
Following is the final electronic text from the Morbidity and Mortality
Weekly Report (MMWR), vol. 44, no. 8, dated March 3, 1995.  The MMWR is
published by the U.S. Department of Health and Human Services, Public
Health Service, Centers for Disease Control and Prevention (CDC), Atlanta,
Georgia.
--------------------------------------------------------------------------

CONTENTS OF THIS ISSUE:
Pages/Title
    137-140
        Exposure of Passengers and Flight Crew to
        Mycobacterium tuberculosis on Commercial Aircraft,
        1992-1995
    141-142
        Prevention Program for Reducing Risk for
        Neural Tube Defects -- South Carolina, 1992-1994
    142-143, 149-150
        Vaccination Coverage of 2-Year-Old Children --
        United States, January-March, 1994
    150-154
        Use of Safety Belts -- Madrid, Spain, 1994
    154
        Monthly Immunization Table
------------------------------------------------------------------------

Exposure of Passengers and Flight Crew to Mycobacterium tuberculosis
on Commercial Aircraft, 1992-1995

     From January 1993 through February 1995, CDC and state health
departments completed investigations of six instances in which passengers
or flight crew traveled on commercial aircraft while infectious with
tuberculosis (TB). All six of these investigations involved symptomatic TB
patients with acid-fast bacillus (AFB) smear-positive cavitary pulmonary
TB, who were highly infectious at the time of the flight(s). In two
instances, Mycobacterium tuberculosis isolated from the index patients was
resistant to both isoniazid and rifampin; organisms isolated from other
cases were susceptible to all antituberculous medications. In addition, in
two instances, the index patients were aware of their TB at the time of
travel and were in transit to the United States to obtain medical care.
However, in none of six instances were the airlines aware of the TB in
these passengers. This report summarizes the investigations by CDC and
state health departments and provides guidance about notification of
passengers and flight crew if an exposure to TB occurs during travel on
commercial aircraft.

    Investigation 1. A flight attendant had documented tuberculin skin test
(TST) conversion in 1989 but had not received preventive therapy (1). While
working on numerous domestic and international flights from May through
October 1992, she developed a progressively severe cough, and pulmonary TB
was diagnosed in November 1992. An investigation by CDC included TSTs of
212 flight crew who worked with the flight attendant from May through
October and 247 flight crew who had not been exposed to her. The prevalence
of positive TSTs among flight crew exposed to the flight attendant during
August through October was higher than among crew exposed from May through
June (25.6% versus 4.1%; p less than 0.01) and among unexposed flight crew
(1.6%; p less than 0.01). TST conversion was documented in two crew members
exposed only in August and October, respectively. TST positivity and
conversions were not associated with aircraft type, but were associated
with cumulative flight time exposure of greater than 12 hours. TST
reactivity was assessed in 59 passengers registered in the airline's
frequent flyer program who had traveled on flights worked by the flight
attendant with TB during August-October. Of these, four (6.7%) were TST
positive; all had traveled in October. The investigation indicated that the
index patient transmitted M. tuberculosis to other members of the flight
crew, but evidence of transmission to passengers was inconclusive (1).

    Investigation 2. During 1993, the Minnesota Department of Health
conducted an investigation of a foreign-born (i.e., born outside the United
States or Canada) passenger with pulmonary TB who traveled in the first
class section of an aircraft during a 9-hour flight from London to
Minneapolis in December 1992 (2). Of the 343 crew and passengers on the
aircraft, TST results were obtained for 59 (61%) of 97 U.S. citizens and
20 (8%) of 246 non-U.S. citizens. TSTs were positive for eight (10%)
persons--all of whom had received bacille Calmette-Guerin (BCG) vaccine or
had a history of past exposure to M. tuberculosis. The investigation
indicated no evidence of transmission of TB during the flight (2).

    Investigation 3. In March 1993, a foreign-born passenger with pulmonary
TB traveled on a 1/2-hour flight from Mexico to San Francisco. This
investigation included efforts by the San Francisco Department of Public
Health to obtain information by mail from all 92 passengers on the flight;
17 persons could not be contacted because of invalid addresses. TSTs were
positive in 10 (45%) of the 22 persons who were contacted and completed TST
screening; nine of these TST-positive persons were born outside the United
States. The other was a 75-year-old passenger who may have become infected
with M. tuberculosis while residing outside the United States or during a
period when TB was prevalent in the United States. The San Francisco
Department of Public Health found no conclusive evidence of transmission
during this flight.

