MMWR. Surveillance summaries: Morbidity and mortality weekly report. Surveillance summaries / CDC
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ABSTRACT: Physical activity is a health-enhancing behavior, and most U.S. adults do not meet the 2008 Physical Activity Guidelines for Americans. Active transportation, such as by walking or bicycling, is one way that persons can be physically active. No comprehensive, multiyear assessments of active transportation surveillance in the United States have been conducted. 1999-2012. Five surveillance systems assess one or more components of active transportation. The American Community Survey and the National Household Travel Survey (NHTS) both assess the mode of transportation to work in the past week. From these systems, the proportion of respondents who reported walking or bicycling to work can be calculated. NHTS and the American Time Use Survey include 1-day assessments of trips or activities. With that information, the proportion of respondents who report any walking or bicycling for transportation can be calculated. The National Health and Nutrition Examination Survey and the National Health Interview Survey both assess recent (i.e., in the past week or past month) habitual physical activity behaviors, including those performed during active travel. From these systems, the proportion of respondents who report any recent habitual active transportation can be calculated. The prevalence of active transportation as the primary commute mode to work in the past week ranged from 2.6% to 3.4%. The 1-day assessment indicated that the prevalence of any active transportation ranged from 10.5% to 18.5%. The prevalence of any habitual active transportation ranged from 23.9% to 31.4%. No consistent trends in active transportation across time periods and surveillance systems were identified. Among systems, active transportation was usually more common among men, younger respondents, and minority racial/ethnic groups. Among education groups, the highest prevalence of active transportation was usually among the least or most educated groups, and active transportation tended to be more prevalent in densely populated, urban areas. Active transportation is assessed in a wide variety of ways in multiple surveillance systems. Different assessment techniques and construct definitions result in widely discrepant estimates of active transportation; however, some consistent patterns were detected across covariates. Although each type of assessment (i.e., transportation to work, single day, and habitual behavior) measures a different active transportation component, all can be used to monitor population trends in active transportation participation. An understanding of the strengths, limitations, and lack of comparability of active transportation assessment techniques is necessary to correctly evaluate findings from the various surveillance systems. When used appropriately, these systems can be used by public health and transportation professionals to monitor population participation in active transportation and plan and evaluate interventions that influence active transportation.MMWR. Surveillance summaries: Morbidity and mortality weekly report. Surveillance summaries / CDC 08/2015; 64(7):1-17. DOI:10.15585/mmwr.ss6407a1
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ABSTRACT: Problem/Condition: Autism spectrum disorders (ASDs) are a group of developmental disabilities characterized by atypical development in socialization, communication, and behavior. ASDs typically are apparent before age 3 years, with associated impairments affecting multiple areas of a person's life. Because no biologic marker exists for ASDs, identification is made by professionals who evaluate a child's developmental progress to identify the presence of developmental disorders. Reporting Period: 2006. Methods: Earlier surveillance efforts indicated that age 8 years is a reasonable index age at which to monitor peak prevalence. The identified prevalence of ASDs in U.S. children aged 8 years was estimated through a systematic retrospective review of evaluation records in multiple sites participating in the Autism and Developmental Disabilities Monitoring (ADDM) Network. Data were collected from existing records in 11 ADDM Network sites (areas of Alabama, Arizona, Colorado, Florida, Georgia, Maryland, Missouri, North Carolina, Pennsylvania, South Carolina, and Wisconsin) for 2006. To analyze changes in identified ASD prevalence, CDC compared the 2006 data with data collected from 10 sites (all sites noted above except Florida) in 2002. Children aged 8 years with a notation of an ASD or descriptions consistent with an ASD were identified through screening and abstraction of existing health and education records containing professional assessments of the child's developmental progress at health-care or education facilities. Children aged 8 years whose parent(s) or legal guardian(s) resided in the respective