Physical Health
A. ISSUE SUMMARY
Vision Statement: "Travis County will be a community where residents, as individuals and groups, provide leadership and take responsibility, in a creative and collaborative way, for the health and well-being of themselves and each other."
Strategies for Building a Stronger Community: A Community Guide
CHRONIC DISEASES
For the period 1980 to 1996, chronic disease indicators for Travis County revealed the following:
- African American males had the highest mortality rate for cardiovascular disease (i.e., coronary heart disease and stroke combined).
- While all other population groups showed a decline in coronary heart disease mortality rates, Hispanic females showed an increase.
- The highest percentage of stroke deaths occurred among White females.
- Although diabetes mortality rates increased among almost all population groups, the highest increase occurred among African American females.
- The mortality rate for lung cancer increased sharply among females but decreased among males.
- African American females had the highest mortality rate for breast cancer.
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COMMUNICABLE DISEASES
- Travis County is experiencing a clear shift in the HIV/AIDS epidemic towards greater incidence among racial/ethnic minorities, women, and people infected through injecting drug use and heterosexual contact.
- AIDS incidence rates for Travis County are higher than rates for the State of Texas.
- AIDS death rates in Travis County are highest among African Americans.
- African Americans in Travis County have lower immunization rates for vaccine- preventable diseases compared to other demographic groups.
- Travis County lacks a community-wide immunization registry, necessary for the achievement of the Year 2000 national childhood immunization objective of 90% up-to-date immunization rates by age 2.
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MATERNAL AND INFANT HEALTH
- The African-American infant mortality rate is about twice the countywide infant mortality rate.
- Hispanic mothers accounted for about 60% of all births with late or no prenatal care.
- Compared with 92.2% of White mothers, 72.5% of Hispanic mothers and 74.3% of African American mothers received care in the first trimester.
- Pregnancy rates for Travis County teen-age mothers (age 13-17) have declined from an annual rate of roughly 50 pregnancies per 1,000 between 1992 and 1995 to 46.1 per 1,000 in 1996.
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UNINTENTIONAL INJURY
- Motor vehicle accidents are the leading cause of death from unintentional injuries in Travis County.
- Many unintentional injuries are related to age as a risk factor. For example, falls are the most common cause of injuries among the elderly.
- In Travis County, unintentional injuries were the fourth leading cause of death for all ages in 1996.
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CONTINUUM OF CARE
- In Travis County in 1993, an estimated 142,500 persons were uninsured or underinsured. Of these, 30% were Hispanic and 44% were under the age of 24. It is estimated that in 1997, over 100,000 Travis County residents lacked health insurance coverage, based on extrapolated national data.
- Approximately 897 pregnancies in Travis County in 1996 were to teen mothers. Eighty percent of teen pregnancies are unintended. Based on national data regarding costs of unintended pregnancies, it is estimated that the total costs of these pregnancies would have been $2,870,400. Family planning service utilization reduces the incidences of unintended pregnancies and abortions.
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Health Section Organization
The purpose of the health section is to provide a profile of the Austin/Travis County community with emphasis on the health of its residents. As is the case with other sections of the Community Assessment, this report is driven by the outcomes for Travis County that were included in the 1997 Community Action Network's Strategies for Building A Stronger Community: A Community Guide.
Please note that because of the magnitude of the issue, the health section is organized somewhat differently from other Assessment sections. It begins with a profile of the community and proceeds under two major subject areas: Health Status and Continuum of Care. Covered under the Health Status section are Chronic Diseases, Communicable Diseases, Maternal and Infant Health and Unintentional Injury. As with other sections of the Community Assessment, Part B (Background and Influencing Factors) and Part C (Desired Outcomes and Key Indicators) will be covered but under the specific subject areas. Part D (Other Desired Outcomes and Key Indicators) and Part E (Terms, Concepts, and Definitions) will follow the regular format.
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Profile of Travis County
Racial and ethnic makeup: Rapid population growth in Austin/Travis County has been accompanied by changes in the racial and ethnic composition of the community, with the most noticeable changes being an increase in the Hispanic share of the population and a decrease in the proportion contributed by Whites. In 1996, Travis County had an estimated population of 680,541 persons, with Whites contributing 428,178 or 63% of that estimate, down from 65% in 1990. The county's 1996 population included 156,080 persons of Hispanic origin or 23% of the population, up from 21% in 1990. There were 71,620 Blacks in the county, making up 11% of the population, the same as in 1990. Other racial/ethnic groups (Asian/Pacific Islanders and American Indian/Alaska Natives) contributed 24,663 persons, or 4% of the population, up from 3% in 1990.
By 2000, the expected changes in the county's demographic makeup will see Whites contributing 58% of the Travis County population. Hispanics will contribute 26%, Blacks 11%, and other racial/ethnic groups 5%.
Age makeup: Although the Austin/Travis County community has a relatively young population, our population trends reflect the aging of the U.S. population. Between 1990 and 1996, the age groups with the greatest proportional increases were, in rank order, the 45-54, 0-17, 65+, 55-64, and 35-44 age groups, with the 0-17 age group remaining the single most populous age group with 27% of the population in 2000.
Disparities in Health Status: Membership in certain racial/ethnic and age groups is associated, for a variety of reasons, with higher morbidity and mortality rates for some health conditions. For example, Black infant mortality rates are generally twice the rates seen among Whites. AIDS incidence rates among Blacks are four or five times the rates seen in Whites. While female breast cancer incidence rates are higher among White females, there are higher mortality rates among Black females. Hispanics make up 23% of the Travis County population but contribute 60% of births with late or no prenatal care. And suicide rates among Whites are at least twice the minority rates, with White males aged 65 and over being the most heavily affected group.
