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					                                                  Georgia
                                                     Epidemiology
                                                           Report
  The Georgia Epidemiology Report is a publication of the Epidemiology Section of the Epidemiology and Prevention Branch, Division of Public Health, Department of Human Resources



March 1996                                                                                                                              Volume 12                Number 3
Division Of Public Health
Patrick J. Meehan, M.D. - Director                                      Congenital Anomalies In Georgia
 Epidemiology and Prevention Branch                             An estimated 1 in 33 newborns in Georgia is diagnosed with a major congenital
 State Epidemiologist
                                                           anomaly. Each year this amounts to about 3,300 infants whose future well-being and
 Kathleen E. Toomey, M.D., M.P.H.- Director
                                                           even survival may be challenged. Infants with congenital anomalies often need spe-
  Epidemiology Section                                     cial medical care, and account for 25-30% of all pediatric admissions nationwide, and
  Paul A. Blake, M.D., M.P.H.-Director                     for an estimated yearly expenditure of 1.4 billion dollars1 . Congenital anomalies are
   Surveillance                                            the leading cause of infant mortality in Georgia (Figure 1), accounting for 18% of all
    Jeffrey D. Berschling, M.P.H.; Karen R. Horvat,        infant deaths in recent years.
    M.P.H.; Jane E. Koehler, D.V.M, M.P.H.; Patrick L.
    Osewe, M.D., M.P.H.; Preeti Pathela, M.P.H.;
    Russell C. Sexton Jr., M.H.S.; Sabrina Walton,
                                                                           Figure 1. Causes of Infant Mortality, Georgia 1990-1994
    M.S.P.H.
   Chronic Disease
    Nancy E. Stroup, Ph.D.-Director
    Patricia M. Fox, M.P.H.; David M. Homa, Ph.D.,
    M.P.H.; Thomas W. McKinley, M.P.H.; Edward E.
    Pledger, M.P.A.; D. Lee Warner, M.P.H.
  Tuberculosis
    Bharat K. Pattni, M.B.B.S., M.P.H.
   HIV\AIDS
    Awal D. Khan, Ph.D., M.A.
   Sexually Transmitted Diseases
    Quimby E. McCaskill, M.P.H.; Dhelia Williamson,
    M.S.
   Office of Perinatal Epidemiology
    Roger W. Rochat, M.D. - Director
    Mary D. Brantley, M.P.H.; Raymond E. Gangarosa,
    M.D., M.P.H.; Rebekah Hudgins, M.P.H.; Mary P.
    Mathis, Ph.D., M.P.H.; Florina Serbanescu, M.D.;
    Edward F. Tierney, M.P.H.

  Preventive Medicine Residents
    Lorenzo D. Botto, M.D.; Isabella A. Danel, M.D.,
    M.S.; Hector S. Izurieta, M.D., M.P.H.;Michael M.
    McNeal, M.D., M.P.H.; Peter Strebel,
    M.D.;Sherrilyn Wainwright, M.D.;
  EIS Officers
    Luis G. Castellanos, M.D., Ph.D; Patricia M. Dietz,
    Dr.P.H.

                                                             LBW-low birthweight;RDS-Respiratory Distress Syndrome;SIDS-Sudden Infant Death Syndrome
                                                             Source: Birth/Infant Death Linked files, Division of Public Health

     Georgia Epidemiology Report                               The public is often concerned about environmental problems that may cause
            Editorial Board                                birth defects. Public concern about potential environmental causes of congenital
     Editorial Executive Committee                         anomalies, such as toxic-waste sites, the Gulf War, atomic plants, nuclear-waste
          Patrick L. Osewe, M.D. - Editor
                                                           storage sites, and places of employment often leads to public health investigations.
          Kathleen E. Toomey, M.D., M.P.H.
          Mary D. Brantley, M.P.H.                         Recently, Georgia health professionals have asked public health to investigate clus-
          Jeffrey D. Berschling, M.P.H.                    ters of Down’s syndrome, heart abnormalities and metabolic disorders. Some con-
     Mailing List                                          genital anomalies can be prevented. Examples of these include neural tube defects,
          Edward E. Pledger, M.P.A.                        congenital syphilis, fetal alcohol syndrome, and diabetic embryopathy. Health care


