The following are pre-publication drafts of articles from the
Morbidity and Mortality Weekly Report 44(06) dated February 17, 1995.
Late-breaking articles, and final editorial revisions are not
included.  Therefore, these articles should not be quoted without
consulting the official printed copy that is released to the public,
as received from the CDC.--CDC.Also, please refer to the printed copy
for any charts or graphically represented data.

       Table of Contents
       -----------------

       American Heart Month, February 1995
       Indicators of Nicotine Addiction Among Women -- United States,
            1991-1992
       Prevalence of Recommended Levels of Physical Activity Among
            Women -- Behavioral Risk Factor Surveillance System, 1992
       Smokeless Tobacco Use Among American Indian Women --
            Southeastern North Carolina, 1991
       Update: Dracunculiasis Eradication -- Pakistan, 1994

       -----------------

       American Heart Month, February 1995

       Cardiovascular disease is the most common cause of death in the
United States. Although death rates for cardiovascular disease are
declining, in 1991 the death rate for this problem among women was
approximately five times that for lung or breast cancer (Figure 1). A
high proportion of these deaths are preventable by reducing important
risk factors for heart disease, including smoking, physical
inactivity, and high-fat diet. In conjunction with American Heart
Month (February 1995), this issue of MMWR includes reports that
address two of these modifiable risk factors among U.S. women.


       Indicators of Nicotine Addiction Among Women --
       United States, 1991-1992

       An estimated 22 million U.S. women were current smokers in
1993; of these, 73% wanted to quit smoking (1). However, attempts to
quit smoking and to remain abstinent are hindered by nicotine
addiction and by the subsequent effects of nicotine withdrawal (2). To
assess the prevalence of selected indicators of nicotine addiction
among U.S. women, CDC analyzed data from the National Household Survey
on Drug Abuse (NHSDA) in 1991 and 1992 (3). This report presents the
findings of the analysis.

       The NHSDA is a household survey of a nationally representative
sample of the civilian, noninstitutionalized U.S. population. Combined
data from the 1991 and 1992 surveys (n=7137) were used to estimate the
prevalences of four indicators of nicotine addiction among women who
smoke. Information about these indicators was based on responses to
four questions; current smokers* were asked whether, during the 12
months preceding the survey, they 1) "felt [they] needed or were
dependent on cigarettes," 2) "needed larger amounts [more cigarettes]
to get the same effect," 3) "felt unable to cut down on [their] use
even though [they] tried," and 4) "had withdrawal symptoms, that is,
felt sick because [they] stopped or cut down on [their] use." The
analysis of "unable to cut down" (n=4422) and "felt sick" (n=4646) was
restricted to persons who reported trying to reduce their use of
cigarettes during the preceding 12 months. In addition, for the
indicator "unable to cut down," because of the question design,
respondents who reported not trying to reduce any drug use during the
preceding 12 months (n=224) also were excluded. Because the likelihood
of daily smoking (4; CDC, unpublished data, 1991) and the intensity of
smoking (i.e., number of cigarettes smoked per day) (4,5) varies
directly with age, respondents were classified into two age
groups--12- 24-year-olds and greater than or equal to 25-year-olds.
Data were adjusted for nonresponse and weighted to provide national
estimates. Standard errors were calculated by using SUDAAN (6).

       Among female smokers in both age groups, 75% reported feeling
dependent on cigarettes (Table 1). The prevalence of feeling dependent
varied directly with intensity of smoking; among those who smoked six
to 15 cigarettes per day, 80.6% (95% confidence interval
[CI]=77.1%-84.2%) of those aged 12-24 years and 76.1% (95%
CI=72.3%-79.9%) of those aged greater than or equal to 25 years
reported feeling dependent on cigarettes. Female smokers aged 12-24
years were more likely to report needing more cigarettes to attain the
same effect than were those aged greater than or equal to 25 years
(18.0% [95% CI=15.8%-20.2%] versus 13.2% [95% CI=11.3%- 15.0%]). Among
those who had tried to reduce smoking during the preceding 12 months,
81.5% (95% CI=78.9%-84.1%) of 12-24-year-olds and 77.8% (95% CI=75.1%-
80.5%) of greater than or equal to 25-year-olds reported being unable
to do so; even among those who smoked six to 15 cigarettes per day,
inability to reduce smoking was reported by 82.6% (95% CI=78.7%-86.4%)
of 12-24-year-olds and 73.8% (95% CI=68.4%-79.2%) of the greater than
or equal to 25-year-olds. Of all female smokers aged greater than or
equal to 12 years, 35.4% reported withdrawal symptoms (i.e., feeling
sick) when they tried to reduce their smoking.

