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HICNet Medical News Digest      Sun, 20 Aug 1995        Volume 08 : 
Issue 27

Today's Topics:

  [MMWR] Influenza and Penumonia Vaccine...
  [MMWR] Adult Blood Lead levels...
  [MMWR] Errata in Arthritis..
  [MMWR Jul21] Trends in Smoking...
  [MMWR] Pertussis
  [MMWR] Pneumonia and Influenza Death Rates
  [MMWR] Notice to Readers

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To: hicnews

Influenza and Pneumococcal Vaccination Coverage Levels Among
Persons Aged greater than or equal to 65 Years -- United States,
1973-1993

     Recommendations to provide annual influenza vaccination and
one dose of pneumococcal vaccine to all persons aged greater than
or equal to 65 years (1,2) are intended to reduce the high
morbidity and mortality associated with influenza and pneumococcal
disease. One of the national health objectives for the year 2000 is
to increase influenza and pneumococcal vaccination levels to
greater than or equal to 60% for persons at high risk for influenza
and pneumococcal disease, including those aged greater than or
equal to 65 years (objective 20.11) (3). This report summarizes 1)
estimates of influenza vaccination coverage levels among persons
aged greater than or equal to 65 years during 1973-1985 and
pneumococcal vaccination coverage levels for 1984-1985 based on
data from the United States Immunization Survey (USIS) and 2)
influenza and pneumococcal vaccination coverage levels among
persons aged greater than or equal to 65 years and for selected
population subgroups during 1989-1993 based on data from the
National Health Interview Survey (NHIS).
     The USIS was initiated in 1959 and conducted through 1985 (4)
using a weighted random sample of the U.S. civilian households that
was representative of the civilian noninstitutionalized population
based on the preceding decennial census. During 1973-1985,
approximately 37,500-57,000 households were surveyed; participants
were asked whether they had been vaccinated against influenza
during the previous year. During 1984-1985, participants were asked
whether they had ever received pneumococcal vaccine. Persons aged
greater than or equal to 15 years who were most knowledgeable about
the health status of household members were interviewed regarding
the vaccination histories of all members. The NHIS, conducted
annually since 1957, is a multistage cluster survey of U.S.
civilian households that obtains a representative sample of the
civilian noninstitutionalized population (5). Interviews are
conducted with all available family members aged greater than or
equal to 18 years. Respondents are asked whether they were
vaccinated against influenza during the previous year and whether
they ever received pneumococcal vaccine. Each year, approximately
8000 respondents aged greater than or equal to 65 years
participated in the survey. Responses were analyzed using SUDAAN
and weighted to reflect the age, sex, and race/ethnicity of the
U.S. noninstitutionalized population. To assist in targeting
ongoing vaccination efforts, NHIS data sets also were analyzed by
age, sex, race/ethnicity, income, and reported number of physician
visits during the previous year. Data are presented for white,
black, and Hispanic populations; data for other groups were too
small for meaningful analysis.
     Based on USIS data, during 1973-1985, influenza vaccination
levels among persons aged greater than or equal to 65 years ranged
from 22% to 30%, except for an increase (to 38%) during the 1976-1977 
"swine
flu" National Influenza Immunization Program (Figure
1). Pneumococcal vaccination levels were 9.8% and 10.7% in 1984 and
1985, respectively. Based on NHIS data, from 1989 through 1993,
influenza vaccination coverage levels increased by 19.1%, from
32.9% to 52.0%, and the cumulative pneumococcal vaccination
coverage level increased by 13.5% from 14.7% to 28.2%.
     There was no statistical difference in coverage rates by sex
for either vaccine during any year (Table 1, page 513). However,
vaccination levels for both vaccines were lower among blacks and
Hispanics when compared with whites. In addition, coverage levels
were higher among persons at or above the poverty level* and those
who had visited a physician during the previous year.
Reported by: Adult Vaccine Preventable Disease Br, Epidemiology and
Surveillance Div, National Immunization Program; Div of Health
Interview Statistics, National Center for Health Statistics, CDC.
Editorial Note: Although the USIS and NHIS employed different
methods, both provided national estimates of vaccination rates
based on the weighted response of household-based surveys of the
noninstitutionalized U.S. population. Analysis of data from these