 Epidemiology Section, Epidemiology & Prevention Branch, Two Peachtree St., N.W., Atlanta, GA 30303-3186
                             Phone: (404) 657-2588      FAX: (404) 657-2586
providers and communities can assist in primary prevention               Congenital heart defects are the most common, and ac-
of congenital anomalies and reduce the health impact and             count for 1/4 of all defects in MACDP (Table 1). Using rates
public concern by supporting an integrated approach that in-         from MACDP, we estimate that, statewide, anencephaly and
cludes monitoring, evaluation of services, and prevention.           spina bifida affect 60-70 infants each year .
This report presents strategies to improve information sys-
tems and to prevent congenital anomalies in Georgia.                         Table 1. Number and rate of births with congenital
                                                                             anomalies among singleton live births, from birth
How we know what we know                                                      certificate and MACDP1 data, Georgia, 1989-1994.
      Data on congenital anomalies in Georgia is derived from
statewide and local sources. Vital records include birth, death                                                     Birth Certificate      MACDP1
and fetal death certificates and are a state-wide, population-           Defect Group                           Georgia    Metro-Atlanta Metro-Atlanta
based system at the Division of Public Health.                                                                  No.    Rate     No. Rate    No. Rate2
      The Metropolitan Atlanta Congenital Defects Program                All defects               9,945                 15.31 2,401 10.62             6,839 30.24
(MACDP) monitors congenital anomalies in five adjacent                   Selected defects3
counties of metropolitan Atlanta since 1968. Cases include all             Neural Tube Defects
still and live-born infants with a major birth defect diagnosed               Anencephaly             75                   0.12       24     0.11         39       0.17
within the first year of life, and are actively ascertained by                Spina Bifida           161                   0.25       38     0.17         91       0.40
abstractors from multiple sources, including hospitals and                 Hydrocephaly              151                   0.23       43     0.19        105       0.46
labs. MACDP is managed at the Centers for Disease Control                  Microcephaly               24                   0.04        7     0.03        102       0.45
and Prevention (CDC) in Atlanta, and benefits from close                   Cleft lip/palate          457                   0.70      126     0.56        293       1.30
                                                                           Heart anomalies           432                   0.66      116     0.51      1,755       7.76
collaboration with hospitals and local communities.                        Esophageal atresia/TEF4    62                   0.10        9     0.04         39       0.17
                                                                           Anal atresia               34                   0.05       10     0.04         75       0.34
Improving the reporting system                                             Omphalocele
     The ideal monitoring system would be inexpensive, cover                  /gastroschisis         142                   0.22       51     0.23        106       0.47
all pregnancies, be accurate, be timely, and be useful for im-             Diaphragmatic hernia       64                   0.10       26     0.11         53       0.23
proving the health care of affected infants. No system fully               Renal agenesis             48                   0.07       16     0.07         75       0.33
meets these criteria. MACDP has active case-ascertainment                  Clubfoot                  330                   0.51      103     0.46        364       1.61
yielding data that is more complete, accurate, and timely                  Trisomy 21                342                   0.53      102     0.45        241       1.07
than systems that rely only on reports from hospitals, but it            1
                                                                             Metropolitan Atlanta Congenital Defects Program
requires substantial resources and is thus confined to five              2

