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HICNet Medical News Digest      Fri, 19 May 1995        Volume 08 : 
Issue 19

Today's Topics:

  [MMWR Apr21] Suicide Among Children, Adolescents, and Young Adults
  [MMWR] Update: Influenza Activity -- United States and Worldwide
  [MMWR] Local Transmission of Plasmodium vivax Malaria
  [MMWR] Rates of Cesarean Delivery -- United States, 1993
  [MMWR] Notice to Readers:  National Notifiable Diseases Reporting
  [MMWR Apr28] Clean Air Month -- May 1995
  [MMWR] Children at Risk from Ozone Air Pollution
  [MMWR] Fatal and Nonfatal Suicide Attempts Among Adolescents

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

To: hicnews
Adults

          Suicide Among Children, Adolescents, and Young Adults --
                      United States, 1980-1992

     Suicide was the fifth leading cause of years of potential life lost
before age 65 years in 1990 (CDC, unpublished data, 1995). During 1980-
1992, a total of 67,369 persons aged less than 25 years (i.e., children,
adolescents, and young adults) committed suicide and, in 1992, persons 
in
this age group accounted for 16.4% of all suicides. From 1952 through 
1992,
the incidence of suicide among adolescents and young adults nearly 
tripled
(1). One of the national health objectives for the year 2000 is to 
reduce
the suicide rate for persons aged 15-19 years by greater than 25% to 8.2
per 100,000 persons (objective 7.2a) (2). This report summarizes trends 
in
suicide among persons aged less than 25 years from 1980 through 1992 
(the
latest year for which complete data are available).
     Trends in suicide among young persons were determined using final
mortality data from CDC's underlying cause of death files (3). Suicides 
and
methods of fatal injury were determined by using International
Classification of Diseases, Ninth Revision, codes. Suicide rates were
calculated using population data from the 1980 and 1990 census 
enumerations
and intercensal year estimates compiled by the U.S. Bureau of the 
Census.
     From 1980 to 1992, the number and rate of suicides declined among
persons aged less than 25 years from 5381 (5.7 per 100,000 persons) to 
5007
(5.4). For persons aged 20-24 years, the suicide rate declined 7.2% 
(from
16.1 to 14.9). In comparison, the rate increased among persons aged 15-
19
years by 28.3% (from 8.5 to 10.9) and among persons aged 10-14 years by
120% (from 0.8 to 1.7). For persons aged 20-24 years, suicide rates
declined for all racial and sex groups except black males (Table 1).* 
For
persons aged 15-19 years, the suicide rate increased for all groups 
except
males of other races; in particular, for black males the rate increased
165.3%. For persons aged 10-14 years, suicide rates increased 
substantially
in all racial and sex groups.
     In 1992, firearm-related deaths accounted for 64.9% of suicides 
among
persons aged less than 25 years. Among persons aged 15-19 years,
firearm-related suicides accounted for 81% of the increase in the 
overall
rate from 1980-1992. During 1980-1992, among persons aged less than 25
years, the proportions of suicides by poisoning, cutting, and other 
methods
declined, while the proportions by firearms and hanging increased; 
hanging
was the second most common method of suicide, followed by poisoning.

Reported by: Div of Violence Prevention, National Center for Injury
Prevention and Control, CDC.

Editorial Note: The findings in this report are consistent with previous
reports indicating that the risk for suicide is greatest among young 
white
males (4). However, from 1980 through 1992, suicide rates increased most
rapidly among young black males. Although suicide among children is a 
rare
event, the dramatic increase in the suicide rate among persons aged 10-
14
years underscores the urgent need for intensifying efforts to prevent
suicide among persons in this age group.
     The causes of suicide are multiple and complex. Potential reasons 
for
the increase in suicides among some groups may reflect increasing
interaction of risk factors including substance abuse; mental illness;
impulsive, aggressive, and antisocial behavior; family influences,
including a history of violence and family disruption; severe stress in
school or social life; and rapid sociocultural change (5). The increase 
in
firearm-related suicide probably reflects increased access to firearms 
by
the at-risk population (6).
     Most youth suicide-prevention programs are directed toward older
adolescents and do not include outreach efforts for minorities (6). The
recent increases in suicide rates among young black males and children 
aged
10-14 years especially indicate the need to develop interventions for 
these
groups. In addition, the increasing use of firearms for suicide 
underscores
the need for intensifying the development and assessment of
suicide-prevention measures directed toward firearms. Because a previous
report suggested that suicide attempts among younger persons have not
increased (7), the increased rate of completed suicides may be 
attributed
to the use of more lethal means during attempts.
     Because attempted suicide is a major risk factor for subsequent
suicide, in several states public health surveillance projects have been
initiated to improve the quality of information about persons who are at
risk for suicide (8). In addition, some health departments have 
initiated
comprehensive youth suicide-prevention activities to improve service to 
the
at-risk population (9).
     Based on review of programs throughout the United States, CDC has
identified strategies for preventing suicide among young persons (6). 
These
strategies include 1) training school and community leaders to identify
young persons at highest risk for suicidal thoughts, threats, and 
attempts;
2) educating young persons about suicide, risk factors, and 
interventions;
3) implementing screening and referral programs; 4) developing peer-
support
programs; 5) establishing and operating suicide crisis centers and
hotlines; 6) restricting access to highly lethal methods of suicide; and
7) intervening after a suicide to prevent other young persons from
attempting or completing suicide. Rigorous evaluation of new and 
existing
prevention programs is essential to identify and establish the most
effective interventions for reducing suicide among young persons.
     National Suicide Prevention Week is May 7-13, 1995. This year's 
theme
is "Stop the whispers...suicidal persons can be helped." For additional
information, contact the American Association of Suicidology, telephone
(202) 237-2280.