areas in 2006 met the case definition for an ASD if their records documented behaviors consistent with the "Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision" (DSM-IV-TR) criteria for autistic disorder, pervasive developmental disorder-not otherwise specified (PDD NOS), or Asperger disorder. Presence of an identified ASD was determined through a review of data abstracted from developmental evaluation records by trained clinician reviewers. Results: For the 2006 surveillance year, 2,757 (0.9%) of 307,790 children aged 8 years residing in the 11 ADDM sites were identified as having an ASD, indicating an overall average prevalence of 9.0 per 1,000 population 95% confidence interval [CI] = 8.6-9.3). ASD prevalence per 1,000 children aged 8 years ranged from 4.2 in Florida to 12.1 in Arizona and Missouri, with prevalence for the majority of sites ranging between 7.6 and 10.4. For 2006, ASD prevalence was significantly lower in Florida (p less than 0.001) and Alabama (p less than 0.05) and higher in Arizona and Missouri (p less than 0.05) than in all other sites. The ratio of males to females ranged from 3.2:1 in Alabama to 7.6:1 in Florida. ASD prevalence varied by type of ascertainment source, with higher average prevalence in sites with access to health and education records (10.0) compared with sites with health records only (7.5). Although parental or professional concerns regarding development before age 36 months were noted in the evaluation records of the majority of children who were identified as having an ASD, the median age of earliest documented ASD diagnosis was much later (range: 41 months [Florida]-60 months [Colorado]). Of 10 sites that collected data for both the 2002 and 2006 surveillance years, nine observed an increase in ASD prevalence (range: 27%-95% increase; p less than 0.01), with increases among males in all sites and among females in four of 11 sites, and variation among other subgroups. Interpretation: In 2006, on average, approximately 1% or one child in every 110 in the 11 ADDM sites was classified as having an ASD (approximate range: 1:80-1:240 children [males: 1:70; females: 1:315]). The average prevalence of ASDs identified among children aged 8 years increased 57% in 10 sites from the 2002 to the 2006 ADDM surveillance year. Although improved ascertainment accounts for some of the prevalence increases documented in the ADDM sites, a true increase in the risk for children to develop ASD symptoms cannot be ruled out. On average, although delays in identification persisted, ASDs were being diagnosed by community professionals at earlier ages in 2006 than in 2002. Public Health Actions: These results indicate an increased prevalence of identified ASDs among U.S. children aged 8 years and underscore the need to regard ASDs as an urgent public health concern. Continued monitoring is needed to document and understand changes over time, including the multiple ascertainment and potential risk factors likely to be contributing. Research is needed to ascertain the factors that put certain persons at risk, and concerted efforts are essential to provide support for persons with ASDs, their families, and communities to improve long-term outcome. Brief Update: Prevalence of Autism Spectrum Disorders (ASDs)--Autism and Developmental Disabilities Monitoring (ADDM) Network, United States, 2004 is appended. (Contains 5 figures and 8 tables.)MMWR. Surveillance summaries: Morbidity and mortality weekly report. Surveillance summaries / CDC 06/2010;
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ABSTRACT: Malaria is caused by any of four species of intraerythrocytic protozoa of the genus Plasmodium (i.e., P. falciparum, P. vivax, P. ovale, or P. malariae). These parasites are transmitted by the bite of an infective female Anopheles sp. mosquito. The majority of malaria infections in the United States occur among persons who have traveled to areas with ongoing transmission. In the United States, cases can occur through exposure to infected blood products, by congenital transmission, or by local mosquitoborne transmission. Malaria surveillance is conducted to identify episodes of local transmission and to guide prevention recommendations for travelers. This report covers cases with onset of illness in 2001. Malaria cases confirmed by blood film are reported to local and state health departments by health-care providers or laboratory staff. Case investigations are conducted by local and state health departments, and reports are transmitted to CDC through the National Malaria Surveillance System (NMSS). Data from NMSS serve as the basis for this report. CDC received reports of 1,383 cases of malaria with an onset of symptoms in 2001 among persons in the United States or one of its territories. This number represents a decrease of 1.4% from the 1,402 cases reported for 2000. P. falciparum, P. vivax, P. malariae, and P. ovale were identified in 50.1%, 27.8%, 4.5%, and 3.6% of