2012 Georgia asthma surveillance report [Apr. 2012]

Asthma Surveillance

GEORGIA 2012

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Georgia Department of Public Health

Acknowledgements

Georgia Department of Public Health Brenda Fitzgerald, MD Commissioner, State Health Officer
Health Protection J. Patrick O'Neal, MD Director
Epidemiology Program Cherie L. Drenzek, DVM, MS State Epidemiologist
Chronic Disease, Healthy Behaviors and Injury Epidemiology Section A. Rana Bayakly, MPH Chief Epidemiologist
Lydia Clarkson, MPH Team Lead
Health Promotion and Disease Prevention Programs Shonta Chambers, MSW Director, Office of Prevention and Wellness
Francesca Lopez, MSPH, AE-C Program Manager, Georgia Asthma Control Program

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: Ginny Jacobs
This publication is supported by the Cooperative Agreement 1U59EH000520-01 from the Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official view of the CDC.
Suggested citation: Cheng V., Clarkson L., Lopez F., Chambers S. 2012 Georgia Asthma Surveillance Report. Georgia Department of Public Health, Health Protection, Epidemiology, Chronic Disease, Healthy Behaviors and Injury Epidemiology Section, April 2012.
Publication Number:

Georgia Asthma Surveillance Report, 2012

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Georgia Department of Public Health

Table of Contents
Highlights.................................................................................................... 6
Introduction.................................................................................................7
Prevalence of Asthma in Georgia................................................................. 9 Children Ages 0-17.......................................................................................................................... 9 Middle and High School Students................................................................................................11 Adults............................................................................................................................................. 12
Work-Related Asthma................................................................................. 15
Behavioral Risk Factors.............................................................................. 17 Smoking......................................................................................................................................... 17 Obesity.......................................................................................................................................... 17
Environmental Risk Factors....................................................................... 19 Indoor environmental risk factors..............................................................................................19 Secondhand smoke..................................................................................................................... 20 Environmental modifications...................................................................................................... 21
Asthma Symptoms......................................................................................23
Asthma Management..................................................................................27
Asthma Morbidity.......................................................................................33 Emergency Room (ER) Visits.......................................................................................................33 Hospitalizations........................................................................................................................... 34
Asthma Mortality........................................................................................37
Conclusions................................................................................................39
References.................................................................................................. 41
Apendices...................................................................................................43 Appendix I: D ata Tables........................................................................................................... 43 Appendix II: Maps.......................................................................................................................57 Appendix III: Methods and Data Sources...................................................................................61 Appendix IV: Glossary and Abbreviations................................................................................. 65

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HIGHLIGHTS
In Georgia:
The prevalence of asthma among children aged 0 to 17 years has risen by 2% between 2003 and 2010. Nine percent (9%) of children aged 0 to 17 years currently have asthma. Black children have higher asthma prevalence (14%) than white children (8%). Fifty-eight percent (58%) of school-aged children missed one or more days of school in the past 12 months
due to asthma. Eight percent (8%) of adults aged 18 years and older had current asthma in 2010. Asthma caused more than 52,000 emergency room (ER) visits annually between 2006 and 2010. Asthma is the cause of approximately 10,000 hospitalizations per year between 2006 and 2010. Black males are more likely to visit the ER due to asthma. Black females are more likely to be hospitalized due to asthma. Sixty-two percent (62%) of adults and 71% of children with asthma used prescription medication
in the past 3 months. Ninety-five percent (95%) of adults and children with asthma received professional instruction on
how to use an inhaler. Sixty-two percent (62%) of school-aged children have asthma medication in school. Thirty-eight percent (38%) of adults and 29% of children with asthma do not use prescription medications.

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Georgia Department of Public Health

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 disease affects people of all ages. The causes of asthma are not well understood and likely differ among individuals. Factors such as genetics, environmental exposures, and viral and respiratory infections all play a role in causing asthma1. Asthma symptoms can be triggered or worsened by many things such as allergens (dust, animal fur, cockroaches, mold, and pollens from trees, grasses, and flowers), irritants (tobacco smoke, air pollution, chemicals or dust in the workplace), and exercise1.
According to a 2009 report from the National Center for Health Statistics, 17.5 million adults (8%) and 7.1 million (9.6%) children in America currently have asthma 2. Nationwide, asthma was the reason for 13.3 million visits to physician offices, hospital outpatient clinics, and emergency departments (ED)3. Furthermore, nationwide during 2009, there were 456,000 hospital discharges with asthma as the primary diagnosis; the average length of hospital stay for asthma patients was 3.4 days 4. Although asthma affects everyone, a recent Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report (MMWR) indicated that within the U.S. population, current asthma prevalence varied by demographic and economic groups. Asthma was more prevalent among females, children, the poor, the multiracial, and Puerto Rican Hispanics5.
In Georgia, 8% of adults and 9% of children currently have asthma. Asthma caused more than 51,000 emergency room (ER) visits and 32,000 hospitalizations per year. Sixty-two percent (62%) of schoolaged children missed at least one or more days of school because of asthma. Twenty-three percent (23%) of adults with current asthma said that they experienced asthma symptoms every day. Asthma affect Georgians economically (e.g. ER visits and hospitalizations) as well as the quality of life for those living with the disease.
The 2012 Georgia Asthma Surveillance Report presents asthma prevalence, morbidity, and death rates among adults and children in Georgia during 2006-2010. Information on management, environmental triggers, symptoms, prescription medication use, and work-related asthma is also presented. The pur-pose of this report is to guide and inform public health programs, policy makers, and other healthcare providers in their efforts to reduce the burden of asthma in Georgia.

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ASTHMA PREVALENCE
Asthma prevalence is one of the key indicators to measure and monitor the burden of disease among population groups. It was measured by using the Behavioral Risk Factor Surveillance System (BRFSS) (see Appendix II). Current and lifetime asthma are prevalence measures that are operationally defined in the survey by the following two questions (see Appendix III):
1) "Have you ever been told by a doctor {nurse or other health professional} that you have asthma?" 2) "Do you still have asthma?"
Lifetime asthma when a respondent has been told by a doctor (nurse or other health professional) that they have asthma.
Current asthma when a respondent has ever been told they have asthma AND they still have asthma at the time they responded to the survey.
Only current asthma is used in the analyses presented in this report.
Children Aged 0-17 Years
Asthma is a leading chronic illness among children and youth in the United States. Among school-aged children, asthma is one of the leading causes of absenteeism. In 2003, it was estimated that 12.8 million school days were missed due to asthma nationwide, as reported by the 4 million children who had asthma attacks6. In Georgia, the average lifetime asthma prevalence among children aged 0-17 years between 2006-2010 was 15% while current asthma prevalence for the same period was 11%. However, in 2010 alone, the prevalence of current asthma among children aged 0-17 years was 9%.

