Kern County Department of Public Health Health Status Report 2003

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1 Kern County Department of Public Health Health Status Report 2003 Kern County B.A. Jinadu, M.D., M.P.H. Director of Public Health Services Prepared by: Kirt W. Emery, M.P.H. Assistant Director of Disease Control Emma K. Chaput, M.P.H. Senior Epidemiologist Yasmin El Gamal, M.D., M.P.H. Epidemiologist

2 Introduction Our County s health status comprises many factors in our daily lives. Health is often viewed simply as not being sick. The World Health Organization takes a broader view with their definition of health, a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. i The health of each of Kern County s residents is impacted daily by a variety of influences. Our lifestyle choices, genetics, socioeconomic status, occupation, residence, and outdoor environments all affect our health. This report presents the County s performance in three major health indicators. The Kern County Department of Public Health analyzed data on births, deaths, and communicable diseases in this community. This report compares our health indicators to the National objectives outlined in the U.S. Department of Health and Human Services report, Healthy People 2010: Understanding and Improving Health. Kern County has made appreciable progress towards the 2010 goals in many areas of health. Hepatitis A has been one such success story. Kern County s Hepatitis A case numbers have dropped dramatically in recent years. During , Kern County was listed as a high risk area for hepatitis A by the Centers for Disease Control and Prevention. However in the past four years, Kern County s rates have dropped dramatically, to near or below the Healthy People 2010 goal years early! Yet, in other areas, there is still substantial work to be done to improve the health of our residents. The percent of births to teen mothers in Kern County is substantially higher than comparable numbers for California and the United States. In 2001, the Kern County death rate from heart disease was nearly 20% higher than California s rate. For the health of Kern County s residents to continue improving, public health infrastructure must be supported. Programs to educate and empower our residents to make healthy lifestyle choices will be integral components to maintaining our good work towards achieving the national goals. The Kern County Department of Public Health hopes that this report will be a useful resource to health professionals as well as policy makers, program planners, and community members. If you would like to make suggestions about health indicators to include in future editions, please write to: Epidemiology Section Re: Health Status Report 1800 Mt Vernon Ave., 2 nd Floor Bakersfield, CA i Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.

3 Kern County Department of Public Health Health Status Report, 2003 Section 1. Section 2. Section 3. Appendices. Births Births in Kern County Preterm Delivery Infant Mortality Low Birth Weight Prenatal Care Births to Teens Other Birth Factors References Birth Indicator Table Deaths Deaths in Kern County Coronary Heart Disease Cancer Female Breast Cancer Colorectal Cancer Lung Cancer Prostate Cancer Stroke Chronic Lower Respiratory Diseases Unintentional Injuries Notes and References Communicable Diseases Communicable Diseases in Kern County Coccidioidomycosis Foodborne Illnesses HIV/AIDS Sexually Transmitted Diseases Tuberculosis Vaccine Preventable Diseases Viral Hepatitis References Appendix I. Healthy People 2010 National Objectives Appendix II. California Reportable Diseases and Conditions Appendix III. Kern County Morbidity Report,

4 Section 1. Births This first section of the health status report presents detailed data on live births to Kern County residents. These data provide important information on fertility patterns among Kern County women by characteristics such as age, race/ethnicity, and prenatal care. Up-to-date information is critical for understanding the health of the County as well as the population s growth. The Kern County Department of Public Health and the County Health Officer are the local registrars for births in Kern County. Statistical information collected from birth records is first sent to the California State Office of Vital Records and then to the National Center for Health Statistics at the Centers for Disease Control and Prevention (CDC). Information from Vital Records is essential for the planning and assessment of maternal and child healthcare as well as health services at the national, state, and local levels. The birth indicators described in this section are assessed annually in order to gauge Kern County s progress in maternal and infant health. Birth Trends Kern County saw a gradual decline in the annual number of births in the 1990 s, but the numbers have been increasing since Between 1993 and 2002, the average number of births to Kern County women was 11,842 per year. In this 10-year period, births to White women and African American women declined 26% and 19%, respectively. In contrast, births to Hispanic women increased 20% from The annual crude birth rate is the number of live births occurring in a year within a given geographic area divided by the population of that area in that year. The crude birth rate is reported per 1,000 people. For example, a crude birth rate of 20 per 1,000 population means that for every 1,000 people, there were 20 births. This enables comparison over time, taking into account population changes. In 1993, Kern County s crude birth rate was 20.9 per 1,000 population and in 2002 it was 17.1 per 1,000. The 10-year average crude birth rate was 18.3 per 1,000. During , areas with the highest birth rates included Delano, Shafter, Arvin, and areas of eastern and southern Bakersfield. Age-specific birth rates are a measure of births to mothers in a certain age-group, using the population of that age group. During , birth rates decreased in the 15-19, 20-24, and year age groups. The largest decrease was observed among teens, whose age-specific rate decreased 33%. Increases were observed in the 30-34, 35-39, and year age groups, reflecting a national trend towards later motherhood. 1 The mother s country of birth is another indicator of demographic change. Kern County has seen a slight decline in the percent of U.S. born women giving birth, from 68% in 1993 to 65% in 2002 (Table 1-1). Over 95% of White and African American mothers were born in the United States. Fewer women of Hispanic origin were born in the United States. On average, 44% of Hispanic mothers were born in the United States. The majority of Hispanic mothers were born in Mexico. The group marked Other in Table 1-1 is mostly composed of Asian Americans and Pacific Islanders. A majority of this population is recently arrived in the U.S. only 32% of women in this group were born in the United States. 1-1

5 Figure 1-1. Total Births and Birth Rate, Kern County Residents, , Births 12,500 12,000 11,500 11, Rate per 1,000 population 10, Number of Births 12,529 12,613 11,942 11,557 11,271 11,521 11,375 11,680 11,723 12,211 Birth Rate Figure 1-2. Birth Rate, by Mother s Age Group, Kern County Residents, Rate per 1,000 population

6 Figure 1-3. Birth Rate, by Mother s Race/Ethnicity, Kern County Residents, Rate per 1,000 population Kern County Black Hispanic White Figure 1-4. Birth Rate, by Census Tract, Kern County Residents,

7 Preterm Delivery What is it? Births occurring between 37 to 41 weeks of gestation are considered full-term. Infants born before 37 weeks of gestation are considered preterm births. The length of gestation is calculated as the time difference between the first day of the mother s last normal menstrual period and the infant s date of birth. 2 Healthy People 2010 National Objective How has it changed? Reduction in preterm births 7.6% of live births Between 1993 and 2002, 14,000 infants, or 12% of all births, were born preterm. Preterm births varied by race/ethnicity. A higher proportion of African American women delivered prior to full-term than any other race/ethnicity group, consistent with the national trend. 1 From 1993 to 2002, the percent of preterm births to African American women in Kern County ranged from 15% to 20% and the 10-year average was 17.1% (95% confidence interval [CI]: 16.2%-18.0%), statistically higher than the County preterm average of 11.8% (95% CI: 11.6%-12.0%). Areas of increased preterm births were scattered around Kern County in , including California City, Shafter, Lamont, Arvin, and areas in eastern and southern Bakersfield. Preterm births in Kern County have not appreciably changed over the last 10 years. The Healthy People 2010 goal is to decrease preterm births to 7.6% of all births. Further progress is needed to reach this goal in Kern County, particularly in the African American community. Why is it important? Preterm birth is one of the leading causes for low birth weight and infant death in the United States. Preterm birth is also associated with serious illness, or morbidity, among newborns. Therefore, reduction in preterm births can reduce infant illness, disability, and death. Risk factors for preterm birth include previous preterm birth(s), low weight-gain during pregnancy, vaginal infections, domestic violence, and multiple gestations. Preterm birth is also associated with modifiable risk factors, such as the use of alcohol, tobacco, or other drugs during pregnancy. 3 Intervention and education programs targeted at decreasing substance use and other risk factors during pregnancy may help reduce the rate of preterm births in Kern County, bringing us closer to the Healthy People 2010 goal. Throughout the country there is a greater occurrence of preterm births among African Americans, compared to other race/ethnicity groups, but the reasons for this difference are unclear and need more study. Compared to other racial/ethnic groups, more African American women may be subject to certain risk factors such as shorter inter-pregnancy intervals and psychosocial stress

8 Figure 1-5. Percent of Preterm Births (<37 Weeks), by Race/Ethnicity, Kern County Residents, % Healthy People 2010 Objective: 7.6% Percent of total births 20.0% 15.0% 10.0% 5.0% 0.0% Kern County 11.9% 12.5% 11.9% 12.5% 11.7% 12.2% 13.0% 12.6% 12.3% 12.8% Black 20.2% 20.5% 15.3% 20.3% 17.3% 18.0% 16.1% 17.2% 17.2% 19.7% Hispanic 12.1% 12.5% 12.2% 13.0% 12.0% 12.7% 14.1% 12.8% 13.2% 12.7% White 10.5% 11.5% 11.0% 10.8% 10.6% 10.9% 11.0% 11.5% 10.1% 11.4% Figure 1-6. Percent of Preterm Births, with 95% Confidence Intervals, Kern County Residents, % 20.0% Black Preterm Births County Preterm Births Percent of Total Births 15.0% 10.0% 5.0% 0.0% yr avg. 1-5

9 Figure 1-7. Percent of Preterm Births, by Census Tract, Kern County Residents,

10 Infant Mortality What is it? The infant mortality rate is the measure of deaths among children less than one year of age divided by the total number of live births in the same time period. The infant mortality rate is reported per 1,000 live births. Healthy People 2010 National Objective How has it changed? Reduction in infant deaths 4.5 per 1000 live births During the 10-year period between 1993 and 2002, 989 children under one year of age died in Kern County. From 1993 to 2002, the County infant mortality rate ranged from 6.2 to 11.2 deaths per 1,000 live births. The 10-year average infant mortality rate was 8.4 per 1,000. The infant mortality rate was lowest in 2002, when the rate decreased for the second year in a row to 6.2 deaths per 1,000. The national objective for the year 2010 is to reduce the infant mortality rate to 4.5 deaths per 1, Kern County is headed in the right direction to achieve the 2010 objective, but continued commitment to reduce our infant mortality rate is required. A comparison of infant mortality rates by race/ethnicity group reveals variation from the overall County rates. In 1993, the infant mortality (IM) rate for White infants was 11.0 per 1,000 live births. The IM rate for White infants was lowest in 2000 (4.2 per 1,000), but increased the next two years. The infant mortality rate for Hispanic infants has had a similar trend to that of White infants. In 1993, the Hispanic IM rate was 10.6 per 1,000 live births and has decreased to 4.9 per 1,000 in 2002, the lowest rate for any race/ethnicity group. While there was a clear decrease in the African American IM rate comparing 1993 and 2002 (14.6 to 7.5 per 1,000), the rate varied widely over the 10 years. Although small numbers make individual year comparisons difficult, the 10-year average shows that the African American infant mortality rate (17.3/1,000, 95% CI: /1,000) is significantly higher than the County rate (8.3/1,000, 95% CI: /1,000). The African American infant mortality rate remains higher than the overall Kern County rate. This finding is consistent with state and national data. Why is it important? Infant deaths are preventable in some cases. Several factors contribute to infant death including congenital birth defects, pregnancy complications, preterm birth, low birth weight, sudden infant death syndrome, homicide, and injuries. In Kern County, nearly 60% of neonatal deaths are due to preterm birth and low birth weight. Maintaining support for programs to ensure access to prenatal care and support women through her pregnancy will be essential for improving birth outcomes in Kern County. 1-7

