137,000 (10%) of children ages 0-10 in

Georgia, 2002-2003

Georgia have asthma. Asthma is more common among 25
boys (12%) than girls (8%) (Figure 1).

20

Percent

15 12

10

8

5

0 Male

Female

The prevalence of asthma is similar among Black children (12%) and White children (10%) (Figure 2).

Percent

Figure 2: Prevalence of current asthma among children ages 0-10 by race, Georgia, 2002-2003

25 20 15
10 10
5 0
White

12 Black

Source: Georgia Childhood Asthma Survey

Source: Georgia Childhood Asthma Survey

The prevalence of asthma is 9% among those aged 0 to 4 years and 12% among those 5 to 10 years (Figure 3).
6 | 2007 Georgia Asthma Surveillance Report

Percent

Figure 3: Prevalence of current asthma among children ages 0-10 by age group,
Georgia, 2002-2003

25

20

15 12

10

9

5

0

0-4

5-10

Age Group

Percent

Figure 4: Prevalence of current asthma among children ages 0-10 by annual household income,
Georgia, 2002-2003

25

20

17

15

10

5

0
Less than $20,000

10
$20,000$34,999

9
$35,000$49,999 Income

8

9

$50,000- $75,000 or

$74,999

more

Source: Georgia Childhood Asthma Survey

Asthma prevalence is higher in children living in households with an annual household income of less than $20,000 (17%) than in children living in households with higher household income (Figure 4).

Figure 5: Prevalence of exposure to environmental tobacco smoke* among children ages 0-10 by asthma status, Georgia, 2002-2003
100

80

Percent

60

36

40

29

20

0 No Asthma
*Parent reported smoking in the home and outside of the home

Current Asthma

Source: Georgia Childhood Asthma Survey

Risk Factors for Asthma Attacks among Children Ages 0-10
Avoiding tobacco smoke is one way to reduce the frequency of asthma attacks. Tobacco smoke is known to be a trigger for many people with asthma. More than a third (36%) of children with asthma live in a household where at least one parent smokes inside and outside of the home; a significantly lower percent of children without asthma (29%) have this exposure (Figure 5).

2007 Georgia Asthma Surveillance Report | 7

Source: Georgia Youth Tobacco Survey

Prevalence of Asthma among Middle and High School Students
Approximately 56,000 (15%) middle school students and approximately 70,000 (16%) high school students report they currently have asthma (Figure 6).

Percent

Figure 6: Prevalence of current asthma among middle and high school students,
Georgia, 2005

25 20
15 15 10
5 0
Middle School

16 High School

Source: Georgia Youth Tobacco Survey

There are no significant differences in the prevalence of asthma among the four major race/sex groups in Georgia (Figure 7).

Percent

Figure 7: Prevalence of current asthma among middle and high school students by race and sex,
Georgia, 2005

25
20 16
15 13
10
5
0 White

Male Female

18 16

16 16

Black

White

20 19 Black

Middle School

High School

Asthma prevalence by grade level ranges from 13% to 19% (Figure 8).

Percent

Figure 8: Prevalence of current asthma among middle and high school students by grade,
Georgia, 2005
25

20 15 14

19

17

18

15

16

13

10

5

0

6

7

8

9

10

11

12

Grade

8 | 2007 Georgia Asthma Surveillance Report

Source: Georgia Youth Tobacco Survey

Figure 9: Prevalence of current smoking among middle and high school students by asthma status,
Georgia, 2005

No Asthma Current Asthma

25

19

20

20

15

10

9

8

5

0 Middle School

High School

Source: Georgia Youth Tobacco Survey

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 9).

Percent

Figure 10: Prevalence of exposure to environmental tobacco smoke* among middle and high school students by asthma status, Georgia, 2005

No Asthma Current Asthma

100

80

63 67

60

80 75

Percent

40

20

0 Middle School

High School

**EExxppoossuurre to ttoobbaaccccoossmmookkeeataht ohmome ienianraoormoo, min,aincaar caanrdathnrdouthgrhofurgiehndfrsiewnhdosswmhookessm. oke.

Source: Georgia Youth Tobacco Survey

Exposure to environmental tobacco smoke (ETS) also may trigger an asthma attack or may increase the severity of an asthma attack. Approximately twothirds of middle school students and three-fourths of high school students are exposed to ETS regardless of their asthma status (Figure 10).

Figure 11: Prevalence of obesity* among middle and high school students by asthma status,
Georgia, 2005
No Asthma Current asthma
25

Percent

20

15

14

11

10

12 12

5

0 Middle School

High School

*Obese: BMI-for-age 95th percentile

Source: Georgia Youth Tobacco Survey

In middle school, the prevalence of students who are obese (BMI-for-age 95th percentile) is higher among students with asthma (14%) than among students without asthma (11%). There are no significant differences in the prevalence of obesity among high school students with or without asthma (Figure 11). Although the nature of the relationship between asthma and body weight requires more research, some evidence suggests that people with asthma who are obese experience more symptoms than people with asthma who are not obese. 9-11 Therefore, people with asthma have yet another reason to maintain proper body weight.
2007 Georgia Asthma Surveillance Report | 9

Source: Georgia Behavioral Risk Factor Surveillance System

Prevalence of Asthma among Adults
Approximately 480,000 (7%) adults in Georgia have asthma. The prevalence of asthma among females (9%) is significantly higher than among males (5%) (Figure 12). The prevalence among Blacks (8%) is similar to Whites (7%) (Figure 13). The prevalence of asthma by age group in adults ranges from 6% to 11% (Figure 14).
The prevalence of asthma is significantly higher in adults with annual household incomes less than $15,000 than in adults with household incomes more than $15,000 (Figure 15). Reasons for these differences are unknown but may be related to environmental exposures more common in low socioeconomic populations.
Prevalence of Asthma among Adults by Public Health District
Current asthma prevalence among adult Georgians in the 18 Public Health Districts ranges from 5% to 9% in 2004-2005 (Appendix I, Table 1). There are no significant differences among the Public Health Districts when compared to each other or to the state.