cases, respectively. Fourteen patients (1.0% of total) were infected by >/=2 species. The infecting species was unreported or undetermined in 179 (12.9%) cases. Compared with 2000, the number of reported malaria cases acquired in Africa increased by 13.2% (n = 886), whereas the number of cases acquired in Asia (n = 163) and the Americas (n = 240) decreased by 31.5% and 11.4%, respectively. Of 891 U.S. civilians who acquired malaria abroad, 180 (20.2%) reported that they had followed a chemoprophylactic drug regimen recommended by CDC for the area to which they had traveled. Two patients became infected in the United States, one through congenital transmission and one whose infection cannot be linked epidemiologically to secondary cases. Eleven deaths were attributed to malaria, 10 caused by P. falciparum and one caused by P. ovale. The 1.4% decrease in malaria cases in 2001, compared with 2000, resulted primarily from a decrease in cases acquired in Asia and the Americas, but this decrease was offset by an increase in the number of cases acquired in Africa. This decrease probably represents year-to-year variation in malaria cases, but also could have resulted from local changes in disease transmission, decreased travel to malaria-endemic regions, fluctuation in reporting to state and local health departments, or an increased use of effective antimalarial chemoprophylaxis. In the majority of reported cases, U.S. civilians who acquired infection abroad were not on an appropriate chemoprophylaxis regimen for the country in which they acquired malaria. Additional information was obtained concerning the 11 fatal cases and the two infections acquired in the United States. Persons traveling to a malarious area should take one of the recommended chemoprophylaxis regimens appropriate for the region of travel, and travelers should use personal protection measures to prevent mosquito bites. Any person who has been to a malarious area and who subsequently develops a fever or influenza-like symptoms should seek medical care immediately and report their travel history to the clinician; investigation should include a blood-film test for malaria. Malaria infections can be fatal if not diagnosed and treated promptly. Recommendations concerning malaria prevention can be obtained from CDC by calling the Malaria Hotline at 770-488-7788 or by accessing CDC's Internet site at http://www.cdc.gov/travel.MMWR. Surveillance summaries: Morbidity and mortality weekly report. Surveillance summaries / CDC 07/2003; 52(5):1-14.
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ABSTRACT: Previous studies indicate that each year in the United States, approximately 1.5 million Americans sustain a traumatic brain injury (TBI). Of those injured, approximately one quarter million are hospitalized. Approximately one third of adults hospitalized with TBI still need help with daily activities 1 year after their discharge. This report summarizes surveillance data for TBI in the United States for January-December 1997. Data are from 14 states that participated in an ongoing CDC-funded TBI surveillance system. State health departments used CDC guidelines to identify TBI cases from hospital discharge data or from other statewide injury data systems. Supplementary information was abstracted from medical records. The overall age-adjusted TBI-related live hospital discharge rate was 69.7/100,000 population. Rates were highest for American Indians and Alaska Natives (75.3/100,000) and Blacks (74.4/100,000). The age-adjusted rate for males was approximately twice as high as for females (91.9 versus 47.7/100,000 respectively). For both sexes, the rates were highest among those aged 15-19 years and >/= 65 years. Motor-vehicle crashes, falls, and assaults were the leading causes of injury for TBI-related discharges (27.9, 22.5, and 7.3/100,000 respectively). TBI-related discharge rates for falls were highest among those aged >/= 65 years (82.3/100,000). Black males and American Indian/Alaska Native males had the highest rates of TBI attributable to assault (31.3 and 29.5 per 100,000, respectively), approximately 4 times the rate for white males. An estimated 46% of injured motor-vehicle occupants, 53% of motorcyclists, and 41% of pedal cyclists reportedly were not using personal protective equipment (PPE) (e.g., seat belts or helmets) at the time of their TBI. With regard to outcome assessed before discharge from the hospital, approximately 17% of persons hospitalized with TBI had moderate to severe disability. Data in this report, the most extensive to date from a multistate population-based TBI surveillance system, indicate the importance of TBI as a public health problem. Population-based information regarding TBI hospitalizations can be useful in assessing the effect of prevention efforts and planning for the service needs of persons with TBI.MMWR. Surveillance summaries: Morbidity and mortality weekly report. Surveillance summaries / CDC 06/2003; 52(4):1-20.