11 Figure 1-8. Infant Deaths, by Race/Ethnicity, Kern County Residents, Number of deaths Black Hispanic White Other/Unknown Black Hispanic White Other/Unknown Figure 1-9. Infant Mortality Rate, by Race/Ethnicity, Kern County Residents, Healthy People 2010 Objective: 4.5/1,000 Rate per 1,000 live births Kern County Black Hispanic White

12 Figure Infant Mortality Rate (IMR) with 95% Confidence Intervals, Kern County Residents, Black IMR County IMR Rate per 1,000 live births yr avg 1-9

13 Low Birth Weight What is it? Infants born weighing less than 2,500 grams (about 5.5 pounds) are considered low birth weight. Very low birth weight comprises infants weighing less than 1,500 grams (about 3.3 pounds) at birth. Healthy People 2010 National Objective Reduction in low birth weight 5.0% of live births Reduction in very low birth weight 0.9% of live births How has it changed? During the last 10 years ( ), an average of 6.4% of Kern County infants were born weighing less than 2,500 grams. Higher percentages of low birth weight babies were seen in African American populations than were seen in the rest of the County. The 10-year average of low birth weight for African Americans was 12.9% (95% CI: 12.1%-13.7%), statistically higher than the County s 10-year average of 6.4% (95% CI: 6.3%-6.6%). The majority of African Americans in Kern County live in Bakersfield, indicating that continued outreach efforts should be concentrated in the Bakersfield area. However, other areas with increased low birth weight are found throughout Kern, including Taft and California City. Although Kern County is close to reaching the Healthy People 2010 goal of 5.9% of total live births being low and very low birth weight, further progress is needed in the African American community. Continued efforts are also needed to decrease the low birth weight rate throughout the County, which has not shown any clear decrease in the last 10 years. Why is it important? Low birth weight babies, particularly very low birth weight babies born weighing less than 1,500 grams, are at higher risk for having developmental complications and death within the first year of life. One of the most effective ways of reducing the infant mortality rate is to reduce the number of low birth weight babies. Smoking tobacco during pregnancy slows fetal development and is a known risk factor for low birth weight. 3 Nationwide, smoking is responsible for 20% to 30% of infants born under weight. 3 Decreasing smoking prevalence among pregnant women should lead to a reduction of low birth weight babies. 1-10

14 Figure Percent Low Birth Weight, by Race/Ethnicity, Kern County Residents, % Healthy People 2010 Objective: 5.9% 14.0% Percent of total births 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% Kern County 6.9% 6.5% 6.6% 6.6% 6.0% 6.2% 6.1% 6.6% 6.3% 6.5% Black 15.3% 13.3% 12.3% 13.8% 12.0% 10.6% 10.1% 14.8% 13.0% 13.6% Hispanic 6.6% 5.8% 6.0% 6.1% 5.4% 5.7% 5.6% 5.9% 6.0% 6.1% White 5.9% 6.3% 6.5% 6.0% 5.6% 5.9% 6.2% 6.1% 5.8% 5.8% Figure Percent Low Birth Weight (LBW), with 95% Confidence Intervals, Kern County Residents, % 18.0% 16.0% Black LBW Births County LBW Births Percent of total births 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% yr avg 1-11

15 Figure Percent Low Birth Weight, by Census Tract, Kern County Residents,

16 Prenatal Care in the First Trimester of Pregnancy What is it? Prenatal care is the health care a woman receives during her pregnancy to make sure that her pregnancy and delivery are as safe as possible for her and her baby. Women who start prenatal care early tend to have fewer pregnancy complications and deliver healthier babies than women who delay or have no prenatal care. Women should initiate prenatal care within the first trimester (the first three months) of pregnancy. Prenatal care includes advice about diet, exercise, and the need for regular health care visits to her obstetrician. Healthy People 2010 National Objective Increase percentage of maternal prenatal care beginning in 1 st trimester 90% of live births How has it changed? In , 73% of pregnant Kern County residents received prenatal care within the first trimester of pregnancy. During that time, the percentage of women receiving prenatal care fluctuated slightly, between 71% in 1993 and 73% in The percent of all women receiving timely prenatal care in Kern County has decreased steadily since The number of women who receive prenatal care varies by race/ethnicity group. White women were more likely to obtain timely prenatal care than African American and Hispanic women, possibly reflecting differences in access to care. In the late 1990 s more women in minority groups were beginning to receive timely prenatal care, but the numbers have been falling again in the past several years. The Healthy People 2010 goal is to achieve 90% of women receiving prenatal care within the first trimester of pregnancy. Greater progress must be made for all of Kern County's women in order to meet this goal. Why is it important? Timely and adequate prenatal care may reduce the chances of poor birth outcomes such as low birthweight, preterm delivery (less than 37 weeks of gestation), infant mortality, maternal illness, and complications due to pregnancy. Prenatal care is most beneficial when begun within the first three months of pregnancy, as the baby s major organs are formed by the first 12 weeks of growth. Women receiving late or no prenatal care may have other barriers to accessing the health care system care such as substance abuse, poverty, age, or transportation barriers. Targeting and eliminating these and other barriers to accessing timely and quality care must be a priority to continue improvement in maternal prenatal care coverage towards the national objective. 1-13

17 Figure Percent of Women Receiving Prenatal Care during 1 st Trimester, by Race/Ethnicity, Kern County Residents, % Healthy People 2010 Objective: 90% Percent of total births 80% 70% 60% 50% Kern County 71% 68% 67% 69% 76% 77% 76% 76% 75% 73% Black 66% 66% 64% 65% 72% 75% 78% 77% 76% 69% Hispanic 66% 63% 64% 65% 73% 73% 72% 72% 72% 69% White 76% 75% 71% 75% 80% 82% 82% 83% 81% 80% 1-14

18 Births to Teens What is it? Births to mothers under age 20 years are categorized as teen births. How has it changed? Kern County has higher teen birth rates than state and national rates. In Kern County, the average birth rate was 83 per 1,000 population for women aged In contrast, the state and national birth rates were 57 per 1,000 and 52 per 1,000, respectively. In 2002, the County birth rate in the year age group remained at 67 per 1,000, higher than the state rate of 42 per 1,000 for the same year. Between 1993 and 2002, an average of 17% of the total births in Kern County were to mothers under 20. Teenage birth rates in Kern County differ widely by race/ethnicity. The County s elevated teen birth rates are primarily reflecting higher rates of childbearing among Hispanic and African American teenagers. The table below shows the striking differences in 10-year average teen birthrates among different race/ethnicity groups. Since the early 1990 s, teen birth rates in all race/ethnicity groups have been steadily decreasing. Further reductions are necessary to reach the California and U.S. teen birthrates. Race/Ethnicity Average Teen Birthrate, Kern County, Hispanic per 1,000 African American per 1,000 White 48.6 per 1,000 Kern County average 82.6 per 1,000 Births to teens are often broken out into two sub-groups for clearer analysis: and years. When comparing Kern County to California using these sub-groups, it is clear that Kern remains higher in each category. Younger Kern County teens are following a statewide trend of reducing pregnancies (from 7.0% of pregnancies in 1994 to 5.2% of pregnancies in 2002), but the rates in Kern remain higher than in California. Less change has been observed in older teens (18-19 years), both in Kern and in California. Why is it important? The United States has one of the highest rates of teenage pregnancy among industrialized countries. Teenage pregnancy continues to be a serious national issue. In the last two decades, the number of births to teenage mothers rose 44% in the U.S. 3 Teenage pregnancy can have negative health consequences for both the teen mothers and their infants. Nationwide, pregnant teenagers are more likely to smoke and to delay or forgo prenatal care. 4 As a result of these risk factors, infants born to teen mothers are more likely to be born preterm, at low birthweight, and thus to have other health issues

19 Figure Birth Rate, Year Age Group, U.S., California, Kern County, Rate per 1,000 population US CA Kern Figure Birth Rate, Year Age Group, by Race/Ethnicity, Kern County Residents, Rate per 1,000 population Kern County Black Hispanic White

20 Figure Percent of Births to Teens, by Age Group, Kern County and California Residents, % Percent of total births 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% * Kern % 7.5% 6.9% 6.9% 6.6% 6.6% 6.1% 5.0% 5.2% CA % 4.7% 4.5% 4.4% 4.1% 3.9% 3.6% 3.3% Kern % 10.4% 10.0% 12.0% 10.3% 10.3% 10.6% 10.5% 9.9% CA % 7.4% 7.3% 7.0% 7.0% 7.0% 6.9% 6.8% * 2002 California data not available. Figure Percent of Births to Teens, by Census Tract, Kern County Residents,

21 Other Birth Factors Medi-Cal Deliveries The number of deliveries paid for by Medi-Cal is one indicator of the number of low income women giving birth. Medi-Cal remains an important funding resource for Kern County women, decreasing barriers to appropriate prenatal and perinatal care. Many Kern County residents count on this support to ensure healthy pregnancies and births. Looking at trends in Medi-Cal funded births provides the Kern County Department of Public Health an indicator of what populations may need increased outreach to ensure timely care and the appropriate supportive services during and after pregnancy. There has been little change in the percent of births paid for by Medi-Cal in Kern County over the last 10 years. Between 1993 and 2002, a yearly average of 58% of deliveries in Kern County were paid for by Medi-Cal. In 2002, the proportion of births paid for by Medi-Cal rose to 60% for the first time since An increase was observed in all race/ethnicity groups. There was a marked difference in the number of Medi-Cal deliveries between race/ethnicity groups. On average, 37% of deliveries by White mothers were paid for by Medi-Cal. In comparison, 71% deliveries by African American mothers and 74% of births to Hispanic mothers were paid for by Medi-Cal. Figure Percent of Deliveries Paid by Medi-Cal, by Race/Ethnicity, Kern County Residents, % Percent of total births 80% 60% 40% 20% 0% Kern County 58% 59% 59% 60% 57% 56% 56% 57% 57% 60% Black 74% 74% 71% 71% 69% 71% 71% 66% 69% 73% Hispanic 77% 76% 77% 76% 73% 71% 72% 72% 72% 73% White 36% 39% 39% 40% 35% 36% 34% 34% 34% 37% 1-18

22 Mother's Education Mothers with higher levels of education are more likely to seek timely prenatal care and have better birth outcomes. From 1993 to 2002, there was a slight increase in the level of education attained by mothers in Kern County. In 1993, 59% of mothers in Kern County completed 12 or more years of education, (i.e., high school or beyond). In 2002, the percentage rose to 64%, with a 10-year average of 62%. Displaying the data by race/ethnicity group reveals that mothers of Hispanic origin consistently attained lower levels of education, but this group also saw the largest gain in the 10 year time period. In 1993, only 37% of Hispanic mothers completed high school. By 2002, 50% of Hispanic mothers had graduated from high school, with a 10-year average of 45%. However, these numbers may be influenced by the large number of foreign-born Hispanic mothers in Kern County, since high school is completed after the 10 th grade in Mexico. In contrast, the 10-year averages for completion of high school among White and African American mothers were 81% and 75%, respectively. Figure Percent of Mothers with at least High School Education, by Race/Ethnicity, Kern County Residents, % Percent of total births 80% 60% 40% 20% 0% Kern County 59% 59% 60% 61% 62% 64% 65% 64% 63% 64% Black 69% 71% 69% 75% 75% 81% 77% 82% 75% 74% Hispanic 37% 38% 40% 43% 44% 47% 49% 49% 49% 50% White 79% 79% 80% 81% 82% 83% 83% 84% 83% 83% 1-19