       Females in both the younger and older age groups were equally
likely to report at least one of the four indicators of nicotine
addiction (81.2% [95% CI=78.6%-83.8%] and 79.4% [95% CI=77.3%- 81.5%],
respectively) (Table 1). Even among females who smoked five or fewer
cigarettes per day, 63.1% (95% CI=56.4%-69.8%) of those aged 12-24
years and 53.0% (95% CI=46.9%-59.1%) of those aged greater than or
equal to 25 years reported one or more of these indicators.

Reported by: J Gfroerer, Prevalence Br, Office of Applied Studies,
Substance Abuse and Mental Health Svcs Administration. Office on
Smoking and Health, and Div of Chronic Disease Control and Community
Intervention, National Center for Chronic Disease Prevention and
Health Promotion, CDC.

Editorial Note: In 1990, an estimated 61,000 U.S. women aged greater
than or equal to 35 years died from cardiovascular diseases
attributable to cigarette smoking (7). Because the risk for myocardial
infarction can be reduced by 50% after 1 year of abstaining from
smoking (8), interventions to encourage smoking cessation are an
important strategy to reduce cardiovascular mortality. Although most
women smokers want to quit smoking, only 2.5% of all smokers
successfully quit each year (9). The finding in this report that
approximately 80% of female smokers reported symptoms of nicotine
addiction underscores the importance of measures to increase women's
access to cessation interventions, including adjunctive
nicotine-replacement therapy.

       The findings in this report are subject to at least two
limitations. First, the NHSDA indicators are not comprehensive
measures of nicotine addiction and do not include all symptoms of
nicotine withdrawal (e.g., anxiety, irritability, anger, difficulty
concentrating, hunger, or cravings for cigarettes) (2); as a result,
the NHDSA data may underestimate the proportion of smokers who report
at least one indicator of nicotine addiction. Second, these findings
are based on self-reported data, and perceptions of nicotine addiction
were not validated. However, in previous studies, self-reported
symptoms of nicotine addiction have been confirmed by observer rating
(2).

       Although manifestations of cardiovascular disease occur
primarily during adulthood, related high-risk behaviors, such as
tobacco use, often are initiated during adolescence; an estimated 87%
of female daily smokers began smoking at less than or equal to 18
years of age (CDC, unpublished data, 1991). Young persons often try
using tobacco with a belief that they can quit. However, of adolescent
smokers who have intended to not be smoking in 5-6 years, 73% still
smoked 5 years later (10). The 1991 and 1992 NHSDA data suggest that
an important reason for young smokers' failure to quit smoking is a
prevalence of addiction similar to that among older smokers. Because
of the difficulty in achieving abstinence and the strength and early
onset of nicotine addiction, interventions to prevent smoking
initiation are important.

       School-based programs, combined with community interventions,
have been effective in preventing smoking initiation (10). Other
measures that can prevent smoking initiation, onset of nicotine
addiction, and subsequent morbidity and mortality associated with
cardiovascular diseases include enforcement of laws that prohibit
sales to minors, counter-advertising campaigns that "deglamorize"
smoking to youth, and increases in the real price of cigarettes.

       References

        1. CDC. Cigarette smoking among adults--United States, 1993.
MMWR 1994;43:925-30. 2. CDC. The health consequences of smoking:
nicotine addiction--a report of the Surgeon General. Rockville,
Maryland: US Department of Health and Human Services, Public Health
Service, CDC, 1988; DHHS publication no. (CDC)88-8406.

        3. Substance Abuse and Mental Health Services Administration.
National Household Survey on Drug Abuse: population estimates, 1992.
Rockville, Maryland: US Department of Health and Human Services,
Public Health Service, Substance Abuse and Mental Health Services
Administration, 1993; DHHS publication no. (SMA)93-2053.

        4. Moss AJ, Allen KF, Giovino GA, et al. Recent trends in
adolescent smoking, smoking-uptake correlates, and expectations about
the future. Hyattsville, Maryland: US Department of Health and Human
Services, Public Health Service, CDC, NCHS, 1992. (Advance data no.
221).