Healthy People 2000: National Health Promotion and Disease Prevention Objectives: This national effort has, as one of its three goals, the reduction of health disparities between demographic groups in the U.S. population, with income, gender, age, disability status, and racial and ethnic disparities as specific targets. Although great strides have been made in reducing some disparities in health status, considerable work remains to be done if we are to achieve equality in health status for all Americans.
Whereas Healthy People 2000 aims to reduce disparity in the health status of groups by targeting faster improvement in the health of specific groups, the working draft of Healthy People 2010 sets out to eliminate these disparities during the next decade. Healthy People 2010 Objectives: Draft for Public Comment begins by doing away with differential goals and sets equal targets across all groups. This working draft has been circulated for public input, and the final document (and the targets contained therein) could be substantially different from the draft document.
This report will, among other things, highlight differences in health status among the various demographic groups in Travis County.
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HEALTH STATUS
CHRONIC DISEASES
"The term chronic has dual meaning: the disease takes a long time to develop and can last a long time once contracted. Chronic diseases do not resolve spontaneously and a complete cure is rarely achieved."
(Community Action Network, A Snapshot of Our Community, 1995, p. 5.49)
BACKGROUND AND INFLUENCING FACTORS
Overview: Key Diseases and Definitions
As in the rest of the nation, chronic diseases account for the vast majority of deaths in our community. In Travis County, the top five chronic diseases (coronary heart disease, cancer, stroke, chronic obstructive lung disease, and diabetes) accounted for over six out of every ten deaths in 1996. Heart disease and cancer alone caused 25% and 23%, respectively, of all deaths in Travis County in 1996. The Community Action Network has identified the following chronic diseases as high priority health conditions for Travis County: cardiovascular disease, diabetes, lung cancer, and female breast cancer.
Cardiovascular disease is a disorder that affects the heart muscle or the blood vessels of the heart or body. Healthy People 2000 separates cardiovascular disease into two primary components: coronary heart disease and stroke. While these two components account for a large proportion of cardiovascular disease deaths, they do not encompass all cardiovascular diseases.
Diabetes mellitus is a group of diseases characterized by high levels of blood glucose resulting from defects in insulin secretion, insulin action, or both. Diabetes can be associated with serious complications and premature death, but persons with diabetes can take measures to reduce the likelihood of such occurrences.
Cancer is a group of many related diseases. All forms of cancer involve out-of-control growth and spread of abnormal cells. Cancer is classified by the part of the body in which it originates. Lung cancer refers to a malignant growth of the trachea, bronchus or lung, whereas female breast cancer refers to a malignant growth of a womans breast.
Importance to Community
Chronic diseases are a major health concern for Travis County. Over the last 70 years, chronic diseases have replaced infectious diseases (with the exception of HIV/AIDS) as the leading cause of death in the U.S. and in Travis County.
Chronic diseases can result in the need for long-term, comprehensive medical care and the need for social support and ancillary services such as physical and occupational therapy. Other costs include years of potential life lost, impaired quality of life, and substantial disability. Costs may be even further elevated by underlying or secondary disease diagnoses which greatly increase the percentage of chronic disease hospitalizations. Because of the aging of the population, the economic burden of chronic disease treatment is likely to grow.
Cardiovascular Disease
According to Healthy People 2000, coronary heart disease has been the leading cause of death in the nation for decades and claims nearly 500,000 lives annually. Stroke is the third leading cause of death and accounts for nearly 158,000 annual deaths. The death rate for cardiovascular disease has declined dramatically over the past 20 years: dropping 46% for all cardiovascular diseases, 51% for coronary heart disease, and 60% for stroke. Even so, cardiovascular disease kills nearly as many Americans as all other diseases combined, and is also among the leading causes of chronic disability.
Diabetes
According to estimates by the Centers for Disease Control and Prevention, 15.7 million people in the U.S. (5.9% of the population) have diabetes. Of these, 10.3 million people have been diagnosed; the remaining 5.4 million have not. The estimated incidence of diabetes is 798,000 new cases diagnosed per year. Studies have found mortality rates to be twice as high among middle-aged people with diabetes as among middle-aged people without diabetes. Based on death certificate data, diabetes contributed to 187,800 deaths in 1995 alone and was the seventh leading cause of death for that year. Diabetes is believed to be underreported on death certificates, both as a condition and as a cause of death.
Lung Cancer
Lung cancer is the leading cause of cancer death among both men and women. The American Cancer Society projects that in 1998 alone, there will be approximately 171,500 new cases of lung cancer in the U.S.: 91,400 among men and 80,100 among women. Lung cancer will account for about 14% of all new cancers and about 29% of deaths from cancer. There will be an estimated 160,100 deaths from lung cancer: 93,100 among men and 67,000 among women, accounting for 28% of all cancer deaths. Since 1987, more women have died each year of lung cancer than of breast cancer, which had been the major cause of cancer death in women for the past 40 years.
Female Breast Cancer
Breast cancer is the most common cancer among women, excluding skin cancers. The American Cancer Society expects an estimated 178,700 new cases of invasive breast cancer to be diagnosed in 1998 among women in the U.S. During the 1980s, the breast cancer incidence rate increased by about 4% per year but during the past few years has leveled off. While the breast cancer mortality rate has been decreasing, breast cancer remains the second leading cause of cancer death among women aged 40 to 55. In 1998, there will be approximately 43,500 deaths among women in the U.S. from breast cancer.
Health Risk Behaviors, Factors, and Trends
Many factors play a role in the development and progression of chronic diseases--for instance, heredity/genetics, environmental pollution, and occupational exposure to chemical agents. Factors such as poverty/economic disadvantage, educational level, stress, and access to health care are also influential.