23 References: Unless otherwise noted, data sources are: Kern County Department of Public Health, Epidemiology and Vital Statistics Section; California Department of Health Services, Center for Health Statistics; and National Center for Health Statistics. 1-1 Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Munson ML. Births: Final data for National vital statistics reports; vol 52 no 10. Hyattsville, Maryland: National Center for Health Statistics Blackmore CA, Rowley DL, Kiely JL. Birth outcomes: Preterm Births in From data to action: CDC s Public Health Surveillance for Women, Infants, and Children. Hyattsville, MD. National Center for Health Statistics U.S. Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. 2nd ed. Washington, DC: U.S. Government Printing Office, November Ventura SJ, Matthews TJ, Curtin SC. Declines in teenage birth rates, : National and State patterns. National vital statistics reports: vol. 47 no 12. Hyattsville, Maryland. National Center for Health Statistics

24 Table 1-1. Birth Indicator Data, , Kern County Residents Live Birth* Indicators Year Average Total Births 12,529 12,613 11,942 11,557 11,271 11,521 11,377 11,680 11,723 12,211 11,842 Black percent 7% 7% 6% 6% 6% 6% 6% 5% 6% 5% 6% Hispanic 5,772 5,961 5,766 5,931 5,774 5,915 5,885 6,514 6,511 6,941 6,097 percent 46% 47% 48% 51% 51% 51% 52% 56% 56% 57% 52% Other/Unknown percent 4% 4% 4% 4% 4% 4% 5% 4% 4% 4% 4% White 5,460 5,380 4,968 4,494 4,361 4,406 4,288 4,017 4,065 4,060 4,550 percent 44% 43% 42% 39% 39% 38% 38% 34% 35% 33% 38% Infant Deaths (<1 Year) Infant mortality rate (per 1000) Black deaths Hispanic deaths Other/Unknown deaths White deaths Low Weight Births (<2,500 g) percent 6.9% 6.5% 6.6% 6.6% 6.0% 6.2% 6.1% 6.6% 6.3% 6.5% 6.4% Black Hispanic Other/Unknown White Prenatal Care 1st Trimester 8,853 8,613 8,008 7,985 8,577 8,850 8,700 8,877 8,815 8,930 8,621 percent 71% 68% 67% 69% 76% 77% 76% 76% 75% 73% 73% Black Hispanic 3,795 3,737 3,667 3,883 4,226 4,347 4,261 4,691 4,681 4,774 4,206 Other/Unknown White 4,176 4,025 3,547 3,356 3,510 3,600 3,510 3,325 3,291 3,261 3,

25 Table 1-1. Birth Indicator Data, , Kern County Residents Live Birth* Indicators Year Average Preterm Births (<37 wks) 1,401 1,458 1,304 1,313 1,243 1,383 1,430 1,466 1,442 1,560 1,400 percent 12% 13% 12% 13% 12% 12% 13% 13% 12% 13% 12% Black Hispanic Other/Unknown White Delivery Costs Paid by Medi-Cal 7,208 7,403 7,063 6,940 6,398 6,456 6,368 6,679 6,712 7,277 6,850 percent 58% 59% 59% 60% 57% 56% 56% 57% 57% 60% 58% Black Hispanic 4,438 4,518 4,411 4,483 4,217 4,181 4,227 4,718 4,700 5,084 4,498 Other/Unknown White 1,972 2,083 1,947 1,776 1,527 1,587 1,473 1,357 1,377 1,521 1,662 Mother's Age <20 2,104 2,259 2,201 1,999 1,979 2,000 1,968 2,003 1,852 1,873 2,024 percent 17% 18% 18% 17% 18% 17% 17% 17% 16% 15% 17% Black Hispanic 1,108 1,228 1,300 1,184 1,155 1,163 1,128 1,257 1,151 1,196 1,187 Other/Unknown White Mother 12 Years Education 7,383 7,432 7,120 7,066 6,988 7,376 7,397 7,489 7,437 7,757 7,345 percent 59% 59% 60% 61% 62% 64% 65% 64% 63% 64% 62% Black Hispanic 2,137 2,287 2,278 2,543 2, ,897 3,186 3,210 3,468 2,734 Other/Unknown White 4,310 4,225 3,968 3,647 3,574 3,650 3,577 3,370 3,355 3,382 3,706 Mother U.S. Born 8,468 8,562 8,056 7,643 7,599 7,866 7,686 7,665 7,761 7,970 7,928 percent 68% 68% 67% 66% 67% 68% 68% 66% 66% 65% 67% Black Hispanic 2, ,410 2,517 2,557 2,730 2,667 3,022 3,031 3,216 2,683 Other/Unknown White 5, ,798 4,336 4,224 4,266 4,165 3,847 3,925 3,947 4,

26 Table 1-2. Birth Indicator Data, , Bakersfield Residents 10-Year Live Birth* Indicators Average Mother Bakersfield Resident 7,265 7,541 7,028 6,799 6,769 7,067 6,986 7,223 7,248 7,523 7,145 Low Weight Birth (<2500 g) percent 7% 7% 7% 7% 6% 7% 6% 7% 6% 7% 7% Prenatal Care 1st Trimester 5,091 5,156 4,645 4,657 5,107 5,458 5,345 5,441 5,372 5,322 5,159 percent 70% 68% 66% 68% 75% 77% 77% 75% 74% 71% 72% Preterm Births (<37 weeks) percent 11% 12% 11% 12% 11% 12% 12% 13% 12% 13% 12% Delivery Costs Paid by Medi-Cal 4,066 4,307 4,066 3,990 3,770 3,857 3,711 3,894 3,881 4,164 3,971 percent 56% 57% 58% 59% 56% 55% 53% 54% 54% 55% 56% Mother s age <20 1,260 1,352 1,333 1,219 1,211 1,248 1,200 1,249 1,149 1,127 1,235 percent 17% 18% 19% 18% 18% 18% 17% 17% 16% 15% 17% Mother 12 years education 4,527 4,682 4,436 4,477 4,443 4,860 4,775 4,967 4,845 5,059 4,707 percent 62% 62% 63% 66% 66% 69% 68% 69% 67% 67% 66% Mother U.S. born 5,431 5,639 5,239 5,004 5,022 5,306 5,137 5,212 5,326 5,389 5,271 percent 75% 75% 75% 74% 74% 75% 74% 72% 73% 72% 74% * A live birth is any infant who breathes or shows any other evidence of life (such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles) after separation from the mother s uterus, regardless of the duration of gestation. 1-23

27 Section 2. Deaths in Kern County This next section of the health status report presents data on death in Kern County. This report explores trends in the leading causes of death, the populations that are affected by certain causes of death, and compares Kern County data to California and to the national goals. These data provide important information on mortality patterns among Kern County residents which enable the health community to address issues of premature mortality. The Kern County Department of Public Health and the County Health Officer are the local registrars for deaths as well as births. Death certificate data, similar to birth certificate data, are send to the California State Office of Vital Records and on to the National Center for Health Statistics, within the Centers for Disease Control and Prevention (CDC). Birth and death vital records data are essential to better understand the causes of death in our community, and to evaluate how to best use limited resources to prevent premature death and to prolong high quality life. Death Trends As the population of Kern County has grown, the number of deaths recorded in the County has also increased. In 1993, 4,066 Kern County residents died and in 2002, the number of deaths increased to 4,864. However, to take population changes into account, and to enable comparisons among diverse populations, the age-adjusted mortality rate is calculated. The mortality rate (ageadjusted to the 2000 U.S. standard population) in Kern County has decreased in the past 10 years, from 908/100,000 population in 1993 to 823/100,000 population in The drop in mortality rate was most pronounced among the African American population. Over 10 years, the African American mortality rate fell more than 25%, but remains higher than the mortality rates among the White and Hispanic populations. The leading causes of death have remained relatively consistent among Kern County residents. In the past 5 years ( ), diseases of the heart and cancer have remained the first and second leading causes of death, respectively, accounting for more than 60% of all deaths. Chronic lower respiratory disease, stroke, unintended injuries, and pneumonia/influenza each account for between 5% and 8% of deaths yearly. Diabetes, chronic liver disease, suicide, Alzheimer s disease, and homicide have each ranked in the ten leading causes of death in recent years and account for 1-3% of deaths annually. Looking at the leading causes of death more closely, it is apparent that there is great potential to reduce mortality in our communities. Many of the leading causes of death are associated with known health risk behaviors, including tobacco use, obesity/overweight, poor nutrition, and lack of physical activity. Improving healthy lifestyles among Kern County residents may reduce premature mortality and may reduce the disease burden from chronic diseases. Community-wide efforts to promote daily physical activity, balanced and proportioned eating, and healthy weight are required to address these pressing public health concerns. 2-1

28 Figure 2-1. All Cause Age-adjusted Mortality Rate, by Race/Ethnicity, Kern County Residents, , ,200.0 Rate per 100,000 population 1, Kern County Black 1, , , , , , , ,007.7 Hispanic White Figure 2-2. Leading Causes of Death, Kern County Residents, % 2% 2% 1% 1% 5% 8% 7% 8% 38% Diseases of the heart All cancers Chronic lower resp. diseases Stroke Unintended injuries Pneumonia and influenza Diabetes Chronic liver disease Suicide Alzheimer's disease Homicide 25% 2-2

29 Coronary Heart Disease What is it? Heart disease is the leading cause of death for all people in the United States. Coronary heart disease (CHD) accounts for the largest proportion of heart disease. About 12 million people in the United States have CHD. 1 The lifetime risk for developing CHD is very high in the United States: one of every two males and one of every three females aged 40 years and under will develop CHD sometime in their life. Heart disease continues to be major cause of disability and contributes significantly to high health care costs in the United States. Coronary heart disease, a category which includes heart attack, atherosclerosis, and other chronic heart diseases, is characterized by a reduced flow of blood to the heart muscle. If enough oxygen-carrying blood does not reach the heart, the heart may respond with pain in the chest, called angina. If the blood supply is cut off completely, the result is a heart attack, also called acute myocardial infarction. Healthy People 2010 National Objective Reduce coronary heart disease deaths 166 deaths per 100,000 population* * Age-adjusted to the 2000 U.S. standard population. How has this disease changed over time? The coronary heart disease death rate in the U.S. has declined substantially over the past 20 years, yet remains the leading cause of death in the United States, California, and Kern County. During , 11,174 Kern County residents died from CHD. CHD is consistently the leading cause of death in Kern County. The age-adjusted death rate was at a low of deaths per 100,000 population in There was not a clear upward or downward trend in the mortality rates over the past 10 years in Kern County. The 10-year average mortality rate for Kern County residents was per 100,000. Mortality rates vary among different populations in Kern County. While CHD death rates have shown no decline among the different populations during this time period, the age-adjusted mortality rate among the African American population remains higher than the rates among the White and Hispanic populations. Throughout the country, African American populations have higher CHD mortality rates. The numbers in Kern County appears to be making progress in narrowing this gap, but the relatively small numbers make annual comparisons difficult. Comparing 5-year intervals ( , ), the mortality rate among African Americans dropped from 292 to 265 per 100,000, while rates stayed consistent or increased among Whites and Hispanics. Gender differences also exist in CHD mortality rates, with men experiencing consistently higher death rates than women more than 25% higher between 1993 and However, heart disease remains the largest killer of women as well as men. CHD is primarily a disease of the elderly, with the age-specific mortality rate nearly 5,000 per 100,000 population in the 85 years and older age group. 2-3