surveys indicate that, during 1973-1993, vaccination coverage
levels for influenza and pneumococcal vaccines increased among
persons aged greater than or equal to 65 years. These findings
suggest a substantial impact on coverage levels as the result of
efforts by public- and private-sector health providers and
advocates; however, among some groups levels remain low and are
substantially less than the national health objective for the year
2000, particularly for pneumococcal vaccination.
     Increases in influenza vaccination levels may reflect 1)
greater acceptance of preventive medical services by practitioners
and 2) increased delivery and administration of vaccine by
health-care providers and sources other than physicians (e.g.,
visiting-nurse and home-health agencies). In addition, the
initiation of Medicare reimbursement for influenza vaccination in
1993 also may have contributed to increased rates (6).
     Although pneumococcal vaccine is greater than or equal to 57%
effective against invasive pneumococcal disease (7), some
physicians have expressed persistent uncertainty regarding the
effectiveness of this vaccine against pneumococcal pneumonia (8).
In addition, while campaigns for influenza vaccine occur annually
before the influenza season, many providers and patients may not be
routinely reminded about the need for pneumococcal vaccination
among persons aged greater than or equal to 65 years, underscoring
the need to educate providers and patients about the benefits of
pneumococcal vaccination and current recommendations.
     The findings in this report are consistent with previous
surveys that have documented lower vaccination coverage levels
among blacks than whites (9). These variations may reflect
differences in factors such as socioeconomic status, access to
medical care, and prevalence of specific risks. However,
preliminary analysis indicates that differences by race/ethnicity
persisted when the data were adjusted for socioeconomic status.
     Achievement of national health objectives for the year 2000
will require the continued collaboration of public and private
organizations to improve awareness and vaccine delivery; changes in
clinical practice; delivery mechanisms that limit cost and remove
accessibility constraints; and surveillance data, such as those
provided by NHIS, to assess the progress of current and future
programs. The report of the National Vaccine Advisory Committee
regarding adult vaccination (10) has described these strategies,
which include improvements in education of health-care providers
and the public; major changes in clinical practice; increased
financial support by public and private health insurers;
improvements in surveillance for vaccine-preventable diseases and
vaccine production and delivery; development of new and improved
vaccines; research on and improvements in vaccination practices;
and collaboration on international programs for adult vaccination.
References
1. ACIP. Pneumococcal polysaccharide vaccine. MMWR 1989;38:64-8,73-6.
2. CDC. Prevention and control of influenza: recommendations of the
Advisory Committee on Immunization Practices (ACIP). MMWR
1995;44(no. RR-3).
3. 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,
1991:122; DHHS publication no. (PHS)91-50213.
4. CDC. US immunization survey: 1977, 1978. Washington, DC: US
Department of Health, Education, and Welfare, 1979:59-67; HEW
publication no. (CDC)79-8221.
5. Massey JT, Moore TF, Parsons VL, Tadros W. Design and estimation
for the National Health Interview Survey, 1985-1994. Hyattsville,
Maryland: US Department of Health and Human Services, Public Health
Service, CDC, 1989. (Vital and health statistics; series 2, no.
110).
6. CDC. Implementation of the Medicare influenza vaccination
benefit. MMWR 1994;43:771-3.
7. Butler JC, Breiman RF, Campbell JF, Lipman HB, Broome CV,
Facklam RR. Pneumococcal polysaccharide vaccine efficacy: an
evaluation of current recommendations. JAMA 1993; 270:1826-31.
8. Hirschmann JV, Lipsky BA. The pneumococcal vaccine after 15
years of use. Arch Intern Med 1994;154:373-7.
9. CDC. Race-specific differences in influenza vaccination levels
among Medicare beneficiaries--United States, 1993. MMWR 1995;44:24-7,33.
10. Fedson DS, National Vaccine Advisory Committee. Adult
immunization: summary of the National Vaccine Advisory Committee
report. JAMA 1994;272:1133-7.
* Poverty statistics are based on a definition originated by the
Social Security Administration in 1964, subsequently modified by
federal interagency committees in 1969 and 1980, and prescribed by
the Office of Management and Budget as the standard to be used by
federal agencies for statistical purposes.


