CDC Telebriefing Transcript

CDC Releases Atlas of Stroke Mortality

February 20, 2003

DR. THOMPSON: [in progress]-- those of you who are here with us in St. Louis at the annual Chronic Disease Conference and for those of you who are participating with us by phone.

I'm Dr. Ed Thompson. I'm the deputy director for public health services at the Centers for Disease Control and Prevention, one of the participants and sponsors of this conference that is in fact the work of many, many individuals.

We're here this afternoon to present to you and provide information on a major new publication of the Centers for Disease Control. It is the National Stroke Atlas, a publication showing graphically the location of stroke deaths in literally every county in the United States. For the first time, these data are published both geographically and also for a number of ethnic groups previously not published in this form. It is a landmark publication, the companion to similar atlases for cardiovascular disease, heart disease deaths in both men and women throughout the United States.

We have with us today to help discuss this landmark publication a number of experts on the subject of stroke and stroke prevention. They will discuss in more detail with you the fact that stroke in the United States kills approximately 165,000 Americans each year and that in every year in the United States--using the most recent year, 2000-- approximately 700,000 people suffered a new or recurrent stroke. Stroke is the third leading cause of death after heart disease and cancer in the United States. It imposes an enormous health burden, economic burden, and certainly personal and emotional burden on all of us. And we have in our hands today an important new tool to prevent the occurrence and better treat the occurrence when it does occur of this major killer of Americans.

To present information about the atlas and about stroke, let me first introduce to you Dr. George Mense [sp] , chief of the Cardiovascular Health Program in the Division of Adult and Community Health for the Centers for Disease Control and Prevention. Dr. Mense.

DR. MENSE: Thank you very much, Dr. Thompson. And I want to also welcome you and thank you for listening and joining in.

As Dr. Thompson pointed out, stroke, which is sometimes called a "brain attack," is a major public health problem. As you've already heard, it is the third leading cause of death and a major, major cause of long-term disability. On the average, about every 45 seconds someone suffers a stroke. This amounts to about 700,000 strokes a year--about 500,000 of these, first-time strokes.

Now, much contrary to popular belief, stroke is not just something that kills old folks. For example, an African Americans, half of all the stroke deaths happen before age 75. Also contrary to popular belief, stroke is not something that just kills men. There are 40,000 more stroke deaths in women compared to the deaths in men.

But perhaps the most important misconception is that stroke is a "good way to go." It is not. Most people do not die from their strokes. And in fact, among those who are fortunate to survive, 15 to 30 percent of them suffer major, permanent disability. Another 15 percent of them would die during the year that they're surviving or recovering from their stroke.

If this all sounds like bad news, it really is. But the good news is we know what to do and we know what it takes to prevent stroke. That is why at CDC and working together with our partners, our Healthy People 2010 partners--the American Heart Association, the American Stroke Association, the National Stroke Association, and several of our partners, and particularly including the chronic disease directors--we are taking these steps to help lead to a heart-healthy and a stroke-free America.

We hope that this atlas that you're going to hear more about from Michelle Kasper [sp] and our other participants here will serve as one of the very important first steps in leading to the prevention and the control of stroke. Michelle Kasper will tell us a little bit more about the atlas.

DR. THOMPSON: For those of you listening on the phone, Dr. Michelle Kasper is an epidemiologist with the Cardiovascular Health Branch at the National Centers for Disease Control and Prevention. Dr. Kasper.

DR. KASPER: Thank you. We're very excited to be here today to release this new Atlas of Stroke Mortality: Racial, Ethnic, and Geographic Disparities in the United States. This atlas was developed in collaboration with researchers at West Virginia University and the University of South Florida. And as Dr. Thompson mentioned, it's the third in the serious of atlases that CDC has produced in the previous three years.

The Atlas of Stroke Mortality provides, for the first time, an extensive series of both national and state maps depicting disparities in county-level stroke death rates for five of the largest racial and ethnic groups in the United States--specifically, African Americans, American Indians and Alaska natives, Asians and Pacific Islanders, Hispanics, and whites. The atlas presents data for adults ages 35 and older during the years 1991 through 1998.