        5. Giovino GA, Schooley MW, Zhu B-P, et al. Surveillance for
selected tobacco-use behaviors--United States, 1900-1994. MMWR
1994;43(no. SS-3).

        6. Shah BV. Software for survey data analysis (SUDAAN),
version 5.50 [Software documentation]. Research Triangle Park, North
Carolina: Research Triangle Institute, 1991.

        7. CDC. Cigarette smoking-attributable mortality and years of
potential life lost--United States, 1990. MMWR 1993;42:645-9.

        8. CDC. The health benefits of smoking cessation: a report of
the Surgeon General, 1990. Rockville, Maryland: US Department of
Health and Human Services, Public Health Service, 1990; DHHS
publication no. (CDC)90-8416.

        9. CDC. Smoking cessation during previous year among adults--
United States, 1990 and 1991. MMWR 1993;42:504-7.

       10. US Department of Health and Human Services. Preventing
tobacco use among young people: a report of the Surgeon General.
Atlanta: US Department of Health and Human Services, Public Health
Service, CDC, National Center for Chronic Disease Prevention and
Health Promotion, Office on Smoking and Health, 1994.

       *Defined as persons who had ever smoked 100 cigarettes and had
        smoked during the 30 days preceding the survey.


       Prevalence of Recommended Levels of Physical Activity Among
       Women -- Behavioral Risk Factor Surveillance System, 1992

       Regular physical activity provides important health benefits
for women, including lower risks for coronary heart disease, some
cancers, osteoporosis, and other leading causes of death and
disability (1-3). Despite such benefits, the proportion of women in
the United States reporting regular physical activity has been low
(4). Because even moderately intense physical activity has substantial
health benefits, public health recommendations for physical activity
have been expanded to a broader spectrum of activity, including
gardening, walking, and housework in addition to more vigorous aerobic
exercise (e.g., jogging) (5,6). To improve estimates of the prevalence
of participation in physical activity at levels associated with health
benefits among adult women, data about leisure-time physical activity
were analyzed from the 1992 Behavioral Risk Factor Surveillance System
(BRFSS). This report summarizes the results of these analyses.

       Data were available for 55,506 women aged greater than or equal
to 18 years in 48 states and the District of Columbia who participated
in the 1992 BRFSS, a population-based, random-digit- dialed telephone
survey. Respondents were asked about the frequency, duration, and
intensity of leisure-time physical activities during the preceding
month and were categorized as having reported 1) no leisure-time
physical activity, 2) irregular activity that did not meet the
recommended criteria for either moderate or vigorous physical
activity, or 3) regular activity meeting either the previous
recommendation for vigorous physical activity (greater than or equal
to 20 minutes per day of vigorous physical activity on greater than or
equal to 3 days per week) or the newer moderate activity
recommendation (greater than or equal to 30 minutes per day of
moderate activity on greater than or equal to 5 days per week [6]).
Data were weighted and aggregated, and composite estimates and
standard errors for selected groups were calculated using SESUDAAN
(7). Prevalences and 95% confidence intervals were calculated by age,
race/ethnicity, education level, and annual household income of
respondents.

       Overall, 27.1% of adult women reported participation in
recommended activity levels, a proportion that was generally
consistent across age groups. The prevalence of inactivity increased
with age, from 25.6% among women aged 18-34 years to 42.1% among women
aged greater than or equal to 65 years (Table 1). Reported
participation in recommended levels of physical activity varied
substantially among racial/ethnic groups and by education levels and
incomes. White non-Hispanic women were more likely to be more active
(28.7%) than Hispanic women (24.7%) and black non-Hispanic women
(17.5%).* The prevalence of participation in recommended levels was
inversely related to education level and family income: women with
less than a high school education were less likely to report regular
activity (17.4%) than high school graduates (23.8%) and college
graduates (33.5%). Women in the lowest income category (less than or
equal to $14,999 per year) were least likely to report regular
activity (21.4%), and women in the highest income category (greater
than or equal to $50,000 per year) were most likely to report regular
activity (34.9%).

Reported by: State Behavioral Risk Factor Surveillance System
coordinators. Health Interventions and Translation Br, and Statistics
Br, Div of Chronic Disease Control and Community Intervention,
National Center for Chronic Disease Prevention and Health Promotion,
CDC.

