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HICNet Medical News Digest   Fri, 19 May 1995          Volume 08 : Issue 
20


Today's Topics:

  [MMWR] Evaluation of Vaccination Strategies in Public Clinics
  [MMWR] Discontinuation of Publication of Figures II-V in MMWR
  [MMWR] Addendum: vol. 44, No. 4
  [MMWR] Erratum: Vol. 44, No. RR-1
  [MMWR] Erratum: Vol. 44, No. 6
  [MMWR] AIDS Map
  [MMWR May 5] National Arthritis Month - May 1995
  [MMWR] Trends in Length of Stay for Hospital Deliveries
  [MMWR] Deaths from Melanoma -- United States, 1973-1992
  [MMWR] Reptile-Associated Salmonellosis
  [MMWR] Monthly Immunization Table
  [MMWR] Prevalence and Impact of Arthritis Among Women

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             Lawrence Lee Miller, B.S. Biological Sciences, UCI

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      Jack E. Cross, B.S Health Care Admin, 882 Medical Trng Grp, USAF

  Albert Shar, Ph.D. CIO, Associate Prof, Univ of Penn School of 
Medicine

 Stephen Cristol, M.D. MPH, Dept of Ophthalmology, Emory Univ, Atlanta, 
GA

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

To: hicnews

  Evaluation of Vaccination Strategies in Public Clinics -- Georgia, 
1985-1993

     From 1987 through 1993, the vaccination coverage levels among 
children
served in public health clinics in Georgia more than doubled. This 
increase
followed the implementation of a multifaceted strategy that included 
routine
measurement of vaccination coverage levels. This report describes this 
program
and an analysis of increases in vaccination coverage during 1985-1993.
     In 1985, the Georgia Division of Public Health (GDPH) reviewed the
vaccination records of selected public clinics to assess vaccination 
coverage
levels for the recommended childhood vaccines in relation to the 
national goal
of 90% up-to-date by age 2 years. The results indicated that less than 
40% of
2-year-olds served by the public sector had received a complete set of
recommended vaccinations (i.e., four doses of diphtheria and tetanus 
toxoids
and pertussis vaccine, three doses of oral poliovirus vaccine, and one 
dose of
measles-mumps-rubella vaccine). In response, GDPH initiated a statewide 
annual
assessment of vaccination coverage levels in public clinics. Information 
from
these assessments assists in a program with four elements: 1) assessment 
of
coverage levels and missed opportunity rates through analysis of birth 
and
vaccination dates obtained for a sample of children from each clinic; 2)
feedback of these data to the clinics; 3) issuance of awards (e.g., 
plaques)
to health districts and clinics meeting coverage goals; and 4) 
dissemination
of maps of coverage, rank-order lists, and other information to health
district offices and public clinics.
     During 1987-1989, participation in the program increased from zero 
to
include all of the approximately 220 public clinics and all 19 health
districts in the state; these clinics provide vaccinations to 
approximately
70% of the state's birth cohort. Among children attending these clinics, 
the
proportion who were up-to-date increased from 35% in 1987 to 80% in 1993
(Figure 1), while the rate of missed simultaneous vaccination 
opportunities at
the last visit declined from 15% to less than 1%. In 1987, aggregate 
coverage
rates were less than 50% in 11 of 12 participating districts; in 
comparison,
in 1993, aggregate rates were greater than or equal to 50% in all 19
districts, greater than 75% in 16, and greater than 90% in three.
Reported by: M Chaney, Georgia Div of Public Health. National 
Immunization
Program, CDC.

Editorial Note: National health objectives for the year 2000 include the 
goal
that at least 90% of children should have completed the basic 
vaccination
series by age 24 months (objective 20.11) (1). However, based on the 
National
Health Interview Survey, in 1993, only 67% of 2-year-olds were up-to-
date (2).
Although national coverage levels have increased since 1991, intensified
efforts are needed to improve provider practices and to encourage 
parents to
ensure their children are vaccinated on schedule.
     The findings in this report suggest that institution of the 
multifaceted
program in Georgia was associated with increased vaccination coverage.
Preliminary findings from other states (e.g., Colorado and South 
Carolina)
employing similar programs are consistent with findings in Georgia and
indicate increases in coverage levels (CDC, unpublished data, 1995).
     Assessment of vaccination coverage levels of both public and 
private
providers is specified in the Standards for Pediatric Immunization 
Practices
(3), and federal funding is provided to each state and local grant 
program to
support assessments in the public and private sectors. States receiving
vaccination grant funds during 1995 are required to assess all public 
health
clinics annually.* To assist with these assessments, Clinic Assessment
Software Application (4) is available at no charge to public and private
providers from the National Immunization Program, CDC, telephone (404)
639-8392.
     Efforts are in progress to adapt the assessment methodology to 
assist
private providers in self-assessment. To ensure up-to-date vaccination 
for
children, a high priority is the development and widespread use in the 
private
sector of programs that have been associated in Georgia and other states 
with
increases in vaccination coverage.

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. Vaccination coverage of 2-year-old children--United States, 
1993. MMWR
1994;43:705-9.
3. Ad Hoc Working Group for the Development of Standards of Immunization
Practices. Standards for pediatric immunization practices. JAMA
1993;269:1817-22.
4. CDC. Clinic Assessment Software Application (CASA): user's guide. 
Atlanta:
US Department of Health and Human Services, Public Health Service, CDC, 
1994.
* Public Law 103-333.



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

To: hicnews

         Discontinuation of Publication of Figures II-V in MMWR

Figures II-V, which depict reported cases of acquired immunodeficiency
syndrome, tuberculosis, gonorrhea, and syphilis, respectively, and have 
been
published quarterly in the MMWR, will no longer be published. CDC is
evaluating other methods of representing surveillance data in graphs.