Percent

Percent

Figure 12: Prevalence of current asthma among adults by sex, Georgia, 2004-2005

25
20
15
10 5
5
0 Male

9 Female

Figure 13: Prevalence of current asthma among adults by race, Georgia, 2004-2005

25

20

15

10

7

5

0 White

8 Black

Source: Georgia Behavioral Risk Factor Surveillance System

Source: Georgia Behavioral Risk Factor Surveillance System

Source: Georgia Behavioral Risk Factor Surveillance System Percent

Percent

Figure 15: Prevalence of current asthma among adults by annual household income,
Georgia, 2004-2005

25

20 16
15

10

8

8

7

5

5

5

0
Less than $15,000$15,000 $24,999

$25,000- $35,000$34,999 $49,000
Income

$50,000- $75,000 or $74,999 more

10 | 2007 Georgia Asthma Surveillance Report

Figure 14: Prevalence of current asthma among adults by age group, Georgia, 2004-2005

25

20

15

11

10

6

7

7

8

7

5

0

18-24 25-34 35-44 45-54 55-64

65+

Age Group

Percent

Figure 16: Prevalence of current smoking among adults by asthma status, Georgia, 2004-2005

50
40
30 21
20
10
0 No Asthma

21 Asthma

Figure 17: Prevalence of obesity among adults by asthma status,
Georgia, 2004-2005
50

40

36

30

26

20

10

0 No Asthma

Asthma

Figure 18: Percent of adults with current asthma who received flu shot, Georgia, 2004-2005
Flu Shot 34%
No Flu Shot 66%

Source: Georgia Behavioral Risk Factor Surveillance System

Source: Georgia Behavioral Risk Factor Surveillance System

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, 21% of adults who currently have asthma report cigarette smoking (Figure 16).
Thirty-six percent of adults with asthma are currently obese (Figure 17). This is a significantly higher prevalence than that for people without asthma (26%).
Influenza is associated with substantial adverse effects especially among people who have asthma, including time lost from work or school, costly ER visits and hospitalization.12, 13 Vaccination reduces morbidity in patients with asthma and immunization is recommended for all such patients.12, 13 Only one-third (34%) of the adults with asthma in Georgia reported receiving a flu shot in the past year (Figure 18).

Percent

Source: Georgia Behavioral Risk Factor Surveillance System

2007 Georgia Asthma Surveillance Report | 11

Source: Georgia Behavioral Risk Factor Surveillance System

Health Status
Asthma has a considerable effect on how adult Georgians perceive their health status. Persons with asthma (35%) are more likely to report fair or poor health than those who do not have asthma (15%). Adults with asthma (21%) are also more likely to report mental distress than adults without asthma (10%) (Figure 19).

Percent

Figure 19: Percent of adults who report fair/poor health or mental distress by asthma
status, Georgia, 2004-2005

Asthma No Asthma 50

40

35

30

20

15

10

21 10

0 Fair/Poor Health

Mental Distress

Source: Georgia Behavioral Risk Factor Surveillance System

Adults with asthma (27%) are significantly more likely to report being unable to see a doctor due to cost than those without asthma (15%) (Figure 20).

Figure 20: Percent of adults who could not see a doctor due to cost by asthma status,
Georgia, 2004-2005

Work-related Asthma Prevalence

Percent

50

40

30

27

20

10

0 Asthma

15 No Asthma

Work-related asthma is the most prevalent occupational respiratory lung disorder in the United States.14,15 It is estimated that 15% of asthma cases in the United States are due to exposure to allergens or irritants in the workplace.14, 15 Not much data is available in Georgia on work-related asthma because it is not a reportable condition, but according to the Georgia Behavioral Risk Factor Surveillance System (BRFSS), 16% of adults with current asthma stated that their doctor told them their asthma was workrelated or they told their doctor their asthma was work-related (Figure 21). Work-related asthma is a key target group because adults spend the majority of their day at work. Interventions should be developed to improve ventilation or elimination of triggers within the workplace that can increase the frequency and severity of asthma exacerbations or attacks.

Figure 21: Prevalence of work-related* asthma among adults with current asthma Georgia, 2005
16%
84% Work-related Not Work-related
*Combination of respondents who told their doctor asthma was related to the job or the doctor told respondent asthma related to the job

12 | 2007 Georgia Asthma Surveillance Report

Source: Georgia Behavioral Risk Factor Surveillance System

Figure 22: Asthma ER visits by season, Georgia, 2004

Winter 24%

Spring 27%

Fall 30%

Summer 19%

Source: Georgia Hospital Association

Asthma Morbidity in Georgia
Asthma Emergency Room (ER) Visits in Georgia
There were approximately 47,000 ER visits in 2004 in Georgia with asthma as the primary diagnosis. The overall rate of ER visits due to asthma was 510 per 100,000 population. Asthma ER charges were approximately $35 million. There are fewer ER visits during the summer than in any other season of the year (Figure 22).

ER visits rate per100,000

Figure 23: Age-adjusted asthma ER visit rates by race and sex, Georgia, 2004

1000 800 600 400 200 0

Male Female

929

955

333 216

White

Race and Sex

Black

Source: Georgia Hospital Association

Blacks are 3 times more likely to visit the ER with asthma than Whites (947 vs. 273 per 100,000 population). Females are 1.2 times more likely to visit the ER than males (516 vs. 417 per 100,000 population). Black females have the highest ER visit rate (955 per 100,000 population) among the four major race-sex groups in Georgia (Figure 23). Black females are 3 times more likely to visit the ER than White females. Black males are 4 times more likely to visit the ER than White males (Figure 23).

Figure 24: Age-specific asthma ER visit rates by age group, Georgia, 2004

2000

1500 1397

1000 500

970 650 506 460 384 408 386 299 225

0 0-4 5-10 11-13 14-17 18-24 25-34 35-44 45-54 55-64 65+ Age Group (Years)

Source: Georgia Hospital Association

Children aged 0-4 have the highest ER visit rate, 1,397 per 100,000 population. A possible contributing factor is that asthma is often misdiagnosed and confused with other upper respiratory diseases in this age group (Figure 24).
2007 Georgia Asthma Surveillance Report | 13

ER visits rate per100,000

Asthma ER Visits by County

Asthma ER Visits by District

Thirty of Georgia's 159 counties had significantly higher ER visit rates than the state rate (510 ER visits per 100,000 per year) in 2004 (Appendix I, Table 2). Counties with high rates are located throughout Georgia, but high rates are more common in the southwest corner of the state (Figure 25).

Six of Georgia's 18 Public Health Districts had significantly higher ER visit rates than the state rate in 2004 (Appendix I, Table 3).