    Investigation 4. In March 1993, CDC investigated a case of pulmonary
TB in a refugee who traveled on flights from Frankfurt, Germany, to New
York City (8-1/2 hours) and then to Cleveland, Ohio (1-1/2 hours) (3). Of
219 passengers and flight crew on both flights, 169 (77%) were U.S.
residents; 142 (84%) of the U.S. residents completed TST screening. TSTs
were positive in 32 (23%), including five persons who had converted from
negative on initial postexposure testing to positive on follow-up testing.
Of the 32 TST-positive persons, 29 had received BCG or were born and had
resided in countries where TB is endemic, including all five TST
converters. The five passengers who were TST converters had been seated in
sections throughout the plane. Because none of the U.S.-born passengers on
this flight had TST conversions, the investigation indicated that, although
transmission could not be excluded, the positive TSTs and conversions
probably were associated with prior M. tuberculosis infection, a boosted
immune response from prior exposure to TB, or prior BCG vaccination.

    Investigation 5. In March 1994, a U.S. citizen with pulmonary TB and
an underlying immune disorder who had resided long term in Asia traveled
on flights from Taiwan to Tokyo (3 hours), to Seattle (9 hours), to
Minneapolis (3 hours), and to Wisconsin (1/2 hour). Of 661 passengers on
these four flights, 345 (52%) were U.S. residents. The Wisconsin Division
of Health contacted the 345 U.S. residents and received reports about TST
results from 87 (25%) persons; of these, 14 (17%) had a positive TST. All
14 persons had been seated more than five rows away from the index patient;
nine of these persons had been born in Asia (including two with a known
prior positive TST). Of the five who were TST-positive and U.S.-born, one
was known to have had a positive TST previously, two had resided in a
country with increased endemic risk for TB, and two were aged greater than
or equal to 75 years. The investigation indicated that, although
transmission of TB during flights could not be excluded, the positive TSTs
may have resulted from prior M. tuberculosis infection.

    Investigation 6. In April 1994, a foreign-born passenger with pulmonary
TB traveled on flights from Honolulu to Chicago (7 hours, 50 minutes) and
to Baltimore (2 hours), where she lived with friends for 1 month. During
that month, her symptoms intensified; she returned to Hawaii by the same
route. Investigation in Baltimore determined that TST conversion had
occurred in the 22-month-old child of her friends. The four flights
included a total of 925 passengers and crew who were U.S. residents, of
whom 755 (82%) completed TST screening; of these, 713 (94%) were U.S.-born.
The investigation by CDC indicated no evidence of transmission on the
flight from Honolulu to Chicago or the flight from Chicago to Baltimore.
Of the 113 persons who had traveled on the flight from Baltimore to
Chicago, TSTs were positive in three (3%), including two who were
foreign-born. However, of the 257 persons who traveled from Chicago to
Honolulu (8 hours, 38 minutes), TSTs were positive in 15 (6%), including
six who had converted; two of these six persons apparently had a boosted
immune response, while the other four had been seated in the same section
of the plane as the index patient. Because of TST conversions among
U.S.-born passengers, the investigation indicated that
passenger-to-passenger transmission of M. tuberculosis probably had
occurred.

Reported by: C Hickman, MPH, KL MacDonald, MD, MT Osterholm, PhD, State
Epidemiologist, Minnesota Dept of Health. GF Schecter, MD, TB Control
Program, San Francisco Dept of Public Health; S Royce, MD, DJ Vugia, MD,
Acting State Epidemiologist, California State Dept of Health Svcs. ME
Proctor, PhD, JP Davis, MD, State Epidemiologist for Communicable Diseases,
Bur of Public Health, Wisconsin Div of Health. S Bur, MPH, D Dwyer, MD,
Maryland Dept of Health and Mental Hygiene. Surveillance and Epidemiologic
Investigations Br, and Program Services Br, Div of Tuberculosis
Elimination, National Center for Prevention Svcs; Div of Field
Epidemiology, Epidemiology Program Office; Div of Quarantine, National
Center for Infectious Diseases, CDC.

