Disease Control Bulletin: March 2002
- Chronic Disease in Vermont: Cardiovascular Diseases 2002
- Screening Youth for Substance Abuse
- New England Study of Environment and Health
- Recommended Childhood Immunization Schedule 2002
- Selected Reportable Diseases 12/30/2001–2/23/2002
- Vermont Rabies Control 2002
Chronic Disease in Vermont: Cardiovascular Diseases - 2002
Occurrence of Cardiovascular Disease in Vermont
Despite the substantial decline in mortality during the past several decades, coronary heart disease and stroke are the first and third leading causes of death, respectively, among men and women in Vermont and in the United States. Since 1990, an average of 1,159 Vermonters have died annually from coronary heart disease and an average of 337 have died annually from stroke. In 2000, the age-adjusted death rate for coronary heart disease was 174.5 per 100,000 population (95% confidence interval [CI]: 164.0-184.9) and the age-adjusted death rate for stroke was 55.1 per 100,000 population (95% [CI]: 49.2-61.0) in Vermont.1 The 10-year age-adjusted coronary heart disease mortality rate was statistically higher for men than for women from 1991 to 2000 (p<0.05), while there was no significant difference in the 10-year age-adjusted stroke mortality rate between men and women. In 2000, the coronary heart disease death rate in men was 225 per 100,000 population compared to 137 per 100,000 population in women, and the stroke death rate in men was 56 per 100,000 population versus 54 per 100,000 population in women.
In 1999, weighted estimates from the Behavioral Risk Factor Surveillance Survey (BRFSS) showed that the prevalence of myocardial infarction was higher in adult men than women. As expected, the prevalence of cardiovascular disease increased with age, with a higher prevalence shown in adults aged 65 and older compared to those adults aged 18 to 64 years (see Table 1).
|Coronary Heart Disease||Myocardial Infarction||Stroke|
*Has a doctor ever told you that you had any of the following: heart attack or myocardial infarction, angina or coronary heart disease, or stroke.
In Vermont, hospitalizations for cardiovascular disease declined by 5.3 percent from 1997 to 1999.2 Total annual hospital charges for heart disease and stroke were $64.4 million and $15.7 million, respectively, in 1999; these represent an increase of nearly 12.9 percent for coronary heart disease and 4.3 percent for stroke from the previous year. In 1999, Vermont had significantly lower age-adjusted hospitalization rates than the U.S. for five of the six leading types of cardiovascular disease hospitalizations (see Figure 1).2 Vermont had a significantly higher age-adjusted hospitalization rate than the U.S. for acute myocardial infarction.2
Cardiovascular Disease Risk Factors
Most persons with cardiovascular disease share multiple common risk factors and lifestyle behaviors.3 Established risk factors include cigarette smoking, hypertension (BP ³ 140/90 mmHg or antihypertensive drug use), high blood cholesterol (total cholesterol ³ 240 mg/dL), diabetes and overweight (body mass index [BMI] ³25).4 Figure 2 shows the percentage of Vermonters aged 18 years and older having two or more of the following risk factors for cardiovascular disease: self-reported hypertension, high blood cholesterol, diabetes, obesity or current smoking status. Overall, 24.6 percent (95% [CI]: 23.1–26.1) of adult Vermonters reported having two or more risk factors. County estimates show that, compared to Vermont overall, Chittenden County has a statistically significantly lower prevalence of adults reporting two or more risk factors, while Franklin County has a significantly higher percentage of adults reporting a multiple cardiovascular disease risk factor profile.
Healthy Lifestyle Behaviors
Prior evidence has shown that people with a favorable cardiovascular disease risk factor profile are at lower age-specific risk for cardiovascular disease deaths and have greater life expectancy than others in the population.5 Figure 3 shows the percentage of Vermonters aged 18 years and older who engaged in three or more healthy lifestyle behaviors: self-reported non-smoker, regular leisure-time physical activity (at least 30 minutes five or more times per week), healthy weight ([BMI] = 18.5-25) or having adequate fruit and vegetable consumption (five or more servings daily). Overall, 23.4 percent (95% [CI]: 21.7-23.7) of adult Vermonters were engaged in three or more of these healthy lifestyle behaviors. County estimates show that Franklin, Caledonia, Grand Isle and Rutland counties have a significantly lower prevalence of adults practicing three or more healthy lifestyle behaviors, while Chittenden and Windham counties have a significantly greater percentage of adults engaging in multiple healthy lifestyle behaviors.
