Cancer Surveillance among American Indians in AZ, NV, and...

ITCA Tribal Epidemiology Center

Allergy, Asthma, and

Respiratory Disease

Surveillance among

American Indians in

Arizona, Nevada, and Utah

i ITCA Tribal Epidemiology Center

Allergy, Asthma, and Respiratory Disease

Surveillance among American Indians in


Prepared by:

Inter Tribal Council of Arizona, Inc.

Tribal Epidemiology Center

2214 N. Central Ave.

Phoenix, AZ 85004

Telephone: 602-258-4822

Fax: 602-258-4825

Email: [email protected]

Website: www.itcaonline.com/TEC

Funded by:

Indian Health Service Cooperative Agreement

Department of Health and Human Services

Grant No. U1B1IHSW0003-21-01

mailto:[email protected]

Allergy, Asthma, and Respiratory Disease Surveillance among American Indians in AZ, NV, and UT

ii

Contributions Publication of this document would not have been possible without the contribution of the following

individuals:

Inter Tribal Council of Arizona, Inc. Executive Director

Maria Dadgar, MBA

Inter Tribal Council of Arizona, Inc. Assistant Director

Travis Lane, BA

Inter Tribal Council of Arizona, Inc. Tribal Epidemiology Center Director

Jamie Ritchey, MPH, PhD

Inter Tribal Council of Arizona, Inc. Tribal Epidemiology Center Staff Anne Burke, MS – Epidemiologist II

Stephanie Bustillo, MPH – Epidemiologist II

Esther Corbett, BS – Program Manager

Jonathan Davis, MA – ArcGIS analyst

Vanessa Dodge, BA – Epidemiologist II

Anne van Duijnhoven, MPH, MS – Epidemiologist III

Esther Gotlieb, MPH – Epidemiologist II

Flor Olivas, AAS – Project Support Specialist

Nicholet Deschine Parkhurst, MSW, MPP – PHED Policy Analyst

Emery Tahy, BA – Epidemiologist II

Acknowledgements

We would like to thank the Arizona Department of Health Services, Office of Disease Integration

Services; Nevada Division of Public and Behavioral Health, State Biostatistician; and Utah Department of

Health, Bureau of Epidemiology for their assistance in creating this report.

Recommended Citation Inter Tribal Council of Arizona, Inc. Tribal Epidemiology Center. Allergy, Asthma, and Respiratory Disease Surveillance among American Indians in Arizona, Nevada, and Utah. October, 2018.

iii ITCA Tribal Epidemiology Center

October 1, 2018

TO: Tribal Leader and Tribal Health Director

FROM: Inter Tribal Council of Arizona, Inc.

Maria Dadgar, MBA, Executive Director

RE: Allergy, Asthma, and Respiratory Disease Surveillance among American Indians in


On behalf of the Inter Tribal Council of Arizona, Inc. (ITCA) Tribal Epidemiology Center (TEC),

ITCA TEC is pleased to present the Allergy, Asthma, and Respiratory Disease Surveillance among

American Indians in Arizona, Nevada, and Utah report.

This surveillance report was prepared in response to allergy, asthma, and respiratory disease

concerns among Tribal communities within the Phoenix and Tucson Indian Health Service

Areas. The TEC utilized data from the Indian Health Service, Arizona Department of Health

Services Bureau of Epidemiology and Disease Control, Nevada Division of Public and Behavioral

Health, and Utah Department of Health, Bureau of Epidemiology to construct the report.

This surveillance report highlights the prevalence of allergy, asthma, and respiratory disease

among the American Indian population within Arizona, Nevada, and Utah.


iv

Table of Contents

TABLES .......................................................................................................................................................... vi

FIGURES ........................................................................................................................................................ vi

GLOSSARY....................................................................................................................................................... i

STATISTICAL NOTES TABLE ........................................................................................................................... iv

PURPOSE ....................................................................................................................................................... 1

INTRODUCTION ............................................................................................................................................. 1

EXECUTIVE SUMMARY .................................................................................................................................. 3

ANALYSIS HIGHLIGHTS .................................................................................................................................. 4

Leading Causes of Mortality among American Indians and Alaska Natives ............................................. 4

Allergic Rhinitis .......................................................................................................................................... 8

Asthma .................................................................................................................................................... 10

Chronic Lower Respiratory Disease and Chronic Obstructive Pulmonary Disease ................................. 14

Acute Upper Respiratory Infection ......................................................................................................... 17

Influenza and Pneumonia ....................................................................................................................... 21

Valley Fever ............................................................................................................................................. 24

PREVENTION, TREATMENT, AND RISK FACTORS ........................................................................................ 26

Vaccination.............................................................................................................................................. 26

Inhalers ................................................................................................................................................... 28

Antihistamines ........................................................................................................................................ 29

Commercial Tobacco ............................................................................................................................... 30

Particulate Matter ................................................................................................................................... 31

Ozone ...................................................................................................................................................... 33

Wildfires .................................................................................................................................................. 35

ACTION ITEMS ............................................................................................................................................. 36

Individuals ............................................................................................................................................... 36

Tribal Communities ................................................................................................................................. 36

Tribal Health Care Providers ................................................................................................................... 36

Tribal Public Health ................................................................................................................................. 37

Tribal Leaders .......................................................................................................................................... 37

Non-Tribal Public Health ......................................................................................................................... 37

TECHNICAL NOTES ...................................................................................................................................... 38

v ITCA Tribal Epidemiology Center

State Hospital Discharge Data................................................................................................................. 38

Indian Health Service Epi Data Mart ....................................................................................................... 38

The Behavioral Risk Factor Surveillance System ..................................................................................... 38

Data Barriers ........................................................................................................................................... 38

Race/Ethnicity Misclassification .............................................................................................................. 39

Primary Coding System ........................................................................................................................... 39

Case Definitions ...................................................................................................................................... 39

REFERENCES ................................................................................................................................................ 43


vi

TABLES

Table 1. Leading causes of mortality by rank and mortality rate per 100,000 among AI/AN in Arizona ..... 5

Table 2. Leading causes of mortality by rank and mortality rate per 100,000 among AI/AN in Nevada ..... 6

Table 3. Leading causes of mortality by rank and mortality rate per 100,000 among AI/AN in Utah.......... 7

Table 4. CLRD mortality rate and mortality rate ratio per 100,000 between American Indians/Alaska

Natives and non-Hispanic Whites in Arizona, Nevada, and Utah ............................................................... 16

Table 5. Distribution of type of acute upper respiratory infection among those with acute upper

respiratory infection hospital admission among AI/AN in Arizona, Nevada, and Utah.............................. 20

Table 6. Influenza and pneumonia (combined) mortality rate and mortality rate ratio per 100,000

between American Indians/Alaska Natives and non-Hispanic Whites in Arizona, Nevada, and Utah ....... 23

Table 7.Valley fever case count among AI/AN in Arizona, Nevada, and Utah ............................................ 25

Table 8. PM10 and PM2.5 in Arizona, Nevada, and Utah .............................................................................. 32

Table 9. Ozone in Arizona, Nevada, and Utah ............................................................................................ 34

Table 10. Wildfires in Arizona, Nevada, and Utah ...................................................................................... 35

FIGURES

Figure 1. Percentage of hospital admissions due to allergic rhinitis among AI/AN in AZ, NV, and UT ......... 9

Figure 2. Current and lifetime asthma prevalence among AI/AN in Arizona ............................................. 11

Figure 3. Current and lifetime asthma prevalence among AI/AN in Nevada ............................................. 11

Figure 4. Current and lifetime asthma prevalence among AI/AN in Utah .................................................. 12

Figure 5. Percentage of hospital admissions due to asthma among AI/AN in AZ, NV, and UT ................. 13

Figure 6. Percentage of hospital admissions due to COPD among AI/AN in AZ, NV, and UT ..................... 15

Figure 7. CLRD mortality rate per 100,000 among AI/AN in AZ, NV, and UT .............................................. 15

Figure 8. Percentage of hospital admissions due to acute upper respiratory infection among AI/AN in AZ,

NV, and UT .................................................................................................................................................. 18

Figure 9. Distribution of type of acute upper respiratory infection among those with acute upper

respiratory infection hospital admission among AI/AN in AZ, NV, and UT ................................................ 19

Figure 10. Percentage of hospital admissions due to influenza among AI/AN in AZ, NV, and UT ............. 22

Figure 11. Percentage of hospital admissions due to pneumonia among AI/AN in AZ, NV, and UT .......... 22

Figure 12. Age-adjusted percentage of those who ever received a pneumococcal vaccine among AI/AN in

AZ, NV, and UT ............................................................................................................................................ 27

Figure 13. Age-adjusted percentage of those who received influenza vaccine in last 12 months among

AI/AN in AZ, NV, and UT .............................................................................................................................. 27

Figure 14. Percentage of active IHS AI/AN users prescribed an inhaled sympathomimetic bronchodilator

at least once in AZ, NV, and UT ................................................................................................................... 28

Figure 15. Percentage of active IHS AI/AN users prescribed an antihistamine at least once in AZ, NV, and

UT ................................................................................................................................................................ 29

Figure 16. Age-adjusted percentage of current smokers among AI/AN in AZ, NV, and UT ....................... 30

i ITCA Tribal Epidemiology Center

GLOSSARY

Acute bronchitis and bronchiolitis - Acute bronchitis is when the lung airways swell and produce mucus.

Symptoms of acute bronchitis last less than 3 weeks. Similar to bronchitis, bronchiolitis is when the

smaller airways in the lungs become inflamed 16, 17.

Acute laryngitis - Acute laryngitis is the inflammation of the voice box and vocal cords and can be due to

a virus, bacteria, allergies, and bronchitis24.

Acute nasopharyngitis - Acute nasopharyngitis, or the common cold is caused by a wide range of

respiratory viruses21.

Acute pharyngitis - Acute pharyngitis, or sore throat, can be caused by viruses, bacteria, allergies,

pollution, or exposure to smoke22.

Acute sinusitis - Sinusitis occurs when the sinuses become inflamed and fluid filled, which allows germs

to grow in the sinuses10, 5.

Acute tonsillitis - Acute tonsillitis is the inflammation of the tonsils, lumps of tissue in the throat, which

help protect against germs23.

Acute tracheitis - Acute tracheitis is an infection of the windpipe and is primarily caused by a virus or

bacteria25.

Alaska Native – a member or descendant of indigenous peoples in Alaska.

American Indian – a member or descendant of indigenous people in the United States; this term is

generally used for Native Americans who are members of tribes in all states except Alaska and Hawaii.

Allergy – a person’s immune system reaction to substances (allergens) found in their environment.

Reactions can be minimal to life-threatening.

Asthma – a lung disease that can cause coughing, tightness in the chest, and difficulty breathing.

Behavioral Risk Factor Surveillance System (BRFSS) – a national survey that collects information on

health conditions, health-related risk behaviors, and involvement in preventative services.

Chronic Obstructive Pulmonary Disease (COPD) – a group of respiratory diseases causing breathing

problems and airflow blockages.

Count – the number of disease, events, or other health-related occurrences.

Data – items of information expressed as measurements or statistics used to learn more about a disease

or risk factor. Data are used for calculations, support of evidence, assessments, and often for decision

making.


ii

Ethnicity – relating to cultural factors such as a shared creation narrative, ancestry, language, and

beliefs. A social group characterized by ethnic affiliation or distinctiveness. Ethnicity is largely self-

identified.

Incidence rate – the rate at which new cases of disease or health condition occur in a population. The

incidence rate is calculated by the following formula in public health practice:

Incidence rate = Number of new cases in specified period

Total number of persons at risk during this period 10n

Indian Health Service (IHS) – U.S. Department for Health and Human Services funded agency

responsible for providing health services to American Indians and Alaska Natives. The IHS provides

health services for approximately 1.9 million American Indians and Alaska Natives who belong to 566

federally recognized Tribes, state recognized Tribes, and California Indians in 35 states. The IHS is

divided into 12 geographic “Areas” of the United States: Alaska, Albuquerque, Aberdeen, Bemidji,

Billings, California, Nashville, Navajo, Oklahoma, Phoenix, Portland, and Tucson.