Editorial Note: The investigations described in this report were undertaken
to determine whether exposure to persons with infectious pulmonary TB was
associated with transmission of M. tuberculosis to others traveling on the
same aircraft. Two of these investigations indicated that transmission
occurred (investigation 1, from flight attendant to other flight crew, and
investigation 6, from passenger to passenger). In investigation 6,
transmission occurred on the return to Hawaii, when the index passenger was
most symptomatic and on the longest flight. All persons with TST
conversions were seated in the same section of the aircraft as the index
passenger, suggesting that transmission was associated with seating
proximity. Because the origins of all foreign-born passengers were
countries in which TB is endemic and/or where BCG vaccine is routinely
used, TST results from these passengers do not reliably represent recent
infection. Among persons who could be contacted during the other
investigations, low response rates constrained the interpretation of
findings from those investigations.
     Investigations such as those described in this report are subject to
two substantial constraints. First, because the investigation may be
initiated several weeks to months following the time of the flight and
exposure, passengers may not be readily located. With the exception of
persons who are enrolled in frequent flyer programs, airline companies do
not routinely maintain residence addresses or telephone numbers for
passengers. Second, the time elapsed between the flight and when public
health authorities and airline companies become aware of an exposure and
when passengers are notified and tested limits the use of TSTs to assess
for conversion. To interpret prevalent positive TST results, other possible
reasons for a positive TST result must be considered, including prior
exposure to TB, residence or birth in countries in which TB is endemic, and
BCG vaccination. In the United States, an estimated 4%-6% of the total
population is TST positive (4), and in developing countries, the estimated
prevalence of M. tuberculosis infection ranges from 19.4% (in the Eastern
Mediterranean region) to 43.8% (in the Western Pacific region) (5).
     To prevent exposures to TB aboard aircraft, when travel is necessary,
persons known to have infectious TB should travel by private transportation
(i.e., not by commercial aircraft or other commercial carrier). In
addition, patients with infectious TB should at least be sputum
smear-negative for AFB before being placed in indoor environments conducive
to transmission (6). Three negative sputum smear examinations of specimens
on separate days in a person on effective anti-TB therapy indicate an
extremely low potential for transmission, and a negative culture virtually
precludes potential for transmission (6). Decisions about a TB patient's
infectiousness and ability to travel should be made on an individual basis.
     The risk for M. tuberculosis transmission on an aircraft does not
appear to be greater than in other confined spaces. Based on a
consideration of current evidence indicating low risk for transmission of
TB on aircraft, need for notification of passengers and flight crew members
may be guided by three criteria. First, the person with TB was infectious
at the time of the flight. Persons who, at the time of flight, are
symptomatic with AFB smear-positive, cavitary pulmonary TB or laryngeal TB
are most likely to be infectious. Evidence of transmission to household and
other close contacts also indicates infectiousness. Second, exposure was
prolonged (e.g., duration of flight exceeded 8 hours). Third, priority
should be given to notifying passengers and flight crew who were at
greatest risk for exposure based on proximity to the index passenger (for
example, depending on the aircraft design, proximity may be defined as
seating or working in the same cabin section as the infected passenger).
Notification should be conducted by the airline in coordination with local
and state TB-control programs.

References
1. Driver CR, Valway SE, Morgan WM, Onorato IM, Castro KG. Transmission of
M. tuberculosis associated with air travel. JAMA 1994;272:1031-5.
2. McFarland JW, Hickman C, Osterholm MT, MacDonald KL. Exposure to
Mycobacterium tuberculosis during air travel. Lancet 1993;342:112-3.
3. Miller MA, Valway SE, Onorato IM. Assessing tuberculin skin test
conversion after exposure to tuberculosis on airplanes [Abstract]. In:
Program and abstracts of the annual meeting of the American Public Health
Association. San Francisco: American Public Health Association, 1993.
4. CDC. National action plan to combat multidrug-resistant tuberculosis.
MMWR 1992;41(no. RR-11):1-48.
5. Sudre P, ten Dam G, Kochi A. Tuberculosis: a global overview of the
situation today. Bull World Health Organ 1992;70:149-59.
6. American Thoracic Society. Control of tuberculosis in the United States.
Am Rev Respir Dis 1992;146:1623-33.