Clinical Guidelines and Recommendations
In recent years, national guidelines have been published describing in detail methods to assess a patient’s absolute risk for developing cardiovascular disease based on elevated cholesterol levels, hypertension and overweight status. For more information or for copies of these documents, visit the National Institutes of Health; National Heart, Lung, and Blood Institute website at http://www.nhlbi.nih.gov or call the institute’s health information center at 301-592-8573.
Healthy Vermonters 2010
Reducing heart disease and stroke is a priority in Healthy Vermonters 2010, the states blueprint for improving public health. The Healthy Vermonter 2010 goals to reduce cardiovascular disease morbidity and mortality are:
- Reduce coronary heart disease deaths to no more than 166 per 100,000 people. (VT 2000: 174.5 per 100,000)
- Reduce stroke deaths to no more than 48 per 100,000 people. (VT 2000: 55.1 per 100,000)
- Reduce the percentage of adults with high blood pressure to less than 16 percent. (VT 1999: 22%)
- Reduce the percentage of adults who smoke cigarettes to no more than 12 percent. (VT 2000: 21%)
There are also goals relating to obesity, physical activity, nutrition and diabetes. For more information about programs at the Department of Health or a full copy of Healthy Vermonter’s 2010, please visit the department’s website at www.HealthyVermonters.info or contact the Division of Health Improvement at 802-863-7270.
- Vermont 1999 Vital Statistics Dataset. Age-adjustment standard United States 2000 population.
- Vermont 1997-1999 Hospital Discharge Datasets.
- Brownson RC, Remington PL, Davis JR. Chronic disease epidemiology and control. 2nd ed. Washington, DC: American Public Health Association, 1998.
- Kannel WB. An overview of the risk factors for cardiovascular disease. In: Kaplan NM, Stamler J, eds. Prevention of coronary heart disease: practical management of the risk factors. Philadelphia: Saunders, 1983:1-19.
- Stamler J. Established major coronary risk factors. In: Marmot M, Elliott P, eds. Coronary heart disease epidemiology: from aetiology to public health. Oxford, England: Oxford University Press, 1992:35-66.
Screening Youth for Substance Abuse
Research has documented a strong relationship between early use of alcohol, tobacco and other drugs and later substance abuse problems, making the identification and referral of at-risk youth imperative. Children who drink alcohol (more than a few sips) before their 13th birthday are nearly five times more likely to develop alcohol dependence than those who begin drinking at age 21. Assuring that children are identified and receive intervention and treatment services can help avoid serious problems in the future.
Three of the Healthy Vermonters 2010 goals related to alcohol, tobacco and other drugs are: 1) reduce the percentage of youth who use alcohol prior to age 13 to 0 percent, 2) reduce the percentage of youth who smoked cigarettes in the past month to 16 percent or less, 3) reduce the percentage of youth who used marijuana in the past month to 0.7 percent or less. According to the 2001 Vermont Youth Risk Behavior Survey (results available on-line at www.state.vt.us/adap/ yrbs%202001.pdf ), overall 43 percent of students in grades 8–12 consumed at least one drink of alcohol during the past 30 days, 22 percent reported smoking at least once in the past 30 days, and 26 percent used marijuana during the past 28 days.
Youth are far less likely than adults to be referred to treatment by a parent, family member or self. Professionals who work with youth need to be able to identify youth with alcohol, tobacco and other drug problems and refer these youth for further assessment and/or treatment. Children with alcohol, tobacco and other drug problems can be identified within many public service systems, such as schools, child protective services, county mental health, prenatal alcohol, tobacco and other drug programs, and corrections or probation programs.
According to The Substance Abuse and Mental Health Services Administration’s Adolescent Screening and Assessment Consensus Panel of Experts:2
- Youth in at-risk environments should be screened, using a tool designed for adolescents, to uncover indicators of alcohol, tobacco and other drugs, and related problems.
- The screening tools should be brief and simple enough that a wide range of professionals can administer it with minimal training.
- Youth with possible alcohol, tobacco and other drug problems, as identified through the screening, should be referred to a licensed or certified drug and alcohol counselor or treatment provider for a more comprehensive assessment for substance abuse or dependence. Call the Division of Alcohol and Drug Abuse Programs at 802-651-1550 for a list of licensed or certified alcohol and drug counselors in your area.
