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
Arizona, Nevada, and Utah
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
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
Arizona, Nevada, and Utah
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.
Allergy, Asthma, and Respiratory Disease Surveillance among American Indians in AZ, NV, and UT
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
Allergy, Asthma, and Respiratory Disease Surveillance among American Indians in AZ, NV, and UT
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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.
Allergy, Asthma, and Respiratory Disease Surveillance among American Indians in AZ, NV, and UT
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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.
Allergy, Asthma, and Respiratory Disease Surveillance among American Indians in AZ, NV, and UT
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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
Allergy, Asthma, and Respiratory Disease Surveillance among American Indians in AZ, NV, and UT
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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:
3 ITCA Tribal Epidemiology Center
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.
Allergy, Asthma, and Respiratory Disease Surveillance among American Indians in AZ, NV, and UT
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).
5 ITCA Tribal Epidemiology Center
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
Heart Disease 1 122.7
Cancer 2 100.8
Unintentional Injury 3 94.8
Diabetes 4 80.2
Chronic Liver Disease and Cirrhosis 5 59.2
2013
Heart Disease 1 122.9
Cancer 2 118.2
Unintentional Injury 3 104.5
Diabetes 4 65.7
Chronic Liver Disease and Cirrhosis 5 62.0
2014
Heart Disease 1 107.5
Cancer 2 97.1
Unintentional Injury 3 85.4
Diabetes 4 63.2
Chronic Liver Disease and Cirrhosis 5 52.7
2015
Unintentional Injury 1 139.0
Cancer 2 124.4
Heart Disease 3 119.9
Chronic Liver Disease and Cirrhosis 4 77.6
Diabetes 5 73.9
2016
Heart Disease 1 139.9
Unintentional Injury 2 139.1
Cancer 3 101.2
Chronic Liver Disease and Cirrhosis 4 85.9
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
Allergy, Asthma, and Respiratory Disease Surveillance among American Indians in AZ, NV, and UT
6
Table 2. Leading causes of mortality by rank and mortality rate per 100,000 among
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
Non-transport Accidents 3 50.6 25.8 75.4
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
Non-transport Accidents 3 36.9 17.6 56.2
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
Non-transport Accidents 3 36.7 15.9 57.4
Chronic Lower Respiratory Diseases 4 31.4 8.1 54.7
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
Chronic Liver Disease and Cirrhosis 3 40.9 20.2 61.7
Non-transport Accidents 4 38.2 16.6 59.8
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
Chronic Lower Respiratory Diseases 3 39.1 17.0 61.3
Non-transport Accidents 4 35.8 15.6 56.1
Chronic Liver Disease and Cirrhosis 5 30.2 12.3 48.0
7 ITCA Tribal Epidemiology Center
Table 3. Leading causes of mortality by rank and mortality rate per 100,000 among
AI/AN in Utah from 2011 – 2016 a-c
Utah
Year Cause of Death Rank Mortality
Rate a
Lower 95% Confidence
Interval
Upper 95% Confidence
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
Unintentional Injury 3 86.4 56.4 126.7
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
Unintentional Injury 4 51.1 29.0 83.4
Chronic Liver Disease and Cirrhosis
5 38.7 19.1 69.8
2014
Unintentional Injury 1 104.0 73.8 142.5
Cancer 2 103.3 63.2 159.3
Heart Disease 3 86.0 50.8 136.4
Chronic Liver Disease and Cirrhosis
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
Unintentional Injury 4 55.0 34.4 83.3
Chronic Liver Disease and Cirrhosis
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
Unintentional Injury 3 60.0 39.1 88.1
Diabetes b 4 46.1 22.3 84.4
Chronic Liver Disease and Cirrhosis
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
Allergy, Asthma, and Respiratory Disease Surveillance among American Indians in AZ, NV, and UT
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.
9 ITCA Tribal Epidemiology Center
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
AI/AN = American Indian/Alaska Native
Allergy, Asthma, and Respiratory Disease Surveillance among American Indians in AZ, NV, and UT
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).