Figure 25: Age-adjusted emergency room visit rates for asthma by county, Georgia, 2004
Emergency room visit rates
Significantly higher than state rate No difference Significantly lower than state rate

Source: Georgia Hospital Association
14 | 2007 Georgia Asthma Surveillance Report

Figure 26: Asthma hospitalizations by season, Georgia, 2004

Winter 29%

Spring 27%

Fall 27%

Summer 17%

Source: Georgia Hospital Association

Hospitalizations from Asthma in Georgia
During 2004, there were more than 11,000 hospitalizations (133 per 100,000 population) in Georgia with asthma as the primary diagnosis. Hospital charges total more than $107 million dollars annually. Hospitalization rates in Georgia are 66 times higher than death rates. There are fewer hospitalizations in the summer than in any other season of the year (Figure 26).

Figure 27: Age-adjusted asthma hospitalization rates by race and sex, Georgia, 2004

Male Female

400

350

300

250

200

150

150

100

79

50

0

White

281 172
Black

Source: Georgia Hospital Association

Blacks are twice as likely to be hospitalized as Whites (237 vs. 118 per 100,000 population). Females are almost 2 times more likely to be hospitalized than males (185 vs. 104 per 100,000 population). Black females have the highest hospitalization rate (281 per 100,000 population) among the four major race-sex groups in Georgia (Figure 27).

Hospitialization rate per 100,000

Hospitalization rate per 100,000

Figure 28: Age-specific asthma hospitalization rates by age group, Georgia, 2004

400 364 350

300

250

235

200

167

162

150

133

100 50

81

91

43 36 49

0

0-4 5-10 11-13 14-17 18-24 25-34 35-44 45-54 55-64 65+

Age Group (Years)

Source: Georgia Hospital Association

Hospitalization rates are the highest among the young and elderly (Figure 28). Rates are 2 to 4 times higher for the 0 to 4 years old and the 65+ age group than other age groups.
2007 Georgia Asthma Surveillance Report | 15

Asthma Hospitalizations by County

Asthma Hospitalizations by District

Forty-three of Georgia's 159 counties had significantly higher hospitalization rates than the state rate (133 hospitalizations per 100,000 per year) in 2004 (Appendix I, Table 4). Counties with high rates are located throughout Georgia, but high rates are generally more common in the southern counties of the state (Figure 29).

Nine of Georgia's 18 Public Health Districts had significantly higher hospitalization rates than the state rate in 2004 (Appendix I, Table 5).

Figure 29: Age-adjusted hospitalization rates for asthma by county, Georgia, 2004
Hospitalization rates
Significantly higher than state rate No difference Significantly lower than state rate Not available

Source: Georgia Hospital Association
16 | 2007 Georgia Asthma Surveillance Report

Death rate per 100,000

Figure 30: Age-adjusted asthma death rates, Georgia and United States, 1984-2004
GA US *
5 4 3 2 1 0 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004
Year * Change from ICD-9 to ICD-10 coding

Source: Georgia Vital Records

Asthma Mortality in Georgia
Deaths from Asthma in Georgia
On average, from 2000 to 2004 there were 117 asthma deaths per year (1.6 per 100,000). Age-adjusted asthma death rates in the United States and Georgia increased during the 1980's and early 1990's (Figure 30). 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.

Death rate per 100,000

Figure 31: Age-adjusted asthma death rates by race and sex,
Georgia, 2000-2004

Male Female

10

8

6

4

2

1.4 0.8

0 White

3.3 2.3
Black

Source: Georgia Vital Records

Asthma deaths affect all races and sexes but death rates disproportionately affect minority populations in the U.S. and Georgia. In Georgia, Blacks are more than twice as likely to die from asthma than Whites (2.9 per 100,000 vs. 1.1 per 100,000 population). Women are 1.6 times more likely to die from asthma than men (1.9 per 100,000 vs. 1.2 per 100,000 population). Death rates by race and sex ranged from 0.8 per 100,000 populations for White males to 3.3 per 100,000 population for Black females (Figure 31).

Death rate per 100,000

Figure 32: Age-specific asthma death rates by age group,
Georgia, 2000-2004

25
20 16.0
15

10 6.4

5 0.3

0.2

0.4

0.4

1.0

1.9

2.5

3.7

0

0-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

Age Group

Source: Georgia Vital Records

Deaths from asthma are more common among the elderly (Figure 32).
2007 Georgia Asthma Surveillance Report | 17

Asthma Severity and Impact in Georgia

Asthma is a life threatening disease that can have a negative effect on the lives of children and adults with asthma, as well as the family members who care for them. When asthma is not in control a person's daily life can be disrupted.
Children According to the second Statewide Georgia Childhood Asthma Survey, 60% of children with asthma have had an asthma attack in the past 12 months. Among children 5 to 17 in Georgia, about 75,000 (48%) children reportedly missed 470,000 days of school due to their asthma. In addition, about 48,000 (23%) of children with asthma reportedly had "moderate" to "a lot" of activity limitation when compared to their friends over a lifetime period. (Figure 33). When a person's asthma is under control daily activity should not be limited.
Adults
The National, Heart, Lung and Blood Institute (NHLBI) guidelines classify asthma into four different categories ranging from mild to severe.16 Among adults with asthma in Georgia, 21% fall into the severe persistent category, signifying their asthma is not in control (Figure 34).

Percent

FFiigguurree3333::SAevstehrmityaasnedveimritpyacatnodfiamstphamctaaimn cohnigldcrhenil:dartetnacwksit,h mcisusrerdenstchaostohlmday: sa,ttaancdkas,ctmiviistsyeldimscithaotioolndianypsa,satn1d2amctoivntihtys
limitation in paGseto1r2gima,o2n0t0h2s-,2G0e0o3rgia, 2002-2003

Source: Georgia Childhood Asthma Survey

Percent

80 70
60 60 50 40 30 20 10
0 Asthma attack

48 23
Missed school Activity limitation

Figure 34: Asthma severity classification distribution among adults with current asthma, Georgia, 2005

80

70

60

50

42

40

30 21

20

16

10

0

Mild Mild Persistent Moderate

Intermitent

Persistent

21
Severe Persistent

Source: Georgia Behavioral Risk Factor Surveillance System

Source: Georgia Behavioral Risk Factor Surveillance System

More than half (56%) of the adults with current asthma reported having an episode of asthma or an asthma attack in the past twelve months. In addition, 14% of adults with asthma reported they were unable to work or carry out usual activities on one or more days during the past twelve months (Figure 35).
18 | 2007 Georgia Asthma Surveillance Report

Figure 35: Severity and impact of asthma in adults: attacks and activity limitation in past 12 months Georgia, 2005

Percent

80

70

60

56

50

40

30

20

14

10

0

Asthma attack

Unable to work or do usual activity

Source: Georgia Behavioral Risk Factor Surveillance System

Figure 36: Activity limitation days in the last 12 months among adults with current asthma, Georgia, 2005

Percent

80

73

70

60

50

40

30

20

10

0 0 days

15 1-5 days

11 6-75 days

1 76+ days

Among adults with current asthma, 15% had activity limited on 1-5 days, 11% reported limitation on 6-75 days, and 1% reported limitation on 76 or more days in the past 12 months (Figure 36).