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ABSTRACT: Tetanus is a severe and often fatal infection. The incidence of reported cases in the United States has declined steadily since introduction of tetanus toxoid vaccines in the 1940s. This report covers surveillance data for 1998--2000. Physician-diagnosed cases of tetanus were reported to CDC's National Notifiable Disease Surveillance System. Supplemental clinical and epidemiologic information were provided by states. During 1998--2000, an average of 43 cases of tetanus was reported annually; the average annual incidence was 0.16 cases/million population. The highest average annual incidence of reported tetanus was among persons aged >60 years (0.35 cases/million population), persons of Hispanic ethnicity (0.37 cases/million population), and older adults known to have diabetes (0.70 cases/million population). Fifteen percent of the cases were among injection-drug users. The case-fatality ratio was 18% among 113 patients with known outcome; 75% of the deaths were among patients aged >60 years. No deaths occurred among those who were up-to-date with tetanus toxoid vaccination. Seventy-three percent of 129 cases with known injury information available reported an acute injury; of these, only 37% sought medical care for the acute injury, and only 63% of those eligible received tetanus toxoid for wound prophylaxis. The majority of tetanus cases occurred among persons inadequately vaccinated or with unknown vaccination history who sustained an acute injury. Adults aged >60 years were at highest risk for tetanus and tetanus-related death. Tetanus is preventable through routine vaccination (i.e., primary series and decennial boosters) and appropriate management. A shortage of tetanus and diphtheria toxoids vaccine that began during 2000 ended in 2002. Efforts by health-care providers are warranted to vaccinate persons with delayed or incomplete vaccination, with emphasis on older persons and persons with high-risk conditions.MMWR. Surveillance summaries: Morbidity and mortality weekly report. Surveillance summaries / CDC 06/2003; 52(3):1-8.
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ABSTRACT: Vaccines are usually administered to healthy persons who have substantial expectations for the safety of the vaccines. Adverse events after vaccinations occur but are generally rare. Some adverse events are unlikely to be detected in prelicensure clinical trials because of their low frequency, the limited numbers of enrolled subjects, and other study limitations. Therefore, postmarketing monitoring of adverse events after vaccinations is essential. The cornerstone of monitoring safety is review and analysis of spontaneously reported adverse events. This report summarizes the adverse events reported to the Vaccine Adverse Event Reporting System (VAERS) from January 1, 1991, through December 31, 2001. VAERS was established in 1990 under the joint administration of CDC and the Food and Drug Administration (FDA) to accept reports of suspected adverse events after administration of any vaccine licensed in the United States. VAERS is a passive surveillance system: reports of events are voluntarily submitted by those who experience them, their caregivers, or others. Passive surveillance systems (e.g., VAERS) are subject to multiple limitations, including underreporting, reporting of temporal associations or unconfirmed diagnoses, and lack of denominator data and unbiased comparison groups. Because of these limitations, determining causal associations between vaccines and adverse events from VAERS reports is usually not possible. Vaccine safety concerns identified through adverse event monitoring nearly always require confirmation using an epidemiologic or other (e.g., laboratory) study. Reports may be submitted by anyone suspecting that an adverse event might have been caused by vaccination and are usually submitted by mail or fax. A web-based electronic reporting system has recently become available. Information from the reports is entered into the VAERS database, and new reports are analyzed weekly. VAERS data stripped of personal identifiers can be reviewed by the public by accessing http://www.vaers.org. The objectives of VAERS are to 1) detect new, unusual, or rare vaccine adverse events; 2) monitor increases in known adverse events; 3) determine patient risk factors for particular types of adverse events; 4) identify vaccine lots with increased numbers or types of reported adverse events; and 5) assess the safety of newly licensed vaccines. During 1991-2001, VAERS received 128,717 reports, whereas >1.9 billion net doses of human vaccines were distributed. The overall dose-based reporting rate for the 27 frequently reported vaccine types was 11.4 reports per 100,000 net doses distributed. The proportions of reports in the age groups <1 year, 1-6 years, 7-17 years, 18-64 years, and >/= years were 18.1%, 26.7%, 8.0%, 32.6%, and 4.9%, respectively. In all of the adult age groups, a predominance among the number of women reporting was observed, but the difference in sex was minimal among children. Overall, the most commonly reported adverse event was fever, which appeared in 25.8% of all reports, followed by injection-site hypersensitivity (15.8%), rash (unspecified) (11.0%), injection-site edema (10.8%), and vasodilatation (10.8%). A total of 14.2% of all reports described serious adverse events, which by regulatory definition include death, life-threatening illness, hospitalization or prolongation of hospitalization, or permanent disability. Examples of the uses of VAERS data for vaccine safety surveillance are included in this report. As a national public health surveillance system, VAERS is a key component in ensuring the safety of vaccines. VAERS data are used by CDC, FDA, and other organizations to monitor and study vaccine safety. CDC and FDA use VAERS data to respond to public inquiries regarding vaccine safety, and both organizations have published and presented vaccine safety studies based on VAERS data. VAERS data are also used by the Advisory Committee on Immunization Practices and the Vaccine and Related Biological Products Advisory Committee to evaluate possible adverse events after vaccinations and to develop recommendations for precautions and contraindications to vaccinations. Reviews of VAERS reports and the studies based on VAERS reports during 1991-2001 have demonstrated that vaccines are usually safe and that serious adverse events occur but are rare. Through continued reporting of adverse events after vaccination to VAERS by health-care providers, public health professionals, and the public and monitoring of reported events by the VAERS working group, the public health system will continue to be able to detect rare but potentially serious consequences of vaccination. This knowledge facilitates improvement in the safety of vaccines and the vaccination process.MMWR. Surveillance summaries: Morbidity and mortality weekly report. Surveillance summaries / CDC 01/2003; 52(1):1-24.