Editorial Note: CDC and the American College of Sports Medicine
recently recommended that adults accumulate greater than or equal to
30 minutes of moderate physical activity on greater than or equal to 5
days per week (6). Adherence to either this recommendation or the
previous recommendation (greater than or equal to 20 minutes of
vigorous activity on greater than or equal to 3 days per week) should
provide substantial health benefits (3,6,8). The findings in this
report indicate that leisure-time physical activity levels among women
were strongly associated with demographic characteristics and that two
measures of socioeconomic status (i.e., education and income) were
particularly strong predictors of participation in health-enhancing
levels of physical activity. Because physical inactivity accounts for
approximately 25% of all deaths from chronic disease in the United
States (8), reducing preventable death and disability from disease
(e.g., heart disease) attributable to physical inactivity (8,9) will
require intervention programs that are directed toward and effective
among the approximately 70% of women who are sedentary or irregularly
active. These BRFSS data also address a priority surveillance need for
information about physical activity among racial/ethnic minorities, as
specified by the national health objectives for the year 2000 (5).

       Interpretation of the findings in this report is subject to at
least three limitations. First, because the BRFSS estimates for
physical activity levels were based on self-reported data, activity
levels may be overestimated. Second, the BRFSS did not ascertain
nonleisure-time physical activity (i.e., occupational activity or
walking or cycling to work); therefore, estimates restricted to
leisure-time activity may underestimate the prevalence of physical
activity in some groups. Third, because respondents to the BRFSS can
report only two leisure-time activities, physical activity levels will
be underestimated for those who participate in multiple activities.

       Strategies for increasing levels of leisure-time physical
activity should include public education about the health benefits of
moderate physical activity and education of health-care providers to
increase the number of providers who counsel their patients to become
more active--levels of physical activity have increased among patients
who have been counseled by their physicians to become more active
(10). Employers can encourage employees to walk on breaks or at other
appropriate periods (e.g., lunch) or provide incentives for employees
to participate in community-based programs. Community-based programs
should offer opportunities for all women to participate in moderate
physical activity, particularly women who are older, have low incomes,
or have children. Such programs should address barriers to women for
increasing activity levels (e.g., safety; child care; time; and the
availability and accessibility of walking and cycling trails,
sidewalks, and recreational facilities).

       References

        1. Blair SN, Kohl HW, Paffenbarger RS Jr, Clark DG, Cooper KH,
Gibbons LW. Physical fitness and all-cause mortality: a prospective
study of healthy men and women. JAMA 1989;262:2395-401.

        2. Blair SN, Kohl HW, Gordon NF, Paffenbarger RS Jr. How much
physical activity is good for health? Annu Rev Public Health
1992;13:99-126.

        3. Krall EA, Dawson HB. Walking is related to bone density and
rates of bone loss. Am J Med 1994;96:20-6.

        4. CDC. Prevalence of sedentary lifestyle--Behavioral Risk
Factor Surveillance System, United States, 1991. MMWR 1993;42:576-9.

        5. Public Health Service. Healthy people 2000: national health
promotion and disease prevention objectives--full report, with
commentary. Washington, DC: US Department of Health and Human
Services, Public Health Service, 1991; DHHS publication no.
(PHS)91-50212.

        6. Pate RR, Pratt M, Blair SN, et al. Physical activity and
public health: a recommendation from the Centers for Disease Control
and Prevention and the American College of Sports Medicine. JAMA
1995;273:402-7.

        7. Shah BV. SESUDAAN: standard errors program for computing of
standardized rates from sample survey data. Research Triangle Park,
North Carolina: Research Triangle Institute, 1981.

        8. McGinnis JM, Foege WH. Actual causes of death in the United
States. JAMA 1993;270:2207-12.

        9. Hahn RA, Teutsch SM, Rothenberg RB, Marks JS. Excess deaths
from nine chronic diseases in the United States, 1986. JAMA
1990;264:2654-9.

       10. Long BJ, Calfas KJ, Sallis JF, et al. Evaluation of patient
physical activity after counseling by primary care providers. Med Sci
Sports Exerc 1994;26(suppl):S4.

       *Numbers for other racial/ethnic groups were too small for
        meaningful analysis.