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

To: hicnews

                     Addendum: Vol. 44, No. 4
     In the article, "Occupational Silicosis--Ohio, 1989-1994" the 
following
name should be added to the credits ("reported by") on page 63: RJ 
Blinkhorn,
Jr, MD, Cuyahoga County Tuberculosis Program, Cleveland, Ohio.


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

To: hicnews

                      Erratum: Vol. 44, No. RR-1

     In the article "Injury Control Recommendations: Bicycle Helmets," 
on the
inside front cover, David A. Sleet, Ph.D., should be listed as the 
Acting
Director of the Division of Unintentional Injuries Prevention. In 
addition, on
page iv, Nancy Dean Nowak should be listed as Nancy Dean Nowak, R.N., 
M.P.H.,
and Benjamin Moore, M.P.H., should be listed without an M.P.H.


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

To: hicnews

                              Erratum: Vol. 44, No. 6

     In the article, "Prevalence of Recommended Levels of Physical 
Activity
Among Women--Behavioral Risk Factor Surveillance System, 1992," the 
fifth
sentence on page 106 should read "The prevalence of participation in
recommended levels was directly related to education level and family 
income .
. . ."


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

To: hicnews

                                 AIDS Map

     The following map provides information on the reported number of 
acquired
immunodeficiency syndrome (AIDS) cases per 100,000 population, by 
person's
state of residence from January 1994 through December 1994. More 
detailed
information on AIDS cases is provided in the HIV/AIDS Surveillance 
Report,
single copies of which are available free from the CDC National AIDS
Clearinghouse, P.O. Box 6003, Rockville, MD 20849-6003; telephone (800)
458-5231 or (301) 217-0023.


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

To: hicnews

              National Arthritis Month - May 1995

    May is National Arthritis Month. During this month, nationwide
educational activities are planned to increase awareness of arthritis.
Additional information about arthritis and addresses of local chapters 
are
available from the Arthritis Foundation, P.O. Box 7669, Atlanta, GA 
30357;
telephone (800) 283-7800 or (404) 872-7100.


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

To: hicnews

 Trends in Length of Stay for Hospital Deliveries -- United States, 1970-
1992

     Obstetric delivery is the most frequent cause of hospital admission 
in
the United States, reflecting the approximately 4 million births in this
country each year (1). Because of steadily increasing hospital costs, 
overall
lengths of hospital stay have declined. To assess national trends in 
length of
stay for hospital deliveries, data were analyzed from CDC's National 
Hospital
Discharge Survey (NHDS) from 1970 through 1992, by method of delivery. 
This
report summarizes the results of the analysis.
     Since 1965, the NHDS has collected data from U.S. nonfederal, short-
stay
hospitals. Each year, approximately 200,000 inpatient records are 
selected
from approximately 400 hospitals; data are weighted to represent all
hospitalizations nationally (2,3). Selected patient information (e.g., 
medical
diagnoses and surgical procedures) is abstracted from each record. For 
this
analysis, the NHDS provided information about mother's age and 
race/ethnicity;
method of payment; and the hospital's ownership, size, and location. 
Estimates
for average length of stay were derived from the 20,000-33,000 
deliveries each
year among all records sampled. Hospital stays of less than 24 hours 
were
recoded as 0 days; these hospitalizations accounted for less than 1% of 
all
deliveries and were relatively constant by year (i.e., 0.3% in 1970 to 
0.7% in
1992). The proportion of all deliveries that occurred outside of 
hospitals
also was stable from 1975 (0.9%) to 1990 (1.1%) (4).
     In 1970, the average length of stay for all hospital deliveries was 
4.1
days (median: 4 days). By 1992, the average had decreased by 37% to 2.6 
days
(median: 2.0 days). The average length of stay for women who gave birth
vaginally decreased by 46% (from 3.9 to 2.1 days) and for those who gave 
birth
by cesarean section by 49% (from 7.8 to 4.0 days) (Figure 1). The 
decrease in
the average length of stay for all deliveries was smaller than that for 
either
method because the percentage of deliveries by cesarean section 
increased from
5.5% to 23.5% during this period (5).
     The average length of stay also was analyzed by mother's age (less 
than
20, 20-29, 30-39, and greater than 39 years), race (white or black)*, 
hospital
location (Northeast, Midwest, South, or West regions), hospital 
ownership
(proprietary, government, or nonprofit), and hospital size (less than 
100,
100-299, 300-499, and greater than 499 beds). From 1970 through 1992, 
the
average length of stay decreased similarly for all these groups; 
decreases
ranged from 39% to 52% for vaginal deliveries and from 38% to 53% for 
cesarean
deliveries. NHDS began collecting information about method of payment 
(i.e.,
Blue Cross/Blue Shield**, other private insurance, Medicaid, and self-
paying)
in 1977. From 1977 through 1992, the average length of stay decreased 
for
these payment groups; decreases ranged from 35% to 38% for vaginal 
deliveries
and from 32% to 47% for cesarean deliveries.

Reported by: Div of Reproductive Health, National Center for Chronic 
Disease
Prevention and Health Promotion; Prevention Effectiveness Activity,
Epidemiology Program Office, CDC.