International Classification of Diseases (ICD) – the arrangement of specific conditions and groups of

conditions published periodically by the World Health Organization’s international advisers.

Misclassification – the incorrect assignment of a person, value, or item into a grouping which it should

not be assigned.

Mortality rate – the rate at which people in a population are dying in a certain range or period of time.

Mortality rate is calculated by the following formula:

Mortality Rate = Number of deaths during a specified period

Population at risk during the specified period 10n

Particulate matter 10 (PM10) – Liquid and solid particles found in the air that are 10 micrometers and

smaller in size. This can include mold, dust and pollen.

Particulate matter 2.5 (PM2.5) – Liquid and solid fine particles found in the air that are 2.5 micrometers

and smaller in size. This can include metals, combustion particles, and organic compounds.

Phoenix Service Area – the Phoenix Service Area is one of 12 geographic “Areas” within the Indian

Health Service (IHS). The Phoenix Service Area serves the majority of its tri-state “Area” in Arizona,

Nevada, and Utah.

Prevalence – the proportion of a population that is found to have a specified condition. This measure is

often presented as a percentage, a fraction, or the number of cases per 10,000 or 100,000 people.

Prevalence = Number of new and existing cases in specified period

Population during the same time period 10n

Race – a social construct created to categorize human beings into broad and generic groupings that are

self-selected.

iii ITCA Tribal Epidemiology Center

Rate – a measure of how fast a disease is occurring in the population. Rate is measured by the following

formula:

Rate = Number of events in specified period

Total population during the same time period 10n

Respiratory Diseases – a group of diseases affecting the airways and other lung structures. They include

chronic obstructive pulmonary disease and asthma.

Standard population – A set population that is used to standardize age adjusted rates so rates in

different populations are comparable.

Statistics – the act of collecting, summarizing, and analyzing data.

Surveillance – systematic (orderly) and continuous collection, analysis and interpretation of data, along

with the timely dissemination (distribution) of the results to those who have the right to know so that

action can be taken.

Tucson Service Area – the Tucson Service Area is one of 12 geographic “Areas” within the Indian Health

Service (IHS). The Tucson IHS Area provides health care for two Tribes in southern Arizona: the Tohono

O’odham Nation and the Pascua Yaqui Tribe.


iv

STATISTICAL NOTES TABLE MEASUREMENT

NAME TECHNICAL

DEFINITION OF MEASUREMENT MEASUREMENT PUBLIC

HEALTH USE MEASUREMENT FORMULAS

Count The number of disease, events, or other health-related occurrences

Measures the magnitude of disease occurrence.

Total number of cases during a specific time period

Age-adjusted Rate

A direct age-adjusted rate is a rate that is calculated to “control” for any

differences in the age structure of a population like the US population and

American Indian/Alaska Native population.

An age-adjusted rate includes time so this is a

measure of disease risk for the population.

1. Crude Rate x Standard Population = Expected Cases

2.

⟨Total Expected Cases

Total Standard Population| × 100,000⟩

95% Confidence Intervals (CI 95%)

A range of values defined so that there is a 95% probability that the value of the point estimate, or measure is within it

Used to compare two values to determine if they are different (statistically).

For rates

Point estimate ± [1.96 × SE[point estimate]]

For matched odds ratios

Log OR ± [1.96 × √1

b +

1

c ]

Mortality Rate Ratio (MRR)

The ratio of two mortality rates. The mortality rate among the exposed

proportion of the population, divided by the mortality rate in the unexposed

portion of the population, gives a relative measure of the effect of a given

exposure.

Mortality rate ratios (MRR) determine if racial

disparities are observed in the rates of new cases.

Incidence Rate for American Indians Incidence Rate of other racial/ethnic group

IRR < 1, no disparity

IRR > 1, disparity

Mortality Rate The number of deaths per population in a given time period

Measure of the risk of death within a specified

period of time. ⟨

Number of deathwithin a subgroup

during a specific time periodAmerican Indian population

within a subgroupduring the same time period

|

|× 100,000⟩

Prevalence The proportion of a population that have both new and pre-existing cases of a

given disease, within a specified period of time.

Measure of the burden of a disease in a population

during a specified period of time. ⟨

New and pre − existing casesduring a given time period

Populaiton during the same time period

| × 100,000⟩

Years of Potential Life Lost (YPLL) Rate

The sum of the difference between an end point (75 years) and the age at

death, in a population during a specified period of time.

Measure of the impact of premature mortality in a

specified population over a specified period of time.

⟨

Years of potential life lost (end point − age at death) in

a populaitonPopulation under age

75 years|

|× 100,000⟩

1 ITCA Tribal Epidemiology Center

PURPOSE

The purpose of the Allergy, Asthma, and

Respiratory Disease Surveillance among

American Indians in Arizona, Nevada, and Utah

report is to provide information for Tribal health

departments in the Phoenix and Tucson Indian

Health Service Areas. This report focuses on

allergy, asthma, and respiratory diseases among

American Indians/Alaska Natives (AI/AN). This

surveillance report demonstrates the current

trends in allergy, asthma, and respiratory disease

prevalence using data requested from state

hospital discharge data, vital statistics, Indian

Health Service Epi Data Mart, and national

surveys.

INTRODUCTION

This is the first publication of the report Allergy,

Asthma, and Respiratory Disease Surveillance

among American Indians in Arizona, Nevada,

and Utah by the Inter Tribal Council of Arizona,

Inc. (ITCA) Tribal Epidemiology Center (TEC).

This allergy, asthma, and respiratory disease

surveillance report demonstrates the current

trends in allergy, asthma, and respiratory disease

incidence and detection using data requested

from state hospital discharge data, vital

statistics, Indian Health Service, and national

surveys among American Indians and Alaska

Natives (AI/AN) in Arizona, Nevada, and Utah.

The surveillance data analyzed in this report is

extracted from state hospital discharge data in

Arizona, Nevada, and Utah. Hospital discharge

data contains information on patient

demographics and diagnoses, and is a reliable

source of health information as it used for

hospital payment.

Respiratory disease surveillance data for AI/AN

are used by key Tribal leaders, community health

representatives (CHRs), health care providers

(e.g., Indian Health Services, and other clinicians

and nurses), and researchers to identify disease

trends, focus prevention efforts, plan programs,

allocate resources, and develop public health

policies.

The identification and classification of allergy,

asthma, and respiratory disease cases is based

on case definitions. A case definition is a set of

uniform criteria used to define a disease for

public health surveillance. Case definitions

enable public health to classify and count cases

consistently across reporting jurisdictions, and

should not be used by healthcare providers to

determine how to meet an individual patient’s

health needs.

This publication includes age-adjusted mortality

rates and prevalence information for several

common allergy, asthma, and respiratory

diseases among AI/AN from three different

states, including Arizona, Nevada, and Utah. The

distribution of hospital admissions tell us about

the amount of inpatient and emergency

department admissions in a population and the

risk of disease. Age-adjusted rates can be

compared across states when data collection

methods are similar.

This report is organized into ten main sections:

Glossary

Statistical Notes Table

Purpose

Introduction

Executive Summary

Analysis Highlights

Prevention, Treatment, and Risk Factors

Action Items

Technical Notes


2

References

The Analysis Highlights include seven main

sections. The first section focuses on the

leading causes of mortality among American

Indians that are related to respiratory

illnesses. The second section focuses on

allergy hospitalizations, and some of the

many causes (i.e. pollen, animal dander) of

these allergies. The third section focuses on

asthma, and the percentage of AI/AN that

reported current and lifetime asthma, as

well as the percentage of hospital

admissions that were due to asthma. The

fourth section focuses on chronic lower

respiratory disease (CLRD) and chronic

obstructive pulmonary disease (COPD). This

section provides information regarding the

percentage of hospitalizations due to COPD,

CLRD mortality rates, CLRD disparity, and

premature mortality due to CLRD. The fifth

section focuses on acute upper respiratory

infections and provides information on the

percentage of hospitalizations due to acute

upper respiratory infections and the type of

acute upper respiratory infection. The sixth

section focuses on pneumonia and the

percentage of hospitalizations that were due

to pneumonia. The seventh section focuses

on influenza and provides information on

the percentage of hospitalizations that were

due to influenza. Additional analyses related

to allergy, asthma, and respiratory diseases

can be provided to ITCA TEC Tribal partners

upon special request for additional

information by contacting us directly at:

[email protected].


EXECUTIVE SUMMARY

This surveillance report demonstrates current trends in allergy, asthma, and respiratory disease related

prevalence, mortality rates, and hospital admittances from state hospital discharge data systems, vital

records, and national surveys including American Indians and Alaska Natives (AI/AN) in Arizona, Nevada,

and Utah between 2011 and 2016. The following summary provides brief key findings found within the

allergy, asthma, and respiratory disease surveillance report:

Exposure to poor air quality can dramatically affect an individual’s risk for developing respiratory

conditions. In Arizona, particulate matter 10 (PM10) levels were much higher in Cochise County (years

2013 and 2014), Gila County (year 2011), Maricopa County (years 2011-2016), Pima County (years 2011-

2013), Pinal County (years 2011-2016), and Yuma County (years 2012-2014, 2016) than all counties in

both Nevada and Utah with available particulate matter data between 2011 and 2016. In Arizona,

particulate matter levels were nearly 10 times the acceptable level in Pinal County in 2011 and 2015.

Ozone levels were higher than acceptable across much of Arizona, Nevada, and Utah between 2011 and

2016. In Utah, ozone levels were much higher in Duchesne County (years 2011 and 2013) and Uintah

County (years 2011, 2013, and 2016) than all counties in both Arizona and Nevada with available ozone

data between 2011 and 201637.

Allergic rhinitis, asthma, acute upper respiratory infections, and influenza hospitalizations were often

the greatest among those residing in Arizona. Individuals residing in Nevada and Utah had the highest

percentage of hospitalizations due to chronic lower respiratory diseases and chronic obstructive

pulmonary disease; chronic lower respiratory diseases were a leading cause of death at least once

between 2011 and 2016 among AI/AN in Nevada and Utah. Individual behavioral preventative efforts

increased between 2011 and 2016; the proportion of individuals identifying as current smokers

decreased overall in all three states12, and the proportion of individuals that reported receiving an

annual influenza vaccine increased overall in Nevada and Utah.

There are many steps individuals, Tribal communities, Tribal health care providers and public health

professionals, Tribal leaders, and non-Tribal public health entities can do to reduce the burden of

asthma, allergy, and respiratory diseases. Individuals can continue to practice preventative efforts, such

as vaccination and non-smoking, while public health professionals and healthcare providers can provide

health education, and develop Tribal codes to support respiratory disease surveillance. Tribal leaders

can develop and support Tribal codes for clean air initiatives on Tribal lands, as well as Tribal codes that

support data surveillance from Tribally run facilities.


4

ANALYSIS HIGHLIGHTS

Leading Causes of Mortality among American Indians and Alaska

Natives

Nationwide, the 5 leading causes of mortality among AI/AN are heart disease, cancer, chronic lower

respiratory diseases, unintentional injury, and cerebrovascular diseases1.

Almost 6% of all deaths among AI/AN can be attributed to chronic lower respiratory diseases

(CLRD)1.

Chronic lower respiratory diseases are the 3rd leading cause of death among all AI/AN1.

In Arizona, CLRD was not a leading cause of death among AI/AN between 2011 and 2016 (Table 1).