       Smokeless Tobacco Use Among American Indian Women --
       Southeastern North Carolina, 1991

       Rates of smokeless tobacco use among U.S. adults are highest
for young males, American Indians/Alaskan Natives, persons residing in
the South or rural areas of the country, and those of low
socioeconomic status (1). In addition, the prevalence of smokeless
tobacco use has been reported to be high in tobacco-producing regions,
including rural North Carolina and Kentucky (2,3). In southeastern
North Carolina, reports from physicians and dentists suggested a high
prevalence of smokeless tobacco use in the local American Indian
population, the Lumbee--particularly among women and children. In
response to these reports, the Department of Family and Community
Medicine at the Bowman Gray School of Medicine of Wake Forest
University analyzed data from a National Cancer Institute-sponsored
cervical cancer prevention program to estimate the prevalence of
smokeless tobacco use during 1991 among Lumbee women aged greater than
or equal to 18 years residing in Robeson County, North Carolina (1990
population: 105,179).

       This analysis was based on responses to a survey conducted as
part of the cancer-prevention program; these data are the most
complete on tobacco use for this population. The survey included
questions about cervical cancer knowledge, attitudes, and practices;
demographic characteristics; social support; and health behavior,
including use of tobacco and alcohol. A random sample of 479 women was
selected from the official Lumbee tribal enrollment database using a
computer-generated list of phone numbers; the database lists
approximately 43,000 persons (86% of the estimated 1990 population of
the Lumbee tribe). A telephone number was listed for 99% of the Lumbee
tribal members in the database. The survey was conducted in
respondents' homes during August-October 1991 by nine Lumbee women who
had been trained as research assistants.

       Smokeless tobacco use was classified as ever or never use based
on the question, "Have you ever used chewing tobacco or snuff?" Ever
use was further subdivided into current use (those who reported using
smokeless tobacco at the time of the survey) and former use (those who
reported not using smokeless tobacco at the time of the survey). Early
initiation (defined as beginning use at age less than 6 years) was
based on the question, "How old were you when you began using chewing
tobacco or snuff regularly?" The survey also assessed smoking status
(never, former [smoked at least 100 cigarettes during their lifetime
but did not smoke at the time of the survey], and current [smoked at
least 100 cigarettes during their lifetime and smoked at the time of
the survey]), self-reported health status (excellent, good, fair, or
poor), social or church group participation, number of close friends,
and reported use of medical services. Chi-square analysis was used to
assess differences in smokeless tobacco use by demographic, social
support, and health behavior categories and to assess the frequency of
early initiation of smokeless tobacco use in relation to age group.

       Of the 479 women surveyed, 307 (64%) reported never using
smokeless tobacco, 64 (13%) reported former use, and 108 (23%)
reported current use. The prevalence of current smokeless tobacco use
was greatest among women aged greater than or equal to 65 years (51%)
and lowest among those aged 25-34 years (6%) and 18-24 years (11%)
(Table 1). Current use also was high among women who had less than 12
years of education (42%), whose annual income was less than $11,000
(31%), who were widowed (42%), who had never smoked cigarettes (30%),
and who perceived their health as poor or fair (39%). Current
smokeless tobacco use was not associated with alcohol use, use of
medical services, church or social group participation, or number of
close friends.

       Age at initiation of smokeless tobacco use was unknown for 18
(10%) of the 172 ever users; although demographic characteristics of
these women were similar to those for whom complete initiation data
were available, these respondents were excluded from analyses of age
at initiation of use. The median age at initiation of smokeless
tobacco use was 10 years; of the ever users for whom data were
available, 90% initiated smokeless tobacco use before age 18 years.
Median duration of smokeless tobacco use among all current users was
37 years.

       Because women in older age groups had a greater chance of
beginning smokeless tobacco use at age greater than or equal to 18
years, women who initiated smokeless tobacco use at age greater than
or equal to 18 years (n=16) were eliminated from the analysis of women
who initiated smokeless tobacco use at an early age to ensure
comparability between the youngest and older age groups; the women who
were excluded did not differ from the others by income or education.
The prevalence of early initiation of smokeless tobacco use was
highest among those aged 18-24 years (77%) (Table 2). The prevalence
of early initiation in other age groups ranged from 18% to 30%. Based
on analysis of aggregated data, 35% of women aged less than or equal
to 44 years began smokeless tobacco use before age 6 years, compared
with 22% of women aged greater than or equal to 45 years.