Editorial Note: The length of stay associated with hospital deliveries
steadily decreased during 1970-1992. Early hospital discharge results in
reduced health-care costs and enables mothers to return home sooner with 
their
newborns. However, careful postpartum follow-up is necessary to ensure 
prompt
diagnosis and treatment of any maternal or neonatal complications. Early
discharge should not preclude efforts traditionally conducted during
postpartum hospitalization to educate women about breastfeeding, family
planning, care of their newborn, and other topics important for new 
mothers.
     The optimal length of stay for uncomplicated deliveries reflects 
several
factors, including the presence of others in the home who can support 
the
mother after discharge, the mother's awareness of complications, and 
access to
health-care services. Guidelines published by the American Academy of
Pediatrics and the American College of Obstetricians and Gynecologists 
suggest
that, when there have been no complications, the duration of postpartum
hospital stays range from an average of 48 hours for vaginal delivery to 
an
average of 96 hours for cesarean birth (excluding the day of delivery) 
(6). In
addition, specific criteria should be met for a woman to be discharged 
early,
especially within 24 hours of delivery.
     One potential limitation of the analysis in this report is that 
data from
the NHDS on length of stay does not distinguish the postpartum period 
from the
rest of the hospitalization. Therefore, this analysis could not 
determine
whether the decrease in the average length of stay resulted from a 
shorter
antepartum stay or postpartum stay. However, since 1970, most of the 
efforts
to decrease length of stay for hospital deliveries has been directed 
toward
the postpartum period.
     Since 1970, the rate of health-care costs has increased more 
rapidly than
that of general inflation; efforts to decrease hospital health-care 
costs by
reducing length of stay will probably intensify. Most studies have not
detected an increased rate of morbidity in association with early 
postpartum
discharge (7-9). However, these studies--which were conducted among 
carefully
selected women at low risk for postpartum complications--documented 
rates of
complications of up to 14% among women and 11% among their infants (7). 
In
addition, home visits by nurse practitioners after discharge (a practice 
not
routinely used by health-care providers) ensured prompt diagnosis and
treatment of postpartum complications. These findings underscore the 
need to
ensure adequate follow-up care for women and infants and to maintain the
educational activities traditionally provided during postpartum
hospitalization. The prevalence of complications also should be 
monitored to
accurately determine the costs and benefits of early postpartum 
discharge.

References
1. Agency for Health Care Policy and Research. The national bill for 
diseases
treated in U.S. hospitals, 1987. Washington, DC: US Department of Health 
and
Human Services, Public Health Service, 1994. (Provider studies research 
note
no. 19).
Hospital
Discharge Survey. Hyattsville, Maryland: US Department of Health and 
Human
Services, Public Health Service, 1986; DHHS publication no. (PHS)86-
1250.
(Advance data no. 127).
Hyattsville,
Maryland: US Department of Health and Human Services, Public Health 
Service,
CDC, 1992; DHHS publication no. (PHS)92-1250. (Advance data no. 210).
4. NCHS. 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. 17, suppl).
5. CDC. Rates of cesarean delivery--United States, 1991. MMWR 
1993;42:285-9.
6. American Academy of Pediatrics/American College of Obstetricians and
Gynecologists. Guidelines for perinatal care. 3rd ed. Washington, DC: 
American
College of Obstetricians and Gynecologists, 1992:105-8.
7. Welt SI, Cole JS, Myers MS, Sholes DM Jr, Jelovsek FR. Feasibility of
postpartum rapid hospital discharge: a study from a community hospital
population. Am J Perinatol 1993;10:384-7.
8. Brooten D, Roncoli M, Finkler S, Arnold L, Cohen A, Mennuti M. A 
randomized
trial of early hospital discharge and home follow-up of women having 
cesarean
birth. Obstet Gynecol 1994;84:832-8.
9. Norr KF, Nacion K. Outcomes of postpartum early discharge, 1960-1986: 
a
comparative review. Birth 1987;14:135-41.

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

            Deaths from Melanoma -- United States, 1973-1992

     Approximately three fourths of all skin cancer-associated deaths 
are
caused by melanoma. During 1973-1991, the incidence of melanoma 
increased
approximately 4% each year (1). In addition, the incidence of melanoma 
is
increasing faster than that of any other cancer (2). To characterize the
distribution of deaths from melanoma in the United States, CDC analyzed
national mortality data for 1973 through 1992. This report summarizes 
the
results of that analysis.
     Decedents for whom the underlying cause of death was melanoma
(International Classification of Diseases, Adapted, Ninth Revision, 
codes
172.0-172.9) were identified from public-use, mortality data tapes from 
1973
through 1992 (3). The denominators for rate calculations were derived 
from
U.S. census population estimates (4,5). Rates were directly standardized 
to
the age distribution of the 1970 U.S. population and were analyzed by 
state,
age group, sex, year, and race. To increase the precision of the rates
presented, race was characterized as white and all other races because
approximately 98% of deaths from melanoma occurred among whites.
     From 1973 through 1992, the overall percentage increase in the rate 
of
deaths from melanoma (34.1%) was the third highest of all cancers; for 
males,
the percentage increase for melanoma (47.9%) was the highest for all 
cancers
(6). During the same period, the increase in the rate of deaths from 
melanoma
was greater for white males than for other racial and sex groups (Figure 
1).
In 1992, the rate of deaths from melanoma was 5.9 times higher for 
whites than
for all other races (2.5 and 0.4 per 100,000 population, respectively), 
and
2.1 times higher for males than females (3.1 and 1.5, respectively).
     To increase statistical precision, the rate of deaths from melanoma 
by
state was aggregated for 1988-1992. In every state, the rate of deaths 
from
melanoma was substantially higher for whites than for persons of all 
other
races. For whites, the age-adjusted death rate by state ranged from 2.2 
to 5.0
per 100,000 population for males and 0.8 to 2.3 for females (Table 1). 
Most
states that are in the two highest death rate quartiles are not in the 
lower
U.S. latitudes where sun exposure is generally more intense (Figure 2).
     During 1973-1975 and 1990-1992, death rates were highest for white 
men
aged greater than or equal to 50 years (Figure 3). The death rate 
increased
more with age for males than for females during 1990-1992.

Reported by: Div of Cancer Prevention and Control, National Center for 
Chronic
Disease Prevention and Health Promotion, CDC.