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ABSTRACT: CDC began abortion surveillance in 1969 to document the number and characteristics of women obtaining legal induced abortions and to monitor unintended pregnancy. This report summarizes and describes data reported to CDC regarding legal induced abortions obtained in the United States in 1999. For each year since 1969, CDC has compiled abortion data by state or area of occurrence. From 1973 through 1997, data were received from or estimated for 52 reporting areas in the United States: 50 states, the District of Columbia, and New York City. Beginning in 1998, CDC compiled abortion data from 48 reporting areas. Alaska, California, New Hampshire, and Oklahoma did not report, and data for these areas were not estimated. The availability of data regarding the characteristics of women who obtained an abortion in 1999 varied by state and by the number of states reporting each characteristic. The total number of legal induced abortions is reported by state of residence and also by state of occurrence for most areas; characteristics of women obtaining abortions in 1999 are reported by state of occurrence. A total of 861,789 legal induced abortions were reported to CDC for 1999, representing a 2.5% decrease from the 884,273 legal induced abortions reported by the same 48 reporting areas for 1998. The abortion ratio, defined as the number of abortions per 1,000 live births, was 256 in 1999, compared with 264 reported for 1998; the abortion rate for these 48 reporting areas was 17 per 1,000 women aged 15-44 years for 1999, the same as in 1997 and 1998. The highest percentages of abortions were reported for women aged < 25 years, women who were white, and unmarried women; slightly more than half were obtaining an abortion for the first time. Fifty-eight percent of all abortions for which gestational age was reported were performed at < or = 8 weeks of gestation, and 88% were performed before 13 weeks. From 1992 (when these data were first collected) through 1999, increases have occurred in the percentage of abortions performed at < or = 6 weeks of gestation. Few abortions were provided after 15 weeks of gestation; 4.3% were obtained at 16-20 weeks and 1.5% were obtained at > or = 21 weeks. A total of 27 reporting areas submitted data stating that they performed medical (nonsurgical) procedures (two of these areas categorized medical abortions with "other" procedures), making up < 1.0% of all procedures reported from all reporting areas. In 1998 (for which data have not been published previously and the most recent year for which such data are available), nine women died as a result of complications from known legal induced abortion; no deaths were associated with known illegal abortion. From 1990 through 1997, the number of legal induced abortions gradually declined. In 1998 and in 1999, the number of abortions continued to decrease when comparing the same 48 reporting areas. In 1998, as in previous years, deaths related to legal induced abortions occurred rarely. Abortion surveillance in the United States should continue so that trends and characteristics of women who obtain legal induced abortions can be examined and efforts to prevent unintended pregnancy can be enhanced.MMWR. Surveillance summaries: Morbidity and mortality weekly report. Surveillance summaries / CDC 12/2002; 51(9):1-9, 11-28.