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To: hicnews

Adult Blood Lead Epidemiology and Surveillance -- United States,
1994 and First Quarter 1995

     CDC's National Institute for Occupational Safety and Health
(NIOSH) Adult Blood Lead Epidemiology and Surveillance program
(ABLES) monitors elevated blood lead levels (BLLs) among adults in
the United States (1). Twenty-three states currently report
surveillance results to ABLES. Maine is the 23rd state, and its
data (beginning in 1994) are included for the first time in this
report. This report presents ABLES data for the first quarter of
1995 compared with the first quarter of 1994 and annual data for
1994 compared with 1993.
     First Quarter Reports 1995. During January-March 1995, the
number of reports of elevated BLLs increased by 10% over those
reported for the same period in 1994 (Table 1). The number of
reports increased at the lowest reporting level (25-39 ug/dL), but
decreased at all higher reporting levels (40-49 ug/dL, 50-59 ug/dL,
and greater than or equal to 60 ug/dL). The trend of increasing
reports at the lower levels and decreasing reports at the higher
levels is consistent with the 1994 fourth quarter report (2).
     Annual Reports 1994. The reported number of adults with
elevated BLLs increased from 11,240 in 1993 to 12,137 in 1994
(Table 2); this increase resulted, in part, from the addition of
three reporting states in 1994. A total of 5619 new cases accounted
for 46% of the cases reported in 1994, compared with 59% new cases
in 1993 (Table 2). Compared with 1993, the proportion of new cases
declined in the 25-39 ug/dL, 40-49 ug/dL, and 50-59 ug/dL
categories and increased in the greater than or equal to 60 ug/dL
category. Even with additional states reporting, the number of new
cases decreased 15% from 1993 through 1994 (Table 2). This decrease
may be explained in part by the definition of a new case, which is
an elevated BLL ( greater than or equal to 25 ug/dL) in an adult
reported in state surveillance data in the current year but which
was not recorded in the immediately preceding year. By this
definition, all persons reported represent new cases in the year a
state begins surveillance.
Reported by: JP Lofgren, MD, Alabama Dept of Public Health. C
Fowler, MS, Arizona Dept of Health Svcs. S Payne, MA, Occupational
Lead Poisoning Prevention Program, California Dept of Health Svcs.
BC Jung, MPH, Connecticut Dept of Public Health and Addiction Svcs.
M Lehnherr, Occupational Disease Registry, Div of Epidemiologic
Studies, Illinois Dept of Public Health. R Gergely, Iowa Dept of
Public Health. B Carvette, MPH, Occupational Health Program, Bur of
Health, Maine Dept of Human Svcs. E Keyvan-Larijani, MD, Lead
Poisoning Prevention Program, Maryland Dept of the Environment. R
Rabin, MSPH, Div of Occupational Hygiene, Massachusetts Dept of
Labor and Industries. M Scoblic, MN, Michigan Dept of Public
Health. L Thistle-Elliott, MEd, Div of Public Health Svcs, New
Hampshire State Dept of Health and Human Svcs. B Gerwel, MD,
Occupational Disease Prevention Project, New Jersey State Dept of
Health. R Stone, PhD, New York State Dept of Health. S Randolph,
MSN, North Carolina Dept of Environment, Health, and Natural
Resources. E Rhoades, MD, Oklahoma State Dept Health. A Sandoval,
MS, State Health Div, Oregon Dept of Human Resources. J Gostin, MS,
Occupational Health Program, Div of Environmental Health,
Pennsylvania Dept of Health. R Marino, MD, Div of Health Hazard
Evaluations, South Carolina Dept of Health and Environmental
Control. D Perrotta, PhD, Bur of Epidemiology, Texas Dept of
Health. D Beaudoin, MD, Bur of Epidemiology, Utah Dept of Health.
L Toof, Div of Epidemiology and Health Promotion, Vermont Dept of
Health. J Kaufman, MD, Washington State Dept of Labor and
Industries. V Ingram-Stewart, MPH, Wisconsin Dept of Health and
Social Svcs. Div of Surveillance, Hazard Evaluations, and Field
Studies, National Institute for Occupational Safety and Health,
CDC.
Editorial Note: Approximately 54% of the persons reported to ABLES
in 1993 were reported again to the system in 1994. Reasons for
these repeat reports include 1) recurring exposure resulting from
inadequate control measures and worker-protection practices; 2)
routine tracking of elevated employee BLLs that remain below levels
requiring medical removal; and 3) increased employer monitoring
during medical removal. Increased testing of workers in
construction trades--as new workplace medical monitoring programs
are established to comply with new OSHA regulations (3)--also has
contributed to the increases.
     Reporting of adults with elevated BLLs reflects monitoring
practices by employers. Variation in national quarterly reporting
totals, especially first quarter totals, may result from 1) changes
in the number of participating states, 2) timing of receipt of
laboratory BLL reports by state-based surveillance programs, and 3)
interstate differences in worker BLL testing by lead-using
industries.
     The data in this report underscore that work-related lead
exposures are an ongoing occupational health problem in the United
States. ABLES can further enhance surveillance for this preventable
condition by expanding the number of participating states, reducing
variability in reporting, and distinguishing between new and
recurring elevated BLLs in adults. The Council of State and
Territorial Epidemiologists, at its annual meeting in May 1995,
designated elevated BLLs among adults as a condition reportable to
the National Public Health Surveillance System (formerly the
National Notifiable Diseases Surveillance System) (4).
References
1. CDC. Surveillance of elevated blood lead levels among adults--United
States, 1992. MMWR 1992;41:285-8.
2. CDC. Adult blood lead epidemiology and surveillance--United
States, fourth quarter, 1994. MMWR 1995;44:286-7.
3. Office of the Federal Register. Code of federal regulations:
occupational safety and health standards. Subpart Z: toxic and
hazardous substances--lead. Washington, DC: National Archives and
Records Administration, Office of the Federal Register, 1993 (29
CFR section 1926, Part II).
4. CDC. Summary of notifiable diseases, United States, 1993. MMWR

_
                                                             

1993;42(53):iii-v.


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

To: hicnews

Erratum: Vol. 44, No. 17
     In the article, "Prevalence and Impact of Arthritis Among
Women--United States, 1989-1991," a programming error led to
incorrect estimates for nonarthritis conditions listed in Table 2.
The corrected table follows.
     The error does not change statements in the text on the
relative ranking of arthritis compared with other chronic
conditions but does change the following: 1) under the subheading
"Comparison With Other Chronic Conditions Affecting Women" on page
332, the first sentence of the second paragraph should read
"Arthritis was the most common self-reported chronic condition
affecting women (Table 2), ranking ahead of self-reported
hypertension (15.7 million), ischemic heart disease (2.4 million),
and other chronic conditions ..."; and 2) the second sentence of
the same paragraph should read "Among the conditions reported
responsible for activity limitations, women most frequently
mentioned arthritis (4.6 million), followed by orthopedic deformity
(3.7 million) and hypertension (1.9 million)."


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

To: hicnews

Trends in Smoking Initiation Among Adolescents and Young Adults --
United States, 1980-1989