Editorial Note: The findings in this report indicate that the rate of 
deaths
from melanoma was higher for whites than persons of all other races--a 
finding
consistent with the more common occurrence of melanoma among persons 
with
lightly pigmented skin (2) and an incidence among whites that is more 
than 10
times higher than that for blacks (1). Based on estimates by the 
American
Cancer Society, during 1995 an estimated 34,100 new cases of melanoma 
will be
diagnosed and 7200 deaths will be caused by melanoma (1). The likelihood 
of
survival of melanoma is substantially greater if the disease is detected 
early
and treated (2). Early detection of thin lesions is associated with 
improved
prognosis and treatment outcome than is detection of thicker, later 
stage
tumors (2).
     Risk factors (2,7,8) for melanoma related to ultraviolet radiation
exposure include a history of sunburn or sun sensitivity, a tendency to
freckle, the presence of lightly pigmented skin, blue eyes, and blond or 
red
hair. Other risk factors include a family or personal history of 
melanoma and
the presence of a large number of moles or any atypical moles. Sources 
for
exposure to ultraviolet radiation include sunlight and artificial light 
(e.g.,
tanning booths), both of which can cause acute sunburn. The increased 
risk
among persons who sustain intermittent, acute sunburn at an early age 
(i.e.,
less than 18 years) underscores the need for initiating prevention 
measures
early in childhood (9).
     Adults, particularly older men in whom rates of deaths from 
melanoma are
highest, should be encouraged to perform periodic skin self-examination 
or be
examined by a family member (2) to monitor location, size, and color of 
a
pigmented lesion or mole. The "ABCD approach" can be used to assess 
pigmented
lesions and represents mole asymmetry ("A"), border irregularity ("B"),
nonuniform color (i.e., pigmentation) ("C"), and diameter greater than 6 
mm
("D") (1,2,8).
     Recommendations for preventing melanoma should emphasize reduction 
of
direct exposure to the sun when sunburn is most likely to occur, 
especially
from 10 a.m. to 3 p.m. Specific measures include wearing a broad-brimmed 
hat
and clothes that protect sun-exposed areas, seeking shade when outdoors, 
using
a sunscreen of sun protection factor greater than or equal to 15 that 
provides
protection against ultraviolet radiation A and ultraviolet radiation B, 
and
referring to the daily Ultraviolet Index* rating provided by the 
National
Weather Service and others when planning outdoor activities.
     In 1994, CDC implemented a program to assist in achievement of the
national health objectives for the year 2000 for preventing skin cancer 
(10).
Elements of the CDC program include funding support for state health
departments to develop and implement prevention projects aimed at 
parents and
caregivers of young children; enhancing prevention messages for the 
public;
initiating the development of school health curriculum guidelines; 
enhancing
Ultraviolet Index public health messages; and developing a public and
professional education plan for skin cancer prevention.
    May is Melanoma/Skin Cancer Detection and Prevention Month. 
Additional
information is available from the American Academy of Dermatology, 930 
North
Meacham Road, Schaumburg, IL 60173-4965.

References
1. American Cancer Society. Cancer facts and figures, 1995. Atlanta: 
American
Cancer Society, 1995; publication no. 5008.95.
2. Koh HK. Cutaneous melanoma. N Engl J Med 1991;325:171-82.
3. NCHS. Vital statistics mortality data, underlying cause of death, 
1973-1992
[Machine-readable public-use data tapes]. Hyattsville, Maryland: US 
Department
of Health and Human Services, Public Health Service, CDC, 1973-1992.
4. Bureau of the Census. 1970-1989 Intercensal population estimates by 
race,
sex, and age [Machine-readable data files]. Washington, DC: US 
Department of
Commerce, Bureau of the Census, nd.
5. Irwin R. 1990-1992 Postcensal population estimates by race, sex, and 
age
[Machine-readable data files]. Alexandria, Virginia: Demo-Detail, 1993.
6. Ries LAG, Miller BA, Hankey BF, Kosary CL, Harras A, Edwards BK, eds. 
SEER
cancer statistics review, 1973-1991: tables and graphs. Bethesda, 
Maryland: US
Department of Health and Human Services, Public Health Service, National
Institutes of Health, National Cancer Institute, 1994; publication no.
(NIH)94-2789.
7. Hartman AM, Goldstein AM. Melanoma of the skin. In: Miller BA, Ries 
LAG,
Hankey BF, et al., eds. SEER cancer statistics review, 1973-1990. 
Bethesda,
Maryland: US Department of Health and Human Services, Public Health 
Service,
National Institutes of Health, National Cancer Institute, 1993; 
publication
no. (NIH)93-2789.
8. Marks R, Hill D, eds. The public health approach to melanoma control:
prevention and early detection. Geneva: International Union Against 
Cancer,
1992.
9. Wiley HE. Ways to protect children from sun damage. The Skin Cancer
Foundation Journal 1994;12:41,98.
10. 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.

* The Ultraviolet Index, provided by the National Weather Service, is
broadcast by television and print media in 58 U.S. cities and provides
information on the intensity of the sun's rays during the solar noon 
hour. The
index ranges from 0 to 10+ with greater than or equal to 10 indicating 
the
most intense sunlight.