Practicing healthy behaviors such as exercising regularly, eating a low-fat, high-fiber diet, and eliminating the use of alcohol, tobacco, and other drugs may prevent the death and disability caused by many chronic diseases. Additionally, an increased appreciation and understanding of cultural forces that shape health behavior is necessary for the development of effective prevention strategies.
Tobacco use: Tobacco use is the single largest cause of preventable death and disease in the U.S., being responsible for about 400,000 deaths every year. This risk factor contributes to disease and death from an extraordinarily wide variety of chronic diseases - cancers, diabetes, stroke, chronic obstructive lung disease, coronary heart disease, etc. Overall, 25.5% of men and 21.3% of women surveyed nationally in 1997 smoked on a regular basis, with little change from the 1996 rates. The median prevalence of smoking among adults in all the states has been flat for a number of years - 23.6% in 1996 and 23.2% in 1997. The draft Healthy People 2010 Objectives call for us to reduce to 13% the proportion of adults (18 and older) who use tobacco products.
Each year, there are more deaths in Texas that are related to tobacco use than are related to HIV/AIDS, car accidents, suicides, fire, murder, or the use of crack, heroin, cocaine, and alcoholcombined. Data from the Texas Behavioral Risk Factor Surveillance System show that overall smoking prevalence in the state has remained essentially unchanged from 23.0% in 1987 to 23.7% in 1995. At the same time, there has been a significant increase in smoking among 18- to 24-year-olds.
Cardiovascular Disease
High blood pressure is one of the most important modifiable risk factors for coronary heart disease. Other major modifiable risk factors include high blood cholesterol, cigarette smoking, obesity, and physical inactivity. Many of the risk factors for stroke are the same as those identified for coronary heart disease. The prevention of stroke includes control of hypertension, diabetes, heart disease, and other associated disorders. Smoking should be minimized, or preferably, stopped. Additionally, dietary recommendations that address fat, fiber, fruit, vegetable, and sodium intake may be appropriate for reducing risk of disease. Increased physical activity is also advised.
It is particularly important to focus prevention efforts on women, African Americans, and the elderly. These populations have longer reported delays in seeking care in response to acute myocardial infarction (i.e., heart attack) symptoms.
Diabetes
Diabetes mellitus occurs in several forms: Type I diabetes, Type I I diabetes, and gestational diabetes.
Although the cause of diabetes is unknown, heredity and diet are believed to play a role in its development. Type I diabetes usually occurs in people before the age of 30 and requires insulin injections to survive. Risk factors for Type I diabetes include autoimmune disease, viral infections, and a family history of diabetes.
Type I I diabetes is the most common form of diabetes and is associated with the following risk factors: obesity; age over 40; family history; African American, Hispanic, or Native American ethnicity; history of gestational diabetes; and giving birth to a baby over 10 pounds. Type I I diabetes is usually treated initially with oral medications.
Gestational diabetes, by definition, starts or is first recognized during pregnancy. It usually becomes apparent during the 24th to 28th weeks of pregnancy. In most cases, the blood-glucose level returns to normal after delivery. Risk factors for gestational diabetes are maternal age over 25 years, family history of diabetes, obesity, birth weight over 9 pounds in a previous infant, unexplained death in a previous infant or newborn, congenital malformation in a previous child, and recurrent infections.
Considerable differences exist in the prevalence and incidence of diabetes and associated complications across demographic groups in the U.S. In general, racial and ethnic minoritiesAfrican Americans, Hispanics, American Indians, and certain Pacific Islander and Asian American groups, as well as older Americanssuffer disproportionately compared to other Americans. A possible reason for this disparity may be the inadequacy of access to proper diabetes prevention and control programs. Many diabetes "at risk" groups reside in medically underserved areas and/or are non- or underinsured.
Lung Cancer
Most lung cancers (83%) are associated with, and probably caused by, cigarette smoking. The more cigarettes smoked per day and the earlier the age at which smoking started, the greater the risk of lung cancer.
Second-hand smoke is also considered to increase the risk for lung cancer. High levels of radiation and asbestos exposure may further increase the risk. Occupational exposure may be an additional risk factor.
Female Breast Cancer
Statistics show that one in eight or nine American women will develop breast cancer at some point in life. The risk increases exponentially after age 30. The average age of women diagnosed with breast cancer is 60 years. In the U.S., Whites have a higher incidence compared to non-Whites. However, the incidence in non-Whites, specifically African Americans, is increasing, particularly in women under age 60.
Two genes have recently been implicated in a familial type of breast cancer. A number of other predisposing factors have been identified including obesity, early menarche (start of menstruation before age 12), late menopause (after age 55), and absent or delayed childbearing (i.e., no pregnancies or a first pregnancy after age 30). Additional risk factors include having a family history of breast cancer (particularly in a mother or siblings); a past medical history of breast cancer, ovarian cancer, uterine cancer, or colon cancer; and radiation exposure.
Research suggests that a persons diet may affect the chances of getting some types of cancer. Breast cancer appears to be more likely to develop in women whose diet is very high in fat. Older women who are overweight also seem to have a greater risk. Some scientists believe that eating low-fat, well-balanced meals with plenty of fruits and vegetables and maintaining an ideal weight can lower a womans risk.
There are also studies that suggest a slightly higher risk of breast cancer among women who drink alcohol. Since the risk appears to increase with the amount of alcohol consumed, women who drink should do so in moderation.
Finally, lack of preventive screening is a major factor in breast cancer mortality rates. Mammography is the most effective early detection method. There is some evidence that African American and Hispanic women have less access to such preventive measures.