30 Why is it important? Primary prevention of coronary heart disease and improved access to effective treatment services will be cornerstones to further reductions in mortality and morbidity due to CHD. Individual risk factors associated with CHD include cigarette smoking, high blood cholesterol, high blood pressure, diabetes, obesity, poor nutrition, and physical inactivity. Other nonmodifiable risk factors exist as well, including gender, age, and family history or genetics. Screening tests for risk factors, particularly for high blood pressure and high blood cholesterol, are important tools for identifying individuals at increased risk. Along with the pharmacological therapies available, behavior and lifestyle factors must be emphasized, particularly healthy diet and consistent physical activity. While the prevalences of pharmacologically treatable risk factors (high blood pressure and high blood cholesterol) have been decreasing, overweight and obesity prevalence has been increasing in the U.S. population. 1 Primary prevention needs to be initiated early in life. Many risk factors are present by adolescence, including atherosclerosis, hypertension, overweight/obesity, low physical activity, poor dietary habits, and tobacco use. Physical activity is especially helpful in lowering the prevalence of CHD in both older and younger populations. Developing and maintaining aerobic exercises and endurance, joint flexibility, and muscle strength are important in a comprehensive exercise program, especially as people age. Adherence to regular exercise and training in both male and female elderly populations is high. In addition to the physical benefits of exercise, both short-term exercise and long-term aerobic exercise training are associated with improvements in various indexes of psychological functioning. Cross-sectional studies reveal that, compared with sedentary individuals, active persons are more likely to be better adjusted socially, to perform better on tests of cognitive functioning, to exhibit reduced cardiovascular responses to stress, and to report fewer symptoms of anxiety and depression. Exercise also improves self-confidence, self-esteem, and attenuates cardiovascular and neurohumoral responses to mental health. Introducing exercise to children will instill the awareness of the need for life-long regular physical exercise in our daily lives. The long-term effects of this training include fewer people with life threatening illnesses like heart disease, reduced cost for health care services, and increased worker productivity. 2-4

31 Table 2-1. CHD Deaths, by Gender and Race/Ethnicity, Kern County, Year Total 1, ,024 1,027 1,035 1,133 1,263 1,175 1,215 1,319 Male Female Black Male Female Hispanic Male Female White ,020 Male Female Figure 2-3. Age-adjusted CHD Mortality Rates, by Race/Ethnicity, Kern County Residents, Healthy People 2010 Objective: 166/100,000 Rate per 100,000 population Kern County Black Hispanic White

32 Figure 2-4. Age-adjusted CHD Mortality Rates, by Gender, Kern County Residents, Rate per 100,000 population Male Female Figure 2-5. Age-specific CHD Mortality Rates, by Gender, Kern County Residents, ,000.0 Rate per 100,000 population 4, , , ,000.0 Male Female All Male , ,490.9 Female , ,982.7 All , ,808.1 Age group 2-6

33 Cancer What is it? Cancer is not a single disease; rather it is a term that comprises over 100 diseases each with its own clinical presentation and survival rate. Cancer is the second leading cause of death throughout the United States. Cancer occurs when normal cells in the body grow out of control. In most types of cancer, cells form a lump or mass called a tumor. Some tumors are benign and are not life-threatening, while others are considered malignant because they can break away, invading and damaging nearby tissues and organs. The lung and bronchus, prostate, female breast, and colon and rectum are the most common cancer sites. Healthy People 2010 National Objective Reduce the overall cancer death rate deaths per 100,000 population* * Age-adjusted to the 2000 U.S. standard population. How has this disease changed over time? A total of 9,626 Kern County residents died from cancer between the years 1993 and During the last ten years, the all-cancer age-adjusted mortality rate has not appreciably changed among Kern County residents. However, it appears that Kern County may be following California s general downward trend. The average mortality rate during in Kern County was per 100,000 population, comparable to California s average of 185.0/100,000. Cancer primarily affects older populations, with age-specific mortality rates strikingly higher in older populations. Cancer mortality rates also vary among different race/ethnicity groups. Throughout the country, African American populations have higher cancer mortality rates than other populations. However, this difference is less pronounced in Kern County than elsewhere in the country. Why is it important? Roughly 1,334,100 people in the United States will be diagnosed with cancer in Only heart disease kills more people each year than cancer. The National Institutes of Health estimate that the overall costs of cancer in 2002 were nearly $172 billion, including direct medical costs, and indirect morbidity and mortality costs. 2 The national goal is to reduce the number of new cancer cases as well as the illness, disability, and death caused by cancer. Many of our cancer goals are achievable through helping people make better lifestyle choices. Scientific evidence suggests that approximately two-thirds of cancer deaths in 2003 will be related to tobacco use, poor nutrition, lack of physical activity, obesity, and other lifestyle factors. 2 Prevention, early detection, and effective treatment are essential health strategies that should be employed to ensure the continued reduction in the overall death rate from cancer in Kern County. Some of the differences in death rates may be attributed to risk factors such as cigarette smoking and dietary behavior. However, deaths from cancer can also be prevented by proper access to effective treatment. Adequate access to health care services, which include screening and treatment services, is critical to reducing the rate of death from cancer. 2-7

34 Table 2-2. All Cancer Deaths, by Gender and Race/Ethnicity, Kern County, Year Total , ,066 1,041 Male Female Black Male Female Hispanic Male Female White Male Female Figure 2-6. Age-adjusted All Cancer Mortality Rates, Kern County and California Residents, Healthy People 2010 Objective: 158.7/100,000 Rate per 100,000 population * Kern County California * 2002 California data not available. 2-8

35 Figure 2-7. Age-specific All Cancer Mortality Rates, by Gender, Kern County Residents, ,600.0 Rate per 100,000 population 1, , , Male Female All Male , ,578.6 Female All , ,149.9 Age group Figure 2-8. Age-adjusted All Cancer Mortality Rates, by Race/Ethnicity, Kern County Residents, Rate per 100,000 population Kern County Black Hispanic White

36 Female Breast Cancer What is it? Female breast cancer is a disease caused by an uncontrolled growth of abnormal cells in the breast tissue. In the early stages, breast cancer may reside in the breast as a tiny nodule or lump. In later stages, some cells from the lump spread or metastasize to other parts of the body such as the lung, brain, liver, or bones, and cause tumors to grow in these other tissues and organs. Healthy People 2010 National Objective Reduce the breast cancer death rate 22.2 deaths per 100,000 population* * Age-adjusted to the 2000 U.S. standard population. How has this disease changed over time? During , 722 Kern County women died from breast cancer. The age-adjusted death rate in Kern County for female breast cancer has ranged from a high of 31.3 per 100,000 women in 1996 to a low of 22.3 per 100,000 in There was a slight downward trend in California over this time period and a similar trend in Kern County, though not as clear. Breast cancer mortality was higher among African American women (10-year average: 43.1/100,000) than for White women (10-year average: 29.3/100,000) or Hispanic women (10- year average: 11.6/100,000). While 1 in 8 women may develop breast cancer over the course of their lives, breast cancer typically affects older women more than half of breast cancer deaths were among women over 65 years. Why is it important? Breast cancer is the most frequently diagnosed cancer among women in the United States, and is the second leading cause of cancer death among women. The American Cancer Society estimates that in 2004, 215,990 new breast cancer cases will be diagnosed among women and 40,100 women will die from this disease. 2 Although there have been recent debates in the scientific community over the benefits of mammography, the National Cancer Institute and the American Cancer Society continue their recommendation of regular mammograms to screen for early breast cancer. Screening and early detection can save lives, particularly among women over the age of 40. There is a marked increase in age specific death rates for women beyond the age-group of A woman s risk for breast cancer continues to increase over her lifetime. More than 90% of all breast cancer deaths occur in women over age 44. There are some external factors a person can control to minimize the risk of developing breast cancer. Limiting the use of alcohol, following a healthy diet, exercising regularly, and maintaining a healthy weight may reduce the risk of developing breast cancer. Death from breast cancer can be reduced substantially if the tumor is discovered early. Screening (breast self exams, breast exams by a health care provider, and mammography) is the best available method to detect breast cancer in the earliest, most treatable stage. When breast cancer is diagnosed early and confined to the breast tissue, the 5-year survival rate is 96%. If the disease is diagnosed after it has spread or metastasized to other tissues and organs, the 5-year survival rate decreases to 21%. 2-10

37 Table 2-3. Female Breast Cancer Deaths, by Race/Ethnicity, Kern County Residents, Year Total Black Hispanic White Figure 2-9. Age-adjusted Female Breast Cancer Mortality Rates, Kern County and California Residents, Rate per 100,000 population Healthy People 2010 Objective: 22.2/100, * Kern County California * 2002 California data not available. 2-11

38 Figure Age-adjusted Female Breast Cancer Mortality Rates, by Race/Ethnicity, Kern County Residents, Rate per 100,000 population Kern County Black* Hispanic* White * Numbers too small for reliable rates. Figure Age-specific Female Breast Cancer Mortality Rates, Kern County, Rate per 100,000 population Female Age group 2-12

39 Colorectal Cancer What is it? Colorectal cancer is a slow-growing cancer that affects the lining of the colon and/or the rectum. Symptoms can include blood in the stool, a change in bowel habits (diarrhea, then constipation, then diarrhea again), pencil-thin stools, cramping, full feeling in the rectum, weight loss, fatigue, and pain. In many cases, colorectal cancer can be prevented through timely screening and removal of precancerous polyps. Healthy People 2010 National Objective Reduce the colorectal cancer death rate 13.9 deaths per 100,000 population* * Age-adjusted to the 2000 U.S. standard population. How has this disease changed over time? During , a total of 906 Kern County residents died from colorectal cancer. The age-adjusted mortality rate in Kern County for colorectal cancer has not changed markedly over this time period. In fact, the rate has increased from 13.7 per 100,000 population in 1998 to 19.0 per 100,000 in The 10-year average age-adjusted colorectal cancer mortality rate was 17.3 per 100,000 in Kern County, slightly lower than California s average of 18.5 per 100,000. Given the small numbers, it is difficult to compare the annual mortality rates among Kern s different race/ethnicity groups. On average, though, African Americans (23.2/100,000) had higher colorectal cancer mortality rates than Whites (18.2/100,000). The Hispanic population had the lowest risk of colorectal cancer mortality (14.0/100,000). The risk of developing colorectal cancer increases with advancing age. Approximately 97% of all deaths due to colorectal cancer in Kern County are in residents aged 45 years and older. For this reason, colorectal cancer screening is recommended for all people 50 years and older. Colorectal cancer screening (e.g., flexible sigmoidoscopy or colonoscopy) is unique in that it can both screen for and prevent colorectal cancer. Given that Kern County s colorectal cancer mortality rate has been increasing in the past several years, promotion of colorectal screening is an excellent opportunity to reverse that trend. It has been estimated that colorectal cancer mortality could be decreased by more than 60% if screening was more universally utilized. 3 Why is it important? The American Cancer Society estimates that in 2004, 146,940 new colorectal cancer cases will be diagnosed and 56,730 people will die from this disease. 2 The stage at diagnosis how far the cancer has spread strongly affects survival in colorectal cancer patients. When the disease is diagnosed at an advanced stage, death rates are extremely high: approximately 95% of patients will die within 5 years. However, survival rates improve dramatically when the cancer is diagnosed in its earlier stages (30% mortality within 5 years). Two primary factors affecting colorectal cancer are diet and early detection. Low fruit and vegetable intake, a low-fiber and high-fat diet, obesity, and alcohol consumption are risk factors associated with this disease. Reducing the number of deaths from colorectal cancer chiefly depends on detecting and treating it in its early stages. Precancerous polyps may be present in the colon for years. Identifying and removing these polyps through screening can actually prevent colorectal cancers before invasive cancer develops. Promoting colorectal cancer screening clearly presents an opportunity to improve the health of Kern County s residents. 2-13

40 Table 2-4. Colorectal Cancer Deaths, by Gender and Race/Ethnicity, Kern County Residents, Year Total Male Female Black Male Female Hispanic Male Female White Male Female Figure Age-adjusted Colorectal Cancer Mortality Rates, Kern County and California, Healthy People 2010 Objective: 13.9/100,000 Rate per 100,000 population * Kern County California * 2002 California data not available. 2-14