     The evaluation of efforts to prevent tobacco use among
adolescents requires accurate surveillance of both smoking
prevalence and smoking initiation rates. Although several
surveillance systems provide timely data about adolescent smoking
prevalence (1), data characterizing rates of smoking initiation
among adolescents have been limited. To improve characterization of
trends in smoking initiation among young persons, data from the
Tobacco Use Supplement of the 1992 and 1993 Current Population
Surveys (CPS) (2) were used to estimate smoking initiation rates
for persons who were adolescents (aged 14-17 years) or young adults
(aged 18-21 years) during 1980-1989. This report summarizes the
results of that analysis.
     The CPS are monthly surveys of the U.S. civilian,
noninstitutionalized population aged greater than or equal to 15
years (2). Approximately 56,000 households are surveyed each month;
one household respondent provides information about all household
members aged greater than or equal to 15 years. Questions about
tobacco use were added to the September 1992, January 1993, and May
1993 monthly surveys. The response rates for the three surveys were
84.7%, 84.9%, and 82.0%, respectively (N=293,543 household
members). To minimize biases that could result from discrepancies
between self reports and proxy reports of smoking behavior (3),
this analysis used data from self-respondents only (82% of total
sample). Ever smokers were defined as respondents who answered
"yes" to the question, "Have you smoked at least 100 cigarettes in
your entire life?" Ever smokers were asked, "How old were you when
you started smoking cigarettes fairly regularly?" To restrict the
analysis to persons who were adolescents or young adults for some
period during 1980-1989, only respondents aged 17-34 years at
interview were included. The final sample consisted of 71,321
persons, of whom 27,768 (38.9%) were ever smokers.
     Using the age of respondents at the time of the interview and
the age they reported starting smoking, the age of respondents and
their smoking status were calculated for each year during the
1980s. The denominator for the initiation rate for a given year was
the number of respondents at risk for initiating smoking during
that year (persons already smoking were eliminated from the
denominator for that year). The numerator was the number of
respondents who reported initiating smoking during that year. Data
were weighted by age, sex, and race/ethnicity to provide national
estimates.
     Among adolescents, the smoking initiation rate decreased
slightly from 1980 (5.4%) through 1984 (4.7%) and then increased
through 1989 (5.5%); the largest annual increase occurred in 1988
(Figure 1). In comparison, among young adults, initiation rates
decreased throughout the 1980s (Figure 1). For both age groups,
initiation rates and trends were similar for males and females.
Reported by: KM Cummings, PhD, D Shah, MS, Roswell Park Cancer
Institute, Buffalo, New York. DR Shopland, National Cancer
Institute, National Institutes of Health. Office on Smoking and
Health, National Center for Chronic Disease Prevention and Health
Promotion, CDC.
Editorial Note: The findings in this report indicate an increase in
the rate of initiation of cigarette smoking among adolescents from
1985 through 1989, a period during which the rate among young
adults declined and overall prevalence of smoking among adults
decreased steadily (4). One important consequence of the increased
rate of initiation among adolescents will be the increased future
burden of tobacco- related disease. In particular, because of the
increase in initiation since 1984, an additional 600,000
adolescents began to smoke during 1985-1989.* Of those adolescents
who continue to smoke regularly, approximately 50% will die from
smoking-attributable disease (5).
     Potential reasons for an increase in smoking initiation rates
among adolescents include a decreased real price of cigarettes,
increased levels of disposable income, increased acceptability of
smoking, and intensified cigarette marketing (1). However, because
the real price of cigarettes increased steadily during 1985-1989
and the real average weekly income among high school seniors
remained stable during this period, cigarettes were less affordable
to young persons (1,6) (Table 1). In addition, the acceptability of
smoking among high school seniors did not increase: during this
period there were increases in the percentages of high school
seniors who believed cigarettes are harmful, smoking is a "dirty
habit," and becoming a smoker reflects poor judgment, and who
reported they "mind being around people who are smoking" and would
prefer to date nonsmokers (1).
     The increase in rates of smoking initiation among adolescents
during 1985-1989 may reflect increased real expenditures for
cigarette advertising and promotion. The increase in rates occurred