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OUTCOMES AND KEY INDICATORS
Many chronic diseases are significant in their impact, or potential impact, on various segments of the Travis County population. For the purpose of this health analysis, outcome monitoring specifically targets mortality rates for cardiovascular diseases, diabetes, lung cancer, and female breast cancer.
OUTCOME: Reduced mortality rates for cardiovascular disease (i.e., coronary heart disease and stroke)
The Healthy People 2000 national targets for coronary heart disease deaths are 100.0 per 100,000 population and 115.0 per 100,000 African American population. For stroke deaths, the national targets are 20.0 per 100,000 population and 27.0 per 100,000 African American population.
The draft Healthy People 2010 Objectives calls for a coronary heart disease death rate of no more than 51 per 100,000 population, and a stroke death rate of no more than 16 per 100,000 population.
From 1980 to 1996, deaths from cardiovascular disease (i.e., both heart disease and stroke) declined in Texas and Travis County 26.8% and 36.4%, respectively. In Travis County, all races and both genders experienced the decline; however, White males led the decline with 47.2%, followed by Hispanic males at 32.5% and African American males at 14.6%. The mortality rate for African American females declined 34.4%, followed by White females at 29.9% and Hispanic females at 15.5%.
There has been a significant overall decline in the mortality rate for cardiovascular disease in Travis County. However, the mortality rate (1996) for African American males remains substantially higher than the Year 2000 target, at 357.4 deaths per 100,000 population compared to 195.4 per 100,000 Hispanic male population and 166.8 per 100,000 White male population. The mortality rate (1996) for females ranges from 172.1 deaths per 100,000 African American population to 112.0 per 100,000 White population and 101.7 per 100,000 Hispanic population.
Figure 4.4.1
Cardiovascular Mortality Rates by Ethnicity -- Travis County 1980-1996
Source: Texas Department of Health, Epigram.
Heart disease mortality rates for Texas and Travis County declined from 1980 to 1996 by 25.9% and 33.1%, respectively. In Travis County the White population showed the sharpest decline (37.0%), followed by the Hispanic population (22.8%) and the African American population (15.2%). With the exception of Hispanic females (16.6% increase from 1980 to 1996), all groups showed a decrease in mortality rates.
Despite these decreases, the overall population mortality rate remained above the Year 2000 target of 100.0 per 100,000 population with a rate of 109.7 per 100,000 population (1996). Additionally, the African American population remained above the target of 115 per 100,000 population with a 179.8 per 100,000 mortality rate (breakdown: 247.3 per 100,000 for males and 127.7 per 100,000 for females). In order to reach the Year 2000 targets, declines of 8.8% and 36.0% are necessary for Travis Countys total population and African American population, respectively.
Figure 4.4.2
Heart Disease Mortality Rates by Ethnicity -- Travis County 1980-1996
Source: Texas Department of Health, Epigram.
Overall, stroke mortality rates in both Texas and Travis County have declined significantly from 1980 to 1996, with changes of 33.0% and 30.5% respectively. Despite these improvements, neither Texas nor Travis County met the Year 2000 targets. Travis Countys total population mortality rate for stroke was 28.0 per 100,000 (1996), while the African American populations rate was 46.7 per 100,000 (1996). In order to meet the Year 2000 target, the stroke mortality rate must decline 28.6% for the total population and 42.2% for the African American population.
Of the total number of deaths (3,610) from stroke in Travis County between 1980 to 1996, 1,789 (49.6%) were among White females. This population group appears to be the most heavily impacted.
Figure 4.4.3
Stroke Mortality Rates by Ethnicity Travis County 1980-1996
Source: Texas Department of Health, Epigram.
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OUTCOME: Reduced mortality rates for diabetes
The Healthy People 2000 national targets for diabetes deaths are 34.0 per 100,000 population and 58.0 per 100,000 African American population.
The draft Healthy People 2010 Objectives envisages that diabetes death rates will be reduced to no more than 12.0 per 100,000 population.
The Travis County population overall experienced an increase from 1980 to 1996 in mortality rates due to diabetes. With the exception of Hispanic females, all other males and females in the White, African American, and Hispanic groups experienced increases in diabetes mortality rates. The most significant increase was seen in the African American population, whose rate went from 8.4 per 100,000 in 1980 to 43.6 per 100,000 in 1996, a 419.1% increase. The rate for African American males went from 9.8 per 100,000 in 1980 to 28.8 per 100,000 in 1996, an increase of 193.9%. An even greater increase was seen for African American females, whose rate went from 7.0 per 100,000 in 1980 to 54.1 per 100,000 in 1996, an increase of 672.9%. In order to meet the Year 2000 targets, mortality rates due to diabetes for the African American population must decline 7.6%.
Figure 4.4.4
Diabetes Mortality Rates -- Travis County 1980-1996
Source: Texas Department of Health, Epigram.
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OUTCOME: Reduced mortality rates for lung cancer
The Healthy People 2000 national targets for lung cancer deaths are 42.0 per 100,000 population, 27.0 per 100,000 female population, and 91.0 per 100,000 African American male population.
The draft Healthy People 2010 Objectives calls for a reduction in lung cancer deaths to no more than 33.0 per 100,000 population.
From 1980 to 1996, deaths due to lung cancer increased in Texas by 12.5% but decreased in Travis County by 8.1% (from 37.1 per 100,000 to 34.1 per 100,000). As the overall mortality rate decreased in Travis County, a contrast developed between the rates for males and females. While the lung cancer mortality rate for females increased sharply by 66.5% (16.7 per 100,000 in 1980 and 27.8 per 100,000 in 1996), the male rate decreased by 34.2% (64.6 per 100,000 in 1980 and 42.5 per 100,000 in 1996).