Figure 37: Symptom frequency in the past 30 days among adults with current asthma, Georgia, 2005

80

70

64

60

50

40

30

20

10

0 0-2 days

15

14

7

3-29 days 30 days/not all 30 days all

time

time

Among adults with current asthma, 64% have symptoms only up to two days in the past 30 days and 7% reported symptoms every day in the past 30 days (Figure 37).

Source: Georgia Behavioral Risk Factor Surveillance System

Percent

Source: Georgia Behavioral Risk Factor Surveillance System

Figure 38: Difficulty sleeping in the past 30 days due to asthma symptoms among adults with current asthma, Georgia, 2005

Percent

80

77

70

60

50

40

30

20

10

0

0-2 days

8

6

8

3-4 days

5-10 days

11+ days

Approximately 77% of adults with current asthma reported that they had difficulty sleeping because of asthma symptoms up to two days of the past 30 days (Figure 38). With proper treatment and management the severity and impact of asthma can be reduced.

2007 Georgia Asthma Surveillance Report | 19

Asthma Management in Georgia
Disease Management
Asthma self-management, the direct involvement of patients and their caregivers in strategies to control their disease, has become an important component of asthma care. Asthma self-management reduces ER visits, hospitalizations, unscheduled office visits, and asthma-related healthcare cost. Asthma management should begin with a proper diagnosis of the disease, identification of triggers that are common to people with asthma as well as knowing your personal triggers, and reducing exposure to these triggers. The NHLBI recommends that individuals with asthma work with their doctor to create an asthma management plan, which can help persons recognize early signs and symptoms of an attack, determine which medicines to take and when to take them, and recognize when to seek medical attention. Asthma cannot be cured, but with proper pharmacologic therapy, avoidance of triggers, and management, it can be controlled.

Adults
Routine visits recommended by the NHLBI guidelines should be used to discuss asthma-related problems.16 Patients should develop their management plan and let their doctor know when anything in their management plan is not working, and the doctor should work with them to modify the plan to better suit their needs. Despite these recommendations, in Georgia 42% of adults with asthma have not had a routine checkup for their asthma in the past 12 months (Figure 39).

Percent

Figure 39: "Routine checkups" for asthma in the last 12 months among adults with current asthma, Georgia, 2005

80

70

60

58

50

40

30

20

10

0

Rountine Checkup

42 No Routine Checkup

Source: Georgia Behavioral Risk Factor Surveillance System

Source: Georgia Behavioral Risk Factor Surveillance System

Among adults with asthma, 20% have had 12 unscheduled doctor visits, 6% have had 3-6 unscheduled visits and 10% have had seven or more unscheduled visits in the past 12 months (Figure 40). With proper management unscheduled visits for asthma can be avoided.

Figure 40: Number of unscheduled doctor visits for asthma in the last 12 months among adults with current asthma, Georgia, 2005

Percent

80

70

65

60

50

40

30

20

10

0 0 visits

20 1-2 visits

6 3-6 visits

10 7+ visits

20 | 2007 Georgia Asthma Surveillance Report

Percent using medicine
Source: Georgia Childhood Asthma Survey

Figure 41: Use of asthma prescription medicines among children with asthma, Georgia, 2002-2003

40

35

34

30

25

20

16

15

10

5

0

No Prescription Quick Relief

Medicine

Only

14 Control Only

36
Quick Relief and Control

Children
Among children with asthma, 84% use prescription medicine, including 36% who use prescriptions for both control and quick-relief medicine, 14% who use a prescription only for control medicine, and 34% who use a prescription only for quick relief medicine (Figure 41).

NHLBI guidelines state that use of 2 quick-relief treatments per week or 2 prescriptions per year may indicate need for control medicine to reduce inflammation and prevent exacerbations.16 Among Georgia children with asthma who have a prescription only for quick relief medicine, 17% of all children with asthma use 2 prescriptions per year. The NHLBI Guidelines also recommend that patients receive periodic assessments and be given a written plan by their health care provider.16

Figure 42: Disease management practices and training for children with asthma, Georgia, 2002-2003

Management practice/training

% (95% CI)

No routine check-ups for asthma

30 (25,35)

No written asthma management plan

65 (59,70)

2 or more quick-relief prescriptions per year but no control medicine

17 (13,21)

No training on how to manage asthma*

18 (14,23)

No training to recognize signs and symptoms of an attack *

28 (23,33)

No training about things that can trigger asthma attacks*

23 (20,25)

No training on use of peak flow meter *

13 (9,18)

No training on use of inhaler (among those with inhaler)*

6 (2,9)

No training on use of a spacer (among those with inhaler)*

30 (24,37)

In Georgia, 30% of children with asthma do not have regular asthma check-ups and 65% do not have a written plan to help them manage their asthma (Figure 42). There are other asthma management and training areas in which Georgia could use improvement to help prevent frequency and severity of attacks.