Reported by: JG Spangler, MD, MB Dignan, PhD, R Michielutte, PhD, Dept
of Family and Community Medicine, Bowman Gray School of Medicine of
Wake Forest Univ, Winston-Salem, North Carolina. Office on Smoking and
Health, National Center for Chronic Disease Prevention and Health
Promotion, CDC.

Editorial Note: Based on the findings of this survey, the prevalence
of smokeless tobacco use among Lumbee women in North Carolina in 1991
was nine times the national mean prevalence for American Indian women
(2.5%) and 38 times that for women in the total U.S. population (0.6%)
(1). Robeson County, where most of the Lumbee reside, is the third
largest tobacco-producing county in North Carolina (E. Davis, Robeson
County [North Carolina] Agricultural Extension Service, personal
communication, 1994), and the high prevalence of smokeless tobacco use
among the Lumbee women may reflect, in part, the tobacco-based local
economy. High prevalences of smokeless tobacco use also have been
documented in other tobacco-producing regions of the United States
(2,3). However, the prevalence of smokeless tobacco use among these
women was more than twice that of women in Pitt County, North Carolina
(3), the leading tobacco-producing county in the United States, and
approximates the prevalence among some male adolescent populations
(4).

       Cultural factors specific to American Indians and the economic
impact of tobacco on residents of this region may be associated with
this unusually high prevalence of smokeless tobacco use. For example,
use of tobacco has been a part of American Indian culture, including
medicinal uses such as treatment of gastrointestinal symptoms (5),
since before the arrival of Europeans (6,7). Such uses of tobacco,
combined with the availability of tobacco leaf among tobacco-farming
families, may be associated with initiation of nicotine addiction in
young children.

       The findings in this study are subject to at least two
limitations. First, respondents were asked to recall their use of
smokeless tobacco as children; because early age at initiation among
younger women was more recent and, therefore, more likely to be
remembered, the high prevalence of early onset of use among younger
women may partly reflect this bias. Second, family use of tobacco and
family or personal involvement in tobacco production were not
analyzed. Employment in tobacco production may play a role in
attitudes toward smokeless tobacco use (3) because personal
involvement in growing tobacco has been associated with a high
prevalence of smokeless tobacco use among adolescents (2).

       The high prevalence of smokeless tobacco use among Lumbee women
increases the risk for health hazards, including gingival recession,
tooth loss, leukoplakia, and oral cancer. Nicotine use may also
increase the risk for cardiovascular disease (8) and reproductive
risks such as low birthweight, premature delivery, and spontaneous
abortion (9). Further assessment of parents' attitudes toward
childhood smokeless tobacco use, the anthropologic characteristics of
smokeless tobacco use among the Lumbee, and the influence of a
tobacco-based economy on early initiation and high prevalence of
smokeless tobacco use should assist in the development of culturally
and economically acceptable interventions.

       References

       1. CDC. Use of smokeless tobacco among adults--United States,
1991. MMWR 1993;42:263-6.

       2. Noland MP, Kryscio RJ, Riggs RS, Linville LH, Perritt LJ,
Tucker TC. Use of snuff, chewing tobacco, and cigarettes among
adolescents in a tobacco-producing area. Addict Behav 1990; 15:517-30.

       3. Glover ED, O'Brien K, Holbert D. Prevalence of smokeless
tobacco use in Pitt County, North Carolina. Int J Addict
1987;22:557-65.

       4. Kann L, Warren W, Collins JL, Ross J, Collins B, Kolbe LJ.
Results from the national school-based 1991 Youth Risk Behavior Survey
and progress toward achieving related health objectives for the
nation. Public Health Rep 1993;108(suppl 1):47-55.

       5. Vogel V. American Indian medicine. Norman, Oklahoma:
University of Oklahoma Press, 1994.

       6. Christen AG, Swanson BZ, Glover ED, Henderson AH. Smokeless
tobacco: folklore and social history of snuffing, sneezing, dipping,
and chewing. J Am Dent Assoc 1982;105:821-9.

       7. CDC. Smoking and health in the Americas: a 1992 report of
the Surgeon General, in collaboration with the Pan American Health
Organization. Atlanta: US Department of Health and Human Services,
Public Health Service, CDC, 1992; DHHS publication no. (CDC)92-8419.

       8. Bolinder G, Alfredsson L, Englund A, de Faire U. Smokeless
tobacco use and increased cardiovascular mortality among Swedish
construction workers. Am J Public Health 1994;84: 399-404.