11 ITCA Tribal Epidemiology Center
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
AI/AN = American Indian/Alaska Native
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
AI/AN = American Indian/Alaska Native
Allergy, Asthma, and Respiratory Disease Surveillance among American Indians in AZ, NV, and UT
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
AI/AN = American Indian/Alaska Native
13 ITCA Tribal Epidemiology Center
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
AI/AN = American Indian/Alaska Native
Allergy, Asthma, and Respiratory Disease Surveillance among American Indians in AZ, NV, and UT
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).
15 ITCA Tribal Epidemiology Center
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
Allergy, Asthma, and Respiratory Disease Surveillance among American Indians in AZ, NV, and UT
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
17 ITCA Tribal Epidemiology Center
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).
Allergy, Asthma, and Respiratory Disease Surveillance among American Indians in AZ, NV, and UT
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
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
AI/AN = American Indian/Alaska Native
19 ITCA Tribal Epidemiology Center
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
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
AI/AN = American Indian/Alaska Native
Allergy, Asthma, and Respiratory Disease Surveillance among American Indians in AZ, NV, and UT
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 %
Acute Nasopharyngitis
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
Acute Bronchitis and Bronchiolitis
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
Count % Count % Count % Count % Count % Count %
Acute Nasopharyngitis
* 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
Acute Bronchitis and Bronchiolitis
116 29.7 121 28.5 219 29.2 274 32.5 274 29.5 138 21.9
Acute URI of multiple or
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
Count % Count % Count % Count % Count % Count %
Acute Nasopharyngitis
* 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
Acute Bronchitis and Bronchiolitis
66 28.5 42 30.7 18 31.6 32 41.6 49 38.3 67 33.0
Acute URI of multiple or
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
21 ITCA Tribal Epidemiology Center
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).
Allergy, Asthma, and Respiratory Disease Surveillance among American Indians in AZ, NV, and UT
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
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
AI/AN = American Indian/Alaska Native
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
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
AI/AN = American Indian/Alaska Native
23 ITCA Tribal Epidemiology Center
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
Lower 95% Confidence
Interval
Upper 95% Confidence
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
Allergy, Asthma, and Respiratory Disease Surveillance among American Indians in AZ, NV, and UT
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).
25 ITCA Tribal Epidemiology Center
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.
Allergy, Asthma, and Respiratory Disease Surveillance among American Indians in AZ, NV, and UT
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).
27 ITCA Tribal Epidemiology Center
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
AI/AN = American Indian/Alaska Native
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
AI/AN = American Indian/Alaska Native
Allergy, Asthma, and Respiratory Disease Surveillance among American Indians in AZ, NV, and UT
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
29 ITCA Tribal Epidemiology Center
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
Allergy, Asthma, and Respiratory Disease Surveillance among American Indians in AZ, NV, and UT
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
AI/AN = American Indian/Alaska Native
31 ITCA Tribal Epidemiology Center
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).
Allergy, Asthma, and Respiratory Disease Surveillance among American Indians in AZ, NV, and UT
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
PM10 PM2.5 PM10 PM2.5 PM10 PM2.5 PM10 PM2.5 PM10 PM2.5 PM10 PM2.5
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
PM10 PM2.5 PM10 PM2.5 PM10 PM2.5 PM10 PM2.5 PM10 PM2.5 PM10 PM2.5
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
33 ITCA Tribal Epidemiology Center
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).
Allergy, Asthma, and Respiratory Disease Surveillance among American Indians in AZ, NV, and UT
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
35 ITCA Tribal Epidemiology Center
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
Allergy, Asthma, and Respiratory Disease Surveillance among American Indians in AZ, NV, and UT
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.
37 ITCA Tribal Epidemiology Center
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.
Allergy, Asthma, and Respiratory Disease Surveillance among American Indians in AZ, NV, and UT
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.
39 ITCA Tribal Epidemiology Center
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.
Allergy, Asthma, and Respiratory Disease Surveillance among American Indians in AZ, NV, and UT
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
477.1 Allergic rhinitis due to
food J30.1
Allergic rhinitis due to pollen
477.2 Allergic rhinitis due to
animal hair and dander; cat, dog
J30.2 Other seasonal allergic
rhinitis
477.8 Allergic rhinitis due to
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
41 ITCA Tribal Epidemiology Center
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
Allergy, Asthma, and Respiratory Disease Surveillance among American Indians in AZ, NV, and UT
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
43 ITCA Tribal Epidemiology Center
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.
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