* For either caregiver or child >5 years Source: Georgia Childhood Asthma Survey
Control Medicine: medicine designed to control airway inflammation and prevent attacks from occurring Quick-relief medicine: medicine designed to provide quick relief of asthma symptoms during an attack or exacerbation
2007 Georgia Asthma Surveillance Report | 21

Conclusions
Asthma is a major public health issue in Georgia, as it is in the United States. In Georgia, 10% of children ages 0-10, 15% of middle school students, 16% of high school students, and 7% of adults report currently having asthma. This report shows that asthma affects all age, race, and sex groups, but certain groups are disproportionately affected. Blacks and women are more likely to visit the ER, be hospitalized, and die from asthma than Whites and men. Asthma hospitalizations are highest among the older and younger age groups. Death rates are 25 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 five ways by which the burden of asthma in Georgia can be reduced:
1) Reduce cigarette smoking and exposure to environmental tobacco smoke 2) Improve access to quality healthcare 3) Increase receipt of annual flu vaccination 4) Increase physical activity and improve diet to reduce obesity 5) Increase knowledge and adherence to proper treatment and management practices
Reduce smoking and exposure to environmental tobacco smoke (ETS)
Despite the fact that cigarette smoking may trigger asthma attacks, youth and adults with asthma continue to smoke: 25% of adults with asthma, 20% of high school students with asthma, and 8% of middle school students with asthma currently smoke. Approximately two-thirds middle school students and three-fourths of high school students with asthma are exposed to environmental tobacco smoke. Smoking and exposure to environmental tobacco smoke (ETS) 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 that prohibit or restrict smoking are important factors in this effort.
Improve access to quality healthcare
A substantial number of adults with asthma (27%) 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 to help people receive proper treatment and self-management education need to be made available.
Increase receipt annual flu shot
Respiratory infections are a common trigger of asthma attacks. Annual influenza vaccinations for people with asthma will reduce the incidence of asthma attacks. However, only about one-third of adults with asthma have received their annual flu shot.
22 | 2007 Georgia Asthma Surveillance Report

Increase physical activity and improve diet A higher percent of high school students with asthma are obese (14%) compared to those without asthma (11%). Thirty-six percent of adults with asthma are currently obese. The relationship between asthma and obesity is not well understood, but 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. Programs to help individuals with asthma participate in physical activities and to eat a healthy diet can help reduce asthma symptoms.
Increase knowledge of proper treatment and management practices The NHLBI guidelines recommend that patients with asthma receive periodic assessments and be given a written plan by their health care provider. In Georgia, 30% of children with asthma do not have regular asthma checkups and 42% of adults with asthma do not have regular checkups for their asthma. Two-thirds of children with asthma do not have a written management plan to help manage their asthma. Children who have a prescription for quick relief medications only and are refilling the prescription more than two times a year need to be evaluated for control medication. People with asthma in Georgia can live normal, active, healthy lives by knowing the common asthma triggers and reducing their exposure to them, especially triggers specific to their asthma. Individuals with asthma need to work with their doctor to create an asthma management plan that will tell them what brings on their asthma symptoms, how to avoid triggers and reduce exposure, what medicines to take and when to take them, and when to seek medical help. People with asthma must work with their doctor to understand instructions for their medications and take them as scheduled. If the medications are taken as scheduled and are not working, they should let their physician know and discuss revisions that may be needed. Asthma education, proper treatment and management, policy changes, and modification of risk factors will help reduce frequency and severity of asthma 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, their families, and society at large.
2007 Georgia Asthma Surveillance Report | 23

References
1. Akinbami, L. Asthma Prevalence, Health Care Use and Mortality: United States, 2003-05. Office of Analysis and Epidemiology 4 (Accessed December 28, 2006, at www.cdc.gov./nchs/products/pubs/pubd/hestats/asthma03-05.htm.)
2. American Lung Association. Epidemiology and Statistics Unit, Research and Programs Services. Trends in Asthma Morbidity and Mortality. July 2006.
3. Adams PF, Dey AN, Vickerie JL. Summary of health statistics for US population: National Health Interview Survey, 2005. National Center for Health Statistics Vital Health Stats 10 (233) 2007.
4. National Heart, Lung, and Blood Institute. Chart Book, U.S. Department of Health and Human Services, National Institute of Health, 2004.
5. Gold DR, Wright R, Population disparities in asthma. Annual Review of Public Health, April 2005, Vol. 26, Pages 89113.
6. Akinbami LJ, Schoendorf KC. Trends in childhood asthma: Prevalence, Health care utilization, and mortality. Pediatrics. 2002;110:315322.
7. Mellinger-Birdsong AK, Powell, Iatridis T, Bason J. 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.
8. Blackwell AD, Wu M, Mertz, 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.
9. Stenius-Aarniala, B, Poussa, T, Kvarnstrm, J, et al Immediate and long term effects of weight reduction in obese people with asthma: randomized controlled study. BMJ 2000;320,827-832.
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. Flegal, KM, Carroll, MD, Ogden, CL, et al Prevalence and trends in obesity among US adults, 19992000. JAMA 2002;288,1723-1727.
12. American Lung Association Asthma Clinical Research Centers. The Safety of Inactivated Influenza Vaccine in Adults and Children with Asthma. New England Journal of Medicine, 2001;345(21):1529-1536.
13. Centers for Disease Control and Prevention. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbid Mortal Wkly Rep 2006;55: 1-41.
14. Tarlo SM. Workplace respiratory irritants and asthma. Occup Med 2000;15:471-84.
15. Blanc PD, Toren K. How much adult asthma can be attributed to occupational factors? Am J Med 1999;107:580-7.
16. National Asthma Education and Prevention Program. Expert Panel report: guidelines for the diagnoses and management of asthma. Update on selected topics 2002 Bethesda Md.: National Heart, Lung, and Blood Institute, 2003. (NIH publication no. 02-5074).
24 | 2007 Georgia Asthma Surveillance Report

APPENDIX I: Data Tables

Table 1: Prevalence of asthma among adults by public health district, Georgia, 2004-2005

District Georgia (1-1) Northwest (Rome) (1-2) North Georgia (Dalton) (2-0) North (Gainesville) (3-1) Cobb/Douglas (Marietta) (3-2) Fulton (Atlanta) (3-3) Clayton (Morrow) (3-4) East Metro (Lawrenceville) (3-5) Dekalb (Decatur) (4-0) LaGrange (5-1) South Central (Dublin) (5-2) North Central (Macon) (6-0) East Central (Augusta) (7-0) West Central (Columbus) (8-1) South (Valdosta) (8-2) Southwest (Albany) (9-1) East/Coastal (Savannah/Brunswick) (9-2) Southeast (Waycross) (10-0) Northeast (Athens)

Percent 7.3* 8.8 8.2 6.5 7.2 6.9 7.7 5.3 6.9 8.5 5.6 8.4 7.0 7.6 5.4 7.7 7.4 8.4 5.6