                                                                         3
                                                                             Rate per 1,000 singleton live births
                                                                             Except for heart anomalies, the selected anomalies are usually diagnosable at birth
Atlanta counties, the only systematic monitoring system in               4
                                                                             Tracheoesophageal fistula
Georgia.
     How can we improve the coverage? One option is to im-
                                                                     Impact on infant mortality in Georgia
prove the accuracy of data on congenital anomalies reported
                                                                           From 1990 through 1994, 1,078 Georgia infants died be-
on vital records. The prevalence of congenital anomalies in
                                                                     fore their first birthday from congenital anomalies, account-
the Metro Atlanta area is about 1% according to birth certifi-
                                                                     ing for 18% of all infant deaths (Figure 1). Congenital anoma-
cates compared with 3% reported by MACDP (Table 1). The
                                                                     lies were the first cause of death among white infants, and
birth certificate detected only 28% of MACDP cases, that
                                                                     the second leading cause for African-American infants.
were recognizable at birth; moreover, 23% of infants identi-
                                                                          The high proportion of infant deaths from congenital
fied by the birth certificate as cases turned out not to have
                                                                     anomalies reflects not only the high prevalence at birth of
congenital anomalies recorded in their medical records.2,3
                                                                     congenital anomalies (3%) but also the high risk of death
     Monitoring anomalies must include both birth and fetal
                                                                     associated with some anomalies. The mortality of infants
death certificates. In Atlanta fetal death certificates detected
                                                                     with congenital anomalies was more than 50 times higher
2/3 of all cases of congenital anomalies registered by MACDP
                                                                     than the mortality experienced by infants with no congenital
among stillbirths from 1989 through 1991 (M. Watkins, per-
                                                                     anomalies or low birth weight (16.4% vs. 0.3%), and was 10
sonal communication). However, MACDP medical record re-
                                                                     times higher than among infants with low birth weight alone.
view could only confirm 1/4 of congenital anomalies reported
on the fetal death certificate.                                      Preventable anomalies: time for action.
Impact of prenatal diagnosis                                              Neural tube defects, fetal alcohol syndrome, congenital
                                                                     syphilis, and diabetic and rubella embryopathies are ex-
     Since current monitoring systems rely on ascertainment
                                                                     amples of congenital anomalies that can be prevented by con-
from hospitals or vital records, they would miss most prena-
                                                                     certed efforts of health care providers, educators, communi-
tally terminated cases. The rates in Table 1 will decrease as
                                                                     ties, and families (Table 2).
termination of affected pregnancies increases. If monitoring
                                                                          Based on studies from MACDP and from the Division of
systems do not include prenatal terminations, clusters may
                                                                     Public Health, we estimate that from 1992 through 1994
be missed, the impact of congenital anomalies will be under-
                                                                     about 200 infants in Georgia were born with anencephaly or
estimated, and the efficacy of prevention will not be measur-
                                                                     spina bifida, half of whom would have not been affected had
able.
                                                                     their mothers taken appropriate folic acid supplements from
Prevalence of congenital anomalies                                   before conception; about 70 infants were born with fetal alco-
    Data from the Metropolitan Atlanta Congenital Defects            hol syndrome, and 275 infants with congenital syphilis.
Program indicate that 3% of all live births in Metropolitan               A practical challenge for prevention is that most harmful
Atlanta have a major congenital anomaly (Table 1, right col-         and/or protective factors may have already influenced the fe-
umn). If this figure is applied statewide, an estimated 3,300        tus by the time the pregnancy is recognized. A logical ap-
newborns in Georgia are born each year with a major con-             proach to prevention would then include planning the preg-
genital anomaly.                                                     nancy, so that preventive measures can be implemented from