The highest increase of 89.3% was for White females (16.9 per 100,000 in 1980 and 32 per 100,000 in 1996), followed by an increase of 33% among African American females (28.5 per 100,000 in 1980 and 37.9 per 100,000 in 1996).
The mortality rate decrease of 39.8% for African American males (139 per 100,000 in 1980 and 83.7 per 100,000 in 1996) was followed by the 33.3% decrease for White males (62.1 per 100,000 in 1980 and 41.4 per 100,000 in 1996).
Hispanic males and females reversed this situation, with the male mortality rate increasing by 31.1% (21.9 per 100,000 in 1980 and 28.7 per 100,000 in 1996) and the female rate decreasing by 71.7% (5.3 per 100,000 in 1980 and 1.5 per 100,000 in 1996).
Figure 4.4.5
Lung Cancer Mortality Rates
Travis County 1980-1996
Source: Texas Department of Health, Epigram.
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OUTCOME: Reduced mortality rates for female breast cancer
The Healthy People 2000 national targets for female breast cancer deaths are 20.6 per 100,000 population and 25.0 per 100,000 African American population.
The draft Healthy People 2010 Objectives envisage a female breast cancer death rate of no more than 16.6 per 100,000 females.
The death rate due to breast cancer among the Texas female population has remained relatively steady from 1980 to 1996 (19.3 per 100,000 vs. 18.9 per 100,000, with a decline of 2.1%). For the same time period in Travis County, the mortality rate has decreased from 21.5 per 100,000 to 18.2 per 100,000, with a decline of 15.3%.
In Travis County, White females accounted for 793 (79.2%) of 1,001 total deaths due to breast cancer between 1980 and 1996, with a mortality rate of 21.3 per 100,000 population. African American females accounted for 125 (12.5%) of the total deaths; however, they had the highest mortality rate (26.6 per 100,000 population). Hispanic females accounted for 79 (7.9%) of the total deaths, with the lowest mortality rate (13.3 per 100,000 population).
In 1996, although White and Hispanic females met the Year 2000 target with death rates of 19.2 per 100,000 and 9.2 per 100,000, respectively, the breast cancer mortality rate for African American females remained above target at 28.8 per 100,000 population. In order to meet the Year 2000 goal, the breast cancer mortality rate for African American females must decline 13% from the 1996 rate.
Figure 4.4.6
Breast Cancer Mortality Rates by Ethnicity
Travis County 1980-1996
Source: Texas Department of Health, Epigram.
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COMMUNICABLE DISEASES
"The control of communicable diseases has been the most remarkable achievement of public health. History has amply demonstrated that withdrawal of communicable disease control resources rapidly results in a reciprocal resurgence of the respective infections for which resources were cut, whether it is measles, syphilis, tuberculosis, or some other infectious agent."
(Community Action Network, A Snapshot of Our Community, 1995, p. 5.5)
BACKGROUND AND INFLUENCING FACTORS
Overview: Key Diseases and Definitions
Communicable diseases are defined as those that may be transmitted directly or indirectly from an infected individual, animal or reservoir, to a susceptible host. In Strategies for Building a Stronger Community: A Community Guide, the Community Action Network identifies the following two communicable disease areas as high priority health conditions for outcome monitoring:
- Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS)
- Vaccine Preventable Diseases (e.g., measles, whooping cough, pneumonia, influenza, and hepatitis B)
Acquired immunodeficiency syndrome is a severe and life-threatening condition caused by the human immunodeficiency virus. In its late clinical stage, it results in progressive damage to the immune and other organ systems, including the central nervous system. Although there are treatments available to delay the progression of HIV infection to AIDS, there is presently no known cure.
Measles, also known as rubeola, is a contagious infection caused by a virus. Its symptoms include fever, tiredness, loss of appetite, sneezing and runny nose, hacking cough, lights hurting the eyes, tiny white spots in the mouth, and a blotchy red rash on the forehead and around the ears that spreads to the body. Measles spreads very easily and can be caught by coughing and sneezing.
Pertussis, or whooping cough, is a highly contagious bacterial infection that causes coughing and choking. An infected person may have rapid coughs and make a "whoop" sound when breathing. The whooping-cough bacteria, known as bordatella pertussis, is spread through droplets by coughing, sneezing, and talking, or by contact with anything touched by an infected person.
Pneumococcal pneumonia is an acute bacterial infection spread through droplets, direct oral contact, and indirect contact through articles freshly soiled with respiratory discharges. Symptoms include shaking chills, chattering teeth, high fever, sweating, heavy breathing, rapid pulse rate, severe chest pain, and a cough that produces rust-colored or greenish mucus. An infected persons mental state may become confused or delirious.
Influenza, commonly called "the flu," is caused by viruses that infect the respiratory tract. Compared with most other viral respiratory infections, such as the common cold, influenza often causes a more severe illness. Typical features include high fever and respiratory symptoms, such as cough, sore throat, runny or stuffy nose, as well as headache, muscle aches, and often extreme fatigue. Although nausea, vomiting, and diarrhea can sometimes accompany influenza infection, especially in children, gastrointestinal symptoms are rarely prominent. Most people who get the flu recover completely in one to two weeks, but some people develop serious and potentially life-threatening medical complications, such as pneumonia.
Hepatitis B, an inflammation of the liver which can lead to persistent infections and chronic liver disease, is caused by the infectious hepatitis B virus (HBV). HBV alone is estimated to have infected 400 million people around the globe, making it one of the most common human pathogens. Vaccines are available against HBV, but they may not be 100% effective against all variants of HBV. Furthermore, there is no cure for individuals already infected. Clinical features of hepatitis B include jaundice, fatigue, abdominal pain, loss of appetite, intermittent nausea, and vomiting.