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To: hicnews

       Reptile-Associated Salmonellosis -- Selected States, 1994-1995

     During 1994-1995, health departments in 13 states reported to CDC 
persons
infected with unusual Salmonella serotypes in which the patients had 
direct or
indirect contact with reptiles (i.e., lizards, snakes, or turtles). In 
many of
those cases, the same serotype of Salmonella was isolated from patients 
and
from reptiles with which they had had contact or a common contact. For 
some
cases, infection resulted in invasive illness, such as sepsis and 
meningitis.
This report summarizes clinical and epidemiologic information for six of 
these
cases.
     Connecticut. During January 1995, a 40-year-old man was 
hospitalized
because of an acute illness characterized by constipation, lower back 
pain,
chills, and fever. He reported having taken ranitidine and an antacid 
for
symptoms of heartburn before onset of mild diarrhea 3 days before
hospitalization. A blood culture yielded Salmonella serotype Wassenaar. 
A
magnetic resonance image scan of the right sacrum suggested 
osteomyelitis.
Ciprofloxacin therapy was initiated for presumed Salmonella 
osteomyelitis, and
he was discharged after 14 days. All household contacts were 
asymptomatic. The
family had purchased two iguanas (Iguana iguana) in October 1994; 
although the
patient denied directly handling the iguanas, he reported having 
recently
cleaned their aquarium. Stool samples obtained from both iguanas yielded
Salmonella Wassenaar.
     New Jersey. During September 1994, a 5-month-old girl was 
hospitalized
because of an acute illness including vomiting, lethargy, and fever; on
admission, she had a bulging fontanelle and stiff neck. Blood cultures 
and
cerebrospinal fluid yielded Salmonella serotype Rubislaw. She was 
treated with
intravenous ceftazidime for Salmonella sepsis and meningitis and 
discharged
from the hospital after 10 days. Other members of the family were
asymptomatic. The infant routinely was fed infant formula. Although the 
family
did not own a reptile, the infant frequently stayed at a babysitter's 
house
where an iguana was kept. Culture of a stool sample from the iguana 
yielded
Salmonella Rubislaw. The infant was reported to have not touched the 
iguana;
however, the iguana frequently was handled by the babysitter and other 
members
of the babysitter's family. All members of the babysitter's family were
asymptomatic, but stool cultures from two members, including a child who 
had
frequently played with and fed the infant, yielded Salmonella Rubislaw.
     New York. In December 1994, a 45-year-old man infected with human
immunodeficiency virus was hospitalized because of weakness, nausea, 
vomiting,
and diarrhea. His CD4+ T-lymphocyte count was less than 50 cells/uL. 
Cultures
from blood and sputum samples yielded Salmonella serotype IIIa 41:z 
subscript
4 z subscript 23:- (S. subspecies Arizonae). He owned corn snakes and, 
until
shortly before onset of illness, had worked at a pet store where he 
handled
reptiles frequently. Salmonella sepsis was diagnosed, and he was treated 
with
oral ciprofloxacin.
     North Carolina. During December 1994, a 2-day-old boy born 8 weeks
prematurely developed respiratory difficulties, had pneumothorax 
diagnosed,
and was transferred to a referral hospital. Blood obtained at birth for
culture had been negative, but a culture of blood obtained 9 days later
because of an elevated white blood cell count yielded Salmonella 
serotype
Kintambo. He was treated with intravenous ampicillin for Salmonella 
sepsis and
was discharged from the hospital after 30 days. Eleven days after the 
positive
culture was collected, Salmonella Kintambo was cultured from a blood 
sample
obtained from a 12-day-old acutely ill boy who was born at 28 weeks' 
gestation
and had shared a room at the referral hospital with the first infant. 
The
second infant was treated with intravenous cefotaxime for Salmonella 
sepsis
and was discharged after 44 days. Both infants had been in the hospital
continuously from birth until onset of illness. The mother of the first 
infant
reported having had a diarrheal illness 4 days before the birth of the 
infant;
she frequently handled a savanna monitor lizard (Varanus exanthemapicus) 
that
the family had purchased in September 1994 and kept in a cage in the 
kitchen.
Culture of a stool sample from the lizard yielded Salmonella Kintambo. 
The
second family did not own a reptile.
     Ohio. During January 1994, a 6-week-old boy was hospitalized 
because of
diarrhea, stiff neck, and fever; culture of samples of blood and 
cerebrospinal
fluid yielded Salmonella serotype Stanley. The infant was treated with
intravenous cefotaxime for Salmonella sepsis and meningitis and 
discharged
from the hospital after 56 days. He had been fed only formula and had 
not
attended a child-care facility; household contacts were asymptomatic. 
The
family had purchased a 4-inch water turtle in April 1993. A culture of 
stool
from the turtle yielded Salmonella Stanley. Although the infant had not 
had
contact with the turtle, other family members had had direct contact, 
and the
turtle's food and water bowls were washed in the kitchen sink.
     Pennsylvania. During October 1994, a 21-day-old girl was 
hospitalized
because of an illness including vomiting, bloody diarrhea, and fever. 
She
received empirical treatment with intravenous ampicillin. A culture of 
stool
yielded Salmonella serotype Poona; she was discharged from the hospital 
after
11 days. Other members of the family were asymptomatic. The infant had 
been
fed infant formula and had not attended a child-care center. The family 
owned
an iguana, and culture of a stool sample from the iguana yielded 
Salmonella
Poona. Although the infant did not have contact with the iguana, the 
iguana
was handled frequently by her mother and other members of the family.
     Additional investigations. In addition to the six states in this 
report,
seven other states (California, Colorado, Florida, Illinois, Minnesota,
Oregon, and Utah) have reported recent isolation of the same Salmonella
serotype from samples obtained from patients and reptiles with which 
they had
been in contact or associated. Several of these states issued press 
releases
about the risk for acquiring salmonellosis from reptiles. In addition, 
some
states have issued health alerts to pet stores to warn owners and 
prospective
owners about the risks for salmonellosis associated with contact with 
reptiles
and to provide instructions about proper handling of reptiles; store 
owners
have been asked to post the alert and provide copies to all persons 
purchasing
a reptile.