References
1. Shaffer D, Garland A, Gould M, Fisher P, Trautman P. Preventing 
teenage
suicide: a critical review. J Am Acad Child Adolesc Psychiatry 
1988;27:675-
87.
2. Public Health Service. Healthy people 2000: national health promotion
and disease prevention objectives. Washington, DC: US Department of 
Health
and Human Services, Public Health Service, 1991; DHHS publication no.
(PHS)91-50213.
3. NCHS. Vital statistics mortality data, underlying cause of death, 
1991
[Machine-readable public-use data tapes]. Hyattsville, Maryland: US
Department of Health and Human Services, Public Health Service, CDC, 
1993.
4. CDC. Youth suicide--United States, 1970-1980. MMWR 1987;36:87-9.
5. Goodwin FK, Brown GL. Risk factors for youth suicide. In: Alcohol, 
Drug
Abuse, and Mental Health Administration. Report of the Secretary's Task
Force on Youth Suicide. Volume 2. Washington, DC: US Department of 
Health
and Human Services, Public Health Service, Alcohol, Drug Abuse, and 
Mental
Health Administration, 1989; DHHS publication no. (ADM)89-1622.
6. CDC. Youth suicide prevention programs: a resource guide. Atlanta: US
Department of Health and Human Services, Public Health Service, CDC, 
1992.
7. Mocicki EK, O'Carroll P, Locke BZ, Rae DS, Roy AG, Regier DA. 
Suicidal
ideation and attempts: the epidemiologic catchment area study. In: 
Alcohol,
Drug Abuse, and Mental Health Administration. Report of the Secretary's
Task Force on Youth Suicide. Volume 4: strategies for the prevention of
youth suicide. Washington, DC: US Department of Health and Human 
Services,
Public Health Service, Alcohol, Drug Abuse, and Mental Health
Administration, 1989; DHHS publication no. (ADM)87-1624.
8. Colorado Department of Public Health and Environment. Violence in
Colorado: trends and resources. Denver: Colorado Department of Public
Health and Environment, 1994.
9. Eggert LL, Thompson EA, Randall BP, McCauley E. Youth suicide 
prevention
plan for Washington state. Olympia, Washington: Washington Department of
Health, 1995.

* Because data for racial groups other than black and white were too 
small
for separate analysis, data for these groups were combined. Data on
ethnicity were not analyzed because they were not available for the 
entire
study period.


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

To: hicnews
Worldwide

   Update: Influenza Activity -- United States and Worldwide, 1994-95 
Season,
              and Composition of the 1995-96 Influenza Vaccine

     In collaboration with the World Health Organization (WHO) and the
international network of collaborating laboratories and with state and
local health departments in the United States, CDC conducts surveillance
to monitor influenza activity and to detect antigenic changes in the
circulating strains of influenza viruses. This report summarizes
surveillance for influenza in the United States and worldwide during the
1994-95 season and describes the composition of the 1995-96 influenza
vaccine.

United States
     Influenza activity began in the Northeast in late November 1994 and
from late January to early February spread to other regions of the 
country.
Activity peaked during March and continues to decline.
     From November 27, 1994, through January 14, 1995, regional or
widespread influenza activity* was reported only from northeastern 
states.
Regional activity was first reported outside this area for the week 
ending
January 21, and by February 11 regional or widespread activity had been
reported from every region in the country. Based on reports from state 
and
territorial epidemiologists, peak activity occurred the week ending 
March
11, 1995, when 26 states reported either regional or widespread 
activity.
The number of states reporting regional or widespread activity has 
declined
every week since March 12. For the week ending April 8, four states
reported regional activity, and none reported widespread activity.
     Of total deaths reported through CDC's 121-city mortality 
surveillance
system, the proportion attributed to pneumonia and influenza exceeded 
the
epidemic threshold** for 11 of the 27 weeks from October 2, 1994, 
through
April 8, 1995. Pneumonia and influenza deaths exceeded the epidemic
threshold for 2 consecutive weeks twice during this interval.
     Of the 3423 influenza virus isolates reported to CDC from WHO
collaborating laboratories in the United States through April 8, a total
of 2654 (78%) were type A and 769 (22%) were type B. Of the 1337 type A
viruses that have been subtyped, 1318 (99%) were type A(H3N2) and 19 
(1%)
were type A(H1N1).

Worldwide
     Influenza activity has occurred at low to moderate levels in most
parts of the world. Although a few countries reported epidemic activity,
sporadic activity or localized outbreaks were reported more frequently.
Influenza activity was usually associated with cocirculation of 
influenza
A(H3N2) and influenza B viruses. Influenza A(H1N1) activity was reported
only in association with sporadic cases. Influenza A(H3N2) viruses were
first detected during October in Europe and North America. Outbreaks
associated with influenza A(H3N2) were subsequently reported in the
People's Republic of China, Finland, Hungary, Italy, Spain, the United
Kingdom, and the United States. Although influenza A and influenza B
cocirculated, influenza A(H3N2) viruses predominated in Canada, Finland,
France, Italy, Spain, and the United States.
     Influenza type B viruses were first detected this season in Europe 
in
association with a secondary school outbreak in Portugal during October.
Outbreaks caused by influenza B were reported subsequently in China, 
Iran,
Italy, and the United States. Epidemic activity associated with 
influenza
B was reported in Italy and Russia. In Germany, the Netherlands, 
Portugal,
Russia, and the United Kingdom, influenza B viruses were isolated more
frequently than influenza A(H3N2) viruses.
     Influenza A(H1N1) viruses have been reported in association with
sporadic activity from Canada, China, Hong Kong, the Netherlands, 
Norway,
Poland, Singapore, Switzerland, Thailand, the United Kingdom, and the
United States during the 1994-95 season.

Composition of the 1995-96 Vaccine
     The Food and Drug Administration Vaccines and Related Biologicals
Advisory Committee (VRBAC) has recommended that the 1995-96 trivalent
influenza vaccine for the United States contain A/Johannesburg/33/94-
like
(H3N2), A/Texas/36/91-like (H1N1) and B/Beijing/184/93-like viruses. 
This
recommendation was based on the antigenic analysis of recently isolated
influenza viruses and the antibody responses of persons vaccinated with 
the
1994-95 vaccine.
     Although many of the influenza type A(H3N2) viruses that have been
antigenically characterized are similar to the A/Shangdong/09/93 strain,
some recently isolated A(H3N2) strains from Asia, Europe, and North 
America
are more similar to the antigenic variant A/Johannesburg/33/94 (Table 
1).
Vaccines containing the A/Shangdong/09/93(H3N2)-like virus induced a 
good
antibody response to the vaccine strain but induced lower and less 
frequent
antibody responses to recent type A(H3N2) strains such as
A/Johannesburg/33/94 (1). Therefore, VRBAC recommended changing the
influenza type A(H3N2) vaccine component to an A/Johannesburg/33/94-like
strain for the 1995-96 season.
     Many recent influenza B viruses isolated from Asia, Europe, and 
North
America are antigenically distinguishable from the B/Panama/45/90 strain
included in the 1994-95 vaccine. These recent viruses are similar to the
B/Beijing/184/93, B/Shanghai/04/94, and B/Harbin/07/94 strains. These
strains, which are themselves antigenically indistinguishable, have been
used as reference strains for antigenic analysis (Table 2). Although
vaccines containing B/Panama/45/90 virus induced antibodies at a similar
frequency and titer as the vaccine virus for some recent influenza B
strains, in some studies the antibody response in adults and the elderly
was reduced to the B/Beijing/ 184/93-like strain, B/Shanghai/04/94. 
VRBAC
recommended changing the influenza B component to a B/Beijing/184/93-
like
virus for the 1995-96 season. The actual strain used by U.S. vaccine
manufacturers will be B/Harbin/07/94 because of its growth properties.
     Since the 1992-93 influenza season, isolation of influenza type
A(H1N1) virus has been sporadic worldwide (2). Nine recent viruses from
China and the United States have been characterized as being related to 
the
reference strains A/Taiwan/01/86 and A/Texas/36/91. Vaccines containing 
the
A/Texas/36/91 strain induced antibodies with similar frequency and titer
to the vaccine virus and to type A(H1N1) strains isolated in 1993 and 
1994.
Therefore, VRBAC recommended retaining an A/Texas/36/91-like strain in 
the
1995-96 vaccine.