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ABSTRACT: Elevated blood lead levels (BLLs) in adults can damage the cardiovascular, central nervous, reproductive, hematologic, and renal systems. The majority of cases are workplace-related. U.S. Department of Health and Human Services recommends that BLLs among all adults be reduced to < 25 microg/dL. The highest BLL acceptable by standards of the U.S. Occupational Safety and Health Administration is 40 microg/dL. The mean BLL of adults in the United States is < 3 microg/dL. This report covers cases of adults (aged > or = 16 years) with BLLs > or = 25 microg/dL, as reported by 25 states during 1998-2001. Since 1987, CDC has sponsored the state-based Adult Blood Lead Epidemiology and Surveillance (ABLES) program to track cases of elevated BLLs and provide intervention consultation and other assistance. Overall ABLES program data were last published in 1999 for the years 1994-1997. This report provides an update with data from 25 states reporting for > or = 2 years during 1998-2001. During that period, the ABLES program funded surveillance in 21 states - Alabama, Arizona, Connecticut, Iowa, Maryland, Massachusetts, Michigan, Minnesota, New Jersey, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Texas, Washington, Wisconsin, and Wyoming. Four additional states - California, Nebraska, New Hampshire, and Utah contributed data without CDC funding. During 1998-2001, the overall program's annual mean state prevalence rate for adults with BLLs > or = 25 microg/dL was 13.4/100,000 employed adults. This compares with 15.2/100,000 for 1994-1997. Yearly rates were 13.8 (1998), 12.9 (1999), 14.3 (2000), and 12.5 (2001). For adults with BLLs > or = 40 microg/dL, the overall program's annual mean state prevalence rare during 1998-2001 was 2.9/ 100,000 employed adults. This compares with 3.9/100,000 for 1994-1997. Yearly rates were 3.3 (1998), 2.5 (1999), 2.9 (2000), and 2.8 (2001). Although certain limitations exist, the overall ABLES data indicate a declining trend in elevated BLLs among employed adults. ABLES-funded states increased from 21 to 35 in 2002, and more detailed reporting requirements were put into effect. These, and other improvements, will enable the ABLES program to work more effectively toward its 2010 target of eliminating all cases of BLLs > or = 25 microg/dL in adults caused by workplace exposures.MMWR. Surveillance summaries: Morbidity and mortality weekly report. Surveillance summaries / CDC 12/2002; 51(11):1-10.
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ABSTRACT: Data indicate that approximately 50,000 U.S. residents die as a result of traumatic brain injury (TBI) annually. Survivors of TBI are often left with neuropsychologic impairments that result in disabilities affecting work or social activity. During 1979-1992, TBI-related death rates declined 22%, from 24.6 to 19.3 deaths/100,000 population. This report describes the epidemiology and trends in TBI-related mortality during 1989-1998. January 1, 1989-December 31, 1998. The National Center for Health Statistics (NCHS) Multiple Cause of Death public use data were analyzed for this study. During 1989-1998, an annual average of 53,288 deaths (range: 51,848-54,501) among U.S. residents were associated with TBI. TBI-related death rates declined 11.4%, from 21.9 to 19.4/100,000 population. The major causes of TBI-related deaths were firearm-related (40%), motor-vehicle-related (34%), and fall-related (10%). The leading causes of TBI-related deaths differed among age groups. Among youths aged 0-19 years, motor-vehicle-related TBIs were the leading cause; among persons aged 20-74 years, firearm-related TBIs were the leading cause; and among persons aged > or = 75 years, fall-related TBIs were the leading cause. Comparing rates in 1989 with rates in 1998, motor-vehicle-related causes declined by 22%; the majority of this decline occurred during the first 5 years of the period. During 1989-1998, firearm-related TBI-related deaths declined by 14%; approximately all of this decline occurred during the last 5 years of the period. In contrast, fall-related TBI-related death rates increased by 25% during the period. This analysis of mortality data identifies recent trends in TBI-related deaths occurring during 1989-1998. Fall-related TBI death rates have increased throughout the period. Firearm-related TBI death rates, which were increasing in the early 1990s, declined. Motor-vehicle-related TBI death rates, which were decreasing until the mid-1990s, have since demonstrated only a limited change. More current population-based epidemiologic studies of TBI are needed to assess recent trends of etiologic factors, provide additional guidance for public policy, and evaluate prevention strategies. Despite the decline in fatal TBI incidence, TBI morbidity and mortality remains a public health challenge. Public health, law enforcement, and transportation safety professionals can address these challenges by implementing effective interventions based on a thorough assessment of the factors that influence health-related behaviors.MMWR. Surveillance summaries: Morbidity and mortality weekly report. Surveillance summaries / CDC 12/2002; 51(10):1-14.