Percent

Figure 1. Prevalence of current asthma among children aged 0-17, Georgia and U.S., 2003-2010

GA

US

20

15

10

9%

5

0 2003

2004

2005

2006

2007

Ye ar

2008

Source: National Behavioral Risk Factor Surveillance System

2009

2010

Georgia Asthma Surveillance Report, 2012

9

Percent

Figure 2. Prevalence of current asthma among children aged 0-17 by sex, Georgia, 2006-2010
20

15 12

10

9

5

0 Male
Source: Georgia Behavioral Risk Factor Surveillance System

Female

Figure 3. Prevalence of current asthma among children aged 0-17 by race, Georgia, 2006-2010
25

20

15

14

10

8

5

0 White
Source: Georgia Behavioral Risk Factor Surveillance System

Black

Percent

10

Georgia Department of Public Health

Percent

Figure 4. Prevalence of current asthma among children aged 0-17 by annual household income,
Georgia, 2006-2010
30

25

20

19

15

13

10

10

8

5

0
<$15,000

$15,000-$24,999

$25,000-$49,999

Household Income

Source: Georgia Behavioral Risk Factor Surveillance System

>=$50,000

Figure 5. Prevalence of current asthma among middle and high school students by sex, Georgia, 2007 and 2009

20 Male Female

15

11

11

10

12 9

5

0 Middle School
Source: Georgia Youth Risk Behavior Survey

High School

Percent

Georgia Asthma Surveillance Report, 2012

11

Adults 12

Percent

Percent

Figure 6. Prevalence of current asthma among middle and high school students by race, Georgia, 2007 and 2009
White Black
20

15

14

10 10

11

11

5

0 Middle School
Source: Georgia Youth Risk Behavior Survey

High School

Figure 7. Prevalence of current asthma among adults, Georgia and US, 2001-2010

20

GA

US

15

10

5

0 2001 2002 2003 2004 2005 2006 2007
Year
Source: National Behavioral Risk Factor Surveillance System

2008

2009

2010

Georgia Department of Public Health

Percent

Figure 8. Prevalence of current asthma among adults by sex, Georgia, 2006-2010
20

15
10 10
6 5

0 Male
Source: Georgia Behavioral Risk Factor Surveillance System

Female

Figure 9. Prevalence of current asthma among adults by household income, Georgia, 2006-2010
25

20

15 15

10

10

7

6

5

0
<$15,000

$15,000-$24,999 $25,000-$49,999
Household Income

>=$50,000

Source: Georgia Behavioral Risk Factor Surveillance System

Percent

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Key Findings
Asthma prevalence among Georiga children aged 0-17 years increased by 38% from 2003 (9%) to 2008 (12%) ,followed by a 26% decline in 2010 (9%).
Asthma prevalence in adults for both Georgia and the U.S. increased by 18% from 2001 to 2008. However, based on 2009 and 2010 BRFSS data, Georgia prevalence seems to be fluctuating.
Asthma prevalence in Georgia is significantly higher among: - Boys versus girls - Black children versus white children - Adult females versus adult males
Asthma prevalence in Georgia is higher among adults and children living in households with an annual household income of less than $15,000 (Figures 4 and 9). These differences can also be found in national data7. There are many reasons for these disparities, including genetic, economic, social and cultural factors. Furthermore, individuals within disparate populations may live and work in unhealthy environments that can worsen their asthma symptoms7.

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Georgia Department of Public Health

WORK-RELATED ASTHMA
Work-related asthma (WRA) is defined as asthma caused or made worse by exposures in the work environment. In this report, WRA wass measured using data collected from the Asthma Call Back Survey (ACBS). Respondents who answered "yes" to the question, "Were you ever told by a doctor or other health professional that your asthma was related to any job you ever had?" were classified as having WRA.
The United States Department of Labor estimates that 11 million workers in a wide range of industries and occupations are exposed to at least one of the numerous agents known to be associated with occupational asthma8. Examples of hazardous and toxic substances are paints, fuels, and solvents. Nationwide, the estimated proportion of ever-employed adults with current asthma who had WRA was 9% 9.
Table 1. Proportion of Adult with Current Asthma Attributed to Work, Georgia, 2006-2009

Ever-employed adults who have been told by a health care professional that their asthma was work-related
Currently-employed adults who have been told by a health care professional that their asthma was work-related
Currently-employed adults whose asthma was caused by current job

TOTAL
11.3% 8.8% 18.5%

Male
10.6% 5.8% 18.7%

Currently-employed adults whose asthma was made worse by current job

36.4%

34.9%

Source: Georgia Behavioral Risk Factor Surveillance System Asthma Call Back Survey

Female
11.7% 10.8% 18.3% 37.3%

Key Findings: Work-Related Asthma
The proportion of ever-employed Georgia adults with current WRA was 11.3%. About 9% of currently-employed Georgia adults with current asthma had WRA. About 36% of currently-employed Georgia adults with current asthma reported that their asthma was made
worse by their current job. WRA among currently-employed Georgia women (10.8%) is significantly higher than in men (5.8%).

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Georgia Department of Public Health

BEHAVIORAL RISK FACTORS
Smoking
The harmful effect of tobacco use on health is well-documented. Smoking is especially harmful to the asthmatic smoker. Research showed that in adults who have asthma, tobacco smoking has been associated with an increase in asthma severity and decreased responsiveness to inhaled corticosteroids (ICSs)10, which are asthma medications.

Percent

Figure 10. Prevalence of adults who are current smokers by asthma status, Georgia, 2006-2010
50
Current Asthma No Asthma
40

30

22

20

19

10

23 21

22 16

23 19

18 17

0 Total

Male

Female

Black

Source: Georgia Behavioral Risk Factor Surveillance System

White

Obesity
Obesity is a risk factor that increases the prevalence and incidence of asthma and reduces asthma control11. There are several biological mechanisms that may explain the association between obesity and asthma:
- obesity reduces lung function thereby causing the airway to narrow; - obesity is a state of low-grade system inflammation that may act on the lungs to worsen asthma; - co-morbidities of obesity, such as gastroesophageal reflux, sleep-disordered breathing, type 2 diabetes,
or hypertension may worsen asthma.

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Key Findings: Behavioral Risk Factors
Overall, 22% of Georgia adults with current asthma continue to smoke tobacco products, compared to only 17% of adults who do not have current asthma. This difference is statistically significant.
Among adults in Georgia with current asthma, there is no significant difference between the frequency of men and women who are current smokers or a difference between the frequency of black and white smokers.
The prevalence of Georgia adults with current asthma who are obese (41%) is significantly higher than those who are normal weight (31%) or overweight (28%).

Percent

Figure 11. Adults with current asthma by Body Mass Index categories, Georgia, 2006-2010
25

20

15
10 7
5

11 6

0 Normal Weight

Overweight

Source: Georgia Behavioral Risk Factor Surveillance System

Obese

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Georgia Department of Public Health

ENVIRONMENTAL RISK FACTORS
Up to 90% of Americans spend their time indoors12. Commonly-recognized asthma triggers that can be found indoors include dust mites, pets, cockroaches, mice and rats, mold, environmental tobacco smoke (ETS), and indoor pollutants13. Examples of indoor pollutants include wood-burning stoves or fireplaces, unvented gas appliances, and volatile compounds from new carpeting and painting13. For people with asthma, exposure to these triggers can increase and exacerbate asthma symptoms13.

Table 2. Environmental triggers in the homes of adults and children with current asthma, Georgia, 2006-2009

Adults (% )

Children (% )

Carpeting or rugs in bedrooms Pets inside home Gas used for cooking Saw cockroach inside home Wood burning fireplace or stove used Smoking inside home in past week Unvented gas appliances used

72

74

54

41

38

35

23

16

19

18

16

12

14

6

Mold inside home

10

5

Mice or rats in the home

5

5

Source: Georgia Behavioral Risk Factor Surveillance System Asthma Call Back Survey

Georgia Asthma Surveillance Report, 2012

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Percent

Figure 12. Prevalence of exposure to secondhand tobacco smoke* among middle and high school students by asthma status, Georgia, 2009
Current Asthma No Asthma
100

80

63

60

54

68 62

40

20

0 Middle School

High School

*Secondhand smoke exposure in a room, or in a car, or by living with someone who smokes
Source: Georgia Youth Tobacco Survey

Key Findings
The majority of Georgia adults and children with asthma reported exposure to carpeting/rugs and/or pets inside the home.
Eighty-one percent (81%) of Georgia children with current asthma were exposed to at least one or more indoor environmental triggers.
More than half of Georgia middle (63%) and high school (68%) students who have asthma reported that they were exposed to secondhand smoke. The prevalence of secondhand smoke exposure was significantly higher among middle school students with current asthma than those with no asthma.