The results from the atlas highlight the dramatic geographic disparities in stroke death rates that exist within the United States. Whereas the national stroke death rate was 121 deaths per 100,000 population, states ranges from a low of 89 per 100,000, in New York, to a high of 169 per 100,000 in South Carolina. This means that death rates were almost twice as high in some parts of the country compared to others.

At the county level, disparities were even greater, with death rates ranging from a low of 61 deaths per 100,000 to a high of 241 deaths per 100,000.

The national map of stroke death rates indicates that adults living in Southern counties along the coastal plain and in the Mississippi Delta region experienced the greatest burden of stroke mortality in the United States. Counties in the highest quintile of stroke death rates are concentrated primarily in these two areas; counties with the lowest stroke death rates are located primarily in the Southwest, the Great Plains, and the Northeast.

The atlas also highlights the differences in geographic patterns that exist between the five racial and ethnic groups. For both African Americans and whites, the pattern was actually very similar to that of the total population. That is, high-rate counties were found primarily in Southern counties along the coastal plain and in the Mississippi Delta region.

Among Hispanics, however, there's a very different pattern. The largest concentration of high-rate counties was observed in much of Texas and New Mexico.

For American Indians and Alaska natives, there is essentially a north-south gradient, with the highest rates concentrated in parts of Alaska, Oregon, Idaho, and Montana.

And finally, for Asians and Pacific Islanders, the patterns reflects actually a west-east gradient, with the highest rates concentrated primarily among counties in California, Nevada, and the Pacific Northwest.

The observed differences in the geographic patterns of stroke mortalities reflect important differences in the social and economic histories of each racial and ethnic group, and these histories must be taken into consideration when developing stroke-prevention policies and programs that will meet the needs of local communities. As public health professionals, if we concentrate only on the national map for the total U.S. population, we will completely miss the high-rate areas for minority populations.

In addition to the different geographic patterns observed for each of the racial and ethnic groups, the atlas also highlights disparities in the burden of stroke between the racial and ethnic groups. In particular, findings underscore the excess burden of stroke that continues to be experienced by African Americans. African Americans are 1.4 times more likely to die of a stroke than whites and more than twice as likely as Hispanics and Native Americans.

African Americans are also more like to die of a stroke at an earlier age, as Dr. Mense pointed out. Among African Americans, almost half of stroke deaths occur before age 75, compared to 45 percent for Asians and Pacific Islanders and only 25 percent of stroke deaths for whites.

While we do not yet know exactly why the dramatic disparities in stroke mortality exist, it is important to note that the concentrations of high-rate counties tend to be in areas of the country that have been chronically impoverished and underdeveloped. The persistent lack of social and economic resources make it difficult for those communities to provide stroke-free living and working environments for their residents.

Therefore, it is essential that our stroke-prevention policies and programs are designed to acknowledge any underlying socio-economic inequalities and ensure that all communities have equal access to stroke-free working and living environments.

This entails opportunities for the following types of resources: Access to affordable quality health care; jobs with necessary health benefits; information about the signs and symptoms of a stroke; treatment and control of high blood pressure, the leading risk factor for stroke; universal 911 coverage with emergency medical services in place that can deal with a stroke; parks and recreational facilities and sufficient leisure time to actually use them; affordable foods that are high in fiber and low in fat; and finally, smoking cessation programs.

While there are already many stroke-prevention activities in place that are directed toward achieving these goals, the Atlas of Stroke Mortality can serve as a blueprint for additional stroke-prevention activities.

And with that, I'd like to turn it over to Dr. Benevente [sp], who will address some of the clinical symptoms of a stroke and some of the issues in the Hispanic community.

DR. THOMPSON: Dr. Oscar Benevente is associate professor of neurology at the University of Texas Health Science Center in San Antonio. He is a neurologist who has written extensively in the field of stroke but particularly focusing on the area of stroke prevention. Dr. Benevente.

DR. BENEVENTE: Thank you very much.

One of the issues in order to prevent or treat a stroke is to recognize the symptoms of a stroke. Stroke is not one disease; there are several ways of a stroke, or several forms, and patients can present in different manners. So a very important function of the physician is to educate the population about the early recognition of stroke symptoms.