Prevention Program for Reducing Risk for Neural Tube Defects --
South Carolina, 1992-1994

     Neural tube defects (NTDs) are common and serious malformations that
originate early in pregnancy. In the United States, approximately 4000
pregnancies each year are affected by the two most common NTDs (spina
bifida and anencephaly), and an estimated 2500 infants are born with NTDs.
Based on a Public Health Service (PHS) recommendation published in
September 1992, at least one half of NTDs could be prevented if all women
capable of becoming pregnant consumed 0.4 mg of folic acid daily during the
periconceptional period (1). Women who have previously had an NTD-affected
pregnancy would especially benefit from folic acid supplements (2). In
1992, with support from a CDC cooperative agreement, the South Carolina
Department of Disabilities and Special Needs implemented a prevention
program to reduce the incidence of folic acid-preventable NTDs in the
pregnancies of women with prior NTD-affected pregnancies. This report
describes surveillance findings resulting from this program during 1992-
1994.
     In October 1992, the NTD prevention program initiated a pilot
surveillance system to monitor the occurrence of NTDs in the Piedmont
Region of the state (1990 population: 1.1 million). Data about NTD cases
were collected from hospital medical records, vital records, and prenatal
diagnoses procedure records. In October 1993, the surveillance system was
expanded statewide (1990 population: 3.5 million). During October 1992-
September 1994, the surveillance system identified 105 NTD cases and 72,493
live-born infants, representing a rate of 14.5 cases per 10,000 resident
live-born infants.
     Of the 105 women identified as having had NTD-affected pregnancies,
71 participated in a personal interview about use of folic acid-containing
supplements during the periconceptional period (i.e., 1 month before
conception through the third month of pregnancy). Overall, six (8%) of the
71 women reported using a folic acid-containing multivitamin supplement
during the periconceptional period, including four (7%) of the 54 women who
had a last menstrual period after the PHS recommendation was issued, and
two (12%) of the 17 women who had a last menstrual period before the PHS
recommendation was issued.

Reported by: RE Stevenson, MD, JH Dean, WP Allen, MD, Greenwood Genetic
Center, Greenwood; M Kelly, South Carolina Dept of Disabilities and Special
Needs, Columbia. Birth Defects and Genetic Diseases Br, Div of Birth
Defects and Developmental Disabilities, National Center for Environmental
Health, CDC.

Editorial Note: During 1980-1990, an estimated 18,000 infants were born in
the United States with spina bifida; by 1990, approximately 5000 (28%) of
these children had died. Annual medical and surgical costs in the United
States for all persons with spina bifida exceed $200 million. For each
person with typical severe spina bifida, the estimated lifetime direct and
indirect costs are $250,000 (3).
     In 1992, PHS estimated that, if all women capable of becoming pregnant
adhered to the recommendation to consume 0.4 mg of folic acid per day, the
number of cases of spina bifida and anencephaly would be reduced by 50%.
Consumption of a vitamin supplement containing the prescribed amount of
folic acid is one method to ensure receipt of the proper dosage of folic
acid. In 1992, an estimated 20% of all U.S. women were consuming a
multivitamin containing 0.4 mg of folic acid (4). However, the findings in
this report indicate that, among women with NTD-affected pregnancies in
South Carolina who had conceived after issuance of the PHS recommendation,
only 7% had consumed 0.4 mg of folic acid during the periconceptional
period. In addition, among a sample of 60 women in South Carolina who had
given birth to infants without NTDs during October 1992-September 1994,
seven (12%) reported using folic acid-containing vitamin supplements during
the periconceptional period (Greenwood Genetic Center, Greenwood, South
Carolina, unpublished data, 1994). These findings suggest that overall use
of folic acid-containing supplements in South Carolina is lower than the
1992 PHS estimate of use among the total population of U.S. women (4).
     The findings in this report underscore the need for increased efforts
in South Carolina to 1) publicize the benefits and promote the use of
increased folic acid consumption during the periconceptional period, 2)
encourage women of childbearing age to increase their folic acid
consumption, and 3) ensure that all women have the opportunity to increase
their consumption of folic acid. Since promulgation of the 1992 PHS
recommendation, public and private health-care and advocacy organizations
in South Carolina have initiated information and education campaigns to
promote consumption of folic acid among women of childbearing age. In
addition, educational programs have been designed and implemented to
communicate information about the protective benefits of folic acid to
health professionals, public school educators, and the public.