Reported by: Participating state and territorial health dept
epidemiologists and state public health laboratory directors. M
Chakraverty, PhD, Central Public Health Laboratory, A Hay, PhD, National
Institute for Medical Research, London; G Schild, PhD, J Wood, PhD,
National Institute for Biological Standards and Control, Hertfordshire,
England. I Gust, MD, A Hampson, Commonwealth Serum Laboratories, 
Parkville,
Australia. J Weber, Laboratory Center for Disease Control, Ottawa, 
Ontario.
J Kim, PhD, K Park, PhD, National Institute of Health, Seoul, Korea. E
Claas, PhD, Eramus University, Rotterdam, The Netherlands. World Health
Organization National Influenza Centers, Program on Bacterial, Viral
Diseases, and Immunology, Geneva. Div of Virology, Center for Biologics
Evaluation and Research, Food and Drug Administration. Influenza Br, Div
of Viral and Rickettsial Diseases, National Center for Infectious 
Diseases,
CDC.

Editorial Note: During the 1994-95 season, the impact of influenza in 
most

_
                                                            

parts of the United States and in most other countries in the Northern
Hemisphere was less severe than during the previous season, when
A/Beijing/32/92-like (H3N2) viruses predominated. Although approximately
75% of influenza viruses circulating in the United States during the 
1994-
95 season have been type A(H3N2), compared with the 1993-94 season,
influenza spread more slowly and was associated with less severe 
illness.
The results of mortality surveillance based on the 121-city system 
suggest
relatively low influenza-associated mortality in the United States this
season and are consistent with other influenza surveillance findings.
     Strains to be included in next season's influenza vaccine are 
selected
usually during the preceding January through March because of scheduling
requirements for production, quality control, packaging, and 
distribution
of vaccine for administration before onset of the next influenza season.
Recommendations of the Advisory Committee on Immunization Practices for 
the
use of vaccine and antiviral agents for prevention and control of 
influenza
have been published in the MMWR Recommendations and Reports (3).

References
1. World Health Organization. Recommended composition of influenza virus
vaccines for use in the 1995-96 season. Wkly Epidemiol Rec 1995;70:53-6.
2. CDC. Update: influenza activity--United States and worldwide, 1993-94
season, and composition of the 1994-95 influenza vaccine. MMWR 
1994;43:179-
83.
3. CDC. Prevention and control of influenza: recommendations of the
Advisory Committee on Immunization Practices (ACIP). MMWR 1995;44(no.
RR-3).

* Levels of activity are 1) sporadic--sporadically occurring influenza-
like
illness (ILI) or culture-confirmed influenza, with no outbreaks 
detected;
2) regional--outbreaks of ILI or culture-confirmed influenza in counties
having a combined population of less than 50% of the state's total
population; and 3) widespread--outbreaks of ILI or culture-confirmed
influenza in counties having a combined population of greater than or 
equal
to 50% of the state's total population.
** The epidemic threshold is 1.645 standard deviations above the 
seasonal
baseline. The expected seasonal baseline is projected using a robust
regression procedure in which a periodic regression model is applied to
observed percentages of deaths from pneumonia and influenza since 1983.


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

To: hicnews

    Local Transmission of Plasmodium vivax Malaria -- Houston, Texas, 
1994

     Malaria was endemic in the United States until the late 1940s; 
since
then, most cases of malaria reported in the United States has been 
acquired
during international travel or has occurred in persons who had resided 
in
countries where malaria is endemic. This report summarizes the
investigation of three persons who acquired Plasmodium vivax infection 
in
Houston, Texas, by presumed mosquitoborne transmission during 1994.

Case Reports
     Case 1. On July 8, a 62-year-old man was hospitalized with an 8-day
history of fever chills, sweats, and vomiting. His temperature on 
admission
was 104.0 F (40.0 C). P. vivax parasites were identified on a blood 
smear
on July 11. The patient recovered after treatment with chloroquine and
primaquine.
     Case 2. On July 18, a 37-year-old man sought care in an emergency
department at another hospital because of a temperature of 102.8 F (39.3
C) and a 3-week history of nausea, vomiting, fever, chills, sweats,
headache, and shortness of breath. P. vivax parasites were identified on
a routine peripheral blood smear on July 18. He recovered after 
treatment
with chloroquine; although primaquine was not initially prescribed, he
received it during the investigation in August.
     Case 3. On December 4, a 50-year-old man was admitted to the same
hospital as in case 2 because of altered mental status, fever, and 
headache
of 2 weeks' duration; his temperature on admission was 100.0 F (37.8 C).
P. vivax parasites were identified on a routine peripheral blood smear 
on
December 6. He recovered after treatment with chloroquine and 
primaquine.
He had had similar symptoms with onset during late July and early August
and had been admitted to two different hospitals during August. During 
the
second hospitalization, viral meningitis was presumptively diagnosed;
evaluation included one thick blood smear on August 23 (which was 
reported
as negative for malaria parasites), and acute and convalescent
immunoglobulin M enzyme-linked immunosorbent assay titers for St. Louis
encephalitis (both titers were 1:10). The blood smears from August 23 
were
unavailable for review. However, tests of serum specimens from the 
August
and December hospitalizations for malaria antibody by an indirect
immunofluorescent assay were positive for P. vivax (titer of 1:64 on 
August
23, 1:256 on August 30, and 1:256 on December 6). These results indicate
P. vivax malaria infection before December, and that the December 
episode
most likely was a relapse from dormant liver stages (hypnozoite), which
result only from mosquitoborne inoculation with sporozoites and not from
person-to-person transmission (e.g., through blood transfusions or
injecting drugs).