Reported by: JW Weinstein, MD, EG Seltzer, MD, Yale Univ School of 
Medicine,
New Haven; RS Nelson, DVM, JL Hadler, MD, State Epidemiologist, 
Connecticut
Dept of Public Health and Addiction Svcs. SM Paul, MD, FE Sorhage, VMD, 
Div of
Epidemiology, Environmental and Occupational Health Svcs; K Pilot, S 
Matluck,
Public Health and Environmental Laboratories; K Spitalny, MD, State
Epidemiologist, New Jersey State Dept of Health. M Gupta, MD, J Misage, 
G
Balzano, T Root, G Birkhead, MD, DL Morse, MD, State Epidemiologist, New 
York
State Dept of Health. A Kopelman, MD, S Engelke, MD, L Jones, Pitt 
County
Memorial Hospital, Greenville; L Latour, PhD, P Perry, Wilson County 
Health
Dept, Wilson; B Jenkins, State Laboratory of Public Health, J-M 
Maillard, MD,
JN MacCormack, MD, State Epidemiologist, North Carolina Dept of 
Environment,
Health, and Natural Resources. C Richards, P Fruth, Defiance County 
Health
Dept, Defiance; S Hufford, MD, B Dick, MPH, Toledo Hospital; M Bundesen, 
Bur
of Public Health Laboratories, EP Salehi, MPH, Infectious Disease 
Epidemiology
Unit, TJ Halpin, MD, State Epidemiologist, Ohio Dept of Health. P Lurie, 
MD, M
Deasy, K Mihelcic, JT Rankin, Jr, DVM, State Epidemiologist, 
Pennsylvania Dept
of Health. Foodborne and Diarrheal Diseases Br, Div of Bacterial and 
Mycotic
Diseases, National Center for Infectious Diseases; Div of Field 
Epidemiology,
Epidemiology Program Office, CDC.

Editorial Note: For most of the cases described in this report, the
identification of rare Salmonella serotypes in persons who had no other
apparent exposures was linked to direct or indirect contact with a pet 
reptile
from which the same serotype was isolated. In addition, these cases are
consistent with previous reports indicating that direct contact with a 
reptile
is not necessary for transmission of Salmonella (1,2). This report also
illustrates the severe complications of Salmonella infection that can 
occur in
young children, immunocompromised persons, and infants during the 
peripartum
period.
     Reptiles are popular as pets in the United States: an estimated 7.3
million pet reptiles are owned by approximately 3% of households (G. 
Mitchell,
Pet Industry Joint Advisory Council, personal communication, 1995). 
Because
the most popular reptiles species will not breed if closely confined, 
most
reptiles are captured in the wild and imported. The number of reptiles
imported into the United States has increased dramatically since 1986 
and
primarily reflects importation of iguanas (27,806 in 1986 to 798,405 in 
1993)
(M. Albert, Fish and Wildlife Service, U.S. Department of the Interior,
personal communication, June, 1994).
     A high proportion of reptiles are asymptomatic carriers of 
Salmonella.
Fecal carriage rates can be more than 90% (3); attempts to eliminate
Salmonella carriage in reptiles with antibiotics have been unsuccessful 
and
have led to increased antibiotic resistance (1,4). A wide variety of
Salmonella serotypes has been isolated from reptiles, including many 
that
rarely are isolated from other animals (reptile-associated serotypes).
Reptiles can become infected through transovarial transmission or direct
contact with other infected reptiles or contaminated reptile feces. High 
rates
of fecal carriage of Salmonella can be related to the eating of feces by
hatchlings--a typical behavior for iguanas and other lizards--which can
establish normal intestinal flora for hindgut fermentation (5).
     During the early 1970s, small pet turtles were an important source 
of
Salmonella infection in the United States; an estimated 4% of families 
owned
turtles, and 14% of salmonellosis cases were attributed to exposure to 
turtles

_
                              

(6). In 1975, the Food and Drug Administration prohibited the 
distribution and
sale of turtles with a carapace less than 4 inches; many states 
prohibited the
sale of such turtles. These measures resulted in the prevention of an
estimated 100,000 cases of salmonellosis annually (6). However, since 
1986,
the popularity of iguanas and other reptiles that can transmit infection 
to
humans has been paralleled by an increased incidence of Salmonella 
infections
caused by reptile-associated serotypes (7).
     Because young children are at increased risk for reptile-associated
salmonellosis and severe complications (e.g., septicemia and meningitis)
(7-9), reducing exposure of infants or children aged less than 5 years 
to
reptiles is particularly important. The risks for transmission of 
Salmonella
from reptiles to humans can be reduced by avoiding direct and indirect 
contact
with reptiles (see box).
(BOX)

Recommendations for Preventing Transmission of Salmonella From Reptiles 
to
Humans
o Persons at increased risk for infection or serious complications of
salmonellosis (e.g., pregnant women, children aged less than 5 years, 
and
immunocompromised persons such as persons with AIDS) should avoid 
contact with
reptiles.
o Reptiles should not be kept in child-care centers and may not be
appropriate pets in households in which persons at increased risk for
infection reside.
o Veterinarians and pet store owners should provide information to 
potential
purchasers and owners of reptiles about the increased risk of acquiring
salmonellosis from reptiles.
o Veterinarians and operators of pet stores should advise reptile owners
always to wash their hands after handling reptiles and reptile cages.
o To prevent contamination of food-preparation areas (e.g., kitchens) 
and
other selected sites, reptiles should be kept out of these areas in
particular, kitchen sinks should not be used to bathe reptiles or to 
wash
reptile dishes, cages, or aquariums.