during a period when real expenditures for total cigarette
advertising and promotion** doubled, and expenditures for cigarette
promotion more than quadrupled (7) (Figure 2): from 1980 to 1989,
total annual advertising and promotional expenditures (in 1993
dollars) increased from $2.1 billion to $4.2 billion, while
promotional expenditures alone increased from $771 million (37% of
total expenditures) to $3.2 billion (76%) (Figure 2). Promotional
efforts have been highly effective among adolescents. For example,
among persons aged 12-17 years in 1992, approximately 50% of
smokers and 25% of nonsmokers reported having received promotional
items from tobacco companies (1).
     An association between overall cigarette marketing
expenditures and initiation rates for smoking among adolescents is
plausible for at least four reasons. First, brand loyalty is
usually established with the first cigarette smoked (8); therefore,
cigarette companies have an economic incentive to encourage
first-time smokers to smoke their brands. Second, adolescents are
exposed to cigarette advertising and promotions that employ themes
and images that appeal to young persons (1). Third, advertising
directly influences brand awareness and attitudes toward smoking
among adolescents (1). Specifically, adolescents smoke the most
heavily advertised brands, and changes in brand preferences among
young persons are associated with changes in brand-specific
advertising expenditures (9). For example, the Joe Camel campaign
introduced nationally in 1988 was associated with an increase in
the market share of that specific brand among adolescents (1,9).
Finally, consumer research suggests that younger persons (i.e.,
aged 14-17 years) aspire to be young adults (10); therefore,
advertising and promotional efforts targeted toward young adults
may have greater appeal to adolescents because of their age
aspirations.
     Although current estimates of smoking initiation rates among
adolescents are not available, from 1991 through 1993, the national
prevalence of smoking increased among eighth- and 10th-grade
students (6). To reverse the trend of increasing smoking initiation
rates among adolescents and to achieve the national health
objective for the year 2000 of reducing the initiation of cigarette
smoking by youth (no more than 15% should become regular smokers by
age 20) (objective 3.5) (4), prevention efforts that focus on young
persons should be intensified. Such efforts could include making
cigarettes less affordable by either increasing their real price
(1) or by limiting sales to cartons rather than individual packs,
enforcing laws prohibiting the sale and distribution of cigarettes
to young persons (4), conducting mass media campaigns to discourage
tobacco use (1), and eliminating or severely restricting all forms
of tobacco product advertising and promotion to which young persons
are likely to be exposed (4).
References
1. US Department of Health and Human Services. Preventing tobacco
use among young people: a report of the Surgeon General. Atlanta,
Georgia: US Department of Health and Human Services, Public Health
Service, CDC, National Center for Chronic Disease Prevention and
Health Promotion, Office on Smoking and Health, 1994.
2. Hansen RH. The Current Population Survey: design and methodology
(Technical paper no. 40). Washington, DC: US Department of
Commerce, Bureau of the Census, 1985.
3. Gilpin EA, Pierce JP, Cavin SW, et al. Estimates of population
smoking prevalence: self versus proxy reports of smoking status. Am
J Public Health 1994;84:1576-9.
4. NCHS. Health, United States, 1992, and Healthy People 2000
review. Hyattsville, Maryland: US Department of Health and Human
Services, Public Health Service, CDC, 1993; DHHS publication no.
(PHS)93-1232.
5. Peto R, Lopez AD, Boreham J, Thun M, Heath C. Mortality from
smoking in developing countries, 1950-2000. Indirect estimates from
national vital statistics. Oxford, England: Oxford University
Press, 1994.
6. Johnston LD, O'Malley PM, Bachman JG. National survey results on
drug use from the Monitoring the Future study, 1975-1993. Volume I:
secondary school students. Rockville, Maryland: US Department of
Health and Human Services, Public Health Service, National
Institutes of Health, National Institute on Drug Abuse, 1994.
7. Federal Trade Commission. Report to Congress for 1990: pursuant
to the Federal Cigarette Labeling and Advertising Act. Washington,
DC: U.S. Federal Trade Commission, 1992.
8. DiFranza JR, Eddy JJ, Brown LF, Ryan JL, Bogojavlensky A.
Tobacco acquisition and cigarette brand selection among youth.
Tobacco Control 1994;3:334-8.
9. CDC. Changes in the cigarette brand preferences of adolescent
smokers--United States, 1989-1993. MMWR 1994;43:577-81.
10. Teenage Research Unlimited, Inc. TRU Teenage Marketing and
Lifestyle Study: wave 18, Fall 1991. Northbrook, Illinois: Teenage
Research Unlimited, Inc, 1991.