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Georgia Department of Public Health

Environmental Modifications
Identifying and reducing/avoiding exposure to asthma triggers is an important component of asthma control. According to the American Lung Association (ALA)14, there are simple ways to reduce exposure to some common triggers:
Pests - examples are dust mites and cockroaches. Strategies: wash bedding regularly, fix leaks, store garbage outside, vacuum and dust weekly, use allergen-proof pillow and mattress covers.
Mold- Strategies: cleaning visible mold, throwing away moldy items, running a dehumidifier and using the exhaust fan when taking a shower.
Strong odors- examples are scents from household items such as perfumes, deodorants and cleaning supplies. Strategies: avoid use of products with odors. If you live with someone who has asthma, ventilate the house during and after the use of strong -melling cleaning products.
Table 3. Environmental modifications in the homes of adults and children with current asthma, Georgia, 2006-2009

Adults (% )

Children (% )

Used exhaust fan when cooking

68

71

Used exhaust fan in bathroom

60

55

Washed sheets and pillowcases in hotwater

39

31

Used air cleaner or purifier regularly

33

33

Used mattress cover

32

39

Used pillow cover

31

37

Used dehumidifier

24

23

Source: Georgia Behavioral Risk Factor Surveillance System Asthma Call Back Survey

Key Findings
Forty-five percent (45%) of Georgia adults and 41% of children with current asthma were advised by a health professional to change things in the home, school, or work environments to reduce asthma symptoms.
The majority of adults and children with current asthma lived in homes where exhaust fans were used in the bathroom or in the kitchen.

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Georgia Department of Public Health

ASTHMA SYMPTOMS
Frequency and severity of asthma symptoms are indicators of one's management of asthma. Most asthma symptoms are preventable with appropriate medication, medical care, and self-management15. Poorly-controlled asthma symptoms result in lost work and/or activities among adults. These indirect costs have profound effects on a person's quality of life as well as an economic impact on individuals, communities, counties, states, and the U.S. It is estimated that indirect costs such as lost productivity amounted to $5.9 billion nationwide16.
Studies show that children with persistent asthma miss more school days than children without asthma17. Furthermore, excessive absenteeism is related to lower student grades and lower psychological, social, and educational adjustment17. Parents or caregivers are also affected, resulting in missed workdays and decreased job productivity18.

Figure 13. Time of most recent asthma symptoms

among adults and children with current asthma,

Georgia,

2006-2009

100

Adult Child

80

Percent

60

51

40 27
20

0 <1 wk

42 26

21 13

1 wk to <3 mo

3 mo to <1 yr

Time since recent symptoms

11 10 >=1 yr

Source: Georgia Behavioral Risk Factor Surveillance System Asthma Call Back Survey

Key Findings
O ne in 4 Georgia adults with current asthma had asthma symptoms every day in the past 30 days. Twenty-five percent (25%) of adults and 37% of children with current asthma reported loss of sleep for 1-5 nights
in the past 30 days. Forty-five percent (45%) of Georgia adults with current asthma reported at least one or more days of lost work
or usual activities in the past year due to asthma. Nearly 60% of Georgia children with current asthma missed one or more days of school in the past year.

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Percent

Figure 14. Frequency of asthma symptoms in the past 30 days among adults with current asthma, Georgia,
2006-2009
50

40

30

25

20

10

8

14

15

15

14

7

0
None

Daily

1-2

3-5

6-10

11-15

Number of days with asthma symptoms

16-29

Source: Georgia Behavioral Risk Factor Surveillance System Asthma Call Back Survey

Figure 15. Sleep disturbances in the past 30 days due to asthma symptoms among adults and children with current
asthma, Georgia, 2006-2009

Percent

100

Adult Child

80

60 47 42
40
20

36 25

12 13

16 9

0

None

1-5

6-13

>14

Number of days with sleep disturbances

Source: Georgia Behavioral Risk Factor Surveillance System Asthma Call Back Survey

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Georgia Department of Public Health

Figure 16. Number of days unable to work or carry out usual activities during the past 12 months among adults
with current asthma, Georgia, 2006-2009

100

80

60

55

40

21

19

20

6

0

None

1-6

6-10

>11

Number of days unable to work or carry out usual activities

Percent

Source: Georgia Behavioral Risk Factor Surveillance System Asthma Call Back Survey

Percent

Figure 17. Number of missed school days due to asthma during the past 12 months, school-aged children with current asthma, Georgia, 2006-2009

100

80

60

58

42 40

20

0 None

1 or more days

Number of days

Source: Georgia Behavioral Risk Factor Surveillance System Asthma Call Back Survey

Georgia Asthma Surveillance Report, 2012

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Georgia Department of Public Health

ASTHMA MANAGEMENT
Asthma self-management, the direct involvement of patients and their caregivers in strategies to control their disease, is a key component of asthma care. It reduces emergency room (ER) visits, hospitalizations, unscheduled office visits, and asthma-related healthcare costs. Asthma management should begin after a proper diagnosis of the disease. The National Heart, Lung and Blood Institute (NHLBI) Expert Panel Report 3 (EPR3): Guidelines for the Diagnosis and Management of Asthma10 recommends that individuals with asthma should 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 medications and avoidance of triggers, it can be controlled.

Table 4. Percent of adults and children with current asthma who received asthma management strategies from a doctor or health care
provider, Georgia, 2006-2009

Adults (% )

Children (% )

Taught what to do during asthma episode or attack

74

78

Taught to recognize early asthma sign or symptoms

67

78

Taught how to use a peak flow meter

44

42

Given asthma action plan

25

44

Taken a course to manage asthma

9

18

Source: Georgia Behavioral Risk Factor Surveillance System Asthma Call Back Survey

In addition to the home, children with asthma can spend most of their time in child care centers or in school settings. Asthma management for children should include child care providers, teachers, and other school personnel. Schools can help by being supportive of students and staff with asthma; adopting asthma-friendly policies and procedures; coordinating services with physicians, school personnel, patients, and families to serve students with asthma; and providing asthma education for students and staff19. Many states, including Georgia, have passed legislation that addresses the rights of students to self-administer asthma medication and carry inhalers in schools (Georgia (OCGA 20-2-774 (2004). A statute authorizing students to self administer asthma medication, pursuant to local adopted school policies).

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The Asthma Call Back Survey (ACBS) (Appendix II) asked children (their parents/guardians answering in proxy) the following questions regarding asthma action plan and medications in schools:
- Does the school he/she goes to allow children with asthma to carry their medication with them while at school?
- Does the child have a written asthma action plan or asthma management plan on file at school?
The intent of the medication question is to measure whether the parents/guardians of the child are aware that their schools allow children to carry asthma medications. It is not the intent of the question to answer how many children are using medications, how many are carrying medications, or how many schools are allowing them to carry medications.
Figure 18. Asthma Action Plan and Medication at School, School-aged Children with Current Asthma, Georgia, 2006-2009

Child has written

asthma action plan on

44

file at school

Child allowed to carry

asthma medicine at

64

school

0

20

40

60

80

100

Percent

Source: Georgia Behavioral Risk Factor Surveillance System Asthma Call Back Survey

Key Findings:Asthma Management
Seventy-eight percent (78%) of school-aged children with current asthma were taught to recognize early signs or symptoms of asthma and what to do during an asthma attack.
About 1 of 11 Georgia adults with current asthma reported taking a course to manage asthma compared to one of 6 Georgia children.
Sixty-four percent (64%) of the parents/guardians who have school-aged children with asthma knew that they can have asthma medication at school.

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Georgia Department of Public Health

Medication Use
According to the National Heart Lung and Blood Institute (NHLBI), there are two categories of asthma prescription medications: long-term (also known as long-term preventive, controller, or maintenance) and quick-relief (also known as relief or rescue). The purpose of the long-term medications is to reduce inflammation in the airways. They should be taken daily to achieve control and prevent asthma attacks. Quick-relief medications provide immediate relief of asthma symptoms. They are used to prevent and treat asthma attacks. People with persistent asthma need both control and quick-relief medications. The most common way to take asthma medications is by inhalers.