Importance to Community
There has been a great deal of progress during this century in the control of communicable diseases resulting in their notable decline in developed countries, particularly in population groups that have benefited from public health programs. Nevertheless, communicable diseases continue to be an important cause of morbidity and mortality.
HIV/AIDS
The HIV/AIDS epidemic is a relatively recent public health phenomenon in the U.S. and globally. The disease was first recognized in 1981, and the primary population group affected appeared to be White homosexual men. However, other AIDS cases quickly followed, soon appearing among persons in the general population, with hemophiliacs, recipients of blood transfusions, and persons who inject illicit drugs being especially affected. Eighty percent of the reported AIDS cases in the U.S. were concentrated in six metropolitan areas, predominantly on the east and west coasts.
By the early 1990s, many changes in the epidemic were apparent. AIDS cases were being reported from every state and most large cities. The proportion of AIDS cases in White homosexual men declined, while the proportion in men and women of color began to increase. Cases also appeared to be increasing among injecting drug users and their partners. In recent years, the number of AIDS cases in females has increased steadily and now makes up nearly 20% of the total. In 1992, AIDS became a leading cause of death among Americans aged 25 to 44 years, first among African American females and later among all Americans of this age group. Today, it is the second leading cause of death among Americans 25 to 44 years old and remains the leading cause of death for African Americans in this age group. By 1995, AIDS cases were clearly seen as disproportionately affecting minority populations, with opportunistic infections seven times higher in African Americans and three times higher in Hispanics than among non-Hispanic Whites.
Vaccine Preventable Diseases
Vaccine preventable diseases have remained a major source of morbidity and mortality in the U.S. in spite of predictions by public health experts that the significance of such diseases would continue to wane. New infectious agents and diseases continue to be detected, and diseases once considered under control have reemerged in recent years. Compounding the problem of emerging infections, antimicrobial resistance is evolving rapidly in a variety of hospital- and community-acquired infections.
The global context of infectious diseases also must be considered. Increases in international travel, importation of foods, improper use of antibiotics in the U.S. and abroad, and global environmental changes increase the potential for global epidemics of infectious diseases, including emerging and reemerging diseases as well as drug-resistant strains.
Health Risk Behaviors, Factors, and Trends
HIV/AIDS
The Austin/Travis County Health and Human Services Department recently assessed HIV/AIDS health risk behaviors for the following populations in the community: White men; men of color; injecting drug users; women of childbearing age (15-44); and adolescents (ages 13-19).
Among White men, unprotected male-to-male sex is the leading risk factor for HIV/AIDS incidence. While the rate of infection among this population has slowed somewhat, White gay and bisexual men (particularly those who are younger and those who relapse from safer sex behaviors) continue to be at highest risk for infection. It is therefore critical to sustain efforts to reach this population and to equip each generation of young gay and bisexual men with information, skills, and support to change behavior.
HIV/AIDS incidence has been increasing in communities of color, and this is also true for gay and bisexual men within these communities. Unprotected heterosexual sex and injecting drug use are the leading factors in the spread of HIV/AIDS in the minority community.
The largest increase in AIDS cases among women of childbearing age is occurring in Travis Countys African American community. HIV infection in women is frequently the result of injecting drug use either by the women directly or as a result of infection through sex with a male partner who is an injecting drug user. The increase in HIV/AIDS cases among women of childbearing age means that the children of these women are at increased risk of HIV.
High rates of pregnancy and sexually transmitted diseases among adolescents in our community suggest that many teens are at risk for contracting HIV. Furthermore, the large proportion of AIDS cases in the 20- to 44-year-old age range indicates that many individuals were infected with HIV as adolescents.
The Community Action Network has identified additional risk factors that may cause or contribute to the HIV/AIDS epidemic. These include poverty, poor living conditions, malnutrition, lack of education, homelessness, hopelessness, living in close quarters, alcohol and drug use/abuse, prostitution, sex-for-drugs, and gang-related activities.
Vaccine Preventable Diseases
Measles primarily affects infants and children, particularly those who are malnourished. Nevertheless, all persons who have not had the disease or who have not been successfully immunized are susceptible. The presence of indigenous (i.e., naturally occurring) measles in a community is an indicator of the need for preventive services and/or problems with access to health care.
Pertussis (whooping cough) is usually thought of as a potentially life-threatening childhood disease. It is most dangerous to children less than one year old. Complications for infants include pneumonia, convulsions, and, in rare cases, brain damage or death. Serious complications are less likely to occur in older children and adults. Persons at highest risk for pertussis are those who are unimmunized or inadequately immunized. Although 70% of cases occur in children younger than five years old, many cases occur in adolescents and adults because vaccine protection lasts only five to ten years after the last dose. Adolescents and adults are thus the actual reservoir for pertussis, often inadvertently introducing the infection into households where susceptible preschool-age children are then exposed. Because pertussis is not generally appreciated as a cause of illness in adults, health providers and patients usually fail to consider it in the differential diagnosis of chronic cough in adults.
Vaccination is available to help fight pneumococcal pneumonia; however, it is generally given only to people at high risk of contracting the disease and its life-threatening complications. The vaccine is not recommended for pregnant women or children under age two. Although pneumococcal pneumonia can attack anyone¾ including infants¾ the greatest risk is usually among people who have severe or chronic illnesses, post-operative patients, residents of nursing homes or other chronic care facilities, and those who are aged 65 or older.