* Based on the assumption that the initiation rate during 1985-1989
remained stable at the 1984 rate, and by multiplying the Bureau of
the Census population estimates for persons aged 14-17 years for
each year from 1985 through 1989 by the difference between the
adolescent smoking initiation rate in 1984 and the rate for each
year.
** Based on data from the Federal Trade Commission (7), advertising
expenditures include costs to advertise outdoors (e.g.,
billboards), in newspapers or magazines, and on transportation
(e.g., buses); promotional expenditures include costs of
promotional allowances, distribution of samples or specialty items
(e.g., key chains, lighters, T-shirts, caps, and calendars), public
entertainment, direct mail, coupons, retail value-added promotions
(e.g., specialty items distributed at the point of sale), and
point-of-sale promotions (e.g., store displays).


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To: hicnews

       Pertussis -- United States, January 1992-June 1995

     Pertussis was a major cause of morbidity and mortality among
infants and children in the United States during the prevaccine era
(i.e., before the mid-1940s). Since pertussis became a nationally
reportable disease in 1922, the highest number of pertussis cases
(approximately 260,000) was reported in 1934; the highest number of
pertussis-related deaths (approximately 9000) occurred in 1923.
Following the licensure of whole-cell pertussis vaccine combined
with diphtheria and tetanus toxoids (DTP) in 1949 and the
widespread use of DTP among infants and children, the incidence of
reported pertussis declined to a historical low of 1010 cases in
1976 (Figure 1). However, since the early 1980s, reported pertussis
incidence has increased cyclically with peaks occurring in 1983,
1986, 1990, and 1993 (1-3). This report summarizes national
surveillance data for pertussis from January 1992 through June 1995
from CDC's National Public Health Surveillance System (NPHSS) and
Supplementary Pertussis Surveillance System (SPSS) and assesses the
effectiveness of pertussis vaccination in the United States during
this period using vaccination coverage data from CDC's National
Health Interview Survey (NHIS).
National Surveillance for Pertussis and Vaccination Coverage
     Through NPHSS (formerly the National Notifiable Disease
Surveillance System), state health departments report weekly to CDC
the number of pertussis cases. Data reported include state and
county of residence, age, date of report to CDC, and
race/ethnicity. Through SPSS, more detailed information about
persons with pertussis is reported to CDC, including demographic
variables, vaccination history, selected clinical characteristics,
hospital admission, deaths, and results of laboratory tests for
Bordetella pertussis. Documented limitations of these pertussis
surveillance systems include underreporting, disproportionate
representation of classic and severe cases, lack of uniform
reporting criteria among the states, and reliance on laboratory
diagnosis of pertussis by some states (1). NHIS is an annual
cross-sectional household interview survey of the U.S. civilian,
noninstitutionalized population (4). In 1992, an immunization
supplement was added to the survey to collect data about
vaccinations among children aged less than 6 years. Vaccination
information was obtained from vaccination records; for children for
whom no vaccination records were available (50%-65%), information
was based on parental recall.
     Based on NPHSS data, from 1992 through 1994, a total of 15,286
pertussis cases were reported to CDC (4083 in 1992; 6586 in 1993;
and 4617 in 1994), for crude annual incidence rates of 1.6, 2.6,
and 1.8 cases per 100,000 population in 1992, 1993, and 1994,
respectively. Cases were reported from all 50 states and the
District of Columbia. From January 7 through June 30, 1995, a total
of 1386 pertussis cases were reported--an 18% decrease from the
number reported during the same period in 1994 (1690).
     Based on the NPHSS, during 1992-1994, of 13,615 persons
reported with pertussis for whom age data were available, 5618
(41%) were aged less than 1 year; 2682 (20%), 1-4 years; 1551
(11%), 5-9 years; and 3764 (28%), greater than or equal to 10
years. Of the children aged less than 1 year with pertussis, 4524
(81%) were aged less than 6 months.
     Of 10,989 patients for whom data about vaccination status were
available from SPSS, 6876 (63%) had received fewer than three doses
of DTP. Of 3184 patients aged 7 months-4 years for whom vaccination
status was known, 725 (23%) had received no doses, 714 (22%) had
received one or two doses, and 1745 (55%) had received three or
more doses. The proportion of patients who were hospitalized, had
complications, or died was highest among infants and decreased with
increasing age (Table 1). Of children aged less than 1 year
reported with pertussis, 66% were hospitalized, 15% had pneumonia
confirmed radiographically, and 2% had seizures. Overall, 32
pertussis- related deaths and 17 cases complicated by
encephalopathy were reported.
     Based on the NHIS, from 1992 through the second quarter of
1994 (the most recent period for which data were available), among
children aged 19-35 months (median age: 27 months), vaccination
coverage with three or more doses of DTP or diphtheria and tetanus
toxoids (DT) was 83% for 1992, 88% for 1993, 87% for the first
quarter of 1994, and 90% for the second quarter. Vaccination
coverage with four or more doses of DTP or DT was 59% in 1992, 72%
for 1993, 67% for the first quarter of 1994, and 70% for the second
quarter. Based on vaccine distribution data for 1993, 6.7% of
children may have received DT instead of DTP (CDC, unpublished
data, 1993).
Effectiveness of Pertussis Vaccination
     The screening method (5) was used to calculate the
effectiveness of pertussis vaccine among U.S. children aged 7-47
months during 1992-1994. Estimates of vaccine effectiveness (VE)
were derived using the formula VE=1-[PCV/(1-PCV)][(1-PPV)/PPV] (PPV
is the proportion of the population vaccinated, and PCV is the
proportion of case-patients vaccinated). Persons who were partially
vaccinated (i.e., received one to two doses of vaccine) were
excluded from both PPV and PCV. Data from the national SPSS were
used to determine the PCV. A case of pertussis was defined as
either onset of a cough illness of any duration with isolation of
B. pertussis from a clinical specimen or onset of an acute cough
illness lasting greater than or equal to 14 days plus at least one
pertussis-associated symptom (i.e., paroxysms of cough, inspiratory
"whoop," or posttussive vomiting) with no other apparent cause.
Data from NHIS for 1992, 1993, and the first 2 quarters of 1994
were used to determine PPV for age groups 7-18 months and 19-47
months.
     Compared with zero doses of pertussis vaccine, during 1992-1994, 
among
children aged 7-18 months, VE for three doses was 85%;
among children aged 19-47 months, VE for four or more doses was
94%. When these estimates were corrected by 6.7% to account for use
of DT instead of DTP, VE was 64% and 82% for three doses and four
or more doses, respectively.
Reported by: State and local health depts. Child Vaccine
Preventable Disease Br, Epidemiology and Surveillance Div, and
Assessment Br, Data Management Div, National Immunization Program,
CDC.
Editorial Note: Despite the upward trend in the reported incidence
of pertussis in the United States since the early 1980s, the annual
numbers of cases reported during 1992-1994 represent an
approximately 95% decline from those reported during the prevaccine
era. Following the peak in reported cases in 1993, the numbers
declined during 1994 and the first 2 quarters of 1995--a pattern
consistent with the previously observed 3-4-year periodicity in
pertussis incidence.
     Pertussis remains an important cause of morbidity and
mortality among infants and preschool-aged children. Rates of
complications among infants during 1992-1994 are similar to those
reported during 1980-1989 (1) and 1989-1991 (2). The two groups at
greatest risk for severe complications are infants aged less than
6 months (the recommended age by which children should have
received three doses of DTP) and preschool-aged children who are
undervaccinated. The importance of timely vaccination of children
is emphasized by the high proportion of undervaccination