References
1. CDC. Recommendations for the use of folic acid to reduce the number of
cases of spina bifida and other neural tube defects. MMWR 1992;41(no.
RR-14).
2. MRC Vitamin Study Research Group. Prevention of neural tube defects:
results of the Medical Research Council Vitamin Study. Lancet 1991;338:131-
7.
3. CDC. Economic burden of spina bifida--United States, 1980-1990. MMWR
1989;38:264-7.
4. Moss AJ, Levy AS, Kim I, et al. Use of vitamin and mineral supplements
in the United States: current users, types of products, and nutrients.
Hyattsville, Maryland: US Department of Health and Human Services, Public
Health Service, CDC, NCHS, 1989. (Advance data no. 174).


Vaccination Coverage of 2-Year-Old Children --
United States, January-March, 1994

    The Childhood Immunization Initiative (CII)* was initiated to increase
vaccination coverage among 2-year-old children. The 1996 objective is to
have at least 90% coverage for four of the five critical vaccines routinely
recommended for children (i.e., one dose of measles-mumps-rubella vaccine
[MMR] and at least three doses each of diphtheria and tetanus toxoids and
pertussis vaccine [DTP], oral poliovirus vaccine, and Haemophilus
influenzae type b vaccine [Hib]), and at least 70% coverage for three doses
of hepatitis B vaccine (Hep B) (1). These objectives are an interim step
toward the year 2000 goal of at least 90% coverage for the recommended
series of vaccinations and are being monitored on an ongoing basis. This
report presents national estimates of vaccination coverage among 2-year-old
children derived from provisional data from the National Health Interview
Survey (NHIS) for the first quarter of 1994 and compares these with the
last two quarters of 1993.
     The NHIS, a probability sample of the civilian, noninstitutionalized
U.S. population, provides quarterly data that enables calculation of
national coverage estimates (2). Quarterly estimates for children aged 19-
35 months were based on sample sizes of 483 (third quarter 1993), 490
(fourth quarter 1993), and 608 (first quarter 1994). Children included in
the survey during the first quarter of 1994 were born during February 1991-
August 1992; their median age was 27 months. For the last two quarters in
1993, 37% of NHIS respondents used a vaccination record for reporting
vaccination information; for the first quarter of 1994, the use of
vaccination records increased to 52%. For the other respondents, such
records were unavailable, and information was based on parental recall.
Overall, 12%-16% of respondents were excluded because they either reported
not knowing whether a child had received a particular vaccination or did
not know the number of doses the child had received. Confidence intervals
were calculated using SUDAAN.
     During the first quarter of 1994, vaccination coverage levels for
children aged 19-35 months ranged from 89.6% for measles-containing vaccine
(MCV) to 25.5% for Hep B vaccine (Table 1). Coverage for the most critical
doses for the 1996 objective ranged from 70.6% ( greater than or equal to
3 doses Hib) to 89.6% (MCV). Coverage for the year 2000 goal for the
combined series of four doses of DTP, three doses of polio vaccine, and one
dose of MCV was 66.0%.
     During the last two quarters of 1993 and the first quarter of 1994,
vaccination levels have remained statistically unchanged for the combined
series and individual antigens with the exception of Hib and Hep B. For the
first quarter of 1994, coverage with three doses of Hib vaccine increased
significantly from the third quarter of 1993 to a record high of 70.6%, and
Hep B coverage increased from 15.7% in the third quarter of 1993 to 25.5%
during the first quarter of 1994.

Reported by: Assessment Br, Div of Data Management, National Immunization
Program, CDC.

Editorial Note: The findings in this report document recent statistically
significant increases in the national vaccination levels for Hib and Hep
B. In addition, vaccination levels are near the highest ever recorded for
three doses of DTP, three doses of polio vaccine, and one dose of MCV and
for the combined series. Despite these improved levels of coverage,
however, the findings in this report indicate that coverage levels are 3-19
percentage points below the interim objectives for DTP, polio, and Hib.
Coverage levels for Hep B vaccine are the furthest from the 1996 goal.
However, because recommendations for universal Hep B vaccination of infants
became effective in November 1991, only approximately half of the children
in the survey were eligible for Hep B vaccine. An estimated 2 million
children aged 19-35 months still need one or more doses of DTP, polio, or
MMR vaccine to be completely vaccinated with the combined series of four
doses of DTP, three doses of polio vaccine, and one dose of MCV.
     The levels for three doses of DTP, three doses of polio vaccine, one
dose of MCV, and for the combined series have been constant for three
quarters, suggesting that coverage levels may have plateaued. However, such
data should be interpreted with caution; the larger number of children in
the annual samples provides greater precision for those estimates than the
quarterly samples.
     To achieve the interim objective for 1996, efforts to implement CII
must be accelerated. In particular, as emphasized by the Standards for
Pediatric Immunization Practices (3), providers should use all
opportunities to vaccinate children, regardless of the reason for the visit
(e.g., sick- or well-child visit)--taking advantage of missed opportunities
potentially may increase coverage by 8-22 percentage points (4,5). Because
health-care providers may believe coverage levels within their practices
are higher than actual levels (6), CDC recommends that providers conduct
coverage level assessments; information obtained from such assessments will
assist providers in recognizing undervaccination in their practices and in
instituting measures to increase coverage. In addition, providers should
inform parents about the specific number of vaccine doses needed before age
two years (11-15 doses), and parents should be encouraged to review their
child's vaccination status at each visit to a health-care provider.