The Vermont Department of Health has recently adopted a promising new alcohol and drug screening tool for youth. It is called the CRAFFT.3 This six question “early point of contact” screening tool was developed by John Knight, MD, to address the increasing trend toward younger age of substance abuse, as well as the often missed opportunity to identify early substance abuse at all points of health contact. Dr. Knight currently is a pediatrician and researcher at Children’s Hospital and Division on Addictions, Harvard Medical School. He is an alumnus of the University of Vermont Medical School.
After an extensive research process the CRAFFT was included in the Vermont Department of Health Provider’s Toolkit. In the winter of 2000, the Division of Alcohol and Drug Abuse Programs formed an advisory board of treatment providers and academic researchers to review and select age-appropriate drug and alcohol screening and assessment tools. For ease of adoption, the committee felt the tool had to meet the following criteria: designed specifically for adolescents, easy to use and remember, researched and demonstrating good reliability and validity, and free and in the public domain. Over several months, many forms were reviewed, tried, and discussed. The CRAFFT, like the widely used CAGE for adults, proved to be easy to remember and easy to score. The department has already received positive feedback about the CRAFFT from clinicians in multiple environments such as schools, health clinics, mental health clinics and youth service bureaus.
- Have you ever ridden in a car driven by someone (including yourself) who was high or had been using alcohol or drugs
- Do you ever use alcohol or drugs to relax, feel better about yourself, or fit in?
- Do you ever use alcohol or drugs while you are by yourself (alone)?
- Do you ever forget things you did while using alcohol or drugs?
- Do your family or friends ever tell you that you should cut down on your drinking or drug use?
- Have you ever gotten into trouble while you were using alcohol or drugs?
The CRAFFT screening tool cards are available at no charge through the Division of Alcohol and Drug Abuse Programs at the Vermont Department of Health. Call 802-651-1550 for ordering information.
Clinicians can have a high degree of confidence that those adolescents who report fewer than two “yes” answers are unlikely to need referral to substance abuse treatment specialists. In some settings, an adolescent who responds “yes” to two or more questions has an 80 percent chance of having a serious problem, a greater than 50 percent chance of having an alcohol- or drug-related disorder, and a 25 percent chance of being alcohol or drug dependent.
- Grant, B., Dawson, D. (1997). Age at onset of alcohol use and its association with DSM-IV alcohol abuse and dependence: Results from the National Longitudinal Alcohol Epidemiologic Survey. Journal of Substance Abuse, 9, 103-110.
- Center for Substance Abuse Treatment (CSAT) Treatment Improvement Protocol (TIP) Series Volume #31, 1999. To order call the National Clearinghouse for Alcohol and Drug Information (NCADI), (800) 729-6686.
- Knight JR et al. In A New Brief Screen for Adolescent Substance Abuse. Archives of Pediatrics and Adolescent Medicine. Vol.153 No. 6, June, 1999.
- Rahdert ER (ed.). The adolescent assessment/referral system manual. Problem Oriented Screening Instrument for Teenagers (POSIT); USDHHS Publication NO. (ADM) 91-1735, 1991.
- Riggs SR & Alario A. Compiled from the RAFFT questions, in. RAFFT questions. Project ADEPT manual, Brown University, 1987.
- Schwartz RH & Wirtz PW. Potential substance abuse: Detection among adolescent patients. The Drug and Alcohol Problem (DAP) Quickscreen; Clinical Pediatrics 29(1): 38-43. Jan. 1990.
New England Study of Environment and Health
The Vermont Department of Health is a collaborator with the National Cancer Institute (NCI) in the New England Study of Environment and Health. Data from the NCI’s new cancer atlas covering the period 1970–1994 indicate that bladder cancer mortality rates among white men and women are elevated in the Northeastern United States, particularly in Northern New England. Although the reasons for these high mortality rates are unknown, the persistent elevation in bladder cancer mortality among both men and women suggests the possible role of environmental determinants.
The New England Study of Environment and Health is a population-based case-control study of urinary bladder cancer in three states: New Hampshire, Vermont and Maine. The NCI is collaborating with Dartmouth Medical School and the departments of health from these three states to assess the effects of environmental factors on the risk of developing bladder cancer in this region.