_
                                                                

(approximately 45%) among preschool-aged children with pertussis
who were age-eligible for at least three doses of vaccine. The
Advisory Committee on Immunization Practices and the American
Academy of Pediatrics recommend three doses of DTP to be
administered at ages 2, 4, and 6 months. An additional two doses
are recommended, one each at ages 12-18 months and at 4-6 years
(6). Either DTP or diphtheria and tetanus toxoids and acellular
pertussis vaccine (DTaP) can be administered for the fourth and
fifth doses to children aged 15 months-6 years.
     Since 1992, coverage with three doses of DTP or DT has
increased, indicating progress toward the Childhood Immunization
Initiative goal of 90% coverage by 1996. As a consequence, the
proportion of persons with pertussis who have been vaccinated most
likely will increase. Based on the screening method (which accounts
for changes in vaccination coverage but may not provide an accurate
estimate of vaccine efficacy when vaccination coverage is high)
(5), estimated VE during 1992-1994 was consistent with previous
reports about the efficacy of whole-cell pertussis vaccine in the
United States during the mid-1980s, which documented 64% protection
against mild disease and 95% protection against severe disease (7).
     In the United States, widespread use of whole-cell pertussis
vaccines among infants since 1949 has resulted in the successful
control of pertussis. National pertussis surveillance data during
January 1992-June 1995 indicate the continued effectiveness of the
current pertussis vaccination program. However, despite increasing
vaccination coverage in recent years, pertussis outbreaks (e.g., in
Cincinnati and Chicago in 1993 [3]) continue to occur. Preliminary
results of the protective efficacy of new acellular pertussis
vaccines (when used for the first three doses among infants)
suggest that these vaccines are either equally or more efficacious
than whole-cell vaccines. Further scientific review of these
results is in progress, but until such vaccines are licensed and
available for use among infants, timely age-appropriate vaccination
of infants with whole-cell pertussis vaccines should continue.
Previous delays in administering pertussis vaccine to infants have
resulted in widespread outbreaks (e.g., in the United Kingdom and
Japan during the 1970s and Sweden during the 1980s) (8).
References
1. Farizo KM, Cochi SL, Zell ER, Patriarca PA, Wassilak SGF, Brink
E. Epidemiologic features of pertussis in the United States, 1980-1989. 
Clin
Infect Dis 1992;14:708-19.
2. Davis SF, Strebel PM, Cochi SL, Zell ER, Hadler SC. Pertussis
surveillance--United States, 1989-1991. In: CDC surveillance
summaries (December). MMWR 1992;41(no. SS-8):11-9.
3. CDC. Resurgence of pertussis--United States, 1993. MMWR
1993;42:952-3,959-60.
4. Massey JT, Moore TF, Parsons VL, Tadros W. Design and estimation
for the National Health Interview Survey, 1985-1994. Hyattsville,
Maryland: US Department of Health and Human Services, Public Health
Service, CDC, 1989. (Vital and health statistics; series 2, no.
110).
5. Farrington CP. Estimation of vaccine effectiveness using the
screening method. Int J Epidemiol 1993;22:742-6.
6. CDC. Recommended childhood immunization schedule--United States,
1995. MMWR 1995; 44(no. RR-5).
7. Onorato IM, Wassilak SG, Mead B. Efficacy of whole-cell
pertussis vaccine in preschool children in the United States. JAMA
1992;267:2745-9.
8. Mortimer EA. Pertussis vaccine. In: Plotkin SA, Mortimer EA,
eds. Vaccines. 2nd ed. Philadelphia, Pennsylvania: W.B. Saunders
Co, 1994:91-135.


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Pneumonia and Influenza Death Rates -- United States, 1979-1994