Percent

Figure 19. Adults and children with current asthma who reported any prescription asthma medication use
in the past 3 months, Georgia, 2006-2009
100

80

71

62 60

40

20

0 Adults

Children

Source: Georgia Behavioral Risk Factor Surveillance System Asthma Call Back Survey

Georgia Asthma Surveillance Report, 2012

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Percent

Figure 20. Medication types used by adults and children with current asthma, Georgia, 2006-2009
Adults Children 100

80

60

40

38

29

20
0 No Prescription Medication

10 7 Control Only

24 19
Rescue Only

44 28
Control and Rescue

Source: Georgia Behavioral Risk Factor Surveillance System Asthma Call Back Survey

Figure 21. Proper Use* of Inhaled Prescription Asthma Medications in the Past Three Months, Georgia, 2006-2009

100 80 60 60

Adults Children

60

57

Percent

40

35

20

0 Long-term control

Rescue

*This indicator was generated among individuals with current asthma who reported using inhaled asthma medications in the past three months.
Source: Georgia Behavioral Risk Factor Surveillance System Asthma Call Back Survey

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Georgia Department of Public Health

Key Findings: Medication Use
Thirty-eight percent (38%) of Georgia adults and 29% of children with current asthma do not use asthma prescription medications. The NHLBI recommends that prescription medications should be part of an asthma self-management plan.
Ten percent (10%) of Georgia adults and 7% of children with current asthma use control medications only. The NHLBI recommends that control medications be used daily to achieve control and prevent asthma attacks.
A higher percent of adults (24%) than children (19%) with current asthma use rescue medications only. Sixty percent (60%) of Georgia adults with current asthma properly used inhaled long-term and rescue
medications. Only 35% of children with current asthma used inhaled control medication properly. There are many reasons for the underuse of asthma medication, especially among children. Studies have shown
that parents have concerns regarding their children's use of daily controller medicines, for example, regarding side effects such as growth retardation20.
Flu Vaccination
Adults and children with asthma are at an increased risk of having complications from flu virus infections. The flu virus can increase the inflammation of the airways and lungs. This can lead to pneumonia and other acute respiratory diseases. Asthma is the most-common medical condition among children and adults hospitalized with the flu21. According to a study by the CDC, only one-third of all asthmatic adults and one-fifth of asthmatic adults younger than 50 years of age receive the flu vaccine annually in the United States22. The U.S. Department of Health & Human Services recommends that getting the seasonal and other recommended flu shots (not nasal spray) is the best protection against influenza infection Flu.gov).
Figure 22. Percent of adults and children with asthma who received flu shots in past 12 months, Georgia, 2006-2009
100

80

Percent

60

40

40

40

20

0 Adult

Child

Source: Georgia Behavioral Risk Factor Surveillance System Asthma Call Back Survey

Key Finding Markedly less than half of Georgia adults and children with current asthma received seasonal flu shots.

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Georgia Department of Public Health

ASTHMA MORBIDITY
Asthma severity can be measured by emergency room (ER) visit and hospitalization rates. Asthma wass one of the top 20-leading diagnoses for ER visits during 2008 in the United States23. Furthermore, the rates of hospitalizations and deaths due to asthma are both 3 times higher among African Americans than among whites24. Children have twice the rate of emergency department visits and hospitalizations for asthma as adults24.
In Georgia, there were approximately 154,000 asthma-related ER visits from 2006 to 2010, an average of 51,000 visits per year. The overall rate of ER visits due to asthma was 530 per 100,000 population. During the same period, there were more than 54,000 asthma-related hospital discharges, an average of 10,800 discharges per year. The overall annual rate of hospitalizations due to asthma in Georgia was 113 per 100,000 population.

Rate per 100,000

Figure 23. Age-adjusted asthma ER visit rates by race and sex, Georgia, 2006-2010

2000

Male Female

1500 1000

1100 1047

500

326

238

0

White

Black

Source: Georgia Hospital Discharge Data, accessed through Online Analytical Statistical Information System (OASIS) Georgia Department of Public Health, Office of Health Indicators for Planning (OHIP).

(May 2012) http://oasis.state.ga.us/

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Rate per 100,000

Figure 24. Asthma ER visit rates by age group, Georgia, 2006-2010
2000

1500 1373 1184

1000 500

739
511 516 447 400 411 284 211

0
0-4

5-9 10-14 15-17 18-24 25-34 35-44 45-54 55-64 65+
Age group (years)

Source: Georgia Hospital Discharge Data, accessed through Online Analytical Statistical Information System (OASIS) Georgia Department of Public Health, Office of Health Indicators for Planning (OHIP). (May 2012) http://oasis.state.ga.us/

Rate per 100,000

Figure 25. Age-adjusted asthma hospitalization rates by race and sex, Georgia, 2006-2010

Male Female 400

300

200

110

100

60

208 148

0 White

Black

Source: Georgia Hospital Discharge Data, accessed through Online Analytical Statistical Information System (OASIS) Georgia Department of Public Health, Office of Health Indicators for Planning (OHIP). (May 2012) http://oasis.state.ga.us/

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Georgia Department of Public Health

Rate per 100,000

Figure 26. Age-specific asthma hospitalization rates, Georgia, 2006-2010
400

300 223
200
100
0
0-4

223

149

150

133

70

81

48

30

30

5-9 10-14 15-17 18-24 25-34 35-44 45-54 55-64 65+
Age group (years)

Source: Georgia Hospital Discharge Data, accessed through Online Analytical Statistical Information System (OASIS) Georgia Department of Public Health, Office of Health Indicators for Planning (OHIP). (May 2012) http://oasis.state.ga.us/

Key Findings: Asthma Morbidity
Black males and females with current asthma have significantly higher ER visit and hospitalization rates than white males and females with current asthma.
ER visit rates are highest among Georgian children with current asthma who are 0 to 4 years old. ER visit rates decreass as age increases.
Children 0 to 4 years old and older adults (65+ years) have higher asthma-related hospitalization rates than other age groups.

Georgia Asthma Surveillance Report, 2012

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Georgia Department of Public Health

Asthma Mortality
Asthma mortality is lower than ER visits and hospitalization in the U.S. However, according to the National Asthma Education and Prevention Program (NAEPP), the mortality rate has risen over the past 20 years, especially in Blacks and individuals aged 85 years and older. In Georgia, an average of 104 asthma-related deaths occurred per year (1.3 deaths per 100,000 population) from 2000 to 2008. The mortality rate was disproportionately higher among Blacks (2.0 per 100,000) and older adults aged 65 years and older (5.2 per 100,000).

Rate per 100,000

Figure 27. Age-adjusted asthma death rates by race and sex, Georgia, 2000-2008
Male Female 10

8

6

4

2

1.6 1.1

1.2 0.7

2.9 2.2

0 Total

White

Black

Source: Georgia Death data, accessed through the Online Analytical Statistical Information System (OASIS) Georgia Department of Public Health, Office of Health Indicators for Planning (OHIP).
(January 2011) http://oasis.state.ga.us/

Georgia Asthma Surveillance Report, 2012

37

Rate per 100,000

Figure 28. Age-specific asthma death rates, Georgia, 2000-2008
10

8

6

5.2

4

2
0.2 0
0-4

2.1 1.6

0.9

0.2

0.2

0.2

0.4

0.5

5-9 10-14 15-17 18-24 25-34 35-44 45-54 55-64 65+
Age group (years)

Source: Georgia Death data, accessed through the Online Analytical Statistical Information System (OASIS) Georgia Department of Public Health, Office of Health Indicators for Planning (OHIP). (January 2011) http://oasis.state.ga.us/

Key Findings
In Georgia, Blacks (age-adjusted death rate of 2.6 per 100,000) were almost three times more likely to die from asthma than whites (age-adjusted death rate of 1.0 per 100,000).
Females (age-adjusted death rate of 1.7 per 100,000) were 1.6 times more likely to die from asthma than males (age-adjusted rate of 1.1 per 100,000) but this differences was not statistically significant.
In Georgia, individuals aged 65 years and older had the highest asthma death rate.