References
1. CDC. Iguana-associated salmonellosis--Indiana, 1990. MMWR 1992;41:38-
9.
2. CDC. Lizard-associated salmonellosis--Utah. MMWR 1992;41:610-1.
3. Chiodini RJ, Sundberg JP. Salmonellosis in reptiles: a review. Am J
Epidemiol 1981;113:494-9.
4. Shane SM, Gilbert R, Harrington KS. Salmonella colonization in 
commercial
pet turtles (Pseudemys scripta elegans). Epidemiol Infect 1990;105:307-
16.
5. Troyer K. Transfer of fermentative microbes between generations in
herbivorous lizard. Science 1982;216:540-2.
6. Cohen ML, Potter M, Pollard R, Feldman RA. Turtle-associated 
salmonellosis
in the United States: effect of public health action, 1970 to 1976. JAMA
1980;243:1247-9.
7. Cieslak PR, Angulo FJ, Dueger EL, Maloney EK, Swerdlow DL. Leapin' 
lizards:
a jump in the incidence of reptile-associated salmonellosis [Abstract]. 
In:
Program and abstracts of the 34th Interscience Conference on 
Antimicrobial
Agents and Chemotherapy. Washington, DC: American Society for 
Microbiology,
1994.
8. Ackman D, Drabkin P, Birkhead B, Cieslak P. Reptile-associated
salmonellosis: a case-control study [Abstract]. In: Program and 
abstracts of
the 34th Interscience Conference on Antimicrobial Agents and 
Chemotherapy.
Washington, DC: American Society for Microbiology, 1994.
9. Dalton C, Hoffman R, Pape J. Iguana-associated salmonellosis in 
children.
Pediatr Infect Dis J 1995;14:319-20.


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To: hicnews

                       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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To: hicnews

  Prevalence and Impact of Arthritis Among Women -- United States, 1989-
1991

     Arthritis and other rheumatic conditions are among the most 
prevalent
chronic conditions in the United States, affecting approximately 38 
million
persons (1). The self-reported prevalence of arthritis is greater among 
women
than among men, and for women aged greater than 45 years, arthritis is 
the
leading cause of activity limitation (1,2). This report uses data from 
the
National Health Interview Survey (NHIS) to provide estimates of the 
prevalence
and impact of arthritis among women aged greater than or equal to 15 
years
during 1989-1991, compares the prevalence estimates of arthritis to 
other
chronic conditions affecting women during 1989-1991, and projects the
prevalence of arthritis among women in 2020.

Prevalence and Impact Estimates
     The NHIS is an annual national probability sample of the U.S. 
civilian,
noninstitutionalized population (3). Estimates of the prevalence of 
arthritis
were based on a one-sixth random sample of women aged greater than or 
equal to
15 years during 1989-1991 (n=24,201 of 145,832) who answered questions 
about
the presence of any musculoskeletal condition during the preceding 12 
months
and details about these conditions. Each condition was assigned a code 
from
the International Classification of Diseases, Ninth Revision, Clinical
Modification (ICD-9-CM). This analysis used the definition of arthritis, 
which
included arthritis and other rheumatic conditions,* developed by the 
National
Arthritis Data Workgroup (1). These data were weighted to provide 
average
annual prevalence estimates.
     Arthritis impact, defined as activity limitation caused by 
arthritis, was
estimated using all women aged greater than or equal to 15 years 
participating
in NHIS. Respondents were asked whether they were limited in working,
housekeeping, or performing other activities as a result of health
condition(s) and the condition(s) they considered to be responsible for 
these
activity limitations. Data from women who attributed their activity 
limitation
to arthritis were weighted to provide average annual prevalence 
estimates of
the impact of arthritis among women aged greater than or equal to 15 
years
during 1989-1991.
     An estimated 22.8 million (22.7%) women self-reported arthritis 
during
1989-1991 (Table 1). The prevalence of self-reported arthritis increased
directly with age and was 8.6% for women aged 15-44 years, 33.5% for 
women
aged 45-64 years, and 55.8% for women aged greater than or equal to 65 
years.
Rates were higher for women who were overweight (body mass index [BMI] 
greater
than or equal to 27.3 [28.9%]), had less than or equal to 11 years of
education (30.0%), and resided in households with an annual income less 
than
$20,000 (29.9%).
     An estimated 4.6 million (4.6%) women reported arthritis as a major 
or
contributing cause of activity limitation during 1989-1991 (Table 1). 
Activity
limitation associated with arthritis increased directly with age and was 
1.0%
for women aged 15-44 years, 6.4% for women aged 45-64 years, and 14.2% 
for
women aged greater than or equal to 65 years. Age-adjusted rates of 
activity
limitation were higher for blacks (6.5%) and American Indians/Alaskan 
Natives
(6.9%) than for whites (4.2%). Age-adjusted rates of activity limitation 
for
women who were overweight were nearly twofold greater than for those who 
were
not, and nearly threefold greater for women who resided in a household 
with an
annual income less than $10,000 per year than for those who resided in a
household with an annual income greater than or equal to $35,000.

Comparison With Other Chronic Conditions Affecting Women
     Average annual prevalence estimates of other chronic conditions 
affecting
women were based on a one-sixth random sample of women who answered 
questions,
on separate condition lists, regarding the presence of impairments;
respiratory conditions; circulatory conditions; and selected conditions 
of the
genitourinary, endocrine, and nervous systems. These data were weighted 
to
provide average annual prevalence estimates of other chronic conditions 
among
women aged greater than or equal to 15 years during 1989-1991. Average 
annual
prevalence estimates of activity limitation caused by these chronic 
conditions
were determined as they were for arthritis.
     Arthritis was the most common self-reported chronic condition 
affecting
women (Table 2), ranking ahead of self-reported hypertension (8.1 
million),
ischemic heart disease (3.7 million), and other chronic conditions, 
including
breast cancer and malignancy of the female reproductive tract (e.g., 
ovarian,
endometrial, and cervical cancer). Among the conditions reported 
responsible
for activity limitations, women most frequently mentioned arthritis (4.6
million), followed by orthopedic deformity (3.0 million) and ischemic 
heart
disease (1.3 million).

Projections for 2020
     Arthritis among women aged greater than or equal to 15 years was
projected to 2020 by applying the average annual arthritis prevalence 
rate for
1989-1991, stratified by age and race to the relevant U.S. population
projected by the Bureau of the Census (4).
     From 1989-1991 to 2020, the prevalence of self-reported arthritis 
among
women aged greater than or equal to 15 years is projected to increase 
from
22.8 million (22.7%) to 35.9 million (26.7%).