41 Figure Age-adjusted Colorectal Cancer Mortality Rates, by Race/Ethnicity, Kern County Residents, Rate per 100,000 population Kern County Black* Hispanic* White * Numbers too small for reliable rates. Figure Age-specific Colorectal Cancer Mortality Rates, by Gender, Kern County Residents, Rate per 100, Male Female All Male Female All Age group 2-15

42 Lung Cancer What is it? Lung cancer is caused by malignant growth of abnormal cells in the lungs. The uncontrolled growth may appear in the trachea, air sacs, and other lung tissue. It may appear as an ulcer in the windpipe, as a nodule or small-flattened lump, or on a surface blocking air flow. It may extend into the lymphatic system and into blood vessels. The abnormal cells may no longer do the work of normal cells, instead crowding out and destroying healthy tissue. Lung cancer is the leading cause of cancer death among men and women in the United States. Ninety percent of lung cancer occurs in people who smoke or who have smoked. Other factors that increase the risk of lung cancer death include family history, exposure to radon, and air pollution. With current diagnostic tests, lung cancer is usually undetectable until later stages of disease. When symptoms occur, the cancer is often in an advanced stage. Symptoms of lung cancer include chronic cough, coughing up blood, shortness of breath, wheezing, and chest pain. Healthy People 2010 National Objective Reduce the lung cancer death rate 44.9 deaths per 100,000 population* * Age-adjusted to the 2000 U.S. standard population. How has this disease changed over time? A total of 2,838 Kern County residents died from lung cancer during the years The age-adjusted mortality rate varied during this 10 year period from a high of 62.1 per 100,000 population in 1995 to a low of 44.9 per 100,000 in The average age-adjusted death rate in the last ten years was 54.1 per 100,000, slightly higher than California s average of 48.7 per 100,000. Kern County remains close to achieving the Healthy People 2010 goal, and continued tobacco prevention and cessation programs will return Kern County to heading in the right direction. Following changes in cigarette use patterns decades ago, when women began to smoke in numbers similar to men, the gender differences historically seen in the rates of lung cancer deaths are diminishing. More than half (57%) of lung cancer deaths during were among Kern County men. However, in this time period, mortality rates among males showed a general decline, while rates among females did not appreciably change. Why is it important? Lung cancer is the leading cause of cancer death in Kern County, California, and the U.S. Nationwide, an estimated 173,770 new lung cancer cases will be diagnosed in 2004, and there will be 160,440 deaths from lung cancer. 2 Smoking is the number one preventable cause of lung cancer. The more and longer someone smokes, the greater the risk of developing lung cancer. If smoking is stopped, the risk of cancer decreases steadily each year, as normal cells rapidly replace abnormal cells. Thus, smoking prevention and cessation programs can have a significant long term effect on a community s lung cancer mortality. 2-16

43 Table 2-5. Lung Cancer Deaths, by Gender and Race/Ethnicity, Kern County Residents, Year Total Male Female Black Male Female Hispanic Male Female White Male Female Figure Age-adjusted Lung Cancer Mortality Rates, by Gender, Kern County and California, Healthy People 2010 Objective: 44.9/100,000 Rate per 100,000 population * California male California female Kern male Kern female * 2002 California data not available. 2-17

44 Figure Age-adjusted Lung Cancer Mortality Rates, by Race/Ethnicity, Kern County Residents, Rate per 100,000 population Kern County Black* Hispanic* White * Numbers too small for reliable rates. Figure Age-specific Lung Cancer Mortality Rates, by Gender, Kern County Residents, Rate per 100,000 population Male Female All Male Female All Age group 2-18

45 Prostate Cancer What is it? The prostate is a small gland in the male reproductive system, found below the bladder, behind the pelvis and in front of the rectum. It makes a fluid that mixes with sperm from the testes. Prostate cancer occurs when cells in the prostate grow out of control, adhere to each other and form a malignant tumor. Most prostate cancers have no symptoms, although some men with prostate cancer have the symptomatic problem of slow and painful urination. Healthy People 2010 National Objective Reduce the prostate cancer death rate 28.8 deaths per 100,000 population* * Age-adjusted to the 2000 U.S. standard population. How has this disease changed over time? During , a total of 545 Kern County men died of prostate cancer. The age-adjusted death rate in Kern County for prostate cancer varied from a low of 18.0 per 100,000 population in 2000 to 32.7 per 100,000 in The average age-adjusted prostate cancer mortality rate during this time period was 25.8 per 100,000 in Kern County lower than California s average of 30.4 per 100,000. Prostate cancer is most common among men age 65 years or older. Roughly 80% of all men diagnosed with prostate cancer are in this population. In Kern County, deaths due to prostate cancer have been exclusively among men aged 45 and older. Throughout the country, African American men have higher prostate cancer incidence and mortality rates than men in other racial/ethnic groups. This trend was also seen in Kern County, where the 10-year average for African American males was more than twice the rate of the whole County (60.1/100,000 vs. 25.8/100,000). Why is it important? Prostate cancer is the most commonly diagnosed form of cancer in men. Prostate cancer is second only to lung cancer as the leading cause of cancer death among men in the U.S. The American Cancer Society estimates that 230,110 new cases of prostate cancer will be diagnosed nationwide in 2004 and that approximately 29,900 men will die of the disease. 2 The causes of prostate cancer are largely unknown, but factors such as hormones, family history, race/ethnicity, and nutrition seem to play major roles. Preventable risk factors for prostate cancer are not fully understood, and effective measures to prevent this disease have not been determined. However, there is some evidence of an association between diets high in fat and the occurrence of prostate cancer. It has been suggested that men can lower the risk for prostate cancer by cutting back on food high in animal fat (red meat, processed meat, cheese, and other full fat dairy products), and by eating more tomato-based foods (like pasta or pizza with tomato sauce). Recommended screening may begin at age 50. Methods available for detecting prostate cancer include digital rectal examination, prostate-specific antigen measurement, and a prostatic ultrasound. However, controversy remains over the benefits and potential risks of screening, diagnosis, and treatment, so research continues in this area. 2-19

46 Table 2-6. Prostate Cancer Deaths, by Race/Ethnicity, Kern County, Year Total Black Hispanic White Figure Age-adjusted Prostate Cancer Mortality Rates, Kern County and California, Rate per 100,000 population Healthy People 2010 Objective: 28.8/100, * Kern County California * 2002 California data not available. 2-20

47 Figure Age-adjusted Prostate Cancer Mortality Rates, by Race/Ethnicity, Kern County Residents, Rate per 100,000 population Kern County Black* Hispanic* White * Numbers too small for reliable rates. Figure Age-specific Prostate Cancer Mortality Rates, Kern County Residents, Rate per 100,000 population Male Age group 2-21

48 Stroke What is it? A stroke occurs when the brain does not get sufficient blood, and brain tissue is damaged as a result. The mechanism for stroke is typically a blood vessel bringing oxygen and nutrients to the brain bursting or becoming clogged by a blood clot or some other particle. Stroke, or cerebrovascular accident (CVA), is the third leading cause of death among adults in the U.S., and it is a leading cause of disability. An estimated 600,000 strokes occur annually in the United States resulting in 158,000 deaths. 1 Healthy People 2010 National Objective Reduce stroke deaths 48 deaths per 100,000 population* * Age-adjusted to the 2000 U.S. standard population. How has this disease changed over time? During , a total of 2,881 Kern County residents died of stroke. The age-adjusted stroke mortality rate ranged from 66.6 per 100,000 population in 1995 to 48.8 in The ten year average was 56.5 per 100,000. As with coronary heart disease, disparities among racial and ethnic populations exist. African American populations throughout the country experience higher stroke mortality rates than other groups. This trend is also seen in Kern County where the average mortality rate for African Americans (76.2 per 100,000) was notably higher than that of White (59.7 per 100,000) and Hispanic (45.6 per 100,000) populations. Unlike CHD, the difference between genders is not as marked in stroke. The ten year average for women (57.0 per 100,000) was slightly higher than that for men (54.3 per 100,000). Why is it important? It is estimated that for every stroke death in Kern County there are approximately six stroke survivors. This equates to approximately 1,700 stroke survivors in Kern County every year. Many stroke survivors are rendered severely disabled from the damage to the brain sustained during the stroke. The disabling consequences of stroke include paralysis, blindness, loss of the ability to speak, loss of the ability to understand speech, loss of bowel and bladder control, and persistent vegetative states. Stroke frequently leads to a severe loss of independence often resulting in long-term institutionalization. Stroke has similar risk factors as CHD, including high blood pressure, smoking, little physical exercise, and poor diet habits. Primary prevention for both stroke and CHD provides the opportunity to dramatically improve the lives of many Kern County residents through enhanced quality of life and increased life expectancies. In addition, primary prevention of these diseases can significantly decrease health expenditures, making prevention programs cost-effective opportunities for the County and throughout the country. 2-22

49 Table 2-7. Stroke Deaths, by Gender and Race/Ethnicity, Kern County, Year Total Male Female Black Male Female Hispanic Male Female White Male Female Figure Age-adjusted Stroke Mortality Rates, by Race/Ethnicity, Kern County Residents, Healthy People 2010 Objective: 48/100,000 Rate per 100,000 population Kern County Black* Hispanic* White * Numbers too small for reliable rates. 2-23

50 Figure Age-adjusted Stroke Mortality Rates, by Gender, Kern County Rate per 100,000 population Male Female Figure Age-specific Stroke Mortality Rates, by Gender, Kern County ,400.0 Rate per 100,000 population 1, , Male Female All Male ,021.2 Female ,266.4 All ,179.8 Age group 2-24

51 Chronic Lower Respiratory Diseases What is it? Chronic lower respiratory diseases (CLRD), also known as chronic obstructive pulmonary disease (COPD), include emphysema and bronchitis. These diseases result in a decreased ability of the lungs to perform their function of ventilation, which provides the body with necessary oxygen. Most cases of CLRD are caused by smoking (80-90%). 4 Early symptoms or warning signs are unique to each person. Difficulty in breathing may be accompanied by a chronic cough, ankle swelling, forgetfulness, fatigue, increasing morning headaches, and dizzy spells. Healthy People 2010 National Objective Reduce deaths from COPD/CLRD among adults 60 deaths per 100,000 population* * Age-adjusted to the 2000 U.S. standard population. How has this disease changed over time? During , 2,657 Kern County residents died of CLRD. The age-adjusted mortality CLRD rate for in Kern County has ranged from a high of 60.3 deaths per 100,000 population in 1999 to a low of 42.5 per 100,000 in The average age-adjusted rate for this time period was 50.7 deaths per 100,000. In the United States, CLRD is the only major disease that is rising in prevalence and mortality; while all other major causes of death are declining. Although Kern County is currently below the Healthy People 2010 goal for CLRD deaths, continued smoking prevention efforts will be needed to combat the rising CLRD burden. Why is it important? In Kern County, CLRD is the fourth leading cause of death. Prevalence and mortality have been increasing in contrast to many leading chronic diseases. As life expectancy increases, greater prevalence and mortality from CLRD are likely. It will be important for patients to work with health care providers to determine the appropriate treatment steps for signs and symptoms of respiratory difficulty. The principal modifiable risk factor for CLRD is cigarette smoking. An estimated 82% of CLRD mortality is attributable to smoking. Other documented causes of CLRD include occupational dusts and chemicals. None of the existing treatments for CLRD have been shown to modify the long-term decline in lung function that characterizes this disease. Therefore, drug treatments for CLRD are used primarily to decrease symptoms and complications of the disease. 2-25

52 Table 2-8. CLRD Deaths, by Gender and Race/Ethnicity, Kern County Residents, Year Total Male Female Black Male Female Hispanic Male Female White Male Female Figure Age-adjusted CLRD Mortality Rates, by Race/Ethnicity, Kern County Residents, Healthy People 2010 Objective: 60/100,000 Rate per 100,000 population Kern County Black* Hispanic* White * Numbers too small for reliable rates. 2-26