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Georgia Department of Public Health

CONCLUSIONS
Asthma is a major public health concern in Georgia, as it is in the United States. In Georgia, 9% of children aged 0-17 years, 11% of both middle and high school students, and 8% of adults reported currently having asthma in 2010. This report shows that asthma affects all age, race, and sex groups in Georgia, 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 oldest and youngest age groups. Death rates are about 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).
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 triggers 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 physicians know and discuss revisions that may be needed.
Asthma education, proper treatment and management, policy changes, and modification of risk factors will help reduce the 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 for Georgians with asthma, as well as their familie, and society at large.
Georgia Asthma Control Program
In 2001, the Centers for Disease Control and Prevention (CDC) awarded a grant to the Georgia Department of Public Health (DPH) to create and implement a statewide strategic plan to address asthma. DPH then established the Georgia Asthma Control Program (GACP). In 2009, GACP received additional funding from CDC to participate in a nationwide initiative to reduce the burden of asthma and improve the health and quality of life for all persons affected by asthma through effective control of the disease. The following are the five-year goals of the program:
Enhance Georgia's capacity to address asthma management and treatment at the state and local levels. Enhance the state's surveillance and evaluation capacity for tracking asthma morbidity and mortality and
evaluating program effectiveness. Reduce Georgia's emergency room visits due to asthma. Reduce Georgia's asthma hospitalization rate. Reduce asthma deaths. Reduce asthma prevalence in populations disproportionately affected by asthma. Increase the proportion of people with current asthma that report they have received asthma self-management
education. Increase the proportion of people with asthma who received appropriate asthma care according to the National
Asthma Education and Prevention Program Guidelines.
Surveillance is a key component to guide the asthma program in its efforts. Since 2001, two surveillance reports have been produced--the 2003 Burden of Asthma in Georgia and the 2007 Georgia Asthma Surveillance Report

Georgia Asthma Surveillance Report, 2012

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Georgia Department of Public Health

REFERENCES
1. National Heart Lung and Blood Institute. What Causes Asthma? Available at http://www.nhlbi.nih. gov/health/health-topics/topics/asthma/causes.html [Last accessed: January 2011]
2. Adams PF, Martinez ME, Vickerie JL. Summary health statistics for the U.S. Population: National Health Interview Survey, 2009. Centers for Disease Control and Prevention, National Center for Health Statistics, Hyattsville, MD, USA. Vital Health Stat 10 2010 Dec; (248):1-115.
3. Schappert SM, Rechtsteiner EA. Ambulatory medical care utilization estimates for 2006. National health statistics reports; No. 8. Hyattsville, MD: National Center for Health Statistics. 2008.
4. Hall MJ, DeFrances CJ, Williams SN, Golosinskiy A, Schwartzman A. National Hospital Discharge Survey: 2007 summary. National health statistics reports; no. 29. Hyattsville, MD: National Center for Health Statistics. 2010.
5. Centers for Disease Control and Prevention. Current Asthma Prevalence-United States, 2006--2008. MMWR 2011;60(01):84-86.
6. Centers for Disease Control and Prevention. Families, Clinicians and Schools: Working Together to Improve Asthma Management. Available at http://www.cdc.gov/Features/ManageAsthma/ [Last accessed: June 2012]
7. Centers for Disease Control and Prevention. CDC health disparities and inequalities report---United States, 2001. MMWR 2011;60 (Suppl).
8. United States Department of Labor Occupational Health and Safety Administration. Occupational Asthma. Available at http://www.osha.gov/SLTC/occupationalasthma/ [Last accessed January 2011]
9. Centers for Disease Control and Prevention.Work-Related Asthma 38 States and District of Columbia, 2006-2009. MMWR 2012;61:375-378.
10. National Heart Lung and Blood Institute. Expert Panel Report 3 (EPR3): Guidelines for the Diagnosis and Management of Asthma. Available at http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln. htm [Last accessed: September 2011]
11. S hore, S.A. 2008. Obesity and asthma: possible mechanisms. Journal of Allergy and Clinical Immunology: 121:1087-1093.
12. United States Environmental Protection Agency. Indoor Environmental Asthma Triggers. Available at http://www.epa.gov/asthma/triggers.html [Last accessed: January 2011]
13. United States Environmental Protection Agency. Asthma Triggers: Gain Control. Available at http://epa.gov/asthma/triggers.html [Last accessed: September 12, 2011]
14. American Lung Association. Asthma Triggers. Available at http://www.lung.org/lung-disease/ asthma/living-with-asthma/take-control-of-your-asthma/asthma-triggers.html [Last access: March 1, 2012]
15. Asthma self-management education among youths and adults-United States, 2003. MMWR 2007;56(35):912915.
16. Adults in Asthma Fact Sheet. Available at http://www.lung.org/lung-disease/asthma/resources/ facts-and-figures/asthma-in-adults.html#7 [Last accessed: February 10, 2012]

Georgia Asthma Surveillance Report, 2012

41

17. Moonie, S, et al. The Relationship Between School Absence, Academic Performance, and Asthma Status. Journal of School Health: 78(3):140-148, 2008.
18. Wang, LY, et al. Direct and Indirect Costs of Asthma in School-age Children. Preventing Chronic Disease: 2(1): A11, January 2005.
19. National Asthma Education and Prevention Program. Managing Asthma A Guide for Schools. Available at http://www.nhlbi.nih.gov/health/prof/lung/asthma/asth_sch.pdf [Last accessed: February 14, 2012]
20. Orrell-Valente, JK, et al. Parents' Specific Concerns about Daily Asthma Medications for Children. Journal of Asthma: 44:385-390, 2007.
21. Flu.gov. Asthma & the Flu. Available at http://www.flu.gov/at-risk/health-conditions/asthma/index. html [Last access: March 2, 2012]
22. Centers for Disease Control and Prevention. Adults with Asthma Should Receive Flu Vaccination. Available at http://www.cdc.gov/asthma/flushot.htm [Last access: June 21, 2012]
23. Centers for Disease Control and Prevention. Asthma prevalence, health care use and mortality: United States, 2003-05.
24. National Hospital Ambulatory Medical Care Survey: 2008 Emergency Department Summary Tables. Available at http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/nhamcsed2008.pdf [Last accessed: October 24, 2011]

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Georgia Department of Public Health

APPENDIX I: Data Tables

Table 1. Prevalence of current asthma among adults 18+ years, by Georgia Public Health Districts, 2006-2010

Health District

Percent

Georgia

7.7

(1-1) Northwest (Rome)

8.7

(1-2) North Georgia (Dalton)

7.2

(2-0) North (Gainesville)

6.9

(3-1) Cobb/Douglas

8.1

(3-2) Fulton

7.7

(3-3) Clayton

8.8

(3-4) East Metro (Lawrenceville)

7.6

(3-5) DeKalb

7.0

(4-0) LaGrange

8.5

(5-1) South Central (Dublin)

9.7

(5-2) North Central (Macon)

8.1

(6-0) East Central (Augusta)

8.6

(7-0) West Central (Columbus)

6.5

(8-1) South (Valdosta)

6.8

(8-2) Southwest (Albany)

7.0

(9-1) East (Savannah)

7.0

(9-2) Southeast (Waycross)

7.1

(10-0) Northeast (Athens)

7.5

Georgia Asthma Surveillance Report, 2012

43

Table 2. Prevalence of current asthma among children 0-17 years, by Georgia Public Health Districts, 2006-2010

Health District

Percent

Georgia

10.2

(1-1) Northwest (Rome)

10.3

(1-2) North Georgia (Dalton)

9.7

(2-0) North (Gainesville)

10.2

(3-1) Cobb/Douglas

8.7

(3-2) Fulton

10.0

(3-3) Clayton

14.2

(3-4) East Metro (Lawrenceville)

9.7

(3-5) DeKalb

11.9

(4-0) LaGrange

8.7

(5-1) South Central (Dublin)

13.0

(5-2) North Central (Macon)

9.1

(6-0) East Central (Augusta)

11.2

(7-0) West Central (Columbus)

9.4

(8-1) South (Valdosta)

14.1

(8-2) Southwest (Albany)