References
1. CDC. Reported vaccine-preventable diseases--United States, 1993, and the
Childhood Immunization Initiative. MMWR 1994;43:57-60.
2. Massey JT, Moore TF, Parsons VL, et al. Design and estimation for the
National Health Interview Survey, 1985-94. Hyattsville, Maryland: US
Department of Health and Human Services, Public Health Service, CDC, 1989.
(Vital and health statistics; series 2, no. 110)
3. Ad Hoc Working Group for the Development of Standards for Immunization
Practices. Standards for immunization practice. JAMA 1993;269:1817-22.
4. Dietz VJ, Stevenson J, Zell ER, Cochi S, Hadler S, Eddins D. Potential
impact on vaccination coverage levels by administering vaccines
simultaneously and reducing dropout rates. Archives of Pediatrics and
Adolescent Medicine 1994;148:943-9.
5. CDC. Impact of missed opportunities to vaccinate preschool-aged children
on vaccination coverage levels--selected U.S. sites, 1991-1992. MMWR
1994;43:709-11,717-8.
6. Bushnell C, Link DA. Private provider assessment. In: 28th National
Immunization Conference proceedings. Atlanta: US Department of Health and
Human Services, Public Health Service, CDC. (in press).

* The purposes of CII are to 1) improve delivery of vaccines to children;
2) reduce the cost of vaccines for parents; 3) enhance awareness,
partnerships, and community participation to improve vaccination coverage;
4) monitor vaccination coverage and occurrence of disease; and 5) improve
vaccines and their use.


Use of Safety Belts -- Madrid, Spain, 1994

     An estimated 300,000 persons die and 10-15 million persons are injured
each year in traffic crashes throughout the world (1). In Spain, during
1993, motor-vehicle crashes accounted for 6378 deaths (16 per 100,000
population) and were the leading cause of death for persons aged 1-44 years
and the leading cause of years of potential life lost (2). Safety belts are
40%-70% effective in preventing severe injuries and deaths associated with
motor-vehicle crashes (3). In April 1975, the Traffic Safety Administration
of Spain implemented a mandatory safety-belt-use law for persons who were
front-seat passengers traveling outside city limits (i.e., interurban
traffic). On June 15, 1992, the law was expanded to include all front-seat
passengers traveling in vehicles in the city limits and passengers in the
back seats of vehicles with manufacturer-installed safety belts (4). In
September 1994, the Ministry of Health of Spain, in collaboration with the
Traffic Safety Administration, conducted surveys to assess the impact of
the expanded law. This report summarizes findings of this assessment in
Madrid, including the first direct observation survey of safety-belt use
by front-seat occupants and a telephone sample survey of knowledge,
attitudes, and behaviors related to motor-vehicle use.

Observational Survey
     The observational survey was conducted at five city intersections and
five intersections at principal gates leading out of the city. At each
site, two persons began observations by selecting the second vehicle in a
stopped position and observing three consecutive vehicles per traffic light
cycle. At each site, approximately 400 vehicles were observed, including
approximately 100 observations (50 in each direction) during each of four
time periods (weekday 8-10 a.m., weekday 7-9 p.m., weekend 8-10 a.m., and
weekend 7-9 p.m.). Each front-seat occupant was counted separately.
Vehicles exempted from the law (taxis and public service vehicles) were
excluded.
     Of the 4069 total observations, 2381 (58.5% [95% confidence interval
(CI)=57.0%-60.1%) of front-seat occupants were using safety belts (Table
1). The overall prevalence of use at the interurban city gates was 67.2%
(range: 58.2%-80.0%) while the prevalence within the city was 50.1% (range:
43.5%-59.1%) (prevalence ratio [PR]=1.3; p less than 0.05). The prevalence
of safety-belt use was greater among women than men (61.9% and 56.7%
[PR=1.1; p less than 0.05]) but similar when compared by intersection, day
of week, hour of day, and seat position of vehicle occupant (5,6).