In Nevada, CLRD was the 5th leading cause of death among AI/AN in 2011, with an age-adjusted

mortality rate of 24.8 per 100,000. In 2014, CLRD was the 4th leading cause of death among AI/AN with

an age-adjusted mortality rate of 31.4 per 100,000. In 2016, CLRD was the 3rd leading cause of death

among AI/AN with an age-adjusted mortality rate of 39.1 per 100,000 (Table 2).

In Utah, CLRD was the 5th leading cause of death among AI/AN in 2011 with an age-adjusted mortality

rate of 43.2 per 100,000 (Table 3).


Table 1. Leading causes of mortality by rank and mortality rate per 100,000 among

AI/AN in Arizona from 2011 - 2016 a, b

Arizona

Year Cause of Death Rank Mortality Rate a

2011

Heart Disease 1 111.1

Cancer 2 100.8

Unintentional Injury 3 100.6

Diabetes 4 61.3

Chronic Liver Disease and Cirrhosis 5 43.6

2012


Cancer 2 100.8


Diabetes 4 80.2


2013


Cancer 2 118.2


Diabetes 4 65.7


2014


Cancer 2 97.1


Diabetes 4 63.2


2015


Cancer 2 124.4



Diabetes 5 73.9

2016



Cancer 3 101.2


Diabetes 5 79.9 a Age-adjusted to the 2000 U.S. standard population; b Arizona Department of Health Services, Health Status Profile of American Indians in

Arizona 2011-2016 Data Book AI/AN = American Indian/Alaska Native


6


AI/AN in Nevada from 2011 - 2016 a, b

a Age-adjusted to the 2000 U.S. standard population; b The Center for Health Information Analysis University of Nevada Las Vegas Hospital

Discharge Data

AI/AN = American Indian/Alaska Native

Nevada

Year Cause of Death Rank Mortality

Rate a

Lower 95% Confidence

Interval

Upper 95% Confidence

Interval

2011

Heart Disease 1 144.5 96.7 192.4

Cancer 2 128.3 81.6 175.1

Non-transport Accidents 3 47.4 20.6 74.2

Cerebrovascular Diseases 4 43.1 13.2 72.9

Chronic Lower Respiratory Diseases 5 24.8 5.0 44.6

2012

Heart Disease 1 120.6 79.5 161.8

Cancer 2 108.8 71.1 146.5


Intentional self-harm 4 35.5 13.5 57.6

Cerebrovascular Diseases 5 30.1 9.2 51.0

2013

Heart Disease 1 167.7 117.6 217.8

Cancer 2 113.7 74.3 153.1


Chronic Liver Disease and Cirrhosis 4 33.5 15.3 51.7

Intentional Self-harm 5 22.5 6.9 38.0

2014

Heart Disease 1 161.6 111.5 211.6

Cancer 2 65.2 37.3 93.0



Intentional Self-harm 5 25.3 8.8 41.7

2015

Heart Disease 1 121.0 84.4 157.6

Cancer 2 90.4 57.5 123.3



Diabetes 5 23.2 7.1 39.3

2016

Heart Disease 1 163.6 119.5 207.6

Cancer 2 96.8 64.8 128.9






AI/AN in Utah from 2011 – 2016 a-c

Utah

Year Cause of Death Rank Mortality

Rate a


Interval


Interval

2011

Heart Disease 1 145.3 91.7 218.7

Unintentional Injury 2 97.7 64.6 141.6

Cancer 3 95.5 55.4 153.5

Diabetes b 4 48.0 19.3 98.9

Chronic Lower Respiratory Diseases b

5 43.2 17.6 88.5

2012

Heart Disease 1 115.9 72.4 175.9

Cancer 2 105.8 62.7 167.1


Diabetes 4 64.5 33.1 113.2

Chronic Liver Disease and Cirrhosis

5 33.9 16.4 62.2

2013

Cancer 1 123.9 78.6 185.9

Heart Disease 2 81.1 45.1 134.6

Diabetes 3 53.6 26.6 96.4



5 38.7 19.1 69.8

2014


Cancer 2 103.3 63.2 159.3

Heart Disease 3 86.0 50.8 136.4


4 54.5 30.8 89.3

Diabetes 5 50.6 25.2 90.6

2015

Heart Disease 1 89.5 54.9 137.8

Diabetes 2 83.9 49.4 133.1

Cancer 3 79.7 46.0 128.4



5 47.6 26.0 79.9

2016

Cancer 1 99.2 63.1 148.4

Heart Disease 2 71.4 40.2 117.1


Diabetes b 4 46.1 22.3 84.4


5 23.5 9.4 48.6

a Age-adjusted to the 2000 U.S. standard population; b Use caution in interpreting; the estimate has a coefficient of variation > 30% and is therefore deemed unreliable by Utah Department of Health standards. C Utah Death Certificate Database, Office of Vital Records and Statistics, Utah Department of Health. Population Estimates by Age, Sex, Race, and Hispanic Origin for Counties in Utah, U.S. Bureau of the Census, IBIS Version 2016 AI/AN = American Indian/Alaska Native


8

Allergic Rhinitis

Allergic rhinitis, also called hay fever, is inflammation and swelling inside of the nose due to breathing in

a substance (allergens) that a person is allergic5.

Allergens that cause allergic rhinitis can include outdoor allergens - trees, mold, pollen, grass,

weeds, and indoor allergens - indoor mold, dust mites, and animal dander5,3.

Over 16 million Americans were diagnosed with hay fever in 20166.

In Arizona, the percentage of hospital admissions due to allergic rhinitis increased between 2011

(0.07%) and 2014 (0.13%), and then decreased between 2014 and 2016 (0.08%) (Figure 1).

In Nevada, the percentage of hospital admissions due to allergic rhinitis increased overall between 2011

(0.03%) and 2016 (0.08%), with a slight increase in 2012 (0.09%) and a slight decrease in 2014 (0.06%)

(Figure 1).

In Utah the percentage of hospital admissions due to allergic rhinitis decreased overall between 2011

(0.15%) and 2016 (0.03%), with a sharp decrease in 2013 (0.0%) and increase in 2015 (0.09%) (Figure 1).

The majority of allergic rhinitis admittances in Arizona, Nevada, and Utah among AI/AN were due to an

unspecified cause.


Figure 1. Percentage of hospital admissions due to allergic rhinitis among AI/AN in

Arizona, Nevada, and Utah from 2011 - 2016 a-d

0.00%

0.05%

0.10%

0.15%

0.20%

2011 2012 2013 2014 2015 2016

Pe

rce

nta

ge

Year

AZ

NV

UT

aArizona Department of Health Services Hospital Discharge Data; bThe Center for Health Information Analysis University of Nevada Las Vegas Hospital Discharge Data; cUtah Department of Health Hospital Discharge Data; dIncludes both inpatient and emergency department visits



10

Asthma

Asthma is a long-term disease affecting the lungs. An individual with asthma can experience coughing,

wheezing, tightness in the chest, and breathlessness. Those with asthma can suffer an asthma attack

when the lungs are triggered by an irritant. Asthma cannot be cured, but can be managed by avoiding

triggers, following a doctor’s advice, and paying attention to the warning signs of an asthma attack13.

During an asthma attack airways that carry air into the lungs become smaller, causing difficulty

breathing, tightness in the chest, coughing, and wheezing13.

Common irritants that can cause an asthma attack include air pollution, mold, tobacco smoke,

cockroach allergen, pets, and dust mites13.

Two important measurements of asthma in a population are: lifetime asthma – at any point in

their life a respondent was told by a health professional they had asthma, and current asthma –

those with lifetime asthma who have also been told they still have asthma12.

In Arizona, the prevalence of self-reported current asthma among AI/AN decreased between 2011

(21.7%) and 2016 (2.2%). The percentage of AI/AN self-reporting lifetime asthma decreased between

2011 and 2012, reached a high of 31.2% in 2014, and steadily decreased to 2.2% in 2016 (Figure 2). The

percentage of hospital admissions due to asthma decreased overall between 2011 (1.3%) and 2016

(1.0%), although there was a light increase in admittances in 2015 (1.4%) (Figure 5).

In Nevada, current and lifetime self-reported asthma prevalence among AI/AN in 2011 and 2012 ranged

between 14% and 16%, and both dropped to between 0% and 1% in 2013 and 2014. In 2015, the

proportion of lifetime asthma increased to 8.3% while those reporting current asthma remained very

low. In 2016, both current and lifetime prevalence of asthma was at 1.5% (Figure 3). The percentage of

hospital admissions for asthma increased between 2011 (1.0%) and 2014 (1.2%), while decreasing in

2015 (1.0%) and 2016 (1.0%) (Figure 5).

In Utah, both current and lifetime self-reported asthma prevalence among AI/AN decreased overall

between 2011 and 2016, with slight increases in the prevalence in 2012 and 2015, and a decrease in

2013. In 2011, the current asthma prevalence was 13.5% and the lifetime asthma prevalence was 23.4%.

In 2016, the current asthma prevalence was 3.1% and the lifetime asthma prevalence was 6.7% (Figure

4). The percentage of hospital admissions due to asthma decreased between 2011 (1.1%) and 2016

(0.9%) (Figure 5).


Figure 2. Current and lifetime asthma prevalence among AI/AN in Arizona from 2011 -

2016 a-c

Figure 3. Current and lifetime asthma prevalence among AI/AN in Nevada from 2011 -

2016 a, b

0%

10%

20%

30%

40%

2011 2012 2013 2014 2015 2016

Pre

vale

nce

Year

Current Asthma

Lifetime Asthma

a Age-adjusted to the 2000 U.S. standard population; b National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health, BRFSS 2011-2016; cData for AZ 2013 not-estimitable due to small numbers


0%

10%

20%

30%

40%

2011 2012 2013 2014 2015 2016

Pre

vale

nce

Year

Current Asthma

Lifetime Asthma

a Age-adjusted to the 2000 U.S. standard population; b National Center for Chronic Disease Prevention and Health Promotion, Division of Populaiton Health, BRFSS 2011-2016



12

Figure 4. Current and lifetime asthma prevalence among AI/AN in Utah from 2011- 2016 a, b

0%

10%

20%

30%

40%

2011 2012 2013 2014 2015 2016

Pre

vale

nce

t

Year

Current Asthma

Lifetime Asthma

a Age-adjusted to the 2000 U.S. standard population; b National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health BRFSS 2011-2016



Figure 5. Percentage of hospital admissions due to asthma among AI/AN in Arizona,

Nevada, and Utah from 2011- 2016 a -e

0.0%

0.4%

0.8%

1.2%

1.6%

2011 2012 2013 2014 2015 2016

Pe

rce

nta

ge

Year

AZ

NV

UT

aArizona Department of Health Services Hospital Discharge Data; bThe Center for Health Information Analysis University of Nevada Las Vegas Hospital Discharge Data; cUtah Department of Health Hospital Discharge Data; dIncludes both inpatient and emergency department visits; eExcludes admissions due to chronic asthma



14

Chronic Lower Respiratory Disease and Chronic Obstructive Pulmonary

Disease

Chronic lower respiratory disease (CLRD) and chronic obstructive pulmonary disease (COPD) are groups

of diseases that cause breathing problems and airflow blockages. CLRD includes chronic bronchitis,

chronic emphysema, and chronic asthma27. COPD includes only chronic bronchitis and chronic

emphysema 14.

Symptoms of CLRD and COPD can include shortness of breath, cough, chronic phlegm, and

wheezing14.

Tobacco smoke, secondhand smoke, fumes, air pollutants, and genetics can cause COPD14.

More than 15 million Americans have COPD and 140,000 Americans die of COPD yearly14.

Nationwide, American Indians/Alaska Natives and multiracial non-Hispanics were more likely to

report COPD compared to other racial/ethnic groups14.

In Arizona, the percentage of hospital admissions due to COPD slightly, yet steadily increased between

2011 (0.17%) and 2016 (0.24%) (Figure 6).