Case Investigations
     Case-patients 2 and 3 had never traveled outside of the United 
States;
case-patient 1 had traveled outside the United States only before 1956.
None had a history of blood transfusions, tattoos, malariotherapy for 
Lyme
disease, recent injecting-drug use, or previous malaria infection. They
lived within a 3-mile radius, were not acquainted, and had not been in 
the
same locations. However, all had prolonged nighttime exposure to
mosquitoes, either through working outdoors at night or sleeping in 
housing
without window panes and/or with unscreened windows and doors. They 
lived
10 miles from the nearest international airport, and there are no
prevailing winds in Houston that would carry anophelines beyond their
maximal flight range of 1-2 miles (1).

Active Case-Finding
     Medical record reviews at all clinical laboratories and hospitals 
and
contacts with infectious disease physicians identified 21 additional
malaria patients in Houston and Harris County during June 1-August 22. 
At
the time of the investigation, four (19%) of these patients had been
reported through the existing passive surveillance system; 17 (81%) were
identified by contacting laboratories in the Houston area. All 21 had
traveled to countries where malaria is endemic; however, two of the 21 
had
visited only parts of northern Mexico where malaria transmission has not
been reported. Of the 24 total patients, 10 (including cases 1-3) were
infected with P. vivax; three of the 10 were treated with chloroquine 
only
and had not received primaquine to prevent a relapse infection.
     The Harris County Mosquito Control District identified adult female
Anopheles quadrimaculatus, a competent vector of malaria, in mosquito 
traps
placed near the residences of patients 1 and 2 on August 4. Although
possible breeding sites were identified near these residences, mosquito
larvae were not found. Rainfall was below average during July-August, 
and
many potential breeding sites were dry.

Reported by: R Bell, PhD, J Cousins, W McNeely, MPH, P Rogers, PhD, A
Payne, DrPH, M desVignes-Kendrick, MD, Houston Dept of Health and Human
Svcs; J Billodeaux, R Jones, Harris County Mosquito Control District,
Houston; J Taylor, MPH, K Hendricks, MD, J Perdue, Bur of Communicable
Disease Control, D Simpson, MD, State Epidemiologist, Texas Dept of 
Health.
Div of Field Epidemiology, Epidemiology Program Office; Div of Parasitic
Diseases, National Center for Infectious Diseases, CDC.

Editorial Note: The findings of the Houston investigation indicate that 
the
P. vivax infections for patients 1-3 most likely were acquired locally 
(in
Houston) as the result of mosquitoborne transmission. The course of 
illness
in case 3 strongly supports mosquitoborne transmission and possible
secondary transmission. Airport malaria (i.e., inadvertent 
transportation
of infective anophelines on airplanes) is unlikely.
     This cluster of patients with locally acquired P. vivax malaria in 
an
urban setting occurred 1 year after identification of an outbreak of
locally acquired P. falciparum infection in New York City (M. Layton, 
New
York City Department of Health, personal communication, 1994). Local
transmission in densely populated areas represents a change in the
epidemiologic pattern of malaria: until 1991, when local transmission 
was
reported in a suburban area of New Jersey (2-4), local transmission had
occurred predominantly in rural areas.
     Although malaria is a notifiable disease in all states, only seven
(29%) of the 24 cases identified in this investigation had been reported
to the health department in Houston. The lack of reporting of and
information about these cases delayed the investigation and efforts to
identify other possible locally acquired cases. For example, the two 
cases
in persons who had traveled only to northern Mexico may have been either
imported or locally acquired; however, because they had not been 
reported,
they were not investigated promptly. In addition, although most hospital
laboratories have the capacity to conduct malaria smear examinations,
limitations in the experience of staff may decrease the likelihood of
detection.
     To improve surveillance of all notifiable conditions, the Texas
Department of Health has begun an educational campaign and is 
implementing
an enhanced toll-free telephone reporting system aimed at all health-
care
practitioners; in addition, the Houston Health Department has 
distributed
newsletters to physicians and infection-control practitioners informing
them of the locally acquired cases, the proper treatment for cases, and 
the
importance of reporting. The Harris County Mosquito Control District 
will
enhance vector surveillance for anopheline vectors, which will be linked
to active malaria case detection this summer.
     Malaria continues to be a leading cause of morbidity and mortality
worldwide, particularly because of the development of drug-resistant
strains, and is a continuing concern in the United States because of
increased international migration, travel, and commerce. The basic
requirements for local transmission of malaria--including persons (who 
may
or may not be ill) with malarial gametocytes in their blood (as was
documented in Houston), competent vectors, and conducive weather
conditions--exist in many areas of the United States. Important 
strategies
for preventing the re-establishment of malaria as an endemic disease in 
the
United States are prompt recognition and reporting of cases of malaria;
appropriate treatment of all malaria cases, including primaquine for P.
vivax and P. ovale infections to prevent relapse; and implementation of
appropriate control measures.

References
1. Isaacson M. Airport malaria: a review. Bull World Health Organ
1989;67:737-43.
2. CDC. Transmission of Plasmodium vivax malaria--San Diego County,
California, 1988 and 1989. MMWR 1990;39:91-4.
3. CDC. Mosquito-transmitted malaria--California and Florida, 1990. MMWR
1991;40:106-8.
4. Brook JH, Genese CA, Bloland PB, Zucker JR, Spitalny KC. Brief 
report:
malaria probably locally acquired in New Jersey. N Engl J Med 
1994;331:22-
3.