53 Figure Age-specific CLRD Mortality Rates, by Gender, Kern County Residents, Rate per 100,000 population 1, , , Male Female All Male ,021.2 Female ,266.4 All ,179.8 Age group 2-27

54 Unintentional Injuries What are they? Unintentional injuries are listed by the U.S. Centers for Disease Control and Prevention as the leading cause of death in the United States for people aged Each year, more than 90,000 people die in the U.S. as the result of unintentional injuries. 1 Categories of unintentional injuries include deaths due to motor vehicle crashes (MVC), as well as home and recreation related injuries such as drownings, fires, falls, poisonings, and firearm discharges. Healthy People 2010 National Objective Reduce deaths caused by poisonings 1.5 deaths per 100,000 population* Reduce deaths caused by motor vehicle crashes 9.2 deaths per 100,000 population* Reduce residential fire deaths 0.2 deaths per 100,000 population* Reduce deaths from falls 3.0 deaths per 100,000 population* Reduce drownings 0.9 deaths per 100,000 population* * Age-adjusted to the 2000 U.S. standard population. How has this disease changed over time? During , 2,625 Kern County residents died of unintentional injuries. In Kern County, the age-adjusted mortality rate due to unintentional causes has not appreciably changed since 1993, with a ten year average of 43.3 deaths per 100,000 population. Unlike other areas of the country, Kern County does not have striking disparities among different racial/ethnic populations. However, there are marked gender differences in unintentional injury deaths, with average mortality rates for men more than twice that of women. Motor vehicle crashes are the leading cause of injury death in Kern County. Motor vehicle crashes account for an average of 45% of all unintentional injury deaths, or roughly 117 deaths annually. In Kern County, unintentional poisoning is the leading cause of injury deaths among people aged Nearly half of all deaths due to unintentional poisoning occur among people in this age group. Most unintentional poisonings are associated with legal and illegal drugs. 2-28

55 During , an average of 60 Kern County residents died each year due to unintentional poisoning. Falls are the leading cause of injury deaths among people 65 years and older. During , more than 70% of deaths due to falls occurred in Kern County residents over the age of 65. Among older adults, falls are the most common cause of injuries and hospital admissions for trauma. Drowning is the second leading cause of death among children aged 1-14 after motor vehicle crashes. During , more than 30% of all drownings occurred in Kern County children under 15 years old. More than 75% of all drowning victims are male. Why is it important? To further reduce the number of deaths due to unintentional injuries, prevention activities must focus on the type of injury. Programs that advocate an increase in the use of safety belts and child restraints can reduce motor vehicle deaths. Working smoke alarms can reduce the risk of death in a residential fire by 40%-50%. Understanding injuries allows for development and implementation of effective prevention interventions. Most injuries are predictable and preventable. By prioritizing the Healthy People 2010 objectives there is an opportunity to improve the lives of Kern County residents by decreasing the preventable morbidity and mortality associated with unintentional injuries. Figure Age-adjusted Unintentional Injury Mortality Rates, by Race/Ethnicity, Kern County Residents, Rate per 100,000 population Kern County Black* Hispanic White * Numbers too small for reliable rates. 2-29

56 Figure Age-adjusted Unintentional Injury Mortality Rates, by Gender, Kern County Residents, Rate per 100,000 population Male Female Figure Deaths from Unintentional Injuries, by Cause, Kern County Residents, Number of Deaths MVC Poisoning Fall Drowning Fire Firearm

57 Figure Deaths Due to MVC, by Age Group, Kern County Residents, Number of Deaths < Age group Figure Deaths Due to Falls, by Age Group, Kern County Residents, Number of Deaths < Age group 2-31

58 Figure Deaths Due to Drowning, by Age Group, Kern County Residents, Number of Deaths < Age group Figure Deaths Due to Poisoning, by Age Group, Kern County Residents, Number of Deaths < Age group 2-32

59 Figure Age-adjusted Mortality Rates, Kern County ( ) and Healthy People 2010 Objectives 20.0 Rate per 100,000 population MVC Falls Poisoning Drowning Fire Kern County HP 2010 goal

60 Notes: ICD Codes used for mortality rates (ICD-9 for , ICD-10 for ): Heart disease: ; I20-I25 All cancer: ; C00-C97 Breast cancer: ; C50 Colorectal cancer: ; C18-C21 Lung cancer: 162; C33-C34 Prostate Cancer: 185; C61 Stroke: ; I60-I69 COPD/CLRD: ; J40-J44 Unintentional Injuries (all): E ; V01-X59, Y85-Y86 Motor vehicle crashes: E ; groups Poisonings: E ; X40-X49 Falls: E ; W00-W19 Fires: E ; X00-X09 Drownings: E910; W65-W74 Firearms: E922; W32-W34 Unless otherwise noted, all mortality rates are age-adjusted to the 2000 U.S. standard population. References: Unless otherwise noted, data sources are: Kern County Department of Public Health, Epidemiology and Vital Statistics Section; California Department of Health Services, Center for Health Statistics; and National Center for Health Statistics. 2-1 U.S. Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. 2nd ed. Washington, DC: U.S. Government Printing Office, November American Cancer Society. Cancer Facts & Figures Frazier AL, Colditz GA, Fuchs CS, Kuntz KM. Cost-effectiveness of screening for colorectal cancer in the general population. JAMA. 2000;284(15): American Lung Association. Chronic Obstructive Pulmonary Disease Fact Sheet. March

61 Section 3. Communicable Diseases This third section will address the disease burden in Kern County from communicable, or infectious, diseases. While many of these illnesses, such as food-borne diseases, rarely cause death in developed countries, the economic costs of missed work, physician s visits, and hospitalizations can be substantial. The California Code of Regulations defines a selected list of diseases and conditions that physicians are required, by law, to report to the local health authority (Kern County Department of Public Health). The reporting times vary depending on the severity of the disease and the risk of a public health emergency arising from the spread of the disease. Diseases requiring immediate attention, such as anthrax, plague, and yellow fever are to be reported immediately. Diseases that need urgent, but not immediate, attention, such as measles, pertussis, and poliomyelitis must be reported within one working day. The remaining diseases, such as Lyme disease, tetanus, and coccidioidomycosis (Valley Fever) must be reported within seven calendar days. A complete list of reportable diseases can be found in Appendix II. Trends among disparate diseases showed a variety of patterns in Cases of some diseases, such as AIDS and gonorrhea fell from 2002 to Several of the foodborne illnesses that are tracked, including salmonellosis and shigellosis, remained steady. Increases in case numbers were seen in the diseases that are most frequently reported, chlamydia, hepatitis C, and coccidioidomycosis. Overall the number of cases of disease reported to Kern County has been increasing, but this does not necessarily mean that Kern County residents are getting sicker. This increase could be the result of more complete reporting by physicians and laboratories, since it is well-established that most communicable diseases are under-reported meaning that more cases occur in the population than are counted by local health departments. Figure 3-1. Cases of Reportable Diseases Submitted to the Kern County Department of Public Health 10,000 8,000 Number of cases 6,000 4,000 2, Cases 6,128 5,411 5,975 6,273 6,438 6,539 8,609 8,309 9,

62 Coccidioidomycosis What is it? Coccidioidomycosis (CM), often referred to as Valley Fever or San Joaquin Valley Fever, is one of the most studied and oldest known fungal infections. This disease, which is capable of affecting both humans and animals is caused by inhalation of arthroconidia (spores) of the fungus Coccidioides immitis (CI). CI spores are found in the top few inches of soil in the hillsides of the San Joaquin Valley. CM can not be spread from person to person. Roughly 60% of individuals infected with CI have no symptoms. For the remaining 40%, a wide clinical spectrum of symptoms exists. The most common presentation of CM is a mild, influenza-like illness while the more severe includes pneumonia-like symptoms requiring rest and medication. In approximately 1% of infected persons, disseminated disease develops. This spreading of CI infection beyond the lungs can be fatal. Infected individuals who have recovered, generally will be resistant to later infection, although reoccurrence as a result of immunosuppression is possible. CM varies with the season. The highest incidence of this disease usually occurs in late summer and early fall when the soil is dry and the crops are harvested. If there is rain during the peak season of disease transmission, an unusual event in Kern County, the disease incidence has been noted to decline. Outbreaks frequently follow wind and dust storms in Kern County and throughout California s Central Valley. How has this disease changed over time? Between 1991 and 1994, Kern County experienced an epidemic of CM. The epidemic was attributed to a number of factors including: a five year drought preceding the epidemic years, heavy precipitation in the winter and spring months, sustained wind, and a large susceptible population. In 1990, the Kern County incidence rate of reported CM was 50 cases per 100,000 population. During the peak of the epidemic, the incidence rate rose to 567 per 100,000. From , reported cases of CM dropped, yielding an average annual incidence rate of 63 per 100,000. In , reported cases increased, with an average incidence rate of 156 per 100,000. CM cases occur throughout Kern County, but certain areas of the county clearly experience a heavier CM disease burden. In addition, differences in the incidence rates in racial/ethnic populations are observed. The White population generally has the lowest incidence rates, while African American and Hispanic rates are considerably higher. There are also variations in a person s ability to respond once infected. People of African, Filipino and some other Asian ancestries seem to be at a greater risk of contracting the disseminated form of the disease

63 Why is it important? Coccidioidomycosis is of public health importance for a variety of reasons. There is currently no vaccine available to prevent this infection. Since Kern County is one of the fastest growing counties in California, there will continuously be a new group of residents moving into the area that are susceptible to this infection. It is estimated that a non-immune person living in Kern County has approximately a 1-2% chance (per year) of becoming infected with CM. The existence of the fungus in most soil areas is temporary. There is no effective way to detect and monitor CM growth patterns in the soil. Thus, controlling the growth of the fungus in the environment to reduce the risk to individuals is currently not a viable option. Though severe CM is uncommon, and symptomatic infection often resolves without therapy, many patients are ill for weeks to months. In Kern County, the epidemic was estimated to cost more than $66 million. Furthermore, older persons and persons with compromised immune systems, including pregnant women, people living with HIV and AIDS, people undergoing cancer chemotherapy, and organ transplant recipients, are at increased risk of serious illness. Figure 3-2. Reported Coccidioidomycosis Cases and Incidence Rates, Kern County, , Number of Cases 3,000 2,500 2,000 1,500 1, Rate per 100,000 population Cases 275 1,181 3,342 2,608 1, ,062 1,280 Rate

64 Figure 3-3. Reported Coccidioidomycosis Cases, by Month of Diagnosis, Kern County, Number of Cases avg. 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec avg Figure 3-4. Reported Valley Fever Cases, by Race/Ethnicity, Kern County Residents, ,400 1,200 Number of Cases 1, Unknown White/Other Hispanic Black Asian/Pacific Islander

65 Figure 3-5. Reported Coccidioidomycosis Annualized Incidence Rate (per 100,000 population), by Census Tract, Kern County Residents,