In Nevada, the percentage of hospital admissions due to COPD decreased overall between 2011 (0.64%)

and 2016 (0.58%). However, there were sharp increases in admissions in 2013 (1.1%) and 2014 (1.4%)

(Figure 6).

In Utah, the percentage of hospital admissions due to COPD decreased overall between 2011 (0.28%)

and 2016 (0.18%). However, there was a sharp increase in the percentage of admissions in 2014 (0.97%)

(Figure 6).

In Arizona, the age-adjusted CLRD mortality rate per 100,000 people increased between 2011 (14.4) and

2016 (19.5), with a slight decrease in 2014 (12.4) (Figure 7). The CLRD mortality rate ratio between

AI/AN and NHW was less than 1 between 2011 and 2016, indicating a health disparity was likely not

present (Table 4).

In Nevada, the age-adjusted CLRD mortality rate per 100,000 people increased between 2011 (24.8) and

2016 (39.1). There were slight decreases in CLRD mortality in 2013 (20.2) and 2015 (20.8) (Figure 7). The

CLRD mortality rate ratio between AI/AN and NHW was less than 1 between 2011 and 2016, indicating a

health disparity was likely not present (Table 4).

In Utah, the age-adjusted CLRD mortality rate per 100,000 people decreased between 2011 (43.2) and

2016 (22.2) (Figure 7). The CLRD mortality rate ratio between AI/AN and NHW was greater than 1 in

2011, indicating the presence of a health disparity that year. The CLRD mortality rate ratio between

AI/AN and NHW was less than 1 between 2012 and 2016, indicating a health disparity was likely not

present (Table 4).


Figure 6. Percentage of hospital admissions due to COPD among AI/AN in Arizona,

Nevada, and Utah from 2011- 2016 a - d

Figure 7. CLRD mortality rate per 100,000 among AI/AN in Arizona, Nevada, and Utah

from 2011- 2016 a-e

0.0%

0.4%

0.8%

1.2%

1.6%

2011 2012 2013 2014 2015 2016

Pe

rce

nta

ge

Year

AZ

NV

UT

aArizona Department of Health ServicesHospital Discharge Data; bThe Center for Health Information Analysis University of Nevada Las Vegas Hospital Discharge Data; cUtah Department of Health Hospital Discharge Data; dIncludes both inpatient and emergency department visits

AI/AN = American Indian/Alaska NativeCOPD = Chronic Obstructive Pulmonary Disease

0

10

20

30

40

50

2011 2012 2013 2014 2015 2016

Age

ad

just

ed

mo

rtal

ity

rate

Year

Arizona

Nevada

Utah

a Age-adjusted to the 2000 U.S. standard population; b The estimate has been suppressed for Utah 2012 and 2014 due to small number of observed events; c Arizona Department of Health Services, Health Status Profile of American Indians in Arizona 2011-2016 Data Book; d Nevada Electronic Death Registry Data and Demographics Data, Department of Health and Human Services, Office of Analytics; e Utah Death Certificate Database, Office of Vital Records and Statistics, Utah Department of Health

AI/AN = American Indian/Alaska NativeCLRD = Chronic Lower Respiratory Diseases


16

Table 4. CLRD mortality rate and mortality rate ratio per 100,000 between American

Indians/Alaska Natives and non-Hispanic Whites in Arizona, Nevada, and Utah from 2011

- 2016 a -f

State Year AI/AN Mortality Rate Mortality Rate Ratio

AI/AN:NHW

Arizona

2011 14.4 0.3

2012 18.0 0.4

2013 15.5 0.3

2014 12.4 0.3

2015 14.8 0.3

2016 19.5 0.4

Nevada

2011 24.8 0.4

2012 24.6 0.4

2013 20.2 0.3

2014 31.4 0.5

2015 20.8 0.3

2016 39.1 0.6

Utah

2011 43.2 1.4

2012 .

2013 30.6 0.9

2014 .

2015 15.7 0.4

2016 22.2 0.6 a Age-adjusted to the 2000 U.S. standard population; b Arizona Department of Health Services, Health Status Profile of American Indians in Arizona 2011-2016 Data Book; c Arizona Department of Health Services, Population Health and Vital Statistics, Vital Statistics Trends in Arizona; d Nevada Electronic Death Registry Data and Demographic Data, Department of Health and Human Services, Office of Analytics; e Utah Death Certificate Database, Office of Vital Records and Statistics, Utah Department of Health; f Retrieved Fri, 07 September 2018 from the Utah Department of Health, Indicator-Based Information System for Public Health Web site: http://ibis.health.utah.gov’ AI/AN = American Indian/Alaska Native NHW = non-Hispanic White CLRD = Chronic Lower Respiratory Disease


Acute Upper Respiratory Infection

An acute upper respiratory infection (URI) is an infection that can affect the sinuses, throat, ears, and

airways and is primarily caused by viruses15. Those with an acute upper respiratory infection should

avoid tobacco smoke and pollutants, as they may slow improvement15. Acute upper respiratory

infections include those with a primary diagnosis of any of the following:

Acute Nasopharyngitis

Acute Sinusitis

Acute Pharyngitis

Acute Tonsillitis

Acute Laryngitis and Tracheitis

Acute Bronchitis and Bronchiolitis

Acute upper respiratory infections of multiple or unspecified sites

In Arizona, the percentage of hospitalizations of AI/AN of which the primary diagnosis was any condition

considered an acute URI increased between 2011 (5.7%) and 2016 (6.9%) (Figure 8). Between 2011 and

2016, the majority of acute URI among AI/AN were due to infections of multiple or unspecified sites,

followed by acute bronchitis and bronchiolitis, and acute pharyngitis. The proportion of acute URI due to

acute nasopharyngitis increased from 0.4% in 2011 to 7.3% in 2016 (Figure 9, Table 5).

In Nevada, the percentage of admissions due to acute URI decreased between 2011 (5.0%) and 2015

(4.3%), and increased in 2016 (5.3%). (Figure 8). The majority of acute URI hospitalizations were due to

acute upper respiratory infections of multiple or unspecified sites, acute bronchitis and bronchiolitis,

and acute pharyngitis. The proportion of acute URI admissions due to acute tonsillitis was more than

double in Nevada, as compared to Arizona and Utah (Figure 9, Table 5).

In Utah, the percentage of admissions due to acute URI decreased slightly between 2011 (5.9%) and

2016 (5.2%), with a larger decrease in admissions in 2013 (3.8%) (Figure 8). The majority of acute URI

hospitalizations were due to acute upper respiratory infections of multiple or unspecified site, acute

bronchitis and bronchiolitis, and acute pharyngitis (Figure 9, Table 5).


18

Figure 8. Percentage of hospital admissions due to acute upper respiratory infection

among AI/AN in Arizona, Nevada, and Utah from 2011- 2016 a - d

0%

2%

4%

6%

8%

10%

2011 2012 2013 2014 2015 2016

Pe

rce

nta

ge

Year

AZ

NV

UT




Figure 9. Distribution of type of acute upper respiratory infection among those with

acute upper respiratory infection hospital admission among AI/AN in Arizona, Nevada,

and Utah from 2011- 2016 a - d

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

2011

2012

2013

2014

2015

2016

2011

2012

2013

2014

2015

2016

2011

2012

2013

2014

2015

2016

Ari

zon

aN

evad

aU

tah

Percentage

Stat

e a

nd

Ye

ar

Acute nasopharyngitisAcute sinusitisAcute pharyngitisAcute tonsillitisAcute laryngitis and tracheitisAcute upper respiratory infections of multiple or unspecified sitesAcute bronchitis and bronchiolitis




20

Table 5. Distribution of type of acute upper respiratory infection among those with acute

upper respiratory infection hospital admission among AI/AN in Arizona, Nevada, and Utah

from 2011- 2016 a - e

Arizona

2011 2012 2013 2014 2015 2016

Count % Count % Count % Count % Count % Count %


24 0.4 13 0.2 39 0.6 50 0.8 343 4.2 639 7.3

Acute Sinusitis 172 3.1 154 2.7 191 3.0 190 2.9 274 3.4 338 3.9

Acute Pharyngitis 1,010 18.1 1,094 19.3 1,077 17.1 1,403 21.3 1,655 20.5 2,454 28.0

Acute Tonsillitis 200 3.6 167 3.0 169 2.7 194 3.0 183 2.3 190 2.2

Acute Laryngitis and Tracheitis

323 5.8 313 5.5 396 6.3 302 4.6 356 4.4 332 3.8


1,461 26.1 1,287 22.7 1,478 23.4 1,433 21.8 1,915 23.7 1,770 20.2

Acute URI of multiple or

unspecified sites 2,407 43.0 2,633 46.5 2,960 46.9 3,005 45.7 3,356 41.5 3,056 34.8

Nevada

2011 2012 2013 2014 2015 2016



* 0.3 * 0.9 * 0.7 * 0.6 7 0.8 28 4.4

Acute Sinusitis 21 5.4 16 3.8 24 3.2 15 1.8 48 5.2 34 5.4 Acute Pharyngitis 62 15.9 101 23.8 132 17.6 120 14.2 173 18.6 153 24.3 Acute Tonsillitis 32 8.2 34 8.0 60 8.0 76 9.0 64 6.9 22 3.5 Acute Laryngitis and Tracheitis

29 7.4 19 4.5 38 5.1 36 4.3 34 3.7 25 4.0


116 29.7 121 28.5 219 29.2 274 32.5 274 29.5 138 21.9


unspecified sites 130 33.3 130 30.6 271 36.2 317 37.6 328 35.3 231 36.6

Utah

2011 2012 2013 2014 2015 2016



* 0.0 * 1.5 * 0.0 * 1.3 * 1.6 15 7.4

Acute Sinusitis 12 5.2 * 2.9 * 8.8 * 5.2 12 9.4 15 7.4 Acute Pharyngitis 50 21.6 28 20.4 12 21.1 19 24.7 26 20.3 56 27.6 Acute Tonsillitis * 1.3 6 4.4 * 0.0 * 5.2 7 5.5 7 3.5 Acute Laryngitis and Tracheitis

13 5.6 7 5.1 * 3.5 * 5.2 6 4.7 11 5.4


66 28.5 42 30.7 18 31.6 32 41.6 49 38.3 67 33.0


unspecified sites 88 37.9 48 35.0 20 35.1 13 16.9 26 20.3 32 15.8

aArizona Department of Health Services Hospital Discharge Data;

bThe Center for Health Information Analysis University of Nevada Las Vegas Hospital

Discharge Data; cUtah Department of Health Hospital Discharge Data;

dIncludes both inpatient and emergency department visits; e Percentages rounded to

the nearest tenth of a percentage AI/AN = American Indian/Alaska Native; * = Counts less than 6 suppressed for confidentiality


Influenza and Pneumonia

Influenza (flu) is a respiratory illness caused by the influenza virus. Severity from the flu can range from

mild to severe, even death26.

Symptoms of the flu include fever, fatigue, cough, headache, and sore throat and generally

resolve within 2 weeks26.

Older adults, children, and individuals with underlying medical conditions such as asthma and

other respiratory conditions are at greater risk of developing complications from the flu, which

can include pneumonia, sinus infections, and asthma attacks26.

Pneumonia is a lung infection where the alveoli become filled with pus and fluid, which creates difficulty

breathing, fever, and a cough18.

Pneumonia can be caused by bacteria, viruses, fungi, or being on a ventilator19.

Individuals who smoke or have previous underlying medical conditions are more at risk for

acquiring pneumonia19.