     The combined cause-of-death category pneumonia and influenza
(P&I) (International Classification of Diseases, Ninth Revision,
codes 480-487) ranks as the sixth leading cause of death in the
United States following heart disease, cancer, stroke,
unintentional injuries, and chronic obstructive pulmonary disease
(1). Changes in the epidemiology of Streptococcus pneumoniae and
other recognized respiratory pathogens, the increasing occurrence
of drug-resistant microorganisms, and the detection of new
respiratory pathogens have heightened awareness of the public
health importance of severe respiratory infections (2-5). To
characterize the epidemiology of P&I deaths in the United States,
CDC further analyzed underlying and multiple cause-of-death
mortality files for 1979-1994. This report summarizes the results
of this analysis.
     From 1979 to 1994, the overall crude death rates for P&I
(based on underlying cause of death) increased 59%, from 20.0 to
31.8 deaths per 100,000 population (Figure 1). From 1979 to 1992
(the most recent year for which age-adjusted data are available),
the P&I death rate, age-adjusted to a 1980 standard population,
increased 22%, from 20.4 to 24.8.
     In 1992, persons aged greater than or equal to 65 years
accounted for 89% of all P&I deaths. From 1979 to 1992, P&I death
rates for persons aged greater than or equal to 65 years increased
44%, from 145.6 deaths per 100,000 population to 209.1. During this
period, rates also increased for persons aged 20-44 years; however,
the small number of deaths among persons in this age group (2148 in
1992) limited the contribution to the overall trend.
     To control for the highly variable seasonal contribution of
influenza-associated deaths, the trend for mean weekly number of
P&I deaths for noninfluenza months (May-October) was analyzed. From
1979 through 1992, age-adjusted P&I death rates during these months
increased steadily from 3.1 to 5.0 per 1 million population.
Analysis of P&I deaths listed in any position on the death
certificate (multiple cause-of-death data) indicated a similar
increase.
     During 1979-1992, the diagnostic code for pneumonia of
unspecified etiology (ICD-9 code 486) accounted for most of the
overall increase: age-adjusted death rates in this diagnostic
category increased 74%. In addition, in 1992, 84% of all P&I deaths
were assigned this code, compared with 59% in 1979.
Reported by: Childhood and Respiratory Diseases Br, Div of
Bacterial and Mycotic Diseases, and Div of Viral and Rickettsial
Diseases, National Center for Infectious Diseases; Mortality
Statistics Br, Div of Vital Statistics, National Center for Health
Statistics, CDC.
Editorial Note: The findings in this report document the recent
increase in mortality attributed to P&I in the United States. This
increase reflects both growth in the proportion of persons in older
age groups (from 1970 to 1990, the proportion of persons in the
United States population aged greater than or equal to 65 years
increased from 9.8% to 12.5%) and higher P&I death rates in these
age groups. A high proportion of these deaths was attributed to
pneumonia of unspecified etiology, which probably includes both
pneumonias caused by known pathogens not specified on the death
certificate and pneumonias caused by new or unrecognized agents.
     Changes in the epidemiology of recognized respiratory
pathogens (e.g., S. pneumoniae), for which precise diagnoses are
difficult to make in clinical settings, may have contributed to the
increasing death rate in older persons. Although the proportion of
the increase in P&I death rates accounted for by all
vaccine-preventable respiratory diseases is unknown, the increased
rates also underscore the need for more complete use of
pneumococcal and influenza vaccines as recommended by the
Immunization Practices Advisory Committee (ACIP) (6,7). One of the
national health objectives for the year 2000 is to vaccinate 60% of
persons at risk for pneumococcal disease and influenza (objective
20.11) (8). Although coverage levels for influenza vaccinations
among persons aged greater than or equal to 65 years have increased
(in 1993, 52% reported having received influenza vaccine in the
previous year), only 28% reported ever having received the
pneumococcal vaccine in 1993 (9).
     In addition to known but undiagnosed causes of respiratory
infection, new or previously uncharacterized agents probably
account for some of the increase in age-adjusted death rates
attributed to pneumonia of unspecified etiology. For example, since
the 1970s, several bacterial and viral agents have been identified
as causes of lower respiratory infections, including Legionella
pneumophila, Chlamydia pneumoniae, and Sin Nombre virus (the
etiologic agent of hantavirus pulmonary syndrome). Recent
prospective studies of community-acquired pneumonia have suggested
that an etiology cannot be identified in 40%-50% of cases (10),
probably reflecting both the lack of sensitive diagnostic tests for
some known respiratory pathogens and the occurrence of respiratory
infections for which the etiologies have not yet been identified.
     Based on shifts in the age distribution of the total U.S.
population, respiratory infectious diseases among the elderly
probably will increase the need for health-care services and
require the development of more effective prevention strategies.
Improvements in understanding the epidemiology of morbidity and
mortality associated with unspecified pneumonias will require
further examination of diagnostic and reporting practices for
certification of causes of death and analyses of additional data
sources (e.g., hospital discharge records). In addition, improved
characterization of bacterial and viral causes of pneumonia may
result from prospective epidemiologic and laboratory studies,
development of more sensitive diagnostic tests, and wider use of
available tests.
References
1. NCHS. Advance report of final mortality statistics, 1992.
Hyattsville, Maryland: US Department of Health and Human Services,
Public Health Service, CDC, 1994. (Monthly vital statistics report;
vol 43, no. 6, suppl).
2. Duchin JS, Koster FT, Peters CJ, et al. Hantavirus pulmonary
syndrome: a clinical description of 17 patients with a newly
recognized disease. N Engl J Med 1994;330:949-55.
3. Breiman RF, Spika JS, Navarro VJ, Darden PM, Darby CP.
Pneumococcal bacteremia in Charleston County, South Carolina--a
decade later. Arch Intern Med 1990;150:1401-5.
4. Hoge CW, Reichler MR, Dominguez EA, et al. An epidemic of
pneumococcal disease in an overcrowded, inadequately ventilated
jail. N Engl J Med 1994;331:643-8.
5. Breiman RF, Butler JC, Tenover FC, Elliot JA, Facklam RR.
Emergence of drug-resistant pneumococcal infections in the United
States. JAMA 1994;271:1831-5.
6. CDC. Prevention and control of influenza: recommendations of the
Advisory Committee on Immunization Practices (ACIP). MMWR
1995;44(no. RR-3):2.
7. CDC. Update on adult immunization: recommendations of the
Immunization Practices Advisory Committee (ACIP). MMWR 1991:40(no.
RR-12):33-6,42-4.
8. Public Health Service. Healthy people 2000: national health
promotion and disease prevention objectives. Washington, DC: U.S.
Department of Health and Human Services, Public Health Service,
1991; DHHS publication no. (PHS)91-50213.
9. CDC. Influenza and pneumococcal vaccination coverage levels
among persons aged greater than or equal to 65 years --United
States, 1973-1993. MMWR 1995;44:506-15.
10. Marrie TJ. Community-acquired pneumonia. Clin Infect Dis
1994;18:501-15.



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Notice to Readers
Final 1994 Reports of Notifiable Diseases
     The notifiable diseases table on pages 538-543 summarizes
final data for 1994. These data, final as of July 7, 1995, will be
published in more detail in the Summary of Notifiable Diseases,
1994 (1).
     Population estimates for the states are from the July 1, 1994,
estimates by the U.S. Bureau of the Census, Population Division,
Population Estimates Branch, press release CB94-204. Population
estimates for territories are from the 1990 census, U.S. Bureau of
the Census, press releases CB91-142, 242, 243, 263, and 276.
Reference
1. CDC. Summary of notifiable diseases, United States, 1994. MMWR
1995;44(no. 53) (in press).



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End of HICNet Medical News Digest V08 Issue #27
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---
Editor, HICNet Medical Newsletter
Internet: david@stat.com                 FAX: +1 (602) 451-6135

                                                                                          