66 Foodborne Illnesses What are they? Foodborne diseases are infections that are acquired as a result of eating foods or drinking water that contain sufficient quantities of illness-causing substances or pathogens. The threats are numerous and varied, both in the pathogens that cause illness and in the foods where the pathogens have been found. In recent years, outbreaks in the U.S. have involved Escherichia coli O157:H7 (in ground beef, apple cider, alfalfa sprouts), Salmonella species (in eggs, poultry, cantaloupe), Cyclospora (in raspberries), Cryptosporidium (in drinking water), and hepatitis A virus (in frozen strawberries). Surveillance for these illnesses has been in place for more than 60 years. Over the past several years, foodborne illnesses have become a growing source of public and media concern. The most common foodborne illnesses reported in the United States are campylobacteriosis, salmonellosis, shigellosis, and hepatitis A virus infection. A wide range of symptoms occurs with these foodborne illnesses. Some of the common symptoms that may occur include intestinal discomfort (cramping), nausea, vomiting, diarrhea, and dehydration. The very young and elderly are the most susceptible to severe outcomes. Fatalities are more likely to occur in these susceptible populations than in other populations. Healthy People 2010 National Objectives Reduction of Campylobacter infections 12.3 per 100,000 Reduction of Salmonella infections 6.8 per 100,000 How have these diseases changed over time? In the ten-year period from 1994 to 2003, the most common bacterial foodborne illnesses in Kern County were campylobacteriosis, salmonellosis, and shigellosis. An annual average of 126 campylobacteriosis, 86 salmonellosis, and 60 shigellosis cases were reported to the Health Department. The annual incidence rates for these diseases varied widely. During the time period, the average campylobacteriosis incidence rate was 19.3 per 100,000 population; the average salmonellosis incidence rate was 13.3 per 100,000; and the average shigellosis incidence rate was 9.5 per 100,000. Bakersfield, on average, accounted for approximately 70% of reported foodborne illnesses, and the incidence rates for Bakersfield were roughly twice the rates of the whole county. This observation is not surprising since approximately two-thirds of Kern County s population resides in the greater Bakersfield area. The incidence rates for Kern County remain above the Healthy People 2010 goals for campylobacteriosis and salmonellosis. There is no specific Healthy People 2010 goal for Shigella infections. 3-6

67 Why is it important? When unreported cases of foodborne illnesses are taken into account, estimates of the disease burden of microorganisms in food grow to 76 million illnesses, 325,000 hospitalizations, and 5,000 deaths each year in the United States. The Department of Agriculture (USDA) estimates that medical costs and productivity losses for 7 specific pathogens in food range between $23 billion and $45 billion annually. 2 Total costs for all foodborne illnesses are likely to be much higher. These estimates do not include the total burden placed on society by the chronic illnesses caused by some foodborne pathogens. Helping to improve food safety is an integral component of public health programs. Food safety should remain a priority, especially with the increasingly globalized food supply, the threat of emerging pathogens, and an increasingly at risk population. An integral part of investigating and reporting cases of foodborne illness is to obtain information regarding the role that various food preparation practices and foods (including water and other beverages) play in spreading intestinal illnesses. This information allows public health professionals to implement prevention strategies and control measures that can better safeguard food, from the farm to the table. Furthermore, data gathered from these investigations can lead to the identification of new and emerging pathogens and can lead to better understanding of the temporal and geographic trends in foodborne illnesses. Figure 3-6. Cases of Selected Reported Foodborne Illnesses, Kern County Residents, Number of Cases Campylobacter cases Salmonella cases Shigella cases

68 Figure 3-7. Incidence Rates of Selected Reported Foodborne Illnesses, Kern County Residents, Rate per 100,000 population Campylobacter rate Salmonella rate Shigella rate Table 3-1. Reported Foodborne Illnesses, Bakersfield and Kern County, Disease Average Incidence Rate 2010 Objective Campylobacter 12.3 Kern Co Bakersfield Salmonella 6.8 Kern Co Bakersfield Shigella Kern Co Bakersfield N/A 3-8

69 Figure 3-8. Reported Foodborne Disease* Annualized Incidence Rates (per 100,000 population), by Census Tract, Kern County Residents, * Salmonellosis, Shigellosis, and Campylobacteriosis only are included. 3-9

70 HIV and AIDS What is it? In 1981, AIDS (acquired immunodeficiency syndrome) was identified in the U.S. Several years later, the human immunodeficiency virus (HIV) was discovered as the causative agent of AIDS. AIDS is identified as a group of infections or conditions which may occur in a person who has been infected with HIV. The infections are the result of HIV gradually compromising the body s immune system. AIDS has been reported in every state in the U.S. and in virtually every race, age, and socioeconomic group. Worldwide, over 42 million people are estimated to be infected with HIV. Almost 30 million of those with HIV live in sub-saharan Africa. 3 Healthy People 2010 National Objectives Reduce AIDS cases among adults and adolescents 1.0 new case per 100,000 population Reduce deaths from HIV infection 0.7 deaths per 100,000 population* * Age-adjusted to the 2000 U.S. standard population. How has this disease changed over time? Since 1981, 1,374 Kern County residents have been diagnosed with AIDS. In this same time period, 519 residents died of AIDS and HIV disease. Kern County saw a sharp increase in the number of new AIDS cases in the community in the early 1990 s. AIDS case data are often analyzed by separating out cases diagnosed in correctional facility inmates from cases diagnosed in the remainder of the population. Cases will be delineated as inmate or community to reflect this separation. Since the early 1990 s, the number of new community cases and the number of deaths from AIDS have gradually decreased. However, there has also been an increase in the number of AIDS cases diagnosed in the prison populations in Kern County. Thus, the County s annual reported AIDS case numbers have remained relatively stable. In the beginning of the epidemic in the early 1980 s, AIDS was recognized as a disease occurring predominantly among White males, whose primary reported risk factor was sex with men. Since the late 1980 s, this trend has changed. Between 1989 and 1996, the majority of cases were still among White residents, but substantial numbers of AIDS cases among minority populations were diagnosed each year. From 1997 on, the number of minority cases surpassed the number of cases in the White population. The first AIDS case in a Kern County woman was diagnosed in In the late 1990 s, a greater proportion of cases occurred among minority women than among White women. Throughout the 1990 s, Kern County s incidence rate was lower than the California and U.S. rates. Recently, the California and U.S. rates have decreased while Kern County s rate has remained relatively stable. In 2002, Kern County, California, and the U.S. reported similar incidence rates (Kern: 14/100,000; CA: 13/100,000; U.S.: 15/100,000). However, in 2003, Kern s rate dropped to 8/100,000 while California s rate rose to 15/100,

71 Reported AIDS cases in Kern County are not distributed evenly throughout the population. More than 90% of AIDS cases have been reported among men. Twenty-seven percent of cases have been diagnosed among the African American population in Kern County, even though African Americans account for only about 6% of Kern County s population. In the past 5 years, the average incidence rate in the African American population was 60.6 per 100,000 population, roughly 5 times higher than the average Kern County rate (12.0/100,000). In the early 1990 s, Bakersfield experienced notably higher reported community incidence rates of AIDS than the rest of Kern County. However, in recent years, the Bakersfield rates have been decreasing. In 2002, Bakersfield had its lowest reported community AIDS incidence rate since 1990 (3.9/100,000) while the rest of Kern continued to decrease in 2003 to a rate of 1.2/100,000. Why is it important? Currently, there is no cure for HIV disease and AIDS; there are only therapies that can slow the progression of HIV disease. However, AIDS is highly preventable in the United States. People can protect themselves from HIV infection through education and behavior modification. Overall, community AIDS incidence rates in Kern County have dropped considerably, yet AIDS incidence remains high in certain sub-populations. The Healthy People 2010 objective for adolescent and adult AIDS cases is to reduce incidence rate to 1.0 new case per 100,000 people. In order to achieve this goal, the HIV/AIDS Program at the Kern County Department of Public Health will continue efforts to educate the public about HIV transmission, and strategies for prevention, while encouraging HIV testing. Particular focus on sub-populations at high risk is essential for the success of these efforts. Figure 3-9. Number of Reported AIDS Cases, Kern County, Number of Cases Pre Community Inmate Total

72 Figure Incidence Rates of Reported AIDS Cases, Kern County, California and U.S., Rate per 100,000 population Healthy People 2010 Objective: 1.0/100,000 CA US* Kern * 2003 US data not available. Figure Gender Distribution of Reported AIDS Cases, Kern County, cases, 9% Female Male 1,256 cases, 91% Figure Race/Ethnicity Distribution of Reported AIDS Cases, Kern County, , 2% 399, 29% 357, 26% Afr. Amer White Hispanic Other 592, 43% 3-12

73 Figure Incidence Rate of Reported AIDS Cases, by Race/Ethnicity, Kern County, Rate per 100,000 population Kern County Black Hispanic White Figure Number of Reported AIDS Cases, by Age Group, Kern County, Number of Cases

74 Table 3-2. Exposure Categories for Community AIDS Cases, by Gender, Kern County, Exposure Category Male Female Total Sex between men (MSM) 413 N/A 413 Injection drug use (IDU) MSM and IDU 97 N/A 97 Heterosexual contact Receipt of blood, components or tissue Adult Hemophilia / Coagulation Disorder Pediatric Hemophilia / Coagulation Disorder <5 0 <5 Mother with or at risk for HIV infection <5 <5 <5 Risk not specified Total Figure Community AIDS Incidence Rates, Bakersfield and Remainder of Kern County, Rate per 100,000 population Bakersfied Kern

75 Sexually Transmitted Diseases What are they? Sexually transmitted diseases (STDs) include more than 25 infectious organisms that are primarily transmitted from person to person during sexual contact. Some of the infections can occur without obvious symptoms. This section will focus on three STDs of public health importance in Kern County: chlamydia, gonorrhea, and syphilis. These infections can lead to serious health problems. Gonorrhea and chlamydia are leading causes of infertility nationwide. Untreated syphilis can attack the heart and brain. These diseases are preventable with consistent and correct barrier protection use (male or female condoms), and in most cases are easily cured with antibiotics. Chlamydia is the most common sexually transmitted disease in the United States, with over 115,000 cases reported in California in Chlamydia is caused by an infection with the bacterium Chlamydia trachomatis. Many people who are infected with chlamydia aren t aware of their infection. Chlamydia is asymptomatic in 75% of women and 50% of men. If symptoms are present, the most common sign is an inflammation of the urethra that causes painful urination in both men and women. Women may also experience unusual vaginal discharge and general pain in the lower abdomen. Untreated, chlamydia infection can cause pelvic inflammatory disease (PID). Consequences of PID include infertility and increased risk of a potentially fatal ectopic pregnancy. Gonorrhea is caused by Neisseria gonorrhoeae, a type of bacteria that thrives in moist, warm cavities, including the mouth, throat, rectum, cervix, and urinary tract. Gonorrhea can be spread through vaginal, oral, or anal sexual contact. Gonorrhea can also be spread from mother to child during childbirth. Gonorrhea is also very common in the United States, with over 25,000 cases reported in California in Genital symptoms are more common in men than women. The symptoms generally include burning sensation during urination, itching, or unusual genital discharge. Like chlamydia, gonorrhea can lead to PID, sterility, and an increased risk of ectopic pregnancy in women who don t receive timely diagnosis and treatment. Syphilis is caused by infection with the bacterium Treponema pallidum, and is generally a more complicated disease than chlamydia or gonorrhea. Many of the signs and symptoms of syphilis are similar to those of other diseases, making syphilis more challenging to diagnose. In the primary stage, syphilis often causes painless genital lesions known as chancres within six weeks of infection. Direct contact with these sores can spread syphilis from person to person. The sores heal readily by themselves, but without treatment the disease advances. Within 12 weeks the secondary stage of syphilis begins and most sufferers experience fevers, aches, rashes, hair loss and mouth sores. At later stages, untreated syphilis invades the heart, eyes, brain and other organs. Syphilis can also be spread from a pregnant woman to her fetus, increasing the risk of a stillbirth or infant death. Infection with an STD can put a person at increased risk for acquiring HIV, if exposed. The direct and indirect costs of these infections necessitate that screening and treatment programs, for men as well as women, continue to be supported as an integrated part of our efforts to enhance the health of residents of Kern County. 3-15