Finally over the past 12 or 15 years, we learned that a stroke is an emergency, true medical emergency like a heart attack. But the patients still are not arriving on time to receive their proper treatment that they need. Some of them already [inaudible] stroke are qualified to receive [inaudible] which the cardiologists have been administering to the patient for a long time.

So the way that a patient might present in a stroke are several ways. For instance, the most common symptoms are going to be those of unilateral weakness on the hemi-body or lack of sensation or lost sensation, problems with vision, the patient unable to see, difficulty with walking or difficulty with talking. So education is crucial for the patient to arrive immediately when those symptoms present to emergency and to receive their proper treatment.

In this atlas that Michelle has presented in such an eloquent fashion, which is extremely important, reveals that there are certain striking differences in the way that the strokes affect minorities. And it's well-known that African Americans are affected different, or at least the burden of the disease is largely in the group than in non-African Americans. But it is Hispanic Americans, which is the fastest-growing minority population that we have, is also affected differently.

There are several factors that we can discuss why does it happen and perhaps there are biological factors, so genetics and how the stroke affects differently the population, but also we can observe that due to the higher incidence of intracerebral hemorrhage in Hispanics, which is one type of stroke, they tend to have a higher mortality than non-Hispanic whites at early age.

So in addition to the biological factors, I believe there must be socio-economic and cultural factors that will influence in this disparity. And it is important to understand which one is the most prevalent or how to attack that, to prevent the disparity in minorities.

DR. THOMPSON: Thank you, Dr. Benevente.

Whenever you get this many doctors together, it takes at least one nurse to keep us all straight. So far you've heard from three doctors and an epidemiologist, and now we have a nurse. Ms. Joan Weir [sp] is the director of the heart disease and stroke prevention programs for the Utah State Department of Health--a nurse by background. And also, she is an American Heart Association volunteer and will bring to us something of the perspective of the American Heart Association, American Stroke Association on this important issue. Ms. Weir.

MS. WEIR: Thank you. The American Heart Association, American Stroke Association has been focused on many facets of stroke from primary prevention--of course, which would be our first choice--to treatment and long-term care. We are very excited to have the atlas because the strength of our agency is in our grassroots efforts on the state and local level and in the partnerships that we have built with our state health agencies.

We have not until today had this kind of information down to a county level about stroke. Being able to look at our own states, being able to identify where the problems are gives us an idea of where we might direct our efforts and our resources over the next years to ensure that we can indeed decrease the disability from stroke.

DR. THOMPSON: Thank you. The atlas that we're releasing today is likely to prove one of the most important documents in stroke prevention in many, many years. It provides the means, literally, to see where stroke occurs. It puts before our very eyes the locations and the geographic and ethnic disparities in stroke. It allows us to plan research, to make policy, and to develop interventions.

The atlas, for those of you here in the room, is available on the table in the back. For those of you not here, it's available, for free, from the National Center for Chronic Disease Prevention and Health Promotion. You can e-mail them at cdcinfo@cdc.gov, or you can call them at 1-888-232-2306 for a free copy. You can also get it on the Internet, for those of you who are not here in the room with us. If you'll listen carefully, this is what the document sounds like when the pages are ruffled in the microphone. And you can access it and download the entire document www.cdc.gov\cvh\maps.

And now we'll take questions from those of you here in the room. And also, for those of you who are joining us by telephone, we will alternate between those in the room and those on the telephone to the extent that we can. I suspect there are more of you on the phone than have been able to join us here in St. Louis. So we'll try to keep it fairly even.

And with that, we'll take the first question. Do we have a question from callers on the line? We'll turn to Paul, our AT&T facilitator.

AT&T FACILITATOR: We have a question from the line of Delthia Ricks, Newsday.

QUESTION: Hello there. This question is for Dr. Benevente. We hear over and over again that there is a "biological difference" in the way that people respond to stroke and, as a matter of fact, to a number of other conditions. I want to know if you can spell out what you mean by that. Because, you know, as we get information from the human genome project, we're learning that there are not many differences among people, so why do you say that there are such differences?