11.4

(9-1) East (Savannah)

9.1

(9-2) Southeast (Waycross)

12.2

(10-0) Northeast (Athens)

10.1

44

Georgia Department of Public Health

Table 3. Annual number of asthma ER visits and age-adjusted ER visit rates by public health districts and counties, Georgia 2006-2010

Health Districts, Counties

Average Number of ER Visits (per year)

Age-adjusted ER Visit Rate/100,000

Northwest Health District (Rome)

2191

352.6

Bartow

455

469.4

Catoosa

70

114.5

Chattooga

62

255.2

Dade

8

49.5*

Floyd

427

456.6

Gordon

141

264.1

Haralson

149

529.2

Paulding

551

386.8

Polk

220

524.6

Walker

107

171.6

North Georgia Health District (Dalton)

1274

295.7

Cherokee

613

283.2

Fannin

45

231

Gilmer

70

258.1

Murray

182

446.1

Pickens

96

343.4

Whitfield

268

285.9

North Health District (Gainesville)

1895

314

Banks

50

300.6

Dawson

60

285.3

Forsyth

418

242.2

Franklin

79

378.1

Habersham

118

283.9

Hall

627

337.7

Hart

103

455.7

Lumpkin

74

282.1

Rabun

64

431.9

Stephens

107

449.6

Towns

41

430.9

Union

73

398.8

White

80

334.5

* Rate for county with less than 15 ER visits are unstable.

Georgia Asthma Surveillance Report, 2012

45

Table 3. Annual number of asthma ER visits and age-adjusted ER visit rates by Public Health Districts and cCunties, Georgia 2006-2010

Health Districts, Counties

Average Number of ER Visits (per year)

Age-adjusted ER Visit Rate/100,000

Cobb/Douglas Health District Cobb

3759 3018

446.1 426.6

Douglas Fulton Health District
Fulton

740 8083 8083

553.1 820.8 820.8

Clayton County Health District (Jonesboro)

1925

663.7

Clayton
East Metro Health District (Lawrenceville)

1925 4565

663.7 444.6

Gwinnett Newton

3612 545

430.9 531.4

Rockdale

408

487.7

DeKalb Health District DeKalb

5564 5564

772.2 772.2

LaGrange Health District Butts

3615 130

458.8 542.2

Carroll

544

482.9

Coweta Fayette

463

369.1

321

339.1

Heard Henry

46

402.6

736

365.4

Lamar

109

640.7

Meriwether

88

402.2

Pike

66

384.3

Spalding Troup

488

773.7

364

567.9

Upson

260

985

South Central Health District (Dublin)

745

525.1

Bleckley Dodge Johnson

53

458.1

114

574

44

485.5

Laurens

309

666.9

Montgomery

37

416.6

Pulaski Telfair Treutlen

46

463

60

457.3

28

408.7

Wheeler Wilcox

17

260

37

438.2

* Rate for county with less than 15 ER visits are unstable.

46

Georgia Department of Public Health

Table 3. Annual number of asthma ER visits and age-adjusted ER visit rates by public health districts and counties, Georgia 2006-2010

Health Districts, Counties

Average Number of ER Visits (per year)

North Central Health District (Macon)

2828

Baldwin

264

Bibb

884

Crawford

52

Hancock

55

Houston

717

Jasper

85

Jones

87

Monroe

128

Peach

242

Putnam

99

Twiggs

44

Washington

125

Wilkinson

49

East Central Health District (Augusta)

3328

Burke

232

Columbia

287

Emanuel

119

Glascock

9

Jefferson

154

Jenkins

125

Lincoln

26

McDuffie

160

Richmond

1978

Screven

139

Taliaferro

8

Warren

37

Wilkes

52

* Rate for county with less than 15 ER visits are unstable.

Age-adjusted ER Visit Rate/100,000
555.7
613.4 569.2 421.6 603.6 525.8 624 326.4 515.5 916.6 525.5 450.5 610.4 501.1
739
977.5 254 522.7 353.7* 935.9 1,487.70 366.2 727.8 983.2 965.2 519.2* 669.2 526.3

Georgia Asthma Surveillance Report, 2012

47

Table 3. Annual number of asthma ER visits and age-adjusted ER visit rates by public health districts and counties, Georgia 2006-2010

Health Districts

Average Number of ER Visits (per year)

Age-adjusted ER Visit Rate/100,000

West Central Health District (Columbus)

2175

608.3

Chattahoochee

22

283.9

Clay

7

240.4*

Crisp

147

665.5

Dooly

70

575.9

Harris

68

232.5

Macon

94

705.9

Marion

26

346.5

Muscogee

1355

717.9

Quitman

4

174.9*

Randolph

85

1,181.90

Schley

33

784.8

Stewart

13

310.4*

Sumter

158

494.1

Talbot

25

408.4

Taylor

60

686.1

Webster

8

345.8*

South Health District (Valdosta)

1284

517.2

Ben Hill

126

710

Berrien

93

540.8

Brooks

104

649.8

Cook

110

664.4

Echols

10

248.2*

Irwin

44

475.8

Lanier

59

686.5

Lowndes

537

507.4

Tift

170

402

Turner

31

349.4

* Rate for county with less than 15 ER visits are unstable.

48

Georgia Department of Public Health

Table 3. Annual number of asthma ER visits and age-adjusted ER visit rates by Ppublic Hhealth Ddistricts and Ccounties, Georgia 2006-2010

Health Districts, Counties

Average Number of ER Visits (per year)

Age-adjusted ER Visit Rate/100,000

Southwest Health District (Albany)

2431

672.6

Baker

17

487.1

Calhoun

65

1,103.90

Colquitt

277

598.7

Decatur

163

581.3

Dougherty

788

824.1

Early

102

853.4

Grady

156

623

Lee

86

270.9

Miller

45

775.5

Mitchell

189

798.8

Seminole

36

406.5

Terrell

62

608.7

Thomas

293

675.9

Worth

152

753.9

Southeast Health District (Waycross)

2041

583.7

Appling

40

230.7

Atkinson

40

456.2

Bacon

65

617.1

Brantley

57

357.9

Bulloch

350

557

Candler

93

872.9

Charlton

42

400

Clinch

41

594.9

Coffee

288

686.5

Evans

83

718.2

Jeff Davis

27

192

Pierce

106

585.2

Tattnall

130

555

Toombs

189

673.9

Ware

362

1,050.70

Wayne

127

439.6

* Rate for county with less than 15 ER visits are unstable.

Georgia Asthma Surveillance Report, 2012

49

Table 3. Annual number of asthma ER visits and age-adjusted ER visit rates by public health districts and counties, Georgia 2006-2010

Health Districts, Counties

Average Number of ER Visits (per year)

Age-adjusted ER Visit Rate/100,000

Coastal Health District (Savannah)

3206

580.8

Bryan

97

311.3

Camden

361

717.1

Chatham

1769

707.9

Effingham

151

288

Glynn

391

538.8

Liberty

362

559.5

Long

41

312.9

McIntosh

34

309.3

Northeast Health District (Athens)

1746

385.9

Barrow

279

391.7

Clarke

460

469.1

Elbert

103

519.5

Greene

116

815

Jackson

199

330.1

Madison

81

303.1

Morgan

72

410.4

Oconee

54

169

Oglethorpe

39

288

Walton

343

404

* Rate for county with less than 15 ER visits are unstable.