Telephone Survey
     The Madrid city residential telephone directory was used to obtain a
random sample of eligible potential respondents. Interviewers obtained
information from respondents aged greater than or equal to 18 years about
the number of persons aged greater than or equal to 18 years at home.
     Of 1063 phone numbers called to identify eligible households, 294
(27.7%) could not be contacted (no one answered or the line was busy), and
185 were excluded (because either the phone number was commercial [37], or
no one aged greater than or equal to 18 years was in the home at the time
of the call, or respondents never traveled by vehicle [185]). Categories
of safety-belt use included always, almost always, sometimes, seldom, and
never. Those who reported always wearing safety belts were considered users
for the analysis (7).
     Of the 584 eligible persons, 433 (74.1%) completed the interview
(respondents); 232 (53.6%) were women. Follow-up calls were made to the 151
nonrespondents to obtain demographic information; of these, 91 (60.3%)
agreed to an interview. The distribution by sex was similar among
respondents and nonrespondents; however, a higher proportion of
nonrespondents than respondents were aged greater than or equal to 60 years
(37% compared with 21%, p less than 0.05).
     The prevalence of self-reported safety-belt use in interurban areas
was 94.0% (95% CI=91.8%-96.2%); the prevalence in the city was 64.0% (95%
CI=59.5%-68.5%) (Table 2). Age and sex were not associated with safety-belt
use during interurban or city travel. Characteristics associated with
increased city safety-belt use included history of motor-vehicle collision
(PR=1.2 [95% CI=1.0-1.5]) and positive opinions of effectiveness. Risk
factors associated with safety-belt nonuse in the city included history of
previous motor-vehicle fine (e.g., speeding or running stop signals)
(PR=3.7 [95% CI=1.3-10.5]) and negative opinion of the effectiveness of
safety belts (PR=1.8 [95% CI=1.4-2.3]). The prevalence of safety-belt use
in interurban areas was higher among respondents who reported no history
of fines, who denied driving under the influence of alcohol at least once
during the preceding month, and who had a positive opinion of the
effectiveness of safety belts.

Reported by: P Godoy, J Castell, EF Peiro, D Herrera, J Rullan, Field
Epidemiology Training Program, National Center for Epidemiology, Carlos III
Institute of Health, Ministry of Health and Consumer Affairs, Madrid; A
Patricia, C Ibanez, M Marin, A Molejon, C Plitt, L Relano, C Ruiz, C Sanz,
J Torcal, O Vazquez, F Yanez, autonomous community health depts, Spain.
Field Epidemiology Training Program, Div of Field Svcs, Epidemiology
Program Office; Div of Unintentional Injury Prevention, National Center for
Injury Prevention and Control, CDC.

Editorial Note: The findings from both the direct observational and the
telephone surveys described in this report suggest that persons in Madrid
are less likely to use safety belts while in vehicles traveling within the
city and more likely to use safety belts in interurban areas. Potential
explanations for this difference are 1) the first law enacted in 1975
applied only to travel in areas outside of the city, and the intent of the
expanded law of 1992 has neither been understood nor accepted by many
persons; 2) a substantial proportion of persons are unaware of the risks
for collision associated with the shorter distances traveled within the
city; and 3) efforts to enforce the expanded law have been more vigorous
in interurban areas.
     Direct observational surveys, such as that described in this report,
provide valid estimates of safety-belt use. The telephone survey
supplemented the observational survey by assessing knowledge, attitudes,
and behaviors regarding safety-belt use. However, previous reports indicate
that telephone surveys overestimate the use of safety belts, compared with
estimates by observational surveys (5,6). In the United States, the
National Highway Traffic Safety Administration has recommended the periodic
use of observational probability sample surveys at the same intersections
to assess changes in safety-belt use.*
     In 1992, the motor-vehicle collision fatality rate in Spain (4.8
motor-vehicle deaths per 100 million kilometers [62.5 million miles]
traveled) ranked second in Europe after Portugal (9.0), and was
substantially higher than that in other countries, including the United
Kingdom (1.1), Holland (1.3), Germany (1.9), France (2.0), and the United
States (1.1) (8). Factors associated with the higher rate in Spain may
include the quadrupling in the estimated number of motor vehicles operating
since 1970; road conditions--which are being rapidly improved but lag in
comparison to some other industrialized countries in Europe; and the
condition of currently operating vehicles (i.e., 38% of vehicles in use are
greater than 10 years old).
     Findings in this study indicated that a positive attitude toward
safety-belt effectiveness was most strongly associated with safety-belt
use, both for city and interurban travel. In other countries, safety-belt
use has increased following intense periodic campaigns combining public
education about the benefits of safety-belt use and enforcement of
safety-belt-use laws (9). In Spain, the Ministry of Health in collaboration
with the Traffic Safety Administration will use these results in planning
education programs to improve traffic safety and other projects to increase
safety-belt use.