DR. BENEVENTE: When we mention biological difference, perhaps we are not very specific. But for instance, if you look at African Americans, they suffer a different proportion of strokes when you compare with the non-African Americans, white. Just to give you an example, African Americans suffer stroke at an early age, earlier than whites, do suffer more intracranial stenosis than extracranial disease, and do have more intracerebral hemorrhage than patients who are non-African American.

So there is some reason that we do not understand yet why, if both are exposed--assuming they're exposed to the same risk factors--they will have a different distribution of the disease.

A similar example I can give regarding Hispanics. Hispanics suffer more lacuna stroke, which is a particular type of [inaudible] stroke. They are affected also at earlier age than white non-Hispanics. And also they tend to have--the severity or the frequency of carotid stenosis is not as high as you find in patients who are Caucasians or white.

So why is that? It's something that we need more research to be able to answer, but we don't have a very clear explanation. For instance, Orientals in the manner, they suffer more intracerebral hemorrhage as well as more intracranial disease or intracranial stenosis than Caucasians. They have more affected [inaudible] disease.

DR. THOMPSON: Next question? George, do you want to add to that? Dr. Mense's going to amplify.

DR. MENSE: A very brief comment, and just to say that in terms of the big picture, when we're thinking of the prevention and control of stroke, the most important factors are going to be environmental and some of the major risk factors that we know. The number one, number two, and number three causes of stroke are high blood pressure, high blood pressure, and uncontrolled high blood pressure. These genetic differences do not correspond with the differences that we know when we talk about race or ethnicity; they're not biological variables. They're a social and environmental construct.

So even though genes play an important role in most diseases, they probably don't play anymore than 20, 25 percent. And so we really want to make sure--and I agree with what he said--that if we're going to try to prevent stroke, we must address the major risk factors for which we have more than 50 years of experience--high blood pressure, tobacco use, and the major established risk factors.

DR. THOMPSON: Thanks, Dr. Mense. Next question, from in the room or from one of our telephone callers. We'll go to the phone, and Paul?

AT&T FACILITATOR: We have a question from Kerry Fehr-Snyder, Arizona Republic.

QUESTION: Hi. I appreciate the call. I am trying to figure out why is Southwest so low?

DR. THOMPSON: If we could answer that, we'd really be in good shape. But I think Dr. Kasper can shed some light on that.

DR. KASPER: Yes, this is a question that we have also. And it's interesting when you look--the atlas that we've also published for heart disease show that the West has low rates for heart disease as well. And we don't have any particular answers yet as to exactly why that is. And you have to keep in mind that the rates there are lower than other parts of the country. It doesn't necessarily mean that they're low. It's still the leading cause--heart disease is still the leading cause of death in the Western states and stroke is still the third leading cause of death in those states.

But what it does point out to us is the fact that this disparity is so great. Those states, on average, have stroke death rates that are half their counterparts' in the South. So we need to identify what is going on in the Western states that we could then apply to the Southeastern states, the coastal region and the Mississippi Delta.

QUESTION: Is it possible that we're not digging out from a snowstorm, for example, today, and it's going to be a balmy 74, so we're doing more exercise?

DR. KASPER: I can definitely see that as a contributing factor.

DR. THOMPSON: Next question, please.

AT&T FACILITATOR: There are no further questions on the phone line.

DR. THOMPSON: Okay. For those of you here in the room, any questions that you have that you didn't think of to ask us while you're here, certainly if you contact Dr. Mense, Dr. Kasper, Dr. Benevente, Ms. Weir while they're still here at the conference, they'll be presenting in a plenary session beginning at 1:30, or many of them will, the general issue of stroke, and the discussion of this atlas will be a part of that.

I want to thank you all for participating in this and remind you that it's particularly appropriate that we present this atlas and release it for the first time here in St. Louis, Missouri, at the National Chronic Disease Conference be Missouri is the Show-Me State. And with this atlas, we do exactly that. We show you, we show us things about stroke that we can't determine any other way than by looking at them.

Thank you very much, and we look forward to hearing from most of you further in the conference.

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