* No District rates are significantly higher or lower than the state rate Source: Georgia Behavioral Risk Factor Surveillance System (BRFSS)

2007 Georgia Asthma Surveillance Report | 25

Table 2: Annual number of emergency room (ER) visits for asthma, age-adjusted ER visit rates, and ER charges by county, Georgia, 2004

County

ER visits

County ER visits

Num- Rate/ Charges ber 100,000

Num- Rate/ ber 100,000

Charges

Georgia

46,152

510 $38,976,000

Dade 11

73

$12,200

Appling

23

129

$22,400

Dawson 53

297

$61,300

Atkinson

52

603

$75,300

Decatur 163

562 $4,289,400

Bacon

58

573

$53,500

DeKalb 5175

758*

$89,600

Baker

14

351

$7,400

Dodge 128

664*

$86,200

Baldwin

156

367 $112,000

Dooly 66

571

$50,200

Banks

40

251

$29,100

Dougherty 642

656*

$573,900

Barrow

282

476 $298,300

Douglas 495

441

$473,400

Bartow

498

554 $436,900

Early 108

858*

$68,200

Ben Hill

108

615

$56,700

Echols 13

301

$8,400

Berrien

86

516

$55,200

Effingham 175

383

$115,800

Bibb

755

477 $680,500

Elbert 101

497

$78,100

Bleckley

45

392

$28,600

Emanuel 97

441

$68,900

Brantley

67

444

$49,300

Evans 63

569

$38,700

Brooks

186 1164* $123,900

Fannin 61

312

$55,300

Bryan

79

288

$69,700

Fayette 336

368

$233,800

Bulloch

282

515 $329,500

Floyd 442

474

$510,700

Burke

72

280

$42,500

Forsyth 401

294

$555,700

Butts

113

502 $120,900

Franklin 97

473

$52,600

Calhoun

36

590

$11,900

Fulton 7945

958* $6,697,500

Camden

197

399 $157,700

Gilmer 86

338

$56,900

Candler

95

945*

$51,000

Glascock 11

464

$17,100

Carroll

480

465 $285,600

Glynn 360

524

$217,400

Catoosa

125

211 $124,100

Gordon 97

194

$81,700

Charlton

50

466

$53,000

Grady 187

758*

$120,600

Chatham

1422

593* $1,330,500

Greene 99

671*

$60,700

Chattahoochee

17

131

$11,600

Gwinnett 2943

396 $3,167,200

Chattooga

74

289

$93,000

Habersham 122

320

$68,200

Cherokee

568

315 $546,100

Hall 645

396

$764,700

Clarke

380

412 $280,300

Hancock 21

216

$17,900

Clay

8

269

$10,300

Haralson 133

481

$83,400

Clayton

1435

494 $1,085,300

Harris 39

153

$28,900

Clinch

45

630

$26,500

Hart 100

448

$48,900

Cobb

2800

412 $2,397,700

Heard 35

308

$20,600

Coffee

232

568 $263,000

Henry 485

291

$322,000

Colquitt

283

620* $185,300

Houston 492

386

$341,200

Columbia

228

229 $201,300

Irwin 31

311

$25,300

Cook

69

416

$37,300

Jackson 153

310

$155,300

Coweta

326

300 $2,587,000

Jasper 54

420

$33,000

Crawford

34

262

$30,500

Jeff Davis 46

355

$39,300

Crisp

122

531

$75,800

Jefferson 145

851*

$100,000

* Age-adjusted ER visit rates are significantly higher than the state rate Age-adjusted ER visit rates are significantly lower than the state rate Source: Georgia Hospital Association

26 | 2007 Georgia Asthma Surveillance Report

Table 3: Annual number of emergency room (ER) visits for asthma, age-adjusted ER visit rates, and ER charges by public health district, Georgia, 2004
ER visits

District

Number

Rate/100,000

Charges

Georgia

46,152

510

$38,976,000

(1-1) Northwest (Rome)

2112

364

$2,039,000

(1-2) North Georgia (Dalton)

1235

317

$1,197,000

(2-0) North (Gainesville)

1897

357

$1,945,000

(3-1) Cobb/Douglas (Marietta)

3295

416

$2,871,000

(3-2) Fulton (Atlanta)

7945

958*

$6,698,000

(3-3) Clayton (Morrow)

1435

494

$1,085,000

(3-4) East Metro (Lawrenceville)

3637

399

$3,579,000

(3-5) Dekalb (Decatur)

5175

758*

$4,289,000

(4-0) LaGrange

2798

390

$2,237,000

(5-1) South Central (Dublin)

602

431

$477,000

(5-2) North Central (Macon)

2038

408

$1,565,000

(6-0) East Central (Augusta)

2680

603*

$1,843,000

(7-0) West Central (Columbus)

1949

549*

$1,556,000

(8-1) South (Valdosta)

1052

442

$683,000

(8-2) Southwest (Albany)
(9-1) East/Coastal (Savannah/ Brunswick)
(9-2) Southeast (Waycross)

2320 2593 1872

636* 491 558*

$1,650,000 $2,217,000 $1,745,000

(10-0) Northeast (Athens)

1517

375

$1,299,000

* Age-adjusted ER visit rates are significantly higher than the state rate Age-adjusted ER visit rates are significantly lower than the state rate
Source: Georgia Hospital Association

2007 Georgia Asthma Surveillance Report | 27

Table 4: Annual number of hospitalizations for asthma, age-adjusted hospitalization rates, and hospital charges by county, Georgia, 2004

