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
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
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.
Bharat K. Pattni, M.B.B.S., M.P.H.
Awal D. Khan, Ph.D., M.A.
Sexually Transmitted Diseases
Quimby E. McCaskill, M.P.H.; Dhelia Williamson,
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.;
Luis G. Castellanos, M.D., Ph.D; Patricia M. Dietz,
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 Downs 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
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
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
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
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
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-
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
by the Office of Nutrition and sponsored by Womens 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.
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
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.
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
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