Investigators plan to interview approximately 2,400 men and women between the ages of 30 and 79. Prior to the interview, participants will receive study materials by mail. During the interview, participants will be asked information about previous residences, jobs, health problems, family medical history and tobacco use. Participants will then be asked to fill out a separate questionnaire concerning their dietary habits. They will also be asked to provide biologic samples (saliva, urine, toenail clippings) and samples of drinking water, which will be tested for the presence of minerals and organic compounds.
Once the data have been collected and the samples have been tested, NCI scientists will examine the results to look for common environmental factors that may increase the risk of bladder cancer in northern New England. Results will be reported in the scientific literature and to the state health departments.
Recommended Childhood Immunization Schedule 2002
Please replace your 2001 Childhood Immunization Schedule with this issue’s insert. Additional copies are available at the Vermont Department of Health district offices when you pick up vaccines. The schedule is also available on-line at www.cdc.gov/mmwr/preview/mmwrhtml/mm5102a4.htm
Additions and changes to this year’s schedule are:
- A preference for the birth dose of Hepatitis B vaccine before hospital discharge and guidance regarding mother’s HBsAG status.
- A new section outlining vaccines (hepatitis A, influenza and pneumococcal polysaccharide) for selected populations.
- A highlighted pre-adolescent assessment schedule emphasizing the need to reassess immunization status for all children at their 11–12 year old visit.
- Catch-up bars emphasizing the importance of updating vaccination status through age 18 years.
The Advisory Committee on Immunization Practices also just published new General Recommendations on Immunization (MMWR Feb. 8, 2002;51(RR-2)–available on the web at www.cdc.gov/mmwr/preview/mmwrhtml/ rr5102a1.htm).
Vermont: Selected Reportable Diseases
December 30, 2001 – February 23, 2002
Vermont Rabies Control 2002
Rabies is a fatal viral disease found only in mammals. Wildlife are primarily affected (especially raccoons, foxes, bats, skunks and woodchucks) but rabies can infect domestic animals and humans. In 2001, 62 wild animals tested positive for rabies in Vermont: 41 raccoons, ten skunks, four fox, four woodchucks and three bats. These occurred in the following counties: Addison (9), Bennington (18), Chittenden (3), Grand Isle (1), Lamoille (3), Orange (1), Orleans (1), Washington (3), Windham (13) and Windsor (5).
Prevention efforts, including rabies education, pre-exposure and post-exposure prophylaxis (human vaccination), and animal vaccination and control, have significantly reduced the incidence of human rabies in the United States. Since 1990, 26 cases of rabies in humans reported to CDC were acquired in the US. Two cases were canine rabies in south Texas and 24 cases were due to bat rabies.
Rabies is mainly transmitted by a bite. Rare non-bite exposures can occur if wet infectious saliva or nervous tissue from a rabid animal contacts a fresh open wound or the eyes, nose or mouth. Rabies virus is very fragile in the environment and is not found in blood, urine, feces or skunk spray. When saliva is dry, the virus is quickly inactivated. Rabid animals can appear normal or can be aggressive or lethargic.
Bats are an important part of our ecosystem but should be appreciated at a distance. Bats are increasingly implicated in human rabies cases. A bat found in a room with a sleeping individual or an unattended child, or a bat that has made physical contact with an individual, should be tested for rabies.
The Vermont Department of Health is responsible for the prevention of rabies in humans and for the management of animals that may have exposed humans. The department assesses human and animal rabies exposure, coordinates rabies specimen testing, and provides vaccination guidelines.
In the event of a potential human rabies exposure:
- Consult with the Vermont Department of Health at 800-640-4374 (in VT) or 802-863-7240 with questions about rabies exposure and the need for human rabies post-exposure prophylaxis. Report human post-exposure prophy-laxis to the Vermont Department of Health.
- Notify the local health officer or selectboard member in the town where the bite occurred within 24 hours of all domestic animals that have bitten people.
- The Vermont Rabies Hotline/USDA Wildlife Services, 800-4-RABIES or 802-223-8690, offers excellent rabies and wildlife information by wildlife biologists.
REPORT DISEASE: VERMONT TOLL FREE: 1-800-640-4374 OR 1-802-863-7240
Vermont Department of Health
Division of Health Surveillance P.O. Box 70 Burlington, VT 05402-0070
Agency of Human Services
Jan K. Carney, MD, MPH
THIS BULLETIN IS PRODUCED BY THE DISEASE CONTROL BULLETIN EDITORIAL STAFF.
Ann R. Fingar, MD, MPH
State Epidemiologist Managing Editor