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ABSTRACT: Since 1971, CDC, the U.S. Environmental Protection Agency (EPA), and the Council of State and Territorial Epidemiologists (CSTE) have maintained a collaborative surveillance system for the occurrences and causes of waterborne-disease outbreaks (WBDOs).This surveillance system is the primary source of data concerning the scope and effects of waterborne diseases on persons in the United States. This summary includes data regarding outbreaks occurring during January 1999-December 2000 and previously unreported outbreaks occurring in 1995 and 1997. The surveillance system includes data for outbreaks associated with drinking water and recreational water. State, territorial, and local public health departments are primarily responsible for detecting and investigating WBDOs and voluntarily reporting them to CDC on a standard form. The unit of analysis for the WBDO surveillance system is an outbreak, not an individual case of a waterborne disease. Two criteria must be met for an event to be defined as a WBDO. First, > or = 2 persons must have experienced a similar illness after either ingestion of drinking water or exposure to water encountered in recreational or occupational settings. This criterion is waived for single cases of laboratory-confirmed primary amebic meningoencephalitis and for single cases of chemical poisoning if water-quality data indicate contamination by the chemical. Second, epidemiologic evidence must implicate water as the probable source of the illness. During 1999-2000, a total of 39 outbreaks associated with drinking water was reported by 25 states. Included among these 39 outbreaks was one outbreak that spanned 10 states. These 39 outbreaks caused illness among an estimated 2,068 persons and were linked to two deaths. The microbe or chemical that caused the outbreak was identified for 22 (56.4%) of the 39 outbreaks; 20 of the 22 identified outbreaks were associated with pathogens, and two were associated with chemical poisoning. Of the 17 outbreaks involving acute gastroenteritis of unknown etiology, one was a suspected chemical poisoning, and the remaining 16 were suspected as having an infectious cause. Twenty-eight (71.8%) of 39 outbreaks were linked to groundwater sources; 18 (64.3%) of these 28 groundwater outbreaks were associated with private or noncommunity wells that were not regulated by EPA. Fifty-nine outbreaks from 23 states were attributed to recreational water exposure and affected an estimated 2,093 persons. Thirty-six (61.0%) of the 59 were outbreaks involving gastroenteritis. The etiologic agent was identified in 30 (83.3%) of 36 outbreaks involving gastroenteritis. Twenty-two (61.1%) of 36 gastroenteritis-related outbreaks were associated with pools or interactive fountains. Four (6.8%) of the 59 recreational water outbreaks were attributed to single cases of primary amebic meningoencephalitis (PAM) caused by Naegleria fowleri. All four cases were fatal. Fifteen (25.4%) of the 59 outbreaks were associated with dermatitis; 12 (80.0%) of 15 were associated with hot tubs or pools. In addition, recreational water outbreaks of leptospirosis, Pontiac fever, and chemical keratitis, as well as two outbreaks of leptospirosis and Pontiac fever associated with occupational exposure were also reported to CDC. The proportion of drinking water outbreaks associated with surface water increased from 11.8% during 1997-1998 to 17.9% in 1999-2000. The proportion of outbreaks (28) associated with groundwater sources increased 87% from the previous reporting period (15 outbreaks), and these outbreaks were primarily associated (60.7%) with consumption of untreated groundwater. Recreational water outbreaks involving gastroenteritis doubled (36 outbreaks) from the number of outbreaks reported in the previous reporting period (18 outbreaks). These outbreaks were most frequently associated with Cryptosporidium parvum (68.2%) in treated water venues (e.g., swimming pools or interactive fountains) and by Escherichia coli O157:H7 (21.4%) in freshwater venues. The increase in the number of outbreaks probably reflects improved surveillance and reporting at the local and state level as well as a true increase in the number of WBDOs. CDC and others have used surveillance data to identify the types of water systems, their deficiencies, and the etiologic agents associated with outbreaks and evaluated current technologies for providing safe drinking water and safe recreational water. Surveillance data are used also to establish research priorities, which can lead to improved water-quality regulations. Only the groundwater systems under the influence of surface water are required to disinfect their water supplies, but EPA is developing a groundwater rule that specifies when corrective action (including disinfection) is required. CDC and EPA are conducting epidemiologic studies to assess the level of waterborne illness attributable to municipal drinking water in nonoutbreak conditions. Rules under development by EPA--the Ground Water Rule (GWR), the Long Term 2 Enhanced Surface Water Treatment Rule (LT2ESWTR), and Stage 2 Disinfection Byproduct Rules (DBPR)--are expected to further protect the public from contaminants and disinfection byproducts in drinking water. Efforts by EPA under the Beaches Environmental Assessment, Closure, and Health (BEACH) program are aimed at reducing the risks for infection attributed to ambient recreational water by strengthening beach standards and testing; providing faster laboratory test methods; predicting pollution; investing in health and methods research; and improving public access to information regarding both the quality of the water at beaches and information concerning health risks associated with swimming in polluted water. EPA's Beach Watch (available at http://www.epa.gov/waterscience/beaches) provides online information regarding water quality at U.S. beaches, local protection programs, and other beach-related programs. CDC partnered with a consortium of local and national pool associations to develop a series of health communication materials for the general public who attend treated recreational water venues and to staff who work at those venues. CDC has also developed a recreational water outbreak investigation toolkit that can be used by public health professionals. All of the CDC materials are accessible at the CDC Healthy Swimming website (http://www.cdc.gov/healthyswimming).MMWR. Surveillance summaries: Morbidity and mortality weekly report. Surveillance summaries / CDC 12/2002; 51(8):1-47.