Complications from influenza can occur at any age, however, the elderly and people with chronic health problems are much more likely to develop serious complications after influenza infection than are younger, healthier people. Much of the illness and death caused by influenza can be prevented by annual vaccination. Influenza vaccine is specifically recommended for all people aged 65 or older and people of any age with chronic diseases, weakened immune systems, or severe forms of anemia. Others for whom vaccine is recommended are residents of nursing homes and other chronic-care facilities, and children and teenagers who are receiving long-term aspirin therapy. Influenza vaccine is also recommended for people who are in close or frequent contact with anyone in the high-risk groups defined above. These include health care personnel and volunteers who work with high-risk patients and people who live in a household with a high-risk person. Although annual influenza vaccination has long been recommended for people in the high-risk groups, many still do not receive the vaccine.
The incidence of hepatitis B in the U.S. increased through 1985 and then declined 55% through 1993 because of wider use of vaccine among adults, modification of high-risk behaviors, and possibly a decrease in the number of susceptible persons. Since 1993, increases have been observed among the three major risk groups: sexually active heterosexuals, gay and bisexual males, and injecting drug users. Other people at risk include infants born to infected mothers; infants and children of immigrants from disease-endemic areas; persons from lower socioeconomic levels; persons who have sexual and/or household contact with infected persons; health care workers; and hemodialysis patients. Vaccine is available for the prevention of hepatitis B virus. All individuals at risk for infection should be vaccinated. Post-exposure prophylaxis with hepatitis B immune globulin is effective for non-immune individuals after a known exposure (e.g., needle stick).
Immunizations are clearly the best preventive health measure for communicable diseases for which there are vaccines. In 1995, the Committee on Practice and Ambulatory Medicine of the American Academy of Pediatrics recommended the development of state and local registries to provide a reliable system for tracking children's immunizations.
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OUTCOMES AND KEY INDICATORS
Many communicable diseases are significant in their impact, or potential impact, on various segments of the Travis County population. For the purpose of this health analysis, outcome monitoring specifically targets HIV/AIDS and vaccine preventable diseases.
OUTCOME: Reduced incidence and mortality rates for HIV/AIDS
Healthy People 2000 national targets for HIV/AIDS are as follows:
- 43.0 total AIDS cases per 100,000 population.
- Specific race/ethnicity targets are 136.0 per 100,000 African American population and 76.0 cases per 100,000 Hispanic population.
The draft Healthy People 2010 Objectives seeks to confine the annual incidence of diagnosed AIDS cases among adolescents and adults to no more than 12.0 per 100,000 population. A review of AIDS cases in Travis County for 1993 through 1997 indicates that the AIDS incidence rate has declined, from 95.4 per 100,000 in 1993 to 29.4 per 100,000 in 1997. Nevertheless, Travis County rates remain higher than rates for the State of Texas during the same period.
Figure 4.4.7
AIDS Incidence Rate
Sources: Austin/Travis County Health and Human Services Department; Texas Department of Health, Bureau of HIV and STD Prevention.
Note: The AIDS surveillance definition was expanded in 1993. Comparisons between years are not completely valid due to changing definition criteria.
A review of the data indicates that numerically, more White males suffer from AIDS than do other population segments. However, incidence rates are consistently highest among men of color. The 1997 AIDS incidence rate for White males was 39.2 per 100,000, whereas it was 133.7 per 100,000 for African American males and 52.3 per 100,000 for Hispanic males.
Women of color also have higher AIDS rates than do White women. The 1997 AIDS incidence rate for White females was 1.4 per 100,000, whereas it was 48.4 per 100,000 for African American females and 8.3 per 100,000 for Hispanic females.
Figure 4.4.8
AIDS Cases by Sex and Race/Ethnicity, Travis County
Sources: Austin/Travis County Health and Human Services Department.
Of the AIDS cases reported from Travis County in 1997, the exposure category of male-to-male sex accounted for 43.1%, a decrease from 63.5% in 1993. Conversely, transmission by other modes (e.g., injecting/intravenous drug use and heterosexual sex) has increased from 36.5% in 1993 to 56.9% in 1997.
Figure 4.4.9
AIDS Cases by Mode of Transmission, Travis County
Sources: Austin/Travis County Health and Human Services Department.
In the last two years, there have been three pediatric (defined as age 12 or below) AIDS cases reported from Travis County. All three cases are related to mothers with or at risk for HIV infection. These cases are distributed by race/ethnicity as follows: 33% White (one case) and 67% non-White (one African American and one Hispanic case). National trends in AIDS incidence within the pediatric age group demonstrate the dramatic success of efforts to reduce perinatal (mother-to-child) transmission. However, there continues to be a need for intensified efforts in our community to prevent infection among women of color as well as to reach infected women with early prenatal care and preventive treatment.
HIV/AIDS dropped from its position as the third leading cause of death in Travis County in 1995 to the sixth leading cause in 1996. In rankings by race/ethnicity for cause of death in 1995, HIV/AIDS was sixth for Whites (135 deaths or 32.0 per 100,000 population), third for Hispanics (47 deaths or 31.2 per 100,000 population), and third for African Americans (82 deaths or 116.8 per 100,000 population). In 1996, HIV/AIDS was the seventh leading cause of death for Whites (70 deaths or 16.3 deaths per 100,000 population), fourth for Hispanics (26 deaths or 16.7 deaths per 100,000 population), and third for African Americans (61 deaths or 85.2 deaths per 100,000 population).
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OUTCOME: Reduced incidence and mortality rates for vaccine preventable diseases
Healthy People 2000 identifies measles as a sentinel measure for vaccine preventable diseases. The presence of measles in a community is an indicator of the need for preventive services and/or problems with access to health care. Because immunization can prevent any new cases of measles from occurring, the year 2000 target is zero cases. For pertussis (whooping cough), the year 2000 target is no more than a total of 1000 cases nationally.