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

To: hicnews

          Rates of Cesarean Delivery -- United States, 1993

     The rate of cesarean delivery in the United States is among the
highest for developed nations (1). Because increased risks for maternal
death and morbidity and perinatal morbidity are associated with cesarean
delivery, a national health objective for the year 2000 is to reduce the
overall rate of cesarean delivery to less than or equal to 15.0 per 100
deliveries (1987 baseline: 24.4 per 100 deliveries) (objective 14.8) (2)-
-a
level last observed in 1978 (3). This report uses data from CDC's 
National
Hospital Discharge Survey (NHDS) to characterize cesarean deliveries 
during
1993, compares these rates with rates for 1970-1992, and assesses 
progress
toward the national health objective for the year 2000.
     Since 1965, NHDS has collected data annually on discharges from
short-stay, nonfederal hospitals. For 1993, medical and demographic
information were abstracted from a sample of 235,411 inpatients 
discharged
from the 466 participating hospitals. In this analysis, data about the
number of cesareans and vaginal births after a previous cesarean (VBAC) 
are
based on weighted national estimates from the NHDS sample of 
approximately
27,000 (11.5%) women discharged after delivery. The estimated numbers of
live births by type of delivery were calculated by applying cesarean 
rates
from the NHDS to the number of live births from national vital 
registration
data. Stated differences in this report are significant at the 95%
confidence level.
     In 1993, of the estimated 4,039,000 live births, approximately 
585,000
(14.5%) were primary cesareans, 336,000 (8.3%) repeat cesareans, 115,000
(2.9%) VBACs, and 3,003,000 (74.4%) other vaginal deliveries. The 
overall
rate of cesarean delivery in 1993 was 22.8 per 100 deliveries, the 
lowest
rate since 1985 but approximately four times the rate in 1970 (5.5) 
(Table
1). The primary cesarean rate (i.e., number of first cesareans per 100
deliveries to women who had no previous cesarean) for 1993 (16.3) also 
was
the lowest rate since 1985 but approximately four times the rate in 1970
(4.2). Declines in the overall and primary cesarean delivery rates from 
the
mid-1980s to 1993 were not statistically significant. In 1993, of the 
women
who had a previous cesarean birth, approximately one fourth gave birth
vaginally (VBAC rate: 25.4); the VBAC rate in 1993 more than doubled 
from
1988 (12.6).
     In 1993, the overall rate of cesarean delivery differed by region,
maternal age, hospital size and ownership, and expected source of 
payment
(Table 2). Rates were higher in the South*, for mothers aged greater 
than
or equal to 30 years (especially those aged greater than or equal to 35
years), for hospitals containing less than 100 beds, for proprietary
hospitals, and for mothers with Blue Cross/Blue Shield** or other 
private
insurance.
     The rate of cesarean delivery varied by the complications of 
pregnancy
or delivery that preceded the cesarean. Rates were highest for women who
had fetopelvic disproportion (98.5 per 100 deliveries) or failed 
induction
of labor (94.3). Common medical complications were breech presentation
(rate: 87.1); history of previous cesarean (74.6); antepartum 
hemorrhage,
abruptio placenta, and placenta previa (64.1); obstructed labor (63.5); 
and
multiple gestation (57.8). In 1993, of all women who had a cesarean, 
36.5%
had a previous cesarean delivery, 17.4% had an abnormal labor, and 17.0%
had fetopelvic disproportion. Of all women who delivered, 11.2% had a
previous cesarean, 8.7% each had abnormal labor or uterine inertia, and
7.6% were anemic.

Reported by: Natality, Marriage, and Divorce Statistics Br, Div of Vital
Statistics, National Center for Health Statistics, CDC.

Editorial Note: The findings in this report indicate that the overall 
and
primary cesarean rates have remained relatively stable since the mid-
1980s.
Although the VBAC rate increased twofold during 1988-1993, the 
anticipated
reduction in the overall rate of cesarean delivery was offset by trends
among women giving birth that are associated with higher risk for 
cesarean
delivery (i.e., increases in maternal age at birth and in first order 
and
plural births [4]). In particular, maternal age is an independent risk
factor for cesarean delivery even after adjustments for other potential
confounding factors (e.g., race, education, and complications of labor 
and
delivery) (5).
     In this study, rates of cesarean delivery were analyzed separately 
by
region, hospital size and ownership, and expected source of payment;
therefore, simultaneous effects of the other variables could not be
analyzed. For example, the study could not assess whether the higher 
rates
of cesarean delivery in small hospitals (i.e., less than 100 beds)
reflected the increased likelihood of proprietary ownership of these
hospitals.
     The overall cesarean delivery rate is directly associated with the
primary cesarean rate and the VBAC rate. Therefore, in addition to
establishing year 2000 national health objective 14.8 to assist in
monitoring trends in the overall cesarean delivery rate, two more 
specific
objectives were established to monitor trends in primary cesarean and 
VBAC
rates. The objectives are to reduce the primary cesarean delivery rate 
to
less than or equal to 12.0 per 100 deliveries (1987 baseline: 17.4 per 
100
deliveries) (objective 14.8a) and to increase the number of VBACs to
greater than or equal to 35.0 per 100 women who had a previous cesarean
(objective 14.8b) (2). If the VBAC rate continues to increase at the 
rate
observed during 1988-1993, the national health objective may be met by 
the
year 2000; however, the most recent data indicate the rate stabilized
during 1991-1993. Even with a VBAC rate of 35.0, the primary rate must
decline by nearly half (to 8.4) to achieve the year 2000 target rate for
overall cesarean deliveries (15.0). Based on the stability of the 
primary
cesarean delivery rates during 1985-1993, the overall cesarean rate
probably will not decline to meet the objective by the year 2000.
     In many countries with demographic profiles similar to the United
States, cesarean rates are less than or equal to 15.0 per 100 deliveries
(1). Strategies to achieve this rate in the United States will require 
the
widespread use of four obstetrical practices that have been successful 
in
reducing cesarean delivery rates in many hospitals: 1) active management
of labor; 2) public dissemination of physician-specific cesarean 
delivery
rates to increase public awareness of differences in practices; 3)
implementation of standardized protocols for repeat cesareans, dystocia,
and fetal distress; and 4) establishment of reduction of the rate as an
institutional priority (6-8).

References
1. Notzon FC. International differences in the use of obstetric
interventions. JAMA 1990;263:3286-91.
2. 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.
3. CDC. Rates of cesarean delivery--United States, 1991. MMWR 
1993;42:285-
9.
4. Ventura SJ, Martin JA, Taffel SM, et al. Advance report of final
natality statistics, 1992. Hyattsville, Maryland: US Department of 
Health
and Human Services, Public Health Service, CDC, 1994. (Monthly vital
statistics report; vol 43, no. 4, suppl).
5. Peipert JF, Bracken M. Maternal age: an independent risk factor for
cesarean delivery. Obstet Gynecol 1993;81:200-5.
6. Sanchez-Ramos L, Kaunitz AM, Peterson HB, et al. Reducing cesarean
section rates at a teaching hospital. Am J Obstet Gynecol 1990;163:1081-
8.
7. Socol ML, Garcia PM, Peaceman AM, Dooley SL. Reducing cesarean births
at a primarily private university hospital. Am J Obstet Gynecol
1993;168:1748-58.
8. Myers SA, Gleicher N. A successful program to lower cesarean-section
rates. N Engl J Med 1988;319:1511-6.