       9. National Institutes of Health. Smokeless tobacco or health:
an international perspective. Bethesda, Maryland: US Department of
Health and Human Services, Public Health Service, National Institutes
of Health, 1992; NIH publication no. 93-3461.


       Update: Dracunculiasis Eradication -- Pakistan, 1994

       Dracunculiasis (Guinea worm disease)--a disabling infection
that affects persons in 16 African and three Asian countries--has been
targeted by the World Health Organization (WHO) for global eradication
by the end of 1995. A total of 221,055 cases were reported to WHO for
1993 (1). Efforts to eradicate dracunculiasis in each of the 19
affected countries are focused on interrupting all transmission. This
report summarizes the impact of Pakistan's Guinea Worm Eradication
Program (GWEP).

       The eradication program in Pakistan began in 1986 as a
collaborative effort involving Pakistan's National Institute of
Health, the Global 2000 project of the Carter Center, and CDC. A
nationwide village-by-village survey estimated a total of 2400
incident cases for 1987; cases were detected in three areas including
North West Frontier, Punjab, and Sindh provinces (2). Active
surveillance and control measures were implemented in February 1988 in
all 408 villages at risk for or characterized by endemic
dracunculiasis. Village-based "implementors" were identified and
trained in each village to report cases monthly, promote filtration of
unsafe drinking water through use of cloth filters, and distribute
cloth filters. Other health workers applied temephos
(Abate[Registered]*) to unsafe sources of drinking water monthly in
each affected village to reduce populations of the intermediate
copepod hosts. Because in areas with endemic dracunculiasis most
underground sources of water are brackish, development of such sources
was not a substantial component of the program in Pakistan.

       Measures introduced in 1990 to help ensure rapid detection,
thorough investigation, and complete control of each case included
more intensive surveillance and case-containment measures (e.g., close
supervision of the village implementors) (3). A cash reward of 1000
rupees (approximately $40 U.S.) for reporting the first case in a
village was first offered in 1991. In 1993, other incentives (i.e.,
3000 rupees for each patient who complied with case-containment
measures and 500 rupees for the person reporting the case) were added
and publicized. A registry of reports of potential cases was
established, and all claims of cases were promptly investigated by
staff of the national eradication program.

       For each calendar year during 1988-1994, the numbers of
villages in Pakistan with endemic dracunculiasis were 156, 146, 56,
35, seven, one, and zero, respectively, and the number of cases
detected through village-based surveillance were 1110, 534, 160, 106,
23, two, and zero, respectively (Figure 1).

Reported by: M Azam, National Institute of Health, Pakistan. Global
2000, Inc, The Carter Center, Atlanta. World Health Organization
Collaborating Center for Research, Training, and Eradication of
Dracunculiasis, Div of Parasitic Diseases, National Center for
Infectious Diseases, CDC.

Editorial Note: Because no cases were reported in 1994, Pakistan is
the first of the countries with known endemic dracunculiasis during
the 1980s to have eliminated indigenous transmission of the disease
for 1 year. In addition, dracunculiasis-eradication methods pioneered
by the Pakistan GWEP (e.g., use of village-based health workers and
case containment) have been effectively incorporated into all GWEPs in
Africa (1).

       In 1992, the United Nations Childrens' Fund (UNICEF) began
providing support to the Pakistan GWEP. In 1993, WHO began assisting
Pakistan in maintaining appropriate surveillance activities for the
WHO-required 3-year period without indigenous cases for certification
of eradication. The WHO Collaborating Center for Research, Training,
and Eradication of Dracunculiasis at CDC continues to provide
technical assistance to Pakistan regarding surveillance and
containment of cases.

       References

       1. WHO. Dracunculiasis: global surveillance summary. Wkly
Epidemiol Rec 1994;69:121-8.

       2. WHO. Dracunculiasis: Pakistan. Wkly Epidemiol Rec
1988;63:177- 80.

       3. CDC. Update: dracunculiasis eradication--Pakistan, 1990.
MMWR 1991;40:5-7.

       *Use of trade names and commercial sources is for
        identification only and does not imply endorsement by the
        Public Health Service or the U.S. Department of Health and
        Human Services. *

       DISTRIBUTED BY GENA/aegis, your online global gateway to a
       world of people, information, and resources.  714.248.2836 *
       8N1/Full Duplex * v.34