                                                                   -2-
before conception (Table 2). An estimated 50% of pregnancies
in the U.S. are intended; increasing this proportion would                          A Case Study: Neural Tube Defects
decrease other adverse outcomes related to unintended preg-
nancies. Moreover, using barrier methods of contraception                       Neural tube defects (NTDs), which include anencephaly
would also decrease the risk of syphilis infection.                       and spina bifida, affect about 1 in 2,000 births in Georgia.
                                                                          NTDs exemplify both ends of the spectrum of health impact:
                                                                          anencephaly is uniformly lethal, while spina bifida causes
  Table 2. Preventive strategies for some congenital                      long term paralysis, significant disability, and high lifetime
                      anomalies.                                          costs. Neural tube defects occur with highest prevalence
                                                                          among hispanics, lowest among African-American, and inter-
 Pre-conceptional care                                                    mediate among whites. According to birth certificate data
 q   folic acid supplements to prevent neural tube defects                from 1989 through 1993, NTDs were most common in north-
 q   control maternal diabetes to prevent embryopathy                     eastern and southwestern Georgia, compared to the rest of
 q   reduce alcohol use to prevent Fetal Alcohol Syndrome                 the state.
 q   promote planned pregnancy                                                  We do not know the true impact of neural tube defects
 q   use barrier methods of contraception to prevent syphilis             statewide. Commonly used systems like birth certificates un-
                                                                          derestimate the impact (Table 1, second vs. third column),
 Early prenatal care
                                                                          while even the best reporting systems would miss some
 q   diagnose and treat syphilis to prevent congenital syphilis           cases prenatally diagnosed and terminated (in Atlanta, 1/3 of
 q   reduce alcohol use to prevent Fetal Alcohol Syndrome
                                                                          the total4).
 Early Immunization                                                             At least 50% of neural tube defects could be prevented
 q   Vaccinate prepuberal girls against rubella to prevent ru-            through daily consumption of 0.4 mg of folic acid by women
     bella embryopathy                                                    of childbearing age5. All effective NTD prevention strategies
                                                                          have two points in common: a) they must begin before con-
 Food Fortification                                                       ception and b) they are most effective when implemented
 q  Implement fortification of enriched flour with folic acid, to         collectively by families, communities, health care providers,
    increase folic acid use by all women of reproductive age              and public health workers (Table 2). Prevention involves the
                                                                          promotion of pre-conceptional care, and, more specifically,
 Education on all of the above.
                                                                          nutritional education and promotion of supplemental use of
                                                                          folic acid to all women of childbearing age. Recently, the
     Preconceptional education is a cornerstone of all these
                                                                          Food and Drug Administration announced that it would add
preventive efforts. Current efforts in Georgia to prevent neu-
                                                                          folic acid to the list of vitamins added to enriched flour, thus
ral tube defects through the use of folic acid center on educa-
                                                                          adding a further approach to the prevention of neural tube
tion and supplement usage, and include training, develop-
                                                                          defects.
ment of educational materials, identification of fortified cere-
                                                                                Finally, prevention strategies must be evaluated, which
als for use in the WIC (Women and Infant Children) program.
                                                                          again underscores the importance of having in place an ac-
Nutritional counseling training of public health nurses and
                                                                          curate system of monitoring the occurrence of neural tube
nutritionists, workshops on nutrition competency-based
                                                                          defects, even among those pregnancies terminated after pre-
skills, and training in pre-conceptional health are conducted
                                                                          natal diagnosis.
by the Office of Nutrition and sponsored by Women’s Health.
The March of Dimes is assisting public health to develop
nutrition education materials on the use of folic acid.               References
                                                                            1.   Lynberg M., Edmonds, L. State use of birth defects
                                                                                 surveillance. In:’From data to action’. L. Wilcox, J.
Summary
                                                                                 Marks (Eds), U.S. Department of Health and Hu-
    1.   Congenital anomalies affect 3% of newborns and are
                                                                                 man Services, Public Health Service, Centers for
         the leading cause of infant mortality in Georgia.
                                                                                 Disease Control and Prevention, 1994.
    2.   A public health approach to congenital anomalies
                                                                            2.   Watkins M.L. et al. The surveillance of birth de-
         includes monitoring the prevalence, improving the
                                                                                 fects: the usefulness of the revised US standard
         accuracy of registration, evaluating services to those
                                                                                 birth certificate. Am J Publ Health, 1996, in press.
         affected, and promoting and evaluating prevention
                                                                            3.   Mathis M.P. et al. Birth certificates as a source of
         programs.
                                                                                 fetal alcohol syndrome case ascertainment, Georgia,
    3.   Currently Georgia lacks a statewide network to
                                                                                 1989-1992. In: Mortality and Morbidity Report
         monitor congenital anomalies.
                                                                                 vol.44, n.13:251-3, Apr 7, 1995.
    4.   Medical records staff could improve the usefulness
                                                                            4.   Roberts H.E. et al. Impact of prenatal diagnosis on
         of vital records for selected anomalies by ensuring
                                                                                 the birth prevalence of neural tube defects, Atlanta,
         that medical records are used for reporting medical
                                                                                 1990-1991. Pediatrics vol.96 n.5:880-3, 1995.
         data on birth and death certificates.
                                                                            5.   Centers for Disease Control and Prevention. Recom-
    5.   The most effective prevention starts before concep-
                                                                                 mendations for the use of folic acid to reduce the
         tion and continues through early prenatal care.
                                                                                 number of cases of spina bifida and other neural
         Regular daily consumption of 0.4 milligrams of folic
                                                                                 tube defects. Mortality and Morbidity Report vol.
         acid beginning before conception, rubella vaccina-
                                                                                 41, n.RR-14, Sept 11, 1992.
         tion, early prenatal screening for syphilis, and
         reduced alcohol consumption are examples of fea-
         sible measures of prevention.                                      This report was contributed by R. Hudgins, L. Botto, R. Rochat;
                                                                                 Office of Perinatal Epidemiology, DPH, GA DHR.



