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. 2007 Georgia Asthma Surveillance Report | 31 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. 32 | 2007 Georgia Asthma Surveillance Report 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 2007 Georgia Asthma Surveillance Report | 33 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 34 | 2007 Georgia Asthma Surveillance Report DHR GEORGIA DEPARTMENT OF HUMAN RESOURCES 2007 Georgia Asthma Surveillance Report | 35