County

Hospitalizations

County

Hospitalizations

Number Rate/100,000 Charges

Number Rate/100,000 Charges

Georgia

11,404

133 $107,523,000

Dade

8

47

$78,200

Appling

30

169

$222,800

Dawson

11

54 $149,900

Atkinson

28

377*

$274,500

Decatur

58

195* $8,465,300

Bacon

25

242*

$126,800

DeKalb

925

145* $264,600

Baker

4

##

$32,400

Dodge

48

241* $312,300

Baldwin

45

113

$412,900

Dooly

37

309* $222,500

Banks

15

91

$161,400

Dougherty

188

199* $2,032,200

Barrow

73

150

$888,100

Douglas

171

171* $1,750,600

Bartow

97

116

$965,600

Early

31

247* $182,900

Ben Hill

56

305*

$387,600

Echols

9

240

$46,300

Berrien

32

194

$239,700

Effingham

39

97 $430,600

Bibb

274

178* $3,330,600

Elbert

29

136 $227,300

Bleckley

27

224*

$117,100

Emanuel

45

201* $337,500

Brantley

16

110

$140,900

Evans

37

343* $241,100

Brooks

31

181

$240,300

Fannin

21

85 $175,500

Bryan

34

138

$438,600

Fayette

54

57 $536,500

Bulloch

74

140

$874,800

Floyd

52

54 $485,100

Burke

41

177

$248,700

Forsyth

113

95 $1,608,600

Butts

24

117

$433,800

Franklin

22

103 $189,100

Calhoun

10

183

$35,400

Fulton

1213

159* $13,955,000

Camden

22

58

$232,100

Gilmer

45

167 $385,200

Candler

27

258*

$183,500

Glascock

2

##

$9,300

Carroll

133

144

$983,100

Glynn

94

131 $1,051,100

Catoosa

32

53

$271,900

Gordon

29

57 $315,200

Charlton

4

##

$23,100

Grady

38

152 $306,000

Chatham

380

158* $3,782,400

Greene

12

74

$63,000

Chattahoochee

11

109

$292,500

Gwinnett

663

117 $6,812,800

Chattooga

13

49

$131,500

Habersham

29

75 $262,900

Cherokee

134

77 $1,217,000

Hall

155

107 $2,027,700

Clarke

126

161 $1,148,000

Hancock

12

132

$85,400

Clay

3

##

$37,800

Haralson

36

132 $383,900

Clayton

271

103 $2,475,900

Harris

28

110 $242,400

Clinch

17

228

$62,300

Hart

20

87 $145,200

Cobb

557

85 $5,073,100

Heard

14

131 $117,000

Coffee

112

296* $1,030,300

Henry

137

89 $1,902,100

Colquitt

56

126

$441,600

Houston

203

167* $1,092,600

Columbia

85

91

$855,300

Irwin

31

308* $202,500

Cook

49

305*

$316,000

Jackson

41

84 $340,600

Coweta

86

91

$873,800

Jasper

11

85

$57,900

Crawford

6

45

$41,800

Jeff Davis

48

350* $309,600

Crisp

67

301*

$550,800

Jefferson

61

368* $317,600

28 | 2007 Georgia Asthma Surveillance Report

Table 4 (continued):Annual number of hospitalizations for asthma, age-adjusted hospitalization rates, and hospital charges by county, Georgia, 2004

County

Hospitalizations

County

Hospitalizations

Number Rate/100,000 Charges

Number Rate/100,000 Charges

Jenkins

26

297* $104,600

Schley

5

116 $36,200

Johnson

26

303* $154,400

Screven

29

193 $201,600

Jones

25

97 $258,500

Seminole

29

299* $240,700

Lamar

26

158 $293,400

Spalding

115

192* $1,887,700

Lanier

12

169

$95,800

Stephens

61

262* $434,300

Laurens

138

287* $929,600

Stewart

7

158 $20,100

Lee

21

79 $228,000

Sumter

50

154 $519,400

Liberty

83

134 $574,600

Talbot

5

68 $32,400

Lincoln

7

86

$50,600

Taliaferro

3

## $13,200

Long

13

109

$67,300

Tattnall

68

320* $487,500

Lowndes

122

136 $870,200

Taylor

15

159 $90,700

Lumpkin

19

87 $145,600

Telfair

29

233* $195,300

McDuffie

40

183 $253,300

Terrell

12

112 $129,500

McIntosh

19

171 $367,200

Thomas

74

163 $583,000

Macon

36

260*

$51,900

Tift

140

333* $818,600

Madison

31

116 $284,000

Toombs

65

241* $494,300

Marion

8

109 $268,100

Towns

3

##

$9,400

Meriwether

29

124 $175,700

Treutlen

18

254* $105,800

Miller

10

161

$69,000

Troup

127

209* $607,700

Mitchell

58

243* $560,200

Turner

14

141 $64,700

Monroe

15

69 $110,700

Twiggs

25

231* $326,300

Montgomery

20

236 $190,500

Union

10

40 $84,100

Morgan

19

116 $169,700

Upson

88

308* $705,200

Murray

74

194* $872,200

Walker

41

64 $500,600

Muscogee

244

130 $2,339,100

Walton

98

140 $980,500

Newton

83

103 $602,900

Ware

59

160 $690,300

Oconee

17

67 $182,600

Warren

4

## $23,800

Oglethorpe

18

132 $170,300

Washington

21

101 $129,400

Paulding

101

102 $1,148,200

Wayne

44

159 $296,200

Peach

43

187 $240,700

Webster

4

## $35,800

Pickens

33

124 $354,000

Wheeler

9

149 $67,100

Pierce

30

177 $313,100

White

19

79 $418,700

Pike

18

113 $201,000

Whitfield

125

143 $1,281,400

Polk

26

60 $195,300

Wilcox

26

308* $121,300

Pulaski

42

431* $214,000

Wilkes

14

126 $103,100

Putnam

31

149 $134,800

Wilkinson

14

132 $209,800

Quitman

0

##

$0

Worth

27

123 $173,500

Rabun

19

Randolph

16

Richmond

299

Rockdale

63

115 $154,800 219 $209,700 150 $2,608,100 87 $472,800

* Hospitalization rates are significantly higher than the state rate Hospitalization rates are significantly lower than the state rate ### Rate is not calculated for counties with <5 hospitalizations per year Source: Georgia Hospital Association

2007 Georgia Asthma Surveillance Report | 29

Table 5: Annual number of hospitalizations for asthma, age-adjusted hospitalization rates, and hospital charges by public health district, Georgia, 2004
Hospitalizations

District

Number

Rate/100,000

Charges

Georgia

11,404

133

$107,523,000

(1-1) Northwest (Rome)

435

77

$4,476,000

(1-2) North Georgia (Dalton)

432

117

$4,285,000

(2-0) North (Gainesville)

496

94

$5,792,000

(3-1) Cobb/Douglas (Marietta)

728

97

$6,824,000

(3-2) Fulton (Atlanta)

1213

159*

$13,955,000

(3-3) Clayton (Morrow)

271

103

$2,476,000

(3-4) East Metro (Lawrenceville)

809

110

$7,888,000

(3-5) Dekalb (Decatur)