In Arizona, the percentage of hospital admissions due to influenza among AI/AN increased overall

between 2011 (0.4%) and 2016 (0.9%). However, there were decreases in admittances in 2012 (0.3%)

and 2015 (0.4%) (Figure 10). The percentage of hospital admissions among AI/AN due to pneumonia

decreased each year between 2011 (1.7%) and 2016 (1.2%) (Figure 11). The combined pneumonia and

influenza mortality rate among AI/AN decreased between 2011 (28.4 per 100,000) and 2015 (23.8 per

100,000), and increased in 2016 (29.6). The mortality rate ratio of pneumonia and influenza between

AI/AN and NHW was greater than one for all years between 2011 and 2016, indicating a disparity may

be present (Table 6).

In Nevada, the percentage of hospital admissions due to influenza among AI/AN increased between

2011 (0.1%) and 2016 (0.5%) (Figure 10). The percentage of hospital admissions among AI/AN due to

pneumonia decreased each year between 2011 (1.4%) and 2015 (1.0%), while increasing in 2016 (1.4%).

(Figure 11).The combined pneumonia and influenza mortality rate among AI/AN decreased between

2011 (37.1 per 100,000) and 2015 (6.9 per 100,000), and increased in 2016 (21.0 per 100,000). The

mortality rate ratio of pneumonia and influenza between AI/AN and NHW was greater than one for

years 2011-2013 and 2016, indicating a disparity may be present. The mortality rate ratio was less than

one for years 2014 and 2015, indicating a disparity is not present (Table 6).

In Utah, the percentage of hospital admissions due to influenza among AI/AN increased slightly between

2011 (0.3%) to 2016 (0.6%), with an increase in 2014 (0.7%) (Figure 10). The percentage of hospital

admissions among AI/AN due to pneumonia decreased overall between 2011 (1.7%) and 2016

(1.4%)(Figure 11). The combined pneumonia and influenza mortality rate among AI/AN decreased

between 2011 (53.02 per 100,000) and 2016 (26.15 per 100,000). The mortality rate ratio of pneumonia

and influenza between AI/AN and NHW was greater than one for all years with data, indicating a

disparity may be present (Table 6).


22

Figure 10. Percentage of hospital admissions due to influenza among AI/AN in Arizona,

Nevada, and Utah from 2011- 2016 a - d

Figure 11. Percentage of hospital admissions due to pneumonia among AI/AN in Arizona,

Nevada, and Utah from 2011 - 2016 a - d

0.0%

0.2%

0.4%

0.6%

0.8%

1.0%

2011 2012 2013 2014 2015 2016

Pe

rce

nta

ge

Year

AZ

NV

UT



0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

2011 2012 2013 2014 2015 2016

Pe

rce

nta

ge

Year

AZ

NV

UT




Table 6. Influenza and pneumonia (combined) mortality rate and mortality rate ratio

per 100,000 between American Indians/Alaska Natives and non-Hispanic Whites in

Arizona, Nevada, and Utah from 2011- 2016 a - f

State Year AI/AN

Mortality Rate


Interval


Interval

Mortality Rate Ratio

AI/AN:NHW

Arizona

2011 28.4 . . 3.05

2012 30.0 . . 3.45

2013 24.7 . . 2.57

2014 22.9 . . 2.60

2015 23.8 . . 2.77

2016 29.6 . . 3.08

Nevada

2011 37.1 7.4 66.7 1.86

2012 31.4 8.1 54.7 1.69

2013 26.5 6.9 46.1 1.40

2014 20.0 5.2 34.7 0.84

2015 6.9 0.0 14.6 0.30

2016 21.0 4.2 37.7 1.11

Utah

2011 53.02 16.7 125.7 3.11

2012 25.92* 4.2* 83.7* 1.64

2013 50.53 18.4 110.7 2.76

2014 32.51* 9.1* 82.3* 2.04

2015 ** ** ** .

2016 26.15* 7.0* 67.5* 1.68 a Age-adjusted to the 2000 U.S. standard population; b Arizona Department of Health Services, Health Status Profile of American Indians in Arizona 2011-2016 Data Book; c Arizona Department of Health Services, Population Health and Vital Statistics, Vital Statistics Trends in Arizona; d Nevada Electronic Death Registry Data and Demographic Data, Department of Health and Human Services, Office of Analytics; e Utah Death Certificate Database, Office of Vital Records and Statistics, Utah Department of Health; f Retrieved Thr, 27 September 2018 from the Utah Department of Health, Indicator-Based Information System for Public Health Web site: http://ibis.health.utah.gov’ * Use caution in interpreting; the estimate has a coefficient of variation > 30% and is therefore deemed unreliable by Utah Department of Health standard ** The estimate has been suppressed AI/AN = American Indian/Alaska Native NHW = non-Hispanic White


24

Valley Fever

Valley fever (coccidioidomycosis) is a fungal infection affecting the lungs, caused by the soil-residing

fungus Coccidioides. The fungus is most prominent in the southwestern part of the United States,

especially Arizona. Individuals can become infected with Valley fever after breathing in Coccidioides

spores43.

Symptoms of Valley fever include shortness of breath, cough, headache, and fatigue.

Many individuals infected with Valley fever are asymptomatic. In rare cases, Valley fever can

cause long-term lung complications, or spread to other parts of the body43.

In Arizona, there were more than 100 cases of Valley fever among AI/AN for all years between 2011 and

2016, except in 2013. The lowest number of reported Valley fever cases between 2011 and 2016 was 77

in 2013, and the highest number of cases was 166 in 2011 (Table 7).

In Nevada, there were less than six reported Valley fever cases among AI/AN in 2013, 2015, and 2016.

There were no reported Valley fever cases in 2011, 2012, and 2014 (Table 7).

In Utah, there were no reported cases of Valley fever among AI/AN between the years of 2012 and

2016. In 2011 there were less than six reported Valley fever cases (Table 7).


Table 7.Valley fever case count among AI/AN in Arizona, Nevada, and Utah from 2011 –

2016 a – b, *

State Year Count

Arizona

2011 166

2012 152

2013 77

2014 104

2015 157

2016 136

Nevada

2011 0

2012 0

2013 *

2014 0

2015 *

2016 *

Utah

2011 *

2012 0

2013 0

2014 0

2015 0

2016 0 a Arizona Department of Health Services, Office of Infectious Disease Services; b Nevada Division of Public and Behavioral Health, State Biostatistician; c Utah Department of Health, Bureau of Epidemiology AI/AN = American Indian/Alaska Native * = Case counts less than 6 suppressed for confidentiality Note: 70-80% of Valley fever cases in Arizona are missing race/ethnicity, interpret these numbers with caution. Case counts in Arizona from 2011 and 2012 are not comparable to subsequent years due to surveillance changes.


26

PREVENTION, TREATMENT, AND RISK FACTORS

Vaccination

The influenza vaccine is a seasonal vaccine that helps deliver protection against a combination of influenza viruses that are predicted to be the most widespread during a given influenza season. Those able to obtain the vaccine should be vaccinated to protect themselves and those around them unable to be vaccinated. Vaccination should occur yearly as antibodies reduce over time and influenza strains can change every season. Influenza vaccination has been demonstrated to lower influenza hospitalizations among those with chronic lung conditions29. The pneumococcal vaccine helps prevent pneumococcal disease, which includes pneumonia. There are two types of pneumococcal vaccines, and depending on risk factors such as age, smoking status, and pre-existing medical conditions, a doctor may recommend the pneumococcal vaccine30. In Arizona, the percentage of AI/AN who reported ever receiving a pneumonia vaccine decreased

between 2011 (31.7%) and 2016 (23.8%), however there was a reported increase in vaccination in 2015

(50.9%) (Figure 12). The percentage of AI/AN that reported receiving the influenza vaccine in the

previous 12 months steadily decreased between 2011 (49.8%) and 2016 (24.6%) (Figure 13).

In Nevada, the percentage of AI/AN reporting ever having received a pneumonia vaccine decreased

overall between 2011 (41.1%) and 2016 (25.1%), with larger decrease in 2014 (17.0%) (Figure 12). The

percentage of AI/AN that reported receiving the influenza vaccine in the previous 12 months increased

overall between 2011 (38.5%) and 2016 (43.9%). However, the percentage reporting influenza

vaccination between 2012 and 2015 was much lower (Figure 13).

In Utah, the percentage of AI/AN that reported having received a pneumonia vaccine in their lifetime

increased between 2011 (35.2%) and 2016 (32.3%), with a large increase in 2014 (49.1%) (Figure 12).

The percentage of AI/AN that reported receiving the influenza vaccine in the previous 12 months

increased overall between 2011 (27.0%) and 2016 (42.1%) (Figure 13).


Figure 12. Age-adjusted percentage of those who ever received a pneumococcal vaccine

among AI/AN in Arizona, Nevada, and Utah from 2011- 2016 a-c

Figure 13. Age-adjusted percentage of those who received influenza vaccine in last 12

months among AI/AN in Arizona, Nevada, and Utah from 2011 - 2016 a-c

0%

10%

20%

30%

40%

50%

60%

2011 2012 2013 2014 2015 2016

Pe

rce

nta

ge

Year

AZ

NV

UT

a Age-adjusted to the 2000 U.S. standard population; b National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health BRFSS 2011-2016; cData for AZ 2013 not-estimitable due to small numbers


0%

10%

20%

30%

40%

50%

60%

2011 2012 2013 2014 2015 2016

Pe

rce

nta

ge

Year

AZ

NV

UT

a Age-adjusted to the 2000 U.S. standard population; b National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health BRFSS 2011-2016; cData for AZ 2013 not-estimitable due to small numbers



28

Inhalers

Inhaled sympathomimetic bronchodilators (drug class RE102) are used primarily to treat asthma.

Bronchodilators help to relax muscles around the breathing tubes, which makes it easier to breathe for

an individual suffering from an asthma attack44.

In Arizona, the percentage of active IHS AI/AN users that were prescribed an inhaled sympathomimetic

bronchodilator was greater than those prescribed an inhaled sympathomimetic bronchodilator in both

Nevada and Utah between 2011 and 2016. The percentage of those prescribed an inhaled

sympathomimetic bronchodilator in Arizona increased slightly between 2011 (3.95%) and 2016 (4.59%)

(Figure 14).

In Nevada, the percentage of active IHS AI/AN users that were prescribed an inhaled sympathomimetic

bronchodilator increased slightly between 2011 (2.60%) and 2016 (2.89%) (Figure 14).

In Utah, the percentage of active IHS AI/AN users that were prescribed an inhaled sympathomimetic

bronchodilator increased slightly between 2011 (2.72%) and 2016 (2.86%) (Figure 14).

Figure 14. Percentage of active IHS AI/AN users prescribed an inhaled sympathomimetic

bronchodilator at least once in Arizona, Nevada, and Utah from 2011- 2016 a,b

0%

1%

2%

3%

4%

5%

2011 2012 2013 2014 2015 2016

Pe

rce

nta

ge

Year

AZ

NV

UT

a U.S. Department of Health and Human Services, Indian Health Service, Epi Data Mart; b Fiscal years 2011- 2016

AI/AN = American Indian/Alaska NativeIHS = Indian Health ServiceNote: An active IHS user is a patient that has had at least one workload-reportable encounter within the last three fiscal years


Antihistamines

Antihistamines (drug class RE501 – RE509) are a class of prescription or over-the-counter medication

used to treat allergy symptoms such as sneezing, congestion, itching, runny nose, and nasal passage

swelling. Antihistamines can be used to alleviate symptoms from allergens such as pollen, certain plants,

or pet dander45.

In Arizona, the percentage of active IHS AI/AN users prescribed an antihistamine remained less than

0.50%, and was lower than Nevada and Utah for all years between 2011 and 2016. The percentage of

those prescribed an antihistamine decreased slightly between 2011 (0.49%) and 2016 (0.35%) (Figure

15).

In Nevada, the percentage of active IHS AI/AN users prescribed an antihistamine decreased slightly

between 2011 (1.15%) and 2016 (0.47%), and was less than 1.0% between 2012 and 2016 (Figure 15).