                                                                    -3-
                       The Georgia Epidemiology Report
                       Epidemiology and Prevention Branch
                       Two Peachtree St., NW
                       Atlanta, GA 30303-3186




March 1996                                                                                                          Volume 12            Number 3

    Reported Cases of Selected Notifiable Diseases in Georgia
                  Profile¦ for December 1995
Selected                                    Total Reported                Previous 3 Months Total                   Previous 12 Months Total
Notifiable                                   for December                  Ending in December                        Ending in December
Diseases                                         1995                     1995     1994    1993                      1995     1994    1993
Campylobacteriosis                                  41                      194          267         133              1031        1080         700
Giardiasis                                          32                      146          111         131               572         463         388
H. influenzae B                                      6                       10            8          18                71          67          71
Meningococcal Disease                               16                       41           15          22               124          82          94
Rubella                                              0                        0            0           0                 0           7           0
Salmonellosis                                      109                      448          402         296              1639        1584        1303
Shigellosis                                          5                      161          604         105              1339        1887         471
Viral Meningitis                                    16                       37           12          32               100          80         172
Tuberculosis                                        68                      176          211         260               747         740         809
Congenital Syphilis                                  7                       16           13          18                55          53         112
Early Syphilis                                     183                      601          626         767              2507        2654        3864
Other Syphilis                                      83                      254          202         189              1057         835         976
Cryptosporidiosis                                    4                       26            9           2               110          20          14
E. coli O157:H7                                      1                        7           12           7                28          26          15
Legionnaires' Disease                                0                        0           13           5                14         118          35
Lyme Disease                                         0                        0           15           7                14         127          44
Mumps                                                1                        3            4           4                11          18          20
Pertussis                                            3                        5            8           8                30          37          56
    ¦   The cumulative numbers in the above table reflect the date the disease was first diagnosed rather than the date the report was received at the
         state office; and therefore are subject to change over time due to late reporting. The 3 month delay in the disease profile for a given month is
         designed to minimize any changes that may occur. This method of summarizing data is expected to provide a better overall measure of disease
         trends and patterns in Georgia.
    *   Data not available for this time period
                                                         AIDS Profile Update
Report            Total Cases         Percent                           Risk Group Distribution (%)                          Race Distribution (%)
Period            Reported *          Female          MSM         IDU     MSM&IDU       HS      Blood          Unknown       White Black Other
Last 12 Mos
03/95 to 02/96         2342              18.6          45.7     18.7            4.2          13.6        1.3       16.5        35.4       61.3       3.4
5 Yrs Ago
03/90 to 02/91         1292              9.8           62.9     15.6            7.2            7.6       2.5        4.1        48.7       50.2       1.2
Cumulative
01/80 to 02/96        14946              13.6          53.3     18.9            6.0            9.8       2.1        9.7        42.1       50.2       1.2
                                       MSM - Men having sex with men              IDU - Injection drug users    HS - Heterosexual
*   Case totals are accumulated by date of report to the Epidemiology Section

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