50

Georgia Department of Public Health

Table 4. Annual number of asthma hospitalizations and age-adjusted hospitalization rates by public health districts and counties, Georgia 2006-2010

Health Districts, Counties

Average Number of Hospital- Age-adjusted Hospitalization

izations (per year)

Rate/100,000

Northwest Health District (Rome)

485

78.3

Bartow

110

119

Catoosa

19

30.4

Chattooga

18

65.7

Dade

3

13.4*

Floyd

80

81.9

Gordon

39

73.1

Haralson

22

78.1

Paulding

130

100.6

Polk

38

89.7

Walker

26

38

North Georgia Health District (Dalton)

373

88.8

Cherokee

134

68.3

Fannin

16

67.3

Gilmer

29

92.3

Murray

68

177.2

Pickens

30

96.4

Whitfield

96

101.1

North Health District (Gainesville)

436

71.2

Banks

15

84.9

Dawson

15

68.4

Forsyth

103

67.1

Franklin

31

145

Habersham

35

81.5

Hall

107

62.5

Hart

17

65.8

Lumpkin

16

62.8

Rabun

15

82.8

Stephens

54

224.9

Towns

5

46.8*

Union

8

33.8*

White

16

63.9

*Rate for county with less than 15 number of hospitalizations are unstable

Georgia Asthma Surveillance Report, 2012

51

Table 4. Annual number of asthma hospitalizations and age-adjusted hospitalization rates by public health districts and counties, Georgia 2006-2010

Health Districts

Average Number of Hospitalizations (per year)

Age-adjusted Hospitalization Rate/100,000

Cobb/Douglas Health District

680

85.2

Cobb

542

80.2

Douglas

138

115.1

Fulton Health District

1,138

121.1

Fulton

1,138

121.1

Clayton County Health District (Jonesboro)

262

100.9

Clayton

262

100.9

East Metro Health District (Lawrenceville)

910

108.7

Gwinnett

732

113.3

Newton

101

108.1

Rockdale

78

92.9

DeKalb Health District

882

126.2

DeKalb

882

126.2

LaGrange Health District

761

99

Butts

29

121.4

Carroll

86

80.1

Coweta

88

73

Fayette

47

46.7

Heard

11

92.8*

Henry

120

64.2

Lamar

27

157.6

Meriwether

26

105.1

Pike

23

133.1

Spalding

125

195.7

Troup

120

184.4

Upson

58

214.3

South Central Health District (Dublin)

352

246.4

Bleckley

29

249.5

Dodge

35

170.8

Johnson

22

245

Laurens

151

308.4

Montgomery

12

140.6*

Pulaski

27

281.9

Telfair

25

184.3

Treutlen

19

273.5

Wheeler

8

113*

Wilcox

24

311.4

*Rate for county with less than 15 number of hospitalizations are unstable

52

Georgia Department of Public Health

Table 4. Annual number of asthma hospitalizations and age-adjusted hospitalization rates by public health districts and counties, Georgia 2006-2010

Health Districts, Counties

Average Number of Hospitalizations (per year)

Age-adjusted Hospitalization Rate/100,000

North Central Health District (Macon)

711

137.1

Baldwin

61

140.4

Bibb

227

143

Crawford

13

100.9*

Hancock

16

172.5

Houston

182

136

Jasper

10

74.1*

Jones

30

103.6

Monroe

25

93.2

Peach

46

179.5

Putnam

17

71.7

Twiggs

16

152.5

Washington

47

230.3

Wilkinson

21

201.7

East Central Health District (Augusta)

605

133.3

Burke

41

177.5

Columbia

83

75

Emanuel

40

166

Glascock

3

116.8*

Jefferson

39

222

Jenkins

15

174.6

Lincoln

7

93.9*

McDuffie

27

116.4

Richmond

300

151.5

Screven

26

165.5

Taliaferro

2

108.1*

Warren

6

91.7*

Wilkes

16

144.7

*Rate for county with less than 15 number of hospitalizations are unstable

Georgia Asthma Surveillance Report, 2012

53

Table 4. Annual number of asthma hospitalizations and age-adjusted hospitalization rates by public health districts and counties, Georgia 2006-2010

Health Districts, Counties

Average Number of Hospitalizations (per year)

Age-adjusted Hospitalization Rate/100,000

West Central Health District (Columbus)

419

115.3

Chattahoochee

5

79.2*

Clay

*

*

Crisp

50

219.4

Dooly

32

262.1

Harris

21

67.1

Macon

28

204.3

Marion

7

73.1*

Muscogee

207

109

Quitman

2

55.7*

Randolph

9

107.2

Schley

5

111.1*

Stewart

6

124.1*

Sumter

27

82.6

Talbot

6

80.8*

Taylor

13

141.4*

Webster

*

*

South Health District (Valdosta)

450

184.9

Ben Hill

39

212

Berrien

39

216.7

Brooks

29

172.8

Cook

43

259.9

Echols

4

140.8*

Irwin

22

224.4

Lanier

12

133.8*

Lowndes

160

167.9

Tift

85

197.5

Turner

15

165.4

*Rate for county with less than 15 number of hospitalizations are unstable

54

Georgia Department of Public Health

Table 4. Annual number of asthma hospitalizations and age-adjusted hospitalization rates by public health districts and counties, Georgia 2006-2010

Health Districts

Average Number of Hospitalizations (per year)

Age-adjusted Hospitalization Rate/100,000

Southwest Health District (Albany)

614

165.3

Baker

3

73

Calhoun

17

263.4

Colquitt

66

145.4

Decatur

59

206

Dougherty

190

197.5

Early

17

140.2

Grady

37

142.1

Lee

21

74.6

Miller

15

224.1

Mitchell

36

146.2

Seminole

31

327.6

Terrell

17

162.9

Thomas

64

131

Worth

41

193.3

Southeast Health District (Waycross)

628

182

Appling

39

211.6

Atkinson

21

265.2

Bacon

21

192.8

Brantley

16

103.8

Bulloch

63

114.3

Candler

31

268.9

Charlton

5

48

Clinch

16

231.6

Coffee

100

249.6

Evans

27

224.9

Jeff Davis

47

337.2

Pierce

31

164.2

Tattnall

43

187.4

Toombs

57

195.7

Ware

68

180

Wayne

42

141.7

*Rate for county with less than 15 number of hospitalizations are unstable

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Table 4. Annual number of asthma hospitalizations and age-adjusted hospitalization rates by public health districts and counties, Georgia 2006-2010

Health Districts

Average Number of Hospital- Age-adjusted Hospitalization

izations (per year)

Rate/100,000

Coastal Health District (Savannah)

627

115.8

Bryan

24

95.1

Camden

30

64.9

Chatham

329

130.6

Effingham

42

87.6

Glynn

118

150.6

Liberty

65

122.3

Long

8

72.5

McIntosh

11

92.8

Northeast Health District (Athens)

514

118.1

Barrow

109

164.7

Clarke

109

126.5

Elbert

27

117.7

Greene

20

129.7

Jackson

69

115.8

Madison

35

125.4

Morgan

13

66.5

Oconee

20

64.2

Oglethorpe

14

104.2

Walton

97

116.8

*Rate for county with less than 15 number of hospitalizations are unstable

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Georgia Department of Public Health

APPENDIX ii: Maps
Prevalence of Current Asthma Among Adults 18+ Years, Georgia 2006-2010
Lowest 25% Middle 50% Highest 25%

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Prevalence of Current Asthma Among Children 0-17 Years, Georgia 2006-2010
Lowest 25% Middle 50% Highest 25%

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Georgia Department of Public Health

Age-Adjusted Emergency Room Visit Rates for Asthma, Georgia 2006-2010
Lowest 25% Middle 50% Highest 25%

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Age-Adjusted Hospitalization Rates for Asthma, Georgia 2006-2010
Not Available Lowest 25% Middle 50% Highest 25%

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Georgia Department of Public Health