The incidence of measles in Texas showed dramatic fluctuations from 1980 to 1996. Because of an epidemic across the state, measles incidence for the Texas population increased from 1.3 per 100,000 population in 1980 to 26.0 in 1990, then decreased to 0.3 in 1996. This pattern occurred in all populations, although rates for African American and Hispanic populations tended to be higher than rates for the White population. During the 1990 measles epidemic in Travis County, incidence rates were also highest among the communitys African American and Hispanic population.
The following graphs and tables compare 1993 to 1997 measles and pertussis incidence rates for Travis County to those for the State of Texas.
Figure 4.4.10
Measles Incidence Rate
Source: Austin/Travis County Health and Human Services Department.
* One imported case and two cases linked to it.
Figure 4.4.11
Pertussis Incidence Rate
Source: Austin/Travis County Health and Human Services Department.
No deaths from measles and pertussis have occurred in Travis County during the time period depicted. This is a direct result of the health care systems diligence in immunizing the pre-school population and in successfully treating the few cases which have occurred.
Healthy People 2000 national targets for hepatitis B are as follows:
- 40.0 total hepatitis B cases per 100,000 population.
- Specific race/ethnicity targets are 40.0 cases per 100,000 African American population and 26.9 cases per 100,000 Hispanic population.
The table that follows compare s1993 to 1997 hepatitis B incidence rates for Travis County with those for the State of Texas.
Figure 4.4.12
Incidence Rate of Hepatitis B
Sources: Austin/Travis County Health and Human Services Department; Texas Department of Health, Epidemiology in Texas Annual Report.
From 1990 to 1996, there were a total of 16 deaths (0.4 per 100,000 population) from hepatitis B in Travis County (11 White, 2 African American, 2 Hispanic, and 1 Other).
The Healthy People 2000 national target for pneumococcal pneumonia and influenza is to reduce epidemic-related deaths (i.e., those that occur above and beyond the normal yearly fluctuations of mortality) for these diseases among people aged 65 and older to no more than 15.9 per 100,000 population.
From 1990 to 1996, there were a total of 22 deaths among all age groups combined (0.5 per 100,000 population) from pneumococcal pneumonia in Travis County (13 White, 4 Black, and 5 Hispanic). During this same time period, there were 9 deaths among all age groups (0.2 per 100,000 population) from influenza (6 White, 2 Hispanic, and 1 Other).
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OUTCOME: Increased Immunization Rates
Communicable diseases recommended for childhood immunization include diphtheria, tetanus, pertussis, polio, measles, mumps, rubella, varicella (chickenpox), influenza, and hepatitis B.
A Healthy People 2000 immunization goal is to have at least 90% of children properly immunized by their second birthday.
In 1994, the Travis County immunization rate for children aged 3-24 months was 57.5 %, with African-Americans having the lowest rates. The highest immunization rates were found among Hispanic children. Provisional results from a 1996 Texas Department of Health survey of families with children ages 3 to 24 months showed Travis County with an immunization rate of 71% for children in that age group.
In addition to childhood immunization rates, the other major indicator of a community's childhood immunization status looks for the existence in the community of a computerized immunization registry that provides for automated appointment reminders, and the percentage of children in the community included in the registry. There is, at present, no such immunization tracking system in Travis County or its surrounding counties.
Healthy People 2000 immunization goals for other population groups are as follows:
- Pneumococcal Pneumonia - 80% immunization rate among institutionalized chronically ill or older people; 60% immunization rate among non-institutionalized, high-risk populations.
- Influenza - 80% immunization rate among institutionalized chronically ill or older people; 60% immunization rate among non-institutionalized, high-risk populations.
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OTHER COMMUNICABLE DISEASES
Tuberculosis (TB) is a disease caused by bacteria, which can attack any part of the body, most often, the lungs. Pulmonary TB is transmitted by person-to-person airborne spread. Persons infected with tuberculosis may not feel sick or have signs and symptoms, and may not spread TB. But they may develop active and therefore communicable TB disease at some time in the future. People with active TB disease can be treated and cured if they seek medical help. Even better, people who have TB infection but are not yet sick can be placed on prophylactic treatment to avoid the development of active disease.
The risk of tuberculosis infection is directly related to the degree of exposure to individuals having tuberculosis disease. The risk of developing disease is highest in children under three years old, lowest in later childhood, and high again among adolescents, young adults, the very old and the immunosuppressed. Reactivation of long-latent infections accounts for a large proportion of disease cases in older people. For those with tuberculosis infection, susceptibility to the disease is markedly increased in those with HIV and other forms of immunosuppression, and is also increased among underweight and undernourished people, people with debilitating diseases such as chronic renal failure, cancer, silicosis, diabetes or postgastrectomy, and among substance abusers.
Social conditions such as homelessness, incarceration, overcrowding, and residing in a community where TB is prevalent also increase the risk of becoming infected. Furthermore, TB infection has the potential for increase as a result of changes in demographic patterns, including immigration from countries with a high incidence of TB. Although there is a vaccine for TB known as BCG, it is not widely used in the United States and does not always protect people from TB. Persons with TB infection require preventive therapy with a drug called isonozid (INH). Conversely, those with TB disease must take several different drugs.
Year 2000 national targets for tuberculosis are as follows:
- 3.5 total tuberculosis cases per 100,000 population.
- Specific race/ethnicity targets are 10.0 cases per 100,000 African American population and 5.0 cases per 100,000 Hispanic population.
The graphs and tables that follow compare 1993 to 1997 tuberculosis incidence rates for Travis County with those for the State. A breakdown by sex and age for Travis County tuberculosis cases is also presented.
Figure 4.4.13
Tuberculosis Cases and Rates
Sources: Austin/Travis County Health and Human Services Department, TB Elimination Program; Texas Department of Health, Epidemiology in Texas Annual Report.
Figure 4.4.14
Tuberculosis Cases by Sex and Age, Travis County