In Utah, the percentage of active IHS AI/AN users prescribed an antihistamine was much greater in Utah

than in Arizona and Nevada, sometimes more than fivefold, between 2011 and 2016. The percentage of

those prescribed an antihistamine decreased between 2011 (4.91%) and 2016 (2.56%) (Figure 15).

Figure 15. Percentage of active IHS AI/AN users prescribed an antihistamine at least once

in Arizona, Nevada, and Utah from 2011 - 2016 a,b

0%

1%

2%

3%

4%

5%

6%

2011 2012 2013 2014 2015 2016

Pe

rce

nta

ge

Year

AZ

NV

UT

a U.S. Department of Health and Human Services, Indian Health Serice, Epi Data Mart; b Fiscal years 2011- 2016

AI/AN = American Indian/Alaska NativeIHS = Indian Health ServiceNote: An active IHS user is a patient that has had at least one workload-reportable encounter within the last three fiscal years


30

Commercial Tobacco

Commercial cigarette smoking causes cancer, heart disease, stroke, and is a major risk factor for

developing many respiratory conditions. In 2016, 31.8% of American Indians/Alaska Natives nationwide

identified as current cigarette smokers, the highest percentage of current smokers compared to all

other racial/ethnic groups11.

Smoking is responsible for more than 480,000 deaths among Americans every year11.2

Tobacco smoke is the primary cause of COPD; 3 in 4 people with COPD have reported smoking11.

In Arizona, the percentage of AI/AN that self-reported as current smokers remained equal between

2011 and 2012 (18.7%), decreased in 2014 (13.5%), and increased in 2015 (17.0%) and 2016 (35.6%)

(Figure 16).

In Nevada, the percentage of AI/AN that self-reported as current smokers increased overall between

2011 (16.6%) and 2016 (37.5%), with a sharp increase in 2014 (38.3%) and decrease in 2015 (3.3%)

(Figure 16).

In Utah, the of percentage of AI/AN that self-reported as current smokers decreased steadily between

2011 (20.1%) and 2016 (1.6%), with a sharper decrease in 2013 (7.3%) (Figure 16).

Figure 16. Age-adjusted percentage of current smokers among AI/AN in Arizona, Nevada,

and Utah from 2011- 2016 a-c

0%

10%

20%

30%

40%

2011 2012 2013 2014 2015 2016

Pe

rce

nta

ge

Year

AZ

NV

UT

aAge-adjusted to the 2000 U.S. standard population; bNational Center for Chronic Disease Prevention and Health Promotion, Division of Population Health, BRFSS 2011-2016; cData for AZ 2013 not-estimitable due to small numbers



Particulate Matter

Particulate matter are liquid and/or solid air particles that vary in composition and origin, and are a

major outdoor air pollutant. Particulate matter can be released from forest fires, dust, vehicles,

industrial plants, and coal burning. Increased exposure to particulate matter can contribute to

pneumonia, asthma, poor lung function, and increased risk for mortality, as well as heart

disease31,32,34,35.

Particles between 2.5 and 10 micrometers in size can settle in large airways and the upper

respiratory tract.

o PM10 greater than 150 micrometers of the 2nd highest 24-hr average measurement in the

year is above the respective air quality standard.

Fine particles less than 2.5 micrometers in size can settle in the bronchioles and alveoli.

o PM2.5 greater than 12.0 micrometers of the weighted 24-hr average mean is above the

respective air quality standard.

In Arizona, of the counties with reported data, Maricopa and Pinal Counties had PM10 and PM2.5 levels

above healthy levels for more than half of survey years between 2011 and 2016. With the exception of

PM2.5 levels in 2015, Pinal County greatly exceed recommend levels all other years. Additionally, the

amount of PM10 in Pinal County exceeded 1,600 micrometers, more than 10-times the respective air

quality exposure level. PM10 levels in Yuma County were above healthy levels every year between 2011

and 2016 (Table 8).

In Nevada, of the counties with reported data, Washoe County had particulate matter levels slightly

above the respective air quality standard. Clark and Nye Counties had higher PM10 levels in 2013 and

2014, respectively, than recommended amount (Table 8).

In Utah, of the counties with reported data, there was only one reported particulate matter level greater

than the respective air quality standard (Table 8).


32

Table 8. PM10 and PM2.5 in Arizona, Nevada, and Utah from 2011 - 2016 a

Arizona

County 2011 2012 2013 2014 2015 2016

PM10 PM2.5 PM10 PM2.5 PM10 PM2.5 PM10 PM2.5 PM10 PM2.5 PM10 PM2.5

Apache 59 . 56 . 54 . 48 3.3 32 . 55 .

Cochise 98 6.5 . 6.7 218* . 175* 7.2 84 5.2 51 .

Coconino 37 5.2 35 5.4 27 5.4 . . . . . .

Gila 205* . 137 . 144 . 119 . 109 . 113 .

La Paz . . . . . . 83 2.0 62 . 84 2.4

Maricopa 387* 12.4* 285* 12 280* 10.5 220* 11.1 200* 9 211* 12.9

Mohave 38 . . . 86 . 84 . 68 . 110 .

Navajo 44 . 53 . 46 . 47 . 35 . 45 .

Pima 226* 5.8 228* 5.9 363* 6.8 143 6.3 65 5.1 165* 6.4

Pinal 1638* 13.2* 504* 15.6* 510* 15.7* 521* 14* 985* 10.2 357* 14.0*

Santa Cruz 159* 9.9 72 9.6 87 9.9 180* 9.7 . 9.0 102 9.9

Yavapai 25 3.8 35 4.4 27 4.2 . . . . . .

Yuma 178* 7.6 240* 8.5 228* . 375* 6.3 182* . 224* 8.3

Nevada

County 2011 2012 2013 2014 2015 2016


Clark 102 8.2 139 8.6 169* 10.8 105 10.4 87 9.8 143 10.7

Douglas . . . . . . . 8.2 . . . 6.9

Elko 123 . 111 . 109 . 79 . 86 . . .

Nye 109 . 121 . 153 . 165* . 108 . 90 .

Washoe 169* 6.7 194* 9.1 121 12.3* 126 8.7 72 7.8 78 7.0

Carson City . . . . . . . 5.5 . 5.2 . 4.5

Utah

County 2011 2012 2013 2014 2015 2016


Box Elder . 7.7 . 6.9 . . . 6.3 . 6.5 . .

Cache 52 8.9 61 8.7 85 . 54 8.4 . 7.4 . .

Davis 44 8.4 52 7.9 51 . 55 7.4 . . . 8.0

Duchesne . . . . . . . . . 6.0 . 5.9

Salt Lake 86 8.9 81 8.9 105 . 87 7.7 52 8.7 67 9.4

Tooele . 6.2 . 5.9 . . . 6.2 . . . .

Uintah . . . 5.2 . . . . . . . .

Utah 70 8.1 69 8.1 136 11.5 54 7.1 . 7.3 66 8.3

Washington . 4.6 . 6.6 . . . . . 4.6 38 3.9

Weber 70 9.1 77 9.0 92 14.3* 75 11.0 . . 62 9.2 a United States Environmental Protection Agency, Outdoor Air Quality Data, Air Quality Statistics Report * Levels above acceptable amount PM10 = Particulate matter 10 micrometers or less in size PM2.5 = Particulate matter 2.5 micrometers or less in size


Ozone

Ground level ozone (smog) is an air pollutant that is created as a result of a chemical reaction between

natural sunlight, and volatile organic compounds (VOC) and oxides of nitrogen (NOx), of which can be

emitted from chemical solvents, vehicle exhaust, industrial plants, and gasoline vapors. Ground level

ozone can cause coughing, inflammation of the airways, sore throat, and chest pain, and can exacerbate

asthma, bronchitis, and other respiratory conditions. Natural stratospheric ozone is in the upper

atmosphere and does not harm health, it protects from ultraviolet rays32,36,37.

Ozone levels are highest in warm air, in the late afternoon.

Ozone levels greater than 0.070 ppm of the 4th highest 8-hr daily maximum are above the

respective air quality standard.

In Arizona, of the counties with reported data, every county had ozone levels greater than the

respective air quality standard for at least half of every reported year between 2011 and 2016, except

Navajo County and Yavapai County. The highest reported ozone level in Arizona during this time period

was 0.083 ppm in Maricopa County in 2012 (Table 9).

In Nevada, of the counties with reported data, Clark, Lyon, Washoe, and White Pine Counties had ozone

levels greater than the respective air quality standard for at least half of every reported year between

2011 and 2016. Churchill County did not have any ozone levels greater than the respective air quality

standard between 2011 and 2016. The highest reported ozone level in Nevada during this period was

0.082 in 2013 in Clark County (Table 9).

In Utah, of the counties with reported data, Duchesne and Uintah Counties each had ozone levels above

0.1 twice between 2011 and 2016. Duchesne, Salt Lake, Tooele, Uintah, Utah, Washington, and Weber

Counties had ozone levels greater than the respective air quality standard for at least half of every

reported year between 2011 and 2016. The highest reported ozone level in Utah during this time period

was 0.133 in Uintah County in 2013 (Table 9).


34

Table 9. Ozone in Arizona, Nevada, and Utah from 2011 - 2016 a

Arizona

County 2011 2012 2013 2014 2015 2016

Cochise 0.075* 0.074* 0.072* 0.068 0.065 0.064

Coconino 0.074* 0.073* 0.069* 0.073* 0.07 0.064

Gila 0.076* 0.078* 0.072* 0.072* 0.073* 0.07

La Paz 0.075* 0.071* 0.071* 0.07 0.067

Maricopa 0.082* 0.083* 0.079* 0.08* 0.077* 0.075*

Navajo 0.069 0.073* 0.069 0.068 0.061 0.063

Pima 0.075* 0.071* 0.074* 0.069 0.066 0.069

Pinal 0.075* 0.078* 0.073* 0.068 0.074* 0.072

Yavapai 0.07 0.072* 0.065 0.077* 0.067 0.064

Yuma 0.076* 0.08* 0.073* 0.078* 0.077* 0.067

Nevada

County 2011 2012 2013 2014 2015 2016

Churchill 0.054 0.052 0.064 0.065 0.068 0.069

Clark 0.078* 0.079* 0.082* 0.081* 0.076* 0.079*

Lyon 0.072* 0.071* 0.064 0.067 0.071* 0.069

Washoe 0.067 0.072* 0.069 0.071* 0.073* 0.073*

White Pine 0.072* 0.076* 0.074* 0.064 0.066 0.063

Carson City 0.064 0.072* 0.065 0.068 0.068 0.066

Utah

County 2011 2012 2013 2014 2015 2016

Box Elder 0.066 0.073* 0.071* 0.067 0.068 0.067

Cache 0.063 0.072* 0.066 0.059 0.067 0.062

Carbon 0.067 0.073* 0.067 0.064 0.069 0.067

Daggett . 0.066 0.066. . . .

Davis 0.068 0.067 . 0.074* . 0.076*

Duchesne 0.111* 0.07 0.108* 0.062 0.066 0.085*

Garfield . 0.068 0.067 0.06 0.068 .

Salt Lake 0.075* 0.08* 0.077* 0.072* 0.081* 0.076*

San Juan 0.069 0.072* 0.066 0.064 0.065 0.064

Tooele 0.071* 0.074* 0.072* 0.069 . 0.072*

Uintah 0.116* 0.075* 0.133* 0.079* 0.068 0.096*

Utah 0.065 0.077* 0.077* 0.076* 0.073* 0.072*

Washington 0.072* 0.075* 0.07 0.066 0.069 0.064*

Weber 0.074* 0.076* 0.076* 0.07 0.074* 0.073* a United States Environmental Protection Agency, Outdoor Air Quality Data, Air Quality Statistics Report * Levels above acceptable amount


Wildfires

Wildfires are unplanned fires that occur in forests and other natural wooded areas. Exposure to wildfire

smoke can be harmful to the respiratory system and worsen effects of pre-existing respiratory

conditions38,39.