76 Healthy People 2010 National Objectives Reduce the proportion of females aged 15 to 24 attending family planning clinics with Chlamydia trachomatis infections 3.0% Reduce the proportion of females aged 15 to 24 attending STD clinics with Chlamydia trachomatis infections 3.0% Reduce the proportion of males aged 15 to 24 attending STD clinics with Chlamydia trachomatis infections 3.0% Reduce gonorrhea 19.0 new cases per 100,000 Eliminate sustained domestic transmission of primary and secondary syphilis 0.2 cases per 100,000 How have these diseases changed over time? Currently, the most frequently reported STD in Kern County is chlamydia. During the past decade the number of cases reported annually in Kern County has increased more than twofold. In 1994, 1,313 cases were reported, while 3,393 cases were reported in The chlamydia incidence rate has ranged from a low of per 100,000 population in 1994 to a recorded high of per 100,000 in The incidence rate of reported gonorrhea cases in Kern County decreased markedly in the mid- to late-1990 s, then increased steadily from 1997 through In the past two years, the gonorrhea incidence rate has begun to decrease again, and further improvements are anticipated. The County s gonorrhea incidence rate ranged from a high of per 100,000 in 1995 to a low of 44.5/100,000 in In Kern County, the number of reported cases of primary and secondary syphilis has declined more than 95% from 42 cases in 1994 to only 1 case in Despite the clear decrease in syphilis cases and the improvement in gonorrhea rates, Kern County still needs to lower its rates for all sexually transmitted diseases dramatically to meet the Healthy People 2010 goals. 3-16

77 Why is it important? In a 1997 report, the Institute of Medicine stated that, STDs represent a growing threat to the Nation s health and that national action is urgently needed. 4 Untreated infections in women can lead to pelvic inflammatory disease, a leading cause of infertility. STD infection can increase a person s risk of contracting HIV. STD prevention is integral to improving reproductive health. Timely and complete reporting of STDs by health care practitioners can assist the Health Department staff to reduce the spread of the disease and to help treat those with infections. Investing in public health infrastructure and programs that address the complex psychosocial issues surrounding increased STD prevention, testing, and treatment is vital to reduce the longterm negative health consequences and costs. Figure Cases and Incidence Rates of Chlamydia, Gonorrhea, and Syphilis, Kern County Residents, , Number of Cases 3,000 2,500 2,000 1,500 1, Rate per 100,000 population Gonorrhea cases Syphilis cases# Chlamydia cases 1,313 1,349 1,358 1,497 1,631 2,118 2,528 2,767 2,811 3,393 Gonorrhea rate Syphilis rate# Chlamydia rate # Primary and secondary syphilis 3-17

78 Figure Reported Chlamydia Incidence Rates, Bakersfield, Kern County, and California, Rate per 100,000 population Bakersfield Kern County California Figure Reported Chlamydia Incidence Rates, by Race/Ethnicity Kern County Residents, Rate per 100,000 population Kern County Black Hispanic White

79 Figure Reported Chlamydia Cases, by Age Group, Kern County and Bakersfield Residents, ,000 Number of Cases 7,000 6,000 5,000 4,000 3,000 2,000 1,000 Bakersfield Kern County Bakersfield ,550 4,598 1, Kern County ,387 6,516 2,629 1, Age Group Figure Reported Gonorrhea Incidence Rates, Bakersfield, Kern County, and California, Rate per 100,000 population Healthy People 2010 Objective: 19/100, Bakersfield Kern County California

80 Figure Reported Gonorrhea Incidence Rates, by Race/Ethnicity Kern County Residents, Rate per 100,000 population Kern County Black Hispanic White Figure Reported Gonorrhea Cases, by Age Group, Kern County and Bakersfield Residents, ,600 1,400 Bakersfield Kern County 1,200 Number of Cases 1, Age Group Missing 3-20

81 Figure Reported Syphilis* Incidence Rates Bakersfield, Kern County, and California, Rate per 100,000 population Healthy People 2010 Objective: 0.2/100, Bakersfield Kern County California * Primary and secondary syphilis only Figure Reported Syphilis* Cases, by Age Group, Bakersfield Kern County Number of Cases to 4 5 to 9 10 to to to to to to 39 Age Group 40 to to to and up Unknown * Primary and secondary syphilis only 3-21

82 Figure Reported Chlamydia Annualized Incidence Rates (per 100,000 population), by Census Tract, Kern County Residents, Figure Reported Gonorrhea Annualized Incidence Rates (per 100,000 population), by Census Tract, Kern County Residents,

83 Tuberculosis What is it? Tuberculosis (TB) is a disease caused by bacteria in the Mycobacterium tuberculosis group, which usually attack the lungs. TB can also occur in other organs and tissues. If left untreated, TB can be fatal. Tuberculosis is typically spread from person to person via inhalation of the bacteria in airborne droplets that an infected person has expelled through coughing or sneezing. Not everyone who is exposed will become infected. Generally prolonged indoor contact with a person who has TB is required to pass on the infection. TB symptoms include persistent cough for two or more weeks, fevers, night sweats, and unexplained weight loss. Sometimes people with TB will cough up small amounts of blood. Specialized tests are required for diagnosis of TB. Conventional treatment of active TB in adults comprises an initial regimen of isoniazid, rifampin, pyrazinamide, and either ethambutol or streptomycin, taken daily for two months. 5 Drug susceptibility testing takes time. After completion of the initial regimen, depending on drug susceptibility results, a second, four-month course of isoniazid and rifampin typically follows. 5 Within the first three months of this therapy, 90% of patients are no longer infectious, provided that medication is being taken correctly. 6 Once treatment is completed, follow-up visits are usually not required. The treatment of TB is lengthy and may be complex for patients to follow. Inadequate completion of therapy not only hinders cure but also creates strains of TB that are resistant to anti-tuberculosis drugs. Healthcare agencies have found that the best way to ensure that patients complete treatment is through a more active approach to case management, directly-observed therapy (DOT). DOT is the administration of TB treatment by healthcare staff. Consumption of all necessary medication is observed by staff. DOT is carried out in clinics and in the community through visitations in a variety of locations, including homes, workplaces, and correctional facilities. The TB Control Program at the Kern County Department of Public Health initiated clinic-based DOT in 1993 and added community-based DOT the following year. The TB bacteria and HIV have a synergetic effect on each other one furthers the development of the other. People living with HIV and AIDS develop TB more rapidly and are more likely to die of TB if the disease is left untreated. Thus, there are special considerations for people who are HIV positive and have compromised immune systems. It is important to find HIV-positive persons who have been infected with TB and provide early TB treatment. People living with HIV/AIDS may benefit from regular TB skin testing and with isoniazid treatment for those whose TB tests are positive but do not have active TB disease. Healthy People 2010 National Objective Reduction in TB cases 1 new case per 100,000 population 3-23

84 How has this disease changed over time? Between 1953 and 1985, the number of newly reported tuberculosis (TB) cases in the United States decreased from 84,000 cases per year to 22,201 cases. 7 From 1986 through 1993 a resurgence of TB occurred. The HIV epidemic, immigration from countries where prevalence of TB is high, the decline of public health resources/infrastructure, and transmission of TB in densely-populated environments such as prisons, hospitals, and homeless shelters were all contributing factors to the resurgence. An increase of TB cases was also seen in Kern County during the same time period. In 1990, the incidence rate of tuberculosis peaked in Kern County at 19.9 per 100,000 population. Incidence rates have gradually declined since then to a low of 6.4 per 100,000 in 2003 with a total of 47 new cases in While clear reductions have been achieved, more work in this area is needed to achieve the Healthy People 2010 target of 1 new case per 100,000 population. Asian Americans comprise only 3.6% of Kern County s population. However, the occurrence of TB in this population was greater than in other race/ethnicity groups. Since 1985, the incidence rates among Asians have consistently been higher than for other racial or ethnic groups. In 2001, the incidence rate for Asian Americans was 20 per 100,000 compared to 6 per 100,000 for the rest of Kern County. However, the incidence rates for Asian and Native American populations tend to be based on small numbers, so rates can be unreliable and conclusions are more uncertain. For this reason, data by race/ethnicity are aggregated into 5-year groups to reduce the variability seen with small numbers. This aggregation demonstrates the variation by race/ethnicity group more clearly. Incidence rates in the White population were moderately low and remained relatively stable, despite the resurgence of TB in other ethnic groups. A substantial number of TB cases are reported in Kern County residents born outside of the United States. Between 1985 and 2003, 49% of the TB cases reported in Kern County were in foreign-born residents. Most of these cases (98%) were in either Asian or Hispanic people. For the Asian TB cases, 96% were born in other countries. The Hispanic population had a more even distribution of cases. Fifty-four percent of the Hispanic cases were foreign-born. TB is endemic in many of the countries of origin for the foreign born TB cases. According to the World Health Organization (WHO), the Philippines officially reported 276,295 cases of TB in 1996, accounting for 30% of officially reported cases in the Western Pacific region. 8 Mexico reported 10,852 cases in 1996 but WHO estimated 55,631 cases actually occurred. 8 In comparison, the United States reported 21,337 cases in Geographic analysis of cases in the non-incarcerated population by location shows that Bakersfield had the highest cumulative number of cases, a total of 305 in the ten years from When population is taken into account, the Bakersfield incidence rate is not as high as other cities in the County. Delano had the second highest cumulative number of cases with 111 cases between 1994 and Delano and Lamont showed the highest 10-year annualized incidence rates with rates of 28.6 and 29.2 per 100,000, respectively. The populations of Delano and Lamont are small. In 2000, the population of Delano was 38,824 accounting for 6% of the County s population. With 13,296 people in 2000, the population of Lamont comprised 2% of the County s population. Considering population size, these two areas are over-represented in the number of TB cases. 3-24

85 Why is it important? In many parts of the world, more adults die of tuberculosis than any other infectious disease. Many factors have contributed to the global resurgence of TB. Of increasing concern is the rise in the number of multidrug resistant cases of TB, which are more difficult and expensive to successfully treat. An added challenge is the higher number of people with compromised immune systems, due to HIV infection, cancer chemotherapy, and organ transplantation. Individuals more susceptible to TB infection should be screened regularly, and offered prophylactic antibiotic treatment, if appropriate. To continue to reduce the number of cases diagnosed in Kern County, active case finding and effective treatment, including DOT, must remain a priority. Figure Reported TB Incidence Rates, Kern County, California, U.S., Rate per 100,000 population Healthy People 2010 Objective: 1/100, Kern County Calif ornia USA* *2003 USA not available. Table 3-3. Race/Ethnicity and Place of Birth of TB cases, Kern County Residents, Race/Ethnicity U.S. Born Foreign Born Total African American/Black Asian/Pacific Islander Hispanic Native American White Grand Total ,

86 Figure Reported TB Incidence Rates, by Race/Ethnicity, Kern County Residents, * Rate per 100,000 population Asian/Pacific Is. African American Hispanic Native American White * Data are aggregated into 5-year increments to decrease variability due to small numbers. Table 3-4. Country of Origin of Foreign Born TB Cases, Country of Origin Cases %Total East Asia 48 8% Mexico % Central/South America 39 6% Philippines % India 18 3% Other 18 3% Total

87 Figure Tuberculosis Cases, by Age of Diagnosis, Bakersfield and Kern County, Bakersfield Kern County Number of Cases Bakersfield Kern County Age at Diagnosis City or CDP Table 3-5. Reported Cases and Incidence Rates by City or Census Designated Place (CDP), # Total Cases Annualized Incidence Rate*/100,000 ARVIN BAKERSFIELD DELANO LAMONT MCFARLAND RIDGECREST SHAFTER TAFT TEHACHAPI WASCO # Cases in incarcerated persons not included. * Rates based on 2000 Census population. 3-27

88 Figure Reported Tuberculosis Annualized Incidence Rates (per 100,000 population), by Census Tract, Kern County Residents,

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