Reported by: Statistics Br, and Aging Studies Br, Div of Chronic Disease
Control and Community Intervention, National Center for Chronic Disease
Prevention and Health Promotion, CDC.

Editorial Note: The findings in this report indicate that during 1989-
1991,
arthritis was the most common self-reported chronic condition and cause 
of
activity limitation among women aged greater than or equal to 15 years. 
By
2020, an estimated 36 million women may be affected by arthritis--
primarily
reflecting the increasing average age of the U.S. population.
     The analysis in this report also documents higher prevalences of
self-reported arthritis and related activity limitation among older 
women,
overweight women, and women with lower income and education levels. 
Older age
and overweight are commonly recognized risk factors for arthritis. The
cross-sectional analysis in this report precluded determination of 
whether
overweight precedes or results from arthritis; however, overweight has 
been
established as a risk factor for osteoarthritis of the knee (5). In 
addition,
low socioeconomic status, for which income and education may be markers, 
has
been associated with increased prevalence, mortality, and disability 
among
persons with arthritis and other rheumatic conditions (6,7). Although
prevalence rates for self-reported arthritis among blacks and American
Indians/Alaskan Natives were similar to those among whites, activity
limitation was more prevalent among both of these groups. Reasons for 
the
increased activity limitation among blacks and American Indians/Alaskan
Natives have not been determined but might reflect sociocultural 
differences
or access to health care.
     Diseases considered to have particularly important public health
ramifications for women include those that affect only women (e.g.,
endometrial, ovarian, and cervical cancers); are more prevalent among 
women
(e.g., breast cancer and osteoporosis); are more prevalent overall 
(e.g.,
hypertension, diabetes, and cardiovascular disease); have different risk
factors for women (e.g., menopause and cardiovascular disease or smoking 
and
pregnancy); or require different interventions for women (e.g., 
infertility)
(8). Although the prevalence of arthritis is approximately 60% greater 
among
women than men (1), the public health importance of arthritis among 
women has
not been emphasized previously.
     The NHIS data enables a more accurate estimate of the prevalence 
and
impact of arthritis than alternative data sources (e.g., Medicare, 
health
maintenance organization databases, and hospital discharge data) because 
many
persons with arthritis do not visit physicians for their condition. 
However,
these self-reported conditions and the ICD-9-CM codes assigned to them 
have
not been validated.
     In addition to limitations in understanding the epidemiology of
self-reported arthritis among women, the relation of arthritis to other
chronic conditions among women has not been well characterized. To 
assist in
reducing the public health impact of arthritis among women, priorities 
in the
assessment of this problem include determining frequencies of the 
different
types of arthritis and their natural histories among women, estimating 
more
accurately the economic and societal burden of this condition in women, 
and
evaluating the effectiveness of interventions, including supervised 
exercise
programs, weight loss, and self-education courses (5,9,10). Additional
strategies public health agencies and health-care providers can consider 
to
reduce the impact of arthritis among women include 1) promoting primary
prevention of arthritis through weight reduction and prevention of 
sports- or
occupational-related joint injury and 2) encouraging early detection and
appropriate management of women with arthritis through use of medical 
and
physical therapy, exercise, and established educational programs such as 
the
Arthritis Self-Management Course (9,10).

References
1. CDC. Arthritis prevalence and activity limitations--United States, 
1990.
MMWR 1994;43:433-8.
2. Verbrugge LM, Patrick DL. Seven chronic conditions: their impact on 
U.S.
adults' activity levels and use of medical services. Am J Public Health
1995;85:173-82.
3. Massey JT, Moore TF, Parsons VL, Tadros W. Design and estimation for 
the
National Health Interview Survey, 1985-1994. Vital Health Stat 1989;2:1-
5.
4. Day JC. Population projections of the United States, by age, sex, 
race, and
Hispanic origin: 1993 to 2050. Washington, DC: US Department of 
Commerce,
Bureau of the Census, 1993. (Current population reports; series P25, no.
1104).
5. Felson DT, Zhang Y, Anthony JM, Naimark A, Anderson JJ. Weight loss 
reduces
the risk for symptomatic knee osteoarthritis in women: the Framingham 
Study.
Ann Intern Med 1992;116:535-9.
6. Leigh JP, Fries JF. Occupation, income, and education, as independent
covariates of arthritis in four national probability samples. Arthritis 
Rheum
1991;34:984-94.
7. Badley EM, Ibanez D. Socioeconomic risk factors and musculoskeletal
disability. J Rheumatol 1994;21:515-22.
8. Merritt DH, Kirchstein RL. Women's health: report of the public 
health task
force on women's health issues. Vol II. Washington, DC: US Department of
Health and Human Services, Public Health Service, 1987; DHHS publication 
no.
(PHS)88-50506.
9. Kovar PA, Allegrante JP, MacKenzie CR, Peterson MGE, Gutin B, 
Charlson ME.
Supervised fitness walking in patients with osteoarthritis of the knee: 
a
randomized, controlled trial. Ann Intern Med 1992;116:529-34.
10. Lorig KR, Mazonson PD, Holman HR. Evidence suggesting that health
education for self-management in patients with chronic arthritis has 
sustained
health benefits while reducing health care costs. Arthritis Rheum
1993;36:439-45.

* ICD-9-CM codes 95.6, 95.7, 98.5, 99.3, 136.1, 274, 277.2, 287.0, 
344.6,
353.0, 354.0, 355.5, 357.1, 390, 391, 437.4, 443.0, 446, 447.6, 696.0,
710-716, 719.0, 719.2-719.9, 720-721, 725-727, 728.0-728.3, 728.6-728.9,
729.0-729.1, and 729.4.


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

End of HICNet Medical News Digest V08 Issue #20
***********************************************


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

                                                                                              