Effects of wildfire smoke on respiratory health can include coughing, chest pain, sinus problems,

difficulty breathing, and a trigger for asthma attacks.

In Arizona, there was no less than 100,000 acres burned due to wildfires between 2011 and 2016. The

greatest number of acres burned due to wildfires was 1,016,428 in 2011 (Table 10).

In Nevada, there was no less than 40,000 acres burned due to wildfires between 2011 and 2016. The

greatest number of acres burned due to wildfires was 613,126 in 2012 (Table 10).

In Utah, there was no less than 10,000 acres burned due to wildfires between 2011 and 2016. The

greatest number of acres burned due to wildfires was 415,267 in 2012 (Table 10).

Table 10. Wildfires in Arizona, Nevada, and Utah from 2011 - 2016 a

State Year Number of Fires Number of Acres Burned

Arizona

2011 1,988 1,016,428

2012 1,684 216,090

2013 1,756 105,281

2014 1,543 205,199

2015 1,662 160,152

2016 2,288 308,245

Nevada

2011 817 424,170

2012 944 613,126

2013 763 162,907

2014 531 59,252

2015 551 42,479

2016 467 265,156

Utah

2011 1,102 62,783

2012 1,534 415,267

2013 1,276 70,282

2014 1,035 28,255

2015 930 10,203

2016 1,078 101,096 a National Interagency Fire Center, Statistics


36

ACTION ITEMS

Below are points of action organized by information specifically geared to individuals, Tribal

communities, Tribal health care providers, Tribal leaders, and researchers in an effort to prevent and

detect respiratory diseases. These action items are mostly specific to respiratory diseases and allergens

that have high rates and proportions, or show disparities among American Indians in Arizona, Nevada,

and Utah, although many action items may apply to several or all respiratory diseases in general.

Individuals

Avoid smoking and exposure to secondhand smoke from commercial tobacco products,

especially among those with a diagnosed respiratory condition.

In high ozone areas, avoid exercising outdoors during the late afternoon.

Avoid excessive amount of time outdoors during high pollution days.

Those with asthma should work with their doctor to develop an asthma action plan to help

control asthma, adhere to all prescribed medications, and avoid irritants that may trigger an

asthma attack.

When recommended, obtain a pneumonia vaccine and the yearly influenza vaccine.

Tribal Communities

Develop Tribal codes that allow respiratory disease surveillance from Tribally run facilities to

ensure more complete data capture and reporting.

Facilitate anti-smoking campaigns.

Regulate smoking in public places.

Ensure public spaces and housing areas are free of indoor mold and other irritants, and have

proper ventilation.

Enhance education in the community on ways to prevent the spread of germs, especially during

influenza season.

Tribal Health Care Providers

Educate community members on the importance of not smoking commercial tobacco and

avoiding secondhand smoke of commercial tobacco.

Promote influenza and pneumonia vaccination, as well as proper techniques to avoid the spread

of germs.

Develop an asthma action plan for individuals with asthma and ensure medication compliance.

Adhere to the accurate capture of all health information necessary for proper surveillance.


Tribal Public Health

Develop Tribal codes that allow respiratory disease reporting and surveillance from Tribally run

facilities to ensure more complete data capturing.

Educate the public on the effects of poor air quality on respiratory health, and provide

information on how to reduce exposure to indoor and outdoor air pollutants.

Support Tribal health codes that promote clean air on Tribal land and no smoking in public

places.

Tribal Leaders

Support Tribal codes that allow respiratory disease reporting and surveillance from Tribally run

facilities to ensure more complete data capturing.

Support Tribal health codes for clean air on Tribal land.

Non-Tribal Public Health

Improve AI/AN surveillance data with Tribes, Indian Health Service, state registries, state and

national surveys, and Tribal Epidemiology Centers.

Conduct data quality and assurance control to reduce AI/AN race/ethnicity misclassification.


38

TECHNICAL NOTES

State Hospital Discharge Data

State hospital discharge data (HDD) is a hospital reporting system that contains information on the

utilization of hospital services and is used for medical billing and payment. HDD contains information on

patient demographics, the admitting and principal diagnoses, length of stay, inpatient or outpatient

admittance, and payment type. HDD is increasingly being used to understand and estimate the burden

of disease in a population, and it is considered one of the more reliable sources of data because it is

used for payment28.

Indian Health Service Epi Data Mart

The Epi Data Mart (EDM) is a national repository of healthcare information gathered from associated

Indian Health Service (IHS), Tribal and Urban healthcare sites and regional administrative offices of the

Indian health system. The purpose of the EDM is to provide a snapshot of the broad system for the

purpose of public health surveillance and reporting on community health status for constituent Tribes.

The information in this report includes records for American Indians that were active IHS users. An

active user is defined as “an individual that had at least one workload-reportable encounter within the

last three fiscal years”. The purpose of the IHS National Data Warehouse that the EDM is a subset of is

primarily administrative. Therefore data from this source cannot be used to calculate representative

population based rates or proportions of health outcomes. This data can be used for IHS clinic planning

purposes42.

The Behavioral Risk Factor Surveillance System

The Behavioral Risk Factor Surveillance System (BRFSS) is a Centers for Disease Control and Prevention

health survey that was established in 1984 to collect information on chronic conditions, individual’s

prevention efforts, and behavioral risk factors in adults. The survey is administered via landline and

cellphone in either English or Spanish in all 50 US states and 3 US territories, and includes information

from over 400,000 respondents each year12.

Data Barriers

Hospital discharge data from Utah in 2013 contained a lower number of admissions than other

years, and may underestimate the true number of respiratory conditions in the AI/AN

population that year.

Information used from BRFSS captured information from a very small proportion of the AI/AN

population. Although data was adjusted during the analysis, BRFSS survey data would more

accurately represent AI/AN data with a larger denominator.

Information used from BRFSS in Arizona 2013 was not able to be estimated due to a limited

number of available responses.

BRFSS data is self-reported (example, asthma presence) and may not be entirely representative

of an individual’s medical history.

Hospital discharge data is representative of AI/AN from across the entire state, and therefore

does not represent individuals living only on Tribal Land.


Many state and national surveys and surveillance systems do not capture information for AI/AN,

making it difficult to estimate disease burden or risk factors.

Much of the information presented from this report uses hospital discharge data. As such, it is

only reflective of individuals seeking care at a hospital and likely underestimates the true burden

of the disease/condition.

Responses with a race classified as unknown, missing, other, or unspecified multiple race were

considered non-AI/AN in this report.

Responses are often only coded for those that are AI/AN alone, and do not include those with

multiple races, or Hispanic origin. In doing this, data may not be entirely representative of all

AI/AN.

Race/Ethnicity Misclassification

It is known that race/ethnicity, particularly among American Indians is often misclassified, or American

Indians are considered a different race/ethnicity group. The race/ethnicity misclassification likely under

reports the number of cases of an outcome of interest among American Indians. The lower number of

cases would then lower the incidence rate or prevalence of a given disease or condition among

American Indians.

Primary Coding System

All hospital discharge data sources use the World Health Organization (WHO) International Classification

of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and the WHO International Classification of

Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) coding system to numerically code the

primary diagnosis. More information regarding this coding system is available at:

http://www.who.int/classifications/icd/icdonlineversions/en/ .

Case Definitions

A case definition is a set of uniform criteria used to define a disease for public health surveillance. Case

definitions enable public health to classify and count cases consistently across reporting jurisdictions,

and are not to be used by healthcare providers to determine how to meet an individual patient’s health

needs. Therefore, not all clinically diagnosed cases are included. Any disease counts extracted from a

surveillance system likely under-estimate the burden of disease in the population.

In this report, state hospital discharge records were used for estimating illness presence in a population.

This only represents those individuals seeking care in a hospital and it is likely the true number of cases

in the population is greater. Identification of a disease was gathered from the principal diagnosis code,

or the condition that was responsible for admitting the patient, that was described by ICD-9-CM and

ICD-10-CM codes. The case definitions for the conditions obtained from hospital discharge data in this

report are presented below.

http://www.who.int/classifications/icd/icdonlineversions/en/


40

Allergic Rhinitis

ICD-9-CM ICD-10-CM

477 Allergic rhinitis J30 Vasomotor and allergic

rhinitis

477.0 Allergic rhinitis due to

pollen J30.0 Vasomotor rhinitis


food J30.1

Allergic rhinitis due to pollen


animal hair and dander; cat, dog

J30.2 Other seasonal allergic

rhinitis


other allergen J30.5

Allergic rhinitis due to food

477.9 Allergic rhinitis, cause

unspecified J30.8 Other allergic rhinitis

J30.81 Allergic rhinitis due to

animal hair and dander; cat, dog

J30.89 Other allergic rhinitis -

perennial

J30.9 Allergic rhinitis,

unspecified

Asthma

ICD-9-CM ICD-10-CM

493 Asthma J45 Asthma

493.0 Extrinsic asthma J45.2 Mild intermittent

asthma

493.1 Intrinsic asthma J45.3 Mild persistent asthma

493.8 Other specified asthma J45.4 Moderate persistent

asthma

493.81 Exercise-induced bronchospasm

J45.5 Severe persistent

asthma

493.82 Cough variant asthma J45.9 Other and unspecified

asthma

493.9 Asthma unspecified J45.90 Unspecified asthma

J45.99 Other asthma

J45.990 Exercise induced bronchospasm

J45.991 Cough variant asthma

J45.998 Other asthma


Chronic Obstructive Pulmonary Disease

ICD-9-CM ICD-10-CM

491 Chronic bronchitis J41 Simple and

mucopurulent chronic bronchitis

492 Emphysema J42 Unspecified chronic

bronchitis

J43 Emphysema

J44 Other chronic

obstructive pulmonary disease

Acute Upper Respiratory Infection

ICD-9-CM ICD-10-CM

460 Acute nasopharyngitis J00 Acute nasopharyngitis

461 Acute sinusitis J01 Acute sinusitis

462 Acute pharyngitis J02 Acute pharyngitis

463 Acute tonsilitis J03 Acute tonsillitis

464 Acute laryngitis and

tracheitis J04

Acute laryngitis and tracheitis

465 Acute upper respiratory infections of multiple or

unspecified sites J05

Acute obstructive laryngitis and epiglottis

466 Acute bronchitis and

bronchiolitis J06

Acute upper respiratory infections of multiple and unspecified sites

J20 Acute bronchitis

J21 Acute bronchiolitis

J22 Unspecified acute lower respiratory

infection

Pneumonia

ICD-9-CM ICD-10-CM

480 Viral pneumonia J12 Viral pneumonia, not elsewhere classified

481 Pneumococcal

pneumonia J13

Pneumonia due to Streptococcus pneumoniae


42

482 Other bacterial

pneumonia J14

Pneumonia due to Hemophilus influenzae

483 Pneumonia due to

other specified organism

J15 Bacterial pneumonia,

not elsewhere classified

484 Pneumonia an

infectious disease classified elsewhere

J16

Pneumonia due to other infectious organisms, not

elsewhere classified

485 Bronchopneumonia

organism unspecified J17

Pneumonia in diseases classified elsewhere

486 Pneumonia organism

unspecified J18

Pneumonia, unspecified organism

Influenza

ICD-9-CM ICD-10-CM

487 Influenza J09 Influenza due to certain

identified influenza viruses

488 Influenza due to certain

identified influenza viruses

J10 Influenza due to other

identified influenza virus

J11 Influenza due to

unidentified influenza virus


REFERENCES

1. Centers for Disease Control and prevention, Heron M. Deaths: Leading causes for 2015. National Vital Statistics Reports; vol 66 no 5. Hyattsville, MD: National Center for Health Statistics. 2017; https://www.cdc.gov/nchs/data/nvsr/nvsr66/nvsr66_05.pdf. Accessed 07, 2018.