* South=Alabama, Arkansas, Delaware, District of Columbia, Florida,
Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina,
Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia
** 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.



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To: hicnews
Reporting

       National Notifiable Diseases Reporting -- United States, 1995

     Beginning with the April 28, 1995, MMWR, the following 
modifications
will be incorporated in Tables I and II, Cases of Notifiable Diseases,
United States, and Figure I, Notifiable Disease Reports: 1) diseases
recently deleted from the nationally notifiable diseases list by the
Council of State and Territorial Epidemiologists will no longer appear 
in
Tables I and II and Figure I (i.e., aseptic meningitis, primary and
postinfectious encephalitis, unspecified hepatitis, leptospirosis, and
tularemia) and 2) the column in Table II labeled NA,NB hepatitis will be
relabeled "C/NA,NB" hepatitis.


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To: hicnews

                         Clean Air Month -- May 1995

     The American Lung Association (ALA) sponsors National Clean Air 
Month
each May to educate the public about the relation between clean air and
respiratory health. This year's theme is "Helping Kids Breathe Easier."
     Air pollution is an important contributor to lung disease, the 
third
leading cause of death in the United States. ALA is committed to 
decreasing
lung disease in children by emphasizing the importance of reducing air
pollution. ALA recommends that persons drive less, support state and 
local
clean air regulations, make their homes and workplaces smoke-free, and 
test
them for harmful pollutants (e.g., radon and carbon monoxide).
     Efforts planned by local lung associations throughout the country 
for
Clean Air Month include Clean Commute Days and Clean Air Challenge 
cycling and
walking fundraising events. This issue of MMWR includes a report that 
provides
estimates of the number of children potentially at risk from ozone air
pollution.
     Additional information about Clean Air Month and related activities 
is
available from local ALA offices (telephone [800] 586-4872) or from the
national office (1740 Broadway, New York, NY 10019-4374; telephone [212]
315-8700).


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To: hicnews

     Children at Risk from Ozone Air Pollution -- United States, 1991-
1993

     A national health objective for the year 2000 is to reduce exposure 
to
air pollutants so that at least 85% of persons reside in counties that 
meet
Environmental Protection Agency (EPA) standards (objective 11.5) (1). 
Ozone,
the principle component of summer smog, is the most pervasive air 
pollutant in
the United States. The risks associated with ozone and other air 
pollutants
are especially increased for children and adults with asthma (2); 
however,
children with no underlying pulmonary diseases also are at risk for 
adverse
health effects associated with these pollutants (3). In addition, 
because
children of racial/ethnic minorities are more likely to reside in areas 
with
higher air pollution levels, they may be exposed to higher levels of 
ozone
(4). This report presents the findings of an analysis by the American 
Lung
Association (ALA) to characterize pediatric populations potentially at 
risk
for adverse health effects from exposure to ozone air pollution in the 
United
States during 1991-1993.
     The National Ambient Air Quality Standard for ozone is 0.12 parts 
per
million (ppm) averaged over 1 hour.* The federal standard is met if this 
value
is not exceeded more than once per calendar year on average over a 3-
year
period. The federal "exceedance" of the 0.12 ppm standard is defined as 
all
levels greater than or equal to 0.125 ppm.** For this report, both the 
federal
exceedance level (greater than or equal to 0.125 ppm, averaged over 1 
hour)
and an alternative level--used in recent health studies (greater than or 
equal
to 0.085 ppm, averaged over 8 hours) (5)--were used as cutoff values.
     The 1990 population census provided race/ethnicity-specific data 
for
persons aged less than or equal to 17 years in each county (Bureau of 
the
Census, unpublished data, 1992). The number of children with asthma was
estimated by applying age-specific national prevalence rates from CDC's
National Health Interview Survey (6) to age-specific population 
estimates at
the county level. Information about ozone exposure was based on 1991-
1993
monitored ozone data (EPA, unpublished data, 1994), the most recent data
available from EPA. Although individual levels of ozone exposure may 
vary for
persons who reside in a particular county and differ from those measured 
by
the monitor in that county, ozone levels generally are consistent within
specific geographic areas (7).
     During 1991-1993, ozone levels exceeded 0.085 ppm over 8 hours on 
four or
more occasions in 394 counties and cities; an estimated 136 million 
persons
(54.7% of the U.S. population) resided in these areas. Of the total 
number of
children aged less than or equal to 13 years in the United States
(50,324,764), approximately 27.1 million (53.9%) resided in these areas. 
Among
racial/ethnic groups, 61.3% of all black children, 67.7% of all Asian/ 
Pacific
Islander children, and 69.2% of all Hispanic children resided in these 
areas
(Table 1). An estimated 2.0 million (5.8%) of the 34.3 million children 
(aged
less than or equal to 17 years) residing in these areas were affected by
asthma.
     During 1991-1993, a total of 104 counties and cities had ozone 
levels
greater than 0.125 ppm over a 1-hour period on four or more occasions. 
An
estimated 60 million persons in the United States (24.1% of the U.S.
population) resided in these areas, including an estimated 12.1 million
children (aged less than or equal to 13 years) (24.1% of all children in 
this
age group). Among racial/ethnic groups, 23.1% of black children, 39.9% 
of
Asian/Pacific Islander children, and 44.2% of Hispanic children resided 
in
these areas (Table 2). Approximately 877,000 children (aged less than or 
equal
to 17 years) in these areas were affected by asthma.

Reported by: R White, MST, National Programs Div, S Rappaport, MPH, K 
Lieber,
MPH, A Gorman, Epidemiology and Statistics Div, F DuMelle, D Maple, 
Government
Relations Div, M Bhawnani, Communications Div, N Edelman, MD, American 
Lung
Association, New York. Air Pollution and Respiratory Health Br, Div of
Environmental Hazards and Health Effects, National Center for 
Environmental
Health, CDC.