925

145*

$8,465,000

(4-0) LaGrange

851

126

$8,717,000

(5-1) South Central (Dublin)

383

274*

$5,792,000

(5-2) North Central (Macon)

725

148*

$6,432,000

(6-0) East Central (Augusta)

656

151*

$5,157,000

(7-0) West Central (Columbus)

536

151*

$4,934,000

(8-1) South (Valdosta)

496

213*

$3,282,000

(8-2) Southwest (Albany)

616

(9-1) East/Coastal (Savannah/ Brunswick)

684

(9-2) Southeast (Waycross)

684

169* 134 211*

$5,279,000 $6,845,000 $5,279,000

(10-0) Northeast (Athens)

464

123

$4,537,000

* Age-adjusted hospitalization rates are significantly higher than the state rate Age-adjusted hospitalization rates are significantly lower than the state rate Source: Georgia Hospital Association

30 | 2007 Georgia Asthma Surveillance Report

Appendix II: Data Sources for Asthma
The Georgia Childhood Asthma Survey
The Georgia Childhood Asthma Survey was a random digit-dial telephone survey of households in Georgia. A parent or caregiver in households with at least one child aged less than 18 years reported on all children residing in the home. The survey was conducted from October 2002 through February 2003. The data were collected by the University of Georgia Survey Research Center in Athens, GA. Asthma was defined according to the standard case definition for probable asthma: the child was ever diagnosed with asthma, and 1) has been told by a physician that the child still has asthma, 2) takes prescription medicine for asthma, or 3) has had an asthma attack in past twelve months. Household and caretaker data were weighted according to the number of telephone lines in the household. Child data were weighted according to the number of telephone lines in the household and to the 2000 Georgia Census population.
The Georgia Youth Tobacco Survey
The Georgia Youth Tobacco Survey is a self-administered pencil and paper survey given to Georgia's middle and high school students. The main focus of this survey is tobacco use. This survey was last conducted in 2005. Two questions about asthma were added 1) "Has a doctor or nurse ever told you that you have asthma?" 2) "During the past 12 months have you had an episode or an asthma attack?" Other information included height and weight to calculate BMI. For both middle school and high school the data 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)
The Behavioral Risk Factor Surveillance System (BRFSS) is stratified random digit dial telephone interview survey conducted in cooperation with the Centers for Disease Control and Prevention (CDC). Georgia residents18 years and older are interviewed annually about their health conditions, behaviors, and the use of preventive services. Asthma was one of the topics included in the 2002-2006 core section. The questions were 1) Have you ever been told by a doctor, nurse, or other health professional that you had asthma?" 2) Do you still have asthma?" In addition, the adult asthma history module, which consists of nine questions related to asthma history, healthcare utilization, and asthma medication use were included in 2003-2005 modules. In 2005 the state of Georgia added two questions concerning work-related asthma. 1) "Were you ever told by a doctor or other medical person that your asthma was related to any job you ever had?" 2) "Did you ever tell a doctor or other medical person that your asthma was related to any job you ever had?" Prevalences for 2004-2005 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.
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Georgia Emergency Room (ER) Visit Data Emergency room (ER) visit data in this report are based on ER visit data by Georgia residents who were seen in the ER in 2004 with asthma as the primary diagnosis. The ICD-9 codes used to select hospitalizations were 493.0-493.9. ER visit data included only information reported by non-federal acute care hospitals in Georgia. Rates were age-adjusted to the 2000 US standard population via the direct method. ER visit 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.
Georgia Hospital Inpatient Discharge Data Hospitalization data in the report are based on hospital discharge data for Georgia residents who were hospitalized in 2004 with asthma as the primary diagnosis. The ICD-9 codes used to select hospitalizations were 493.0-493.9. Hospitalization data included only 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. Georgia Vital Statistics Death Data Mortality data are based on deaths of Georgia residents whose underlying cause of death was asthma. Deaths from 1999-2004 with ICD-10 codes J45-J46 were selected. Death rates were age-adjusted to the 2000 US standard population via the direct method. Recent trends suggest that mortality rates are decreasing; one factor may be the change from ICD-9 to ICD-10 coding of deaths in 1999. Death and hospitalization rates are expressed per 100,000 population throughout the report.
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APPENDIX III: Definitions and Abbreviations
Age-adjusted rate: A rate calculated in a manner that allows comparison of populations with different age structures
Control Medicine: medicine designed to control airway inflammation and prevent attacks from occurring
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 (Children): Exposure to tobacco smoke in the house and away from the house.
Exposure to environmental tobacco smoke (Middle and High School): Exposure to tobacco smoke at home in a room, in a car and through friends who smoke.
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. Mental health might not be good because of stress, depression, or problems with emotions
Mild Intermittent: Patients with daytime asthma symptoms 2 days/week and night time asthma symptoms 2 nights/month with no activity limitation
Mild Persistent: Patients with daytime asthma symptoms >2 days/week but < 1x/day and night time asthma symptoms > 2 nights/month
Moderate Persistent: Patients with daily asthma symptoms and nighttime symptoms > 1 night/week
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
Obese (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
Quick-relief medicine: medicine designed to provide quick relief of asthma symptoms during an attack or exacerbation
Risk Factor: a habit, characteristic, or finding on clinical examination that is associated with an increased probability of disease
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Seasons: Winter = Dec-Feb, spring = March-May, summer = June-Aug, and fall = Sept-Nov Severe persistent: Patients with daytime asthma symptoms continual and nighttime asthma symptoms frequently Statistically Significant: In this report a p-value <0.05 was considered statistically significant, showing that the observed results are probably different from what might have occurred as a result of chance alone. Work-related asthma: Includes respondents who answered yes to, "Were you ever told by a doctor or other medical person that your asthma was related to any job you ever had?", or answering yes to, "Did you ever tell a doctor or other medical person that your asthma was related to any job you ever had?".
Abbreviations:
ALA: American Lung Association BMI: Body Mass Index BRFSS: Behavioral Risk Factor Surveillance System CDC: Centers for Disease Control and Prevention DHR: Georgia Department of Human Resources ER: Emergency Room ETS: Environmental Tobacco Smoke ICD-9: International Classification of Diseases. 9th Revision ICD-10: International Classification of Diseases. 10th Revision NHLBI: National Heart, Lung, and Blood Institute
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DHR GEORGIA DEPARTMENT OF HUMAN RESOURCES

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