References
1. Ross A, Baguley C, Hills B, McDonald M, Silcock D. Towards safer roads
in developing countries: a guide for planners and engineers. Crowthorne,
England: Transport and Road Research Laboratory, 1991.
2. Traffic Safety Administration. Accidents 1993 [Spanish]. In: Annual
Bulletin of the Traffic Safety Administration. Madrid, Spain: Ministry of
Justice and Interior, 1993.
3. Chorba TL. Assessing technologies for preventing injuries in motor
vehicle crashes. Int J Technol Assess Health Care 1991;7:296-314.
4. Royal Decree 13, January 17, 1992. General regulations on vehicle
traffic. State official bulletin. January 31, 1992 (no. 27).
5. CDC. Use of seat belts--DeKalb County, Georgia, 1986. MMWR 1987;36:433-
7.
6. CDC. Driver safety-belt use--Budapest, Hungary, 1993. MMWR 1993;42;939-
41.
7. Streff FM, Wagenaar AC. Are there really shortcuts? Estimating seat belt
use with self-report measures. Accid Anal Prev 1989;21:509-16.
8. International Road Federation. International Road Statistics, 1989-1993.
Geneva, Switzerland: International Road Federation, 1994.
9. Dessault C. Seat belt use: the Quebec experience. In: Proceedings of the
National Leadership Conference on Increasing Safety Belt Use in the United
States. Washington, DC: American Coalition for Traffic Safety, National
Highway Traffic Safety Administration, 1991.

* 57 FR 28899-904.


Monthly Immunization Table

     To track progress toward achieving the goals of the Childhood
Immunization Initiative (CII), CDC publishes monthly a tabular summary of
the number of cases of all diseases preventable by routine childhood
vaccination reported during the previous month and year-to-date
(provisional data). In addition, the table compares provisional data with
final data for the previous year and highlights the number of reported
cases among children aged less than 5 years, who are the primary focus of
CII. Data in the table are derived from CDC's National Notifiable Diseases
Surveillance System.
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                              * * *
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Inquiries about the MMWR Series, including material to be considered for
publication, should be directed to: Editor, MMWR Series, Mailstop C-08,
Centers for Disease Control and Prevention, Atlanta, GA 30333; telephone
(404) 332-4555.

The MMWR is available on a paid subscription basis for paper copy and free
of charge in electronic format. For information about paid subscriptions,
contact the Superintendent of Documents, U.S. Government Printing Office,
Washington, DC 20402; telephone (202) 783-3238. For electronic copy, send
an e-mail message to lists@list.cdc.gov -- the body content should read
subscribe mmwr-toc. Electronic copy also is available from CDC's World-Wide
Web server at http://www.cdc.gov/ or CDC's file transfer protocol server
at ftp.cdc.gov. 

All material in the MMWR Series is in the public domain and may be used and
reprinted without special permission; citation of source, however, is
appreciated.
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Director, Centers for Disease Control and Prevention
     David Satcher, M.D., Ph.D.
Deputy Director, Centers for Disease Control and Prevention
     Claire V. Broome, M.D.
Director, Epidemiology Program Office
     Stephen B. Thacker, M.D., M.Sc.
Editor, MMWR Series
     Richard A. Goodman, M.D., M.P.H.
Managing Editor, MMWR (weekly)
     Karen L. Foster, M.A.
Writers-Editors, MMWR (weekly)
     David C. Johnson         Darlene D. Rumph-Person
     Patricia A. McGee        Caran R. Wilbanks
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

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