Editorial Note: Ozone pollution results when hydrocarbons and nitrogen 
oxides
emitted from motor vehicles and other sources react in the presence of
sunlight. Exposure to ozone has been associated with adverse health 
effects,
including hospital and emergency department visits for asthma and other
respiratory problems; reductions in lung function; and exercise-related
wheezing, coughing, and chest tightness (5). Children are at higher risk 
for
detrimental effects of ozone than adults because they spend more time 
outdoors
during summer months when ozone levels are higher and because their 
lungs are
still developing (8).
     Although air pollution has been recognized as a public health 
hazard in
the United States since the 1950s, the disproportionate risks for
racial/ethnic minorities with low incomes have only recently been 
recognized
(4). The findings in this report underscore the increased risk for
exposure--particularly among children--for racial/ethnic minorities who 
reside
in areas
where national air quality standards are not met (4). In addition, since 
the
early 1980s, the risk for asthma-associated mortality and 
hospitalization has
been consistently higher among young persons who are black (9).
     ALA recently issued Danger Zones: Ozone Air Pollution and Our 
Children.
The report is a national and county estimate of the number of children 
who are
at potential risk from exposure to ozone. Copies are available from 
local
offices of the ALA, telephone (800) 586-4872 or (212) 315-8700.

References
1. Public Health Service. Healthy people 2000: national health promotion 
and
disease prevention objectives. Washington, DC: US Department of Health 
and
Human Services, Public Health Service, 1991; DHHS publication no.
(PHS)91-50213.
2. CDC. Populations at risk from air pollution--United States, 1991. 
MMWR
1993;42:301-4.
3. Committee on Environmental Health. Ambient air pollution: respiratory
hazards to children. Pediatrics 1993;91:1210-3.
4. US Environmental Protection Agency. Environmental equity: reducing 
risk for
all communities. Volume 1: workgroup report to the Administrator. 
Washington,
DC: US Environmental Protection Agency, Office of Policy, Planning, and
Evaluation, June 1992; publication no. EPA-230/R-92/008.
5. Lippmann M. Health effects of tropospheric ozone: review of recent 
research
findings and their implications to ambient air quality standards. J Expo 
Anal
Care Environ Epidemiol 1993;3:103-29.
6. NCHS. Current estimates from the National Health Interview Survey, 
1990.
Hyattsville, Maryland: US Department of Health and Human Services, 
Public
Health Service, CDC, 1991; DHHS publication no. (PHS)92-1509. (Vital and
health statistics; series 10, no. 181).
7. Curran T, Fitz-Simons T, Freas W, et al. National air quality and 
emissions
trends report, 1993. Research Triangle Park, North Carolina: US 
Environmental
Protection Agency, Office of Air Quality Planning and Standards, October 
1994;
publication no. EPA-454/R-94/026.
8. World Health Organization. Principles for evaluating health risks 
from
chemicals during infancy and early childhood: the need for a special 
approach.
Geneva: World Health Organization, 1986; environmental criteria 59.
9. CDC. Asthma--United States, 1982-1992. MMWR 1995;43:952-5.

* 44 FR 8202.
** 40 CFR 50.


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To: hicnews

  Fatal and Nonfatal Suicide Attempts Among Adolescents -- Oregon, 1988-
1993

     Suicide is the third leading cause of death among adolescents aged 
15-19
years in the United States and second among adolescents in Oregon. 
During
1959-1961 and during 1990-1992, the rate of suicide in Oregon increased
sixfold among 15-19-year-olds. During 1988-1991, the suicide rate for
adolescents in Oregon (15.5 deaths per 100,000) was 39.6% higher than 
the U.S.
rate (11.1). Because of the magnitude of this problem, in 1987 the state
legislature in Oregon mandated that hospitals treating a child aged less 
than
or equal to 17 years for injuries resulting from a suicide attempt 
report the
attempt to the State Health Division, Oregon Department of Human 
Resources,
and that the patient be referred for counseling; the Oregon Adolescent 
Suicide
Attempt Data System (ASADS) was established in 1988. This report 
presents an
analysis of data for adolescents aged less than or equal to 17 years 
from
ASADS during 1988-1993.
     Notification of suicide attempt is made through a one-page report 
form,
which is usually completed by emergency department or medical records
personnel and is submitted monthly from all hospitals in the state. 
Hospitals
use their own criteria to define attempts. Information collected 
includes age,
race/ethnicity, sex, place of attempt, date of attempt, method of 
attempt, and
whether the patient was admitted to the hospital. Beginning in 1990, 
data also
were collected on reasons for the attempt and number of previous 
attempts.
Data missing from attempt reports were imputed in proportion to known
distributions for the specified variable. The proportion of missing data
ranged from 0.1%-23.5%. In this analysis, fatal attempts were identified 
using
death certificate data.
     During 1988-1993, a total of 3783 suicide attempts were reported 
for
persons aged less than or equal to 17 years; of these, 3773 were by 
persons
aged 10-17 years (Table 1). Sex-specific attempt rates were 326.4 per 
100,000
for females and 73.4 for males. Children as young as age 6 years had 
attempted
suicide. The number of reported attempts increased steadily with age for 
males
but peaked at age 15 years for females (Figure 1).

Characteristics of Fatal and Nonfatal Suicide Attempts
     During 1988-1993, most (2981 [78.8%]) suicide attempts were made in 
the
residence of the attempter; 280 (7.4%), in another residence; 178 
(4.7%), in
school; and seven (0.2%), in jail. Attempts occurred more commonly 
during
spring months (March, April, and May) (1106 [29.2%]) and least commonly 
during
summer months (June, July, and August) (731 [19.3%]). In addition, 
attempts
occurred most frequently on Mondays (660 [17.4%]) and least often on 
Saturdays
(414 [11.0%]).
     Among youth aged 10-17 years, 123 (6.4 per 100,000) made a suicide
attempt that resulted in death (Table 1). The rate of fatal suicide 
attempts
was three times greater for males (9.5) than for females (3.1). In 
addition,
the proportion of attempts that were fatal was more than 100-fold higher 
among
males (94 [11.5%]) than among females (29 [0.1%]). Although the risk for
attempts was 3.8 times greater among youth aged 15-17 years than among 
those
aged 10-14 years, the proportions of fatal attempts were similar among 
males
and females in both age groups.
     During 1990-1993, of the 2511 persons who attempted suicide, 1042 
(41.5%)
reported having made at least one previous attempt during the preceding 
5
years. Previous attempts occurred most often among those who indicated 
their
reason for attempting suicide was rape/sexual abuse (149 [60.7%]), 
substance
abuse (111 [56.6%]), or physical abuse (46 [54.0%]).