APPENDIX iii:
Data Sources and Methods
Data Sources, Methods, and Technical Notes
Data Sources
Behavioral Risk Factor Surveillance System (BRFSS)
The BRFSS is a stratified random-digit dial telephone interview conducted in cooperation with the Centers for Disease Control and Prevention (CDC). Georgia non-institutionalized residents 18 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 2002-2010 core section of the BRFSS. 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 the 2003-2005 BRFSS modules administered in Georgia. Prevalence was estimated from combined 2006-2010 data using SAS and SUDAAN. People without a telephone were not included in the survey.
Asthma Call Back Survey (ACBS)
The Asthma Call-back Survey is conducted approximately two weeks after the Behavioral Risk Factor Surveillance Survey (BRFSS). BRFSS respondents who report ever being diagnosed with asthma are eligible for the asthma call-back. The ACBS first became available in 2005, when it was piloted as a 3-state sample. The 2005 data wawerereleased in 2007. In 2006, 25 states participated. By 2007, 35 states implemented the BRFSS Asthma Call Back Survey, including Georgia.
Youth Risk Behavior Survey (YRBS)
The YRBS monitors priority health-risk behaviors and the prevalence of obesity and asthma among youth and young adults. The YRBS includes a national school-based survey conducted by the Centers for Disease Control and Prevention (CDC) and state, territorial, tribal, and district surveys conducted by state, territorial, and local education and health agencies and tribal governments. The Georgia YRBS is conducted every odd-numbered year; Georgia data are available for 2005, 2007, 2009 and 2011.
Youth Tobacco Survey (YTS)
The Georgia YTS is a self-administered survey given to Georgia's middle and high school students. The main focus of this survey is tobacco use. Two questions about asthma were added in the X year YTS in Georgia: 1) "Has a doctor or nurse ever told you that you have asthma?"; and, 2) "During the past 12 months have you had an episode or an asthma attack?" This survey does not include students who attend private middle school and high schools, were home schooled, or those who do not attend school at all. The Georgia YTS is conducted every odd-numbered year; Georgia YTS data are available for 2005, 2007, 2009 and 2011.

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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 with asthma as the primary diagnosis. The ICD-9 codes (493.0-493.9) used to select ER visits 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 on the total charges reported by the hospital. The amount a hospital is reimbursed is usually less than what is charged.
Hospital Inpatient Discharge Data
Hospitalization data in the report are based on hospital discharge data for Georgia residents who were hospitalized with asthma as the primary diagnosis. The ICD-9 codes (493.0-493.9) used to select hospitalizations 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 on the total charges reported by the hospital. The amount a hospital is reimbursed is usually less than what is charged.
Georgia Vital Records Death Data
Mortality data are based on deaths of Georgia residents whose underlying cause of death was asthma. Deaths from 1999-2008 with ICD-10 codes J45-J46 were selected. Death rates were age-adjusted to the 2000 US standard population via the direct method.

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Methods
Age-Adjusted Rates
A weighted average of the age-specific rates (death, ER visits, or hospitalizations) where the weights are the proportions of persons in the corresponding age groups of a standard population. The calculation of an Age-Adjusted Rate uses the year 2000 U.S. standard million. Benefit: Controls for differences in age structure so that observed differences in rates across areas such as counties are not due solely to differences in the proportion of people in different age groups in different areas.
Age-Specific Rates
[Number of death, hospitalizations, or ER visits in a specific age group / Population of same age group] * 100,000.
Cause of Death
Reported causes of death are based on the underlying cause of death. The underlying cause of death is defined by the World Health Organization as the disease or injury that initiated the sequence of events leading directly to death or as the circumstances of the accident or violence that produced the fatal injury. Cause of death is coded using the International Classification of Diseases, Tenth Revision (ICD-10).
Cause of Hospital Discharge
Causes are based on the principal diagnosis, except in cases where an External (E-code) cause supersedes the principal diagnosis.
Prevalence
The prevalence can be interpreted as the percentage of the population with the given health condition of interest (asthma). The numerator includes the count of those with the condition (asthma) and the denominator includes a count of the total population of interest, resulting in a proportion.
Rates
The count alone will be less useful when comparing populations of unequal size. Knowing population sizes is useful, but computing a rate will allow direct comparison between similar populations. A rate is a fraction that typically has four components:
1. A specified time period. 2. The numerator, which is the number of people for whom an event occurred during a given period of time. 3. The denominator, which is the total number of people in the population at risk for the same period of time.
This is also referred to as the "person-years at risk." 4. A constant. The result of the fraction is usually multiplied by some constant (such as 100,000) to make the
number more legible.

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Statistically-significant
In this report a p-value <.05 was considered statistically significant, showing that the observed results are probably different from what might have occurred as a result of chance alone.
Technical Notes
In this report, some numbers are not shown because they are unreliable. In general, reliability refers to the stability of a number being reported. ACBS follows a rule of not reporting or interpreting point estimates based on fewer than 50 unweighted respondents (e.g. percentages based upon a denominator of or for which the Relative Standard Error is greater than 30%).

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Georgia Department of Public Health

APPENDIX IV:
Glossary and Abbreviations
Glossary
Asthma Action Plan: An asthma action plan (also called a management plan) is a written plan that those with asthma develop with their doctors to help control asthma. The asthma action plan shows daily treatment, such as what kind of medicines to take and when to take them. The personalized plan describes how to control asthma long term and how to handle worsening asthma, or attacks. The plan explains when to call the doctor or go to the emergency room.
Asthma Status
Current asthma: Respondents who answered yes to the following questions; "Have you ever been told by a doctor, nurse, or other health professional that you had asthma?" and "Do you still have asthma?"
Lifetime asthma: Respondents who answered yes to the following question; "Have you ever been told by a doctor, nurse, or other health professional that you had asthma?"
Body Mass Index (BMI)
Adult
Body mass index (BMI) is a measure of body fat based on height and weight that applies to adult men and women. BMI is weight in kilograms divided by height in meters squared.
An adult who has a BMI between 25 and 29.9 is considered overweight. An adult who has a BMI of 30 or higher is considered obese.

Children and Teens
After BMI is calculated for children and teens, the BMI number is plotted on the CDC BMI-for-age growth charts (for either girls or boys) to obtain a percentile ranking. Percentiles are the most commonly used indicators to assess the size and growth patterns of individual children in the United States. The percentile indicates the relative position of the child's BMI number among children of the same sex and age. The growth charts show the weight status categories used with children and teens (underweight, healthy weight, overweight, and obese).
BMI-for-age weight status categories and the corresponding percentiles are shown in the following table.

Weight Status Category Percentile Range

Underweight

Less than the 5th percentile

Healthy weight

5th percentile to less than the 85th percentile

Overweight

85th to less than the 95th percentile

Obese

Equal to or greater than the 95th percentile

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Current Smoking
Adults: Smoked at least 100 cigarettes in their lifetime and who currently smoke.
Teenagers: Smoked cigarettes on one or more days in the past 30 days.
Inhaler: Asthma inhalers are hand-held portable devices that deliver medication to your lungs.
Inhaled corticosteroids (ICSs): ICSs are a class of anti-inflammatory drugs for the treatment of asthma.
Nebulizer: A nebulizer is a device that changes liquid medicine into fine droplets (in aerosol or mist form) that are inhaled through a mouthpiece or mask. Nebulizers are particularly effective in delivering asthma medications to infants and small children and to anyone who has difficulty using an asthma inhaler.
Over-the-counter (OTC) Medication: Medication for which a prescription is not needed.
Peak Flow Meter: A peak flow meter is a device for those with asthma that is used to measure how well air moves out of your lungs. Measuring your peak flow using this meter is an important part of managing your asthma symptoms and preventing an asthma attack. The peak flow meter works by measuring how fast air comes out of the lungs when you exhale forcefully after inhaling fully. This measure is called a "peak expiratory flow," or "PEF." Keeping track of your PEF, is one way you can know if your symptoms of asthma are in control or worsening.
Prescription Medications:
Long-term control Controller medications are taken daily to achieve control and prevent asthma attacks Quick-relief- Taken as needed for rapid, short-term relief of symptoms; used to prevent or treat an
asthma attack. Secondhand Smoke: Secondhand smoke, also known as Environmental Tobacco Smoke (ETS), consists of exhaled smoke from smokers and side stream smoke from the burning end of a cigarette, cigar or pipe and inhaled involuntarily or passively by someone who is not smoking. Secondhand smoke contains more than 4,000 substances, including several compounds that are known carcinogens.
Work-related Asthma (WRA): Asthma caused or made worse by exposures in the work environment.

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