2. Arizona Department of Health Services. Population Health and Vital Statistics; Health Status Profile of American Indians in Arizona. https://pub.azdhs.gov/health-stats/report/hspam/index.php. Updated 2018. Accessed 07/2018.

3. Nevada Electronic Death Registry Data and Demographics Data, Department of Health and Human Services, Office of Analytics.Provided by JZ 07/31/2018.

4. Utah Death Certificate Database, Office of Vital Records and Statistics, Utah Department of Health. Population Estimates by Age, Sex, Race, and Hispanic Origin for Counties in Utah, U.S. Bureau of the Census, IBIS Version 2016.

5. World Health Organization, Allergic rhinitis and sinusitis; http://www.who.int/respiratory/other/Rhinitis_sinusitis/en/. Accessed 07/2018, 2018.

6. Centers for Disease Control and Prevention, National Center for Health Statsitcs, Allergies and Hay Fever; https://www.cdc.gov/nchs/fastats/allergies.htm. Updated 2017. Accessed 07/2018.

7. Arizona Department of Health Services, Bureau of Public Health Statistics, Hospital Discharge Data;.

8. The Center for Health Information Analysis University of Nevada Las Vegas, Hospital Discharge Data

9. Utah Emergency Department Encounter Data (2011-2016). Bureau of Emergency Medical Services/Office of Health Care Statistics. Utah Department of Health. Salt Lake City, Utah. 2017.

10. Centers for Disease Control and Prevention, Antibiotic Prescribing and Use in Doctor’s Offices, Sinus Infection (Sinusitis); https://www.cdc.gov/antibiotic-use/community/for-patients/common-illnesses/sinus-infection.html. Updated 2017. Accessed 07/2018.

11. Centers for Disease Control and Prevention, Smoking & Tobacco Use, Fast Facts; https://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm. Updated 2018. Accessed 07/2018.

12. Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System, Annual Survey Data; https://www.cdc.gov/brfss/annual_data/annual_data.htm. Updated 2017. Accessed 07/2018.

13. Centers for Disease Control and Prevention, Asthma; https://www.cdc.gov/asthma/faqs.htm#. Updated 2017. Accessed 07/2018.

14. Centers for Disease Control and Prevention, Chronic Obstructive Pulmonary Disease (COPD); https://www.cdc.gov/copd/basics-about.html. Updated 2018. Accessed 07/2018.

15. Centers for Disease Control and Prevention, Antibiotic Prescribing and Use in Doctor’s Offices; https://www.cdc.gov/antibiotic-use/community/for-patients/symptom-relief.html. Updated 2018. Accessed 07/2018.

16. Centers for Disease Control and Prevention, Antibiotic Prescribing and Use in Doctor’s Offices, Bronchitis; https://www.cdc.gov/antibiotic-use/community/for-patients/common-illnesses/bronchitis.html. Updated 2017. Accessed 07/2018.

17. Centers for Disease Control and Prevention, Respiratory Syncytial Virus Infection (RSV); https://www.cdc.gov/rsv/index.html. Updated 2018. Accessed 07/2018.

18. World Health Organization, Pneumonia; http://www.who.int/en/news-room/fact-sheets/detail/pneumonia. Updated 2016. Accessed 07/2018.

https://www.cdc.gov/nchs/data/nvsr/nvsr66/nvsr66_05.pdf

https://pub.azdhs.gov/health-stats/report/hspam/index.php

https://pub.azdhs.gov/health-stats/report/hspam/index.php

http://www.who.int/respiratory/other/Rhinitis_sinusitis/en/

https://www.cdc.gov/nchs/fastats/allergies.htm

https://www.cdc.gov/antibiotic-use/community/for-patients/common-illnesses/sinus-infection.html

https://www.cdc.gov/antibiotic-use/community/for-patients/common-illnesses/sinus-infection.html

https://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm

https://www.cdc.gov/brfss/annual_data/annual_data.htm

https://www.cdc.gov/asthma/faqs.htm

https://www.cdc.gov/copd/basics-about.html

https://www.cdc.gov/antibiotic-use/community/for-patients/symptom-relief.html

https://www.cdc.gov/antibiotic-use/community/for-patients/common-illnesses/bronchitis.html

https://www.cdc.gov/antibiotic-use/community/for-patients/common-illnesses/bronchitis.html

https://www.cdc.gov/rsv/index.html

http://www.who.int/en/news-room/fact-sheets/detail/pneumonia

http://www.who.int/en/news-room/fact-sheets/detail/pneumonia


44

19. Centers for Disease Control and Prevention, Pneumonia; https://www.cdc.gov/pneumonia/. Updated 2017. Accessed 07/2018.

20. Center for Disease Control and Prevention, National Center for Injury Prevention and Control; https://webappa.cdc.gov/sasweb/ncipc/ypll10.html. Updated 2015. Accessed 07/2018.

21. Centers for Diseae Control and Prevention, Common Colds:Protect Yourself and Others; https://www.cdc.gov/features/rhinoviruses/. Updated 2018. Accessed 08/2018.

22. Centers for Disease Control and Prevention, Sore Throat; https://www.cdc.gov/antibiotic-use/community/for-patients/common-illnesses/sore-throat.html. Updated 2015. Accessed 08/2018.

23. National Institutes of Health, U.S. National Library of Medicine, MedlinePlus, Tonsillitis; https://medlineplus.gov/tonsillitis.html. Updated 2018. Accessed 08/2018.

24. National Institues of Health, U.S. National Library of Medicine, MedlinePlus, Laryngitis; https://medlineplus.gov/ency/article/001385.htm. Updated 2018. Accessed 08/2018.

25. National Institues of Health, U.S. National Library of Medicine, MedlinePlus, Tracheitis; https://medlineplus.gov/ency/article/000988.htm. Updated 2018. Accessed 08/2018.

26. Centers for Disease Control and Prevention, Flu Symptoms and Complications; https://www.cdc.gov/flu/consumer/symptoms.htm. Updated 2018. Accessed 08/2018.

27. World Health Organization, Chronic respiratory diseases; http://www.who.int/respiratory/en/. Accessed 08/2018.

28. National Association of Health Data Organizations, Data System Tech Resources; https://www.nahdo.org/data_resources. Accessed 08/2018.

29. Centers for Disease Control and Prevention, Influenza (Flu); https://www.cdc.gov/flu/protect/keyfacts.htm. Updated 2018. Accessed 09/2018.

30. Centers for Disease Control and Prevention, Vaccines and Preventable Diseases; https://www.cdc.gov/vaccines/vpd/pneumo/public/index.html. Updated 2017. Accessed 09/2018.

31. Centers for Disease Control and Prevention, Outdoor Air; https://ephtracking.cdc.gov/showAirHIA.action. Updated 2017. Accessed 09/2017.

32. World Health Organization, Outdoor Air Pollution; http://www.who.int/ceh/capacity/Outdoor_air_pollution.pdf. Accessed 09/2018.

33. United States Environmental Progection Agency, Outdoor Air Quality Data, Air Quality Statistics Report; https://www.epa.gov/outdoor-air-quality-data/air-quality-statistics-report. Updated 2018. Accessed 09/2018.

34. United States Environmental Protection Agency, Particulate Matter (PM) Pollution, Particulate Matter (PM) Basics; https://www.epa.gov/pm-pollution/particulate-matter-pm-basics#PM. Updated 2018. Accessed 09/2018.

35. United States Environmental Protection Agency, Particulate Matter (PM) Pollution, Health and Environmental Effects of Particulate Matter (PM); https://www.epa.gov/pm-pollution/health-and-environmental-effects-particulate-matter-pm. Updated 2018. Accessed 09/2018.

36. Centers for Disease Control and Prevention, Ozone and Health; https://www.cdc.gov/air/ozone.html. Updated 2016. Accessed 09/2018.

37. United States Environmental Protection Agency, Ozone Pollution; https://www.epa.gov/ozone-pollution; Updated 2018. Accessed 09/2018.

38. National Interagency Fire Center; Statistics; https://www.nifc.gov/fireInfo/fireInfo_statistics.html; Accessed 09/2018.

39. Centers for Disease Control and Prevention, Protect Yourself from Wildfire Smoke; https://www.cdc.gov/features/wildfires/index.html. Updated 2018. Accessed 09/2018.

https://www.cdc.gov/pneumonia/

https://www.cdc.gov/features/rhinoviruses/

https://www.cdc.gov/antibiotic-use/community/for-patients/common-illnesses/sore-throat.html

https://www.cdc.gov/antibiotic-use/community/for-patients/common-illnesses/sore-throat.html

https://medlineplus.gov/tonsillitis.html

https://medlineplus.gov/ency/article/001385.htm

https://medlineplus.gov/ency/article/000988.htm

http://www.who.int/respiratory/en/

https://www.nahdo.org/data_resources

https://www.cdc.gov/flu/protect/keyfacts.htm

https://www.cdc.gov/vaccines/vpd/pneumo/public/index.html

https://ephtracking.cdc.gov/showAirHIA.action

http://www.who.int/ceh/capacity/Outdoor_air_pollution.pdf

https://www.epa.gov/outdoor-air-quality-data/air-quality-statistics-report

https://www.epa.gov/pm-pollution/particulate-matter-pm-basics#PM

https://www.epa.gov/pm-pollution/health-and-environmental-effects-particulate-matter-pm

https://www.epa.gov/pm-pollution/health-and-environmental-effects-particulate-matter-pm

https://www.cdc.gov/air/ozone.html

https://www.epa.gov/ozone-pollution

https://www.epa.gov/ozone-pollution

https://www.nifc.gov/fireInfo/fireInfo_statistics.html

https://www.cdc.gov/features/wildfires/index.html


40. Arizona Department of health Services, Population Health and Vital Statistics, Vital Statistics Trends in Arizona; https://pub.azdhs.gov/health-stats/menu/info/trend/index.php?pg=deaths. Accessed 08/2018.

41. Utah Department of Health, Indicator-Based Information System for Public Health; https://ibis.health.utah.gov/. Updated 2017. Accessed 08/2018.

42. United States Department of Health and Human Services, Indian Health Service, National data Warehouse, Epidemiology Data Marts.

43. Centers for Disease Control and Prevention, Fungal Diseases, Symptoms of Valley Fever (Coccidioidomycosis); https://www.cdc.gov/fungal/diseases/coccidioidomycosis/symptoms.html. Updated 2017. Access 09/2018.

44. American Lung Association, Lung Health & Diseases, Understand Your Asthma Medication; https://www.lung.org/lung-health-and-diseases/lung-disease-lookup/asthma/living-with-asthma/managing-asthma/understand-your-medication.html. Updated 2018. Accessed 09/2018.

45. United States National Library of Medicine, MedlinePlus, Antihistamines for allergies; https://medlineplus.gov/ency/patientinstructions/000549.htm. Updated 2016. Accessed 09/2018.

https://pub.azdhs.gov/health-stats/menu/info/trend/index.php?pg=deaths

https://ibis.health.utah.gov/

https://www.cdc.gov/fungal/diseases/coccidioidomycosis/symptoms.html

https://www.lung.org/lung-health-and-diseases/lung-disease-lookup/asthma/living-with-asthma/managing-asthma/understand-your-medication.html

https://www.lung.org/lung-health-and-diseases/lung-disease-lookup/asthma/living-with-asthma/managing-asthma/understand-your-medication.html

https://medlineplus.gov/ency/patientinstructions/000549.htm

Cancer Surveillance among American Indians in AZ, NV, and...

Documents

Transcript of Cancer Surveillance among American Indians in AZ, NV, and...