Methods Used
     During 1988-1993, ingestion of drugs accounted for most (2857 
[75.5%])
attempts (Table 2); of the attempts involving drugs, analgesics 
accounted for
1354 (47.4%) (aspirin and acetaminophen were used most commonly). 
Cutting and
piercing injuries accounted for 421 (11.1%) of the attempts, of which 
most
were lacerations of the wrists. Most attempts by multiple methods were
lacerations combined with a drug overdose.
     Drugs were used in 2440 (79.8%) attempts by females, compared with 
417
(57.4%) by males (Table 2). Males who attempted suicide were more likely 
than
females to do so by suffocation/hanging, cutting/piercing, or use of 
firearms
(Table 2).
     Of all methods used to attempt suicide, those used most commonly 
were
least likely to result in death (e.g., of attempts by drug overdose, 
0.4% were
fatal) (Table 2). In comparison, 78.2% and 35.7% of attempts using 
firearms or
poisonings with gas, respectively, were fatal. Of the 124 deaths among 
persons
aged less than or equal to 17 years, most resulted from use of firearms
(63.7%) or suffocation/hanging (18.5%).
     During 1990-1993, persons who had made multiple attempts were more 
likely
to use suffocation/hanging (4.3%) and cutting/piercing (14.3%) than 
those
making attempts for the first time (1.2% and 6.9%, respectively).

Reasons for Suicide Attempt
     During 1990-1993, the most commonly reported reasons for attempting
suicide were family discord (1492 [59.4%]), an argument with a
boyfriend/girlfriend (819 [32.6%]), and school-related problems (578 
[23.0%])
(Table 3). A higher proportion of females (60.8%) and persons aged less 
than
or equal to 12 years (73.0%) reported family discord as their reason for
attempting suicide.

Reported by: DD Hopkins, MS, JA Grant-Worley, MS, DW Fleming, MD, State
Epidemiologist, State Health Div, Oregon Dept of Human Resources. 
National
Center for Injury Prevention and Control, CDC.

Editorial Note: In Oregon, during 1988-1993, for every fatal suicide 
attempt
by an adolescent, 31 nonfatal attempts were reported. Some attempts may 
not
have been made with death as a goal but instead may have reflected a 
desire to
resolve a difficult conflict, indicate an intolerable living situation, 
or
elicit sympathy or guilt (1,2).
     Oregon is the only state with a legal requirement for reporting 
suicide
attempts and a surveillance system for monitoring such attempts. The 
reported
rate of suicide attempts among adolescents in Oregon during 1988-1993 
based on
ASADS data is substantially lower than previously reported using survey 
data.
Based on the 1993 Youth Risk Behavior Survey, 2.7% of U.S. high school
students reported making a suicide attempt during the previous 12 months 
that
required medical attention (3); 3.2% (i.e., 3200 per 100,000) of Oregon 
high
school students reported such attempts. Because ASADS is hospital-based 
and
includes only attempts by persons who actually seek medical care, the 
findings
may provide more valid information than other sources. For example, data 
from
surveys often rely on the respondents' definition of attempted suicide, 
and
only small proportions of respondents who report having attempted 
suicide
actually have taken a substantive action to injure themselves (4).
Furthermore, YRBS may overestimate the prevalence of suicide attempts 
among
high school students. However, ADADS probably underestimates the 
occurrence of
suicide attempts in Oregon for at least four reasons. First, hospital
reporting may be incomplete; in addition, reporting hospitals may use
different criteria in determining whether a patient attempted suicide. 
Second,
reports of adolescent suicide attempts are not required from clinics or
physicians' offices; some attempters may have been treated in these 
settings,
especially those living in rural areas. Third, attempts by adolescents 
who did
not require professional medical care were not reported. Finally, when 
persons
from Oregon receive treatment in another state for a suicide attempt, 
the
event is unreported.
     In Oregon, firearms were used most often in fatal suicide attempts, 
and
most attempts involving firearms were fatal. Nationally, 81% of the 
increase
in suicide among persons aged 15-19 years during 1980-1992 was related 
to use
of firearms (5). Controlling access to firearms is an important 
prevention
measure; however, storing weapons unloaded and locked may not prevent
intentionally inflicted gunshot wounds among suicidal youth (6). Because 
an
attempt with a gun usually results in death, parents and other persons 
who
have responsibility for children should ensure that at-risk adolescents 
have
no access to guns.
     ASADS represents an initial effort to examine the magnitude and
epidemiology of intentionally self-inflicted injury among adolescents. 
This
surveillance system was the first statewide system established to 
quantify the
incidence of adolescent suicide attempts and to characterize the 
attempts and
attempters. Although the system still must undergo vigorous evaluation 
(7), it
provides essential information that will be useful in applying public 
health
measures to the problem of suicide (8). Data from ASADS are being used 
to
develop public and private suicide-education programs. For example, the 
Oregon
Health Division has formed a task force to review the data and propose
intervention methods. This approach may be adopted for use in other 
states to
permit characterization of persons attempting suicide and to assist in
refining prevention and early-intervention measures.

References
1. Bolton IM. Perspectives of youth on preventive intervention 
strategies. In:
Alcohol, Drug Abuse, and Mental Health Administration. Report of the
Secretary's Task Force on Youth Suicide: Volume 3--prevention and
interventions in youth suicide. Washington, DC: US Department of Health 
and

_
                                                                       

Human Services, Public Health Service, 1989:264-75; DHHS publication no.
(ADM)89-1623.
2. Committee on Adolescence, American Academy of Pediatrics. Suicide and
suicide attempts in adolescents and young adults. Pediatrics 1988;81:322-
4.
3. Kann L, Warren CW, Harris WA, et al. Youth risk behavior
surveillance--United States, 1993. In: CDC surveillance summaries 
(March).
MMWR 1995;44(no.
SS-1).
4. Meehan PJ, Lamb JA, Saltzman LE, O'Carroll PW. Attempted suicide 
among
young adults: progress towards a meaningful estimate of prevalence. Am J
Psychiatry 1992;149:41-4.
5. CDC. Suicide among children, adolescents, and young adults--United 
States,
1980-1992. MMWR 1995;44:289-91.
6. Brent DA, Perper JA, Goldstein CE, et al. Risk factors for adolescent
suicide: a comparison of adolescent suicide victims with suicidal 
inpatients.
Arch Gen Psychiatry 1988;45:581-8.
7. Klaucke DN, Buehler JW, Thacker SB, et al. Guidelines for evaluating
surveillance systems. MMWR 1988;37(no. S-5).
8. Potter L, Powell K, Kachur S. Suicide prevention from a public health
perspective. Suicide Life Threat Behav 1995;25:83-92.


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

End of HICNet Medical News Digest V08 Issue #19
***********************************************

---
Editor, HICNet Medical Newsletter
Internet: david@stat.com                 FAX: +1 (602) 451-6135

                                                                                          