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ABSTRACT: In the United States, influenza epidemics occur nearly every winter and are responsible for substantial morbidity and mortality, including an average of approximately 114,000 hospitalizations and 20,000 deaths/year. This report summarizes both actively and passively collected U.S. influenza surveillance data from October 1997 through September 2000. During each October-May in the period covered, CDC received weekly reports from 1) approximately 120 World Health Organization (WHO) and National Respiratory and Enteric Virus Surveillance System (NREVSS) collaborating laboratories in the United States regarding influenza virus isolations; 2) approximately 230, 375, and 430 sentinel physicians during 1997-98, 1998-99, and 1999-00, respectively, regarding their total number of patient visits and the number of visits for influenza-like illness (ILI); and 3) state and territorial epidemiologists regarding estimates of local influenza activity. WHO collaborating laboratories also submitted influenza isolates to CDC for antigenic analysis. Throughout the year, the vital statistics offices in 122 cities reported weekly on deaths related to pneumonia and influenza (P&I). During the 1997-98 influenza season, influenza A(H3N2) was the most frequently isolated influenza virus type/subtype. Influenza A(H1N1) and B viruses were reported infrequently. The proportion of respiratory specimens testing positive for influenza peaked at 28% in late January. The longest period of sustained excess mortality (when the percentage of deaths attributed to P&I exceeded the epidemic threshold) was 10 consecutive weeks. P&I mortality peaked at 9.8% in January. Visits for ILI to sentinel physicians exceeded baseline levels for 7 weeks and peaked at 5% in mid-January through early February. A total of 45 state epidemiologists reported regional or widespread activity at the peak of the season. During the 1998-99 season, influenza A(H3N2) viruses predominated; however, influenza B viruses were also identified throughout the United States. Influenza A(H1N1) viruses were identified rarely. The proportion of respiratory specimens testing positive for influenza peaked at 28% in early February. P&I mortality exceeded the epidemic threshold for 12 consecutive weeks and peaked at 9.7% in early March. Visits for ILI to sentinel physicians exceeded baseline levels for 7 weeks and peaked at 5% in early through mid-February. Forty-three state epidemiologists reported regional or widespread activity at the peak of the season. During the 1999-00 season, influenza A(H3N2) viruses predominated, but influenza A(H1N1) and B viruses also were identified. The proportion of respiratory specimens testing positive for influenza peaked at 31% in mid- to late December. The proportion of deaths attributed to P&I exceeded the epidemic threshold for 13 consecutive weeks and peaked at 11.2% in mid-January. Visits to sentinel physicians for ILI exceeded baseline levels 4 consecutive weeks and peaked at 6% in late December. Forty-four state epidemiologists reported regional or widespread activity at the peak of the season. Influenza A(H1N1), A(H3N2), and B viruses circulated during 1997-2000, but influenza A(H3N2) was the most frequently reported virus type/subtype during all three seasons. Influenza A(H3N2) is the virus type/subtype most frequently associated with excess P&I mortality. Influenza activity during all three seasons occurred at moderate to severe levels, and excess P&I mortality was reported during > or = 10 weeks each year. CDC conducts active national surveillance during each October-May to detect the emergence and spread of influenza virus variants and to monitor influenza-related morbidity and mortality. Surveillance data are provided weekly throughout the influenza season to public health officials, WHO, and health-care providers and are used to guide vaccine strain selection, prevention and control activities, and patient care. Influenza vaccination is the most effective means for reducing the yearly effect of influenza. Typically, one or two of the influenza vaccine component viruses are updated each year so that vaccine strains will closely match circulating viruses. Surveillance data will continue to be used to select vaccine strains and to monitor the match between vaccine strains and the currently circulating viruses.MMWR. Surveillance summaries: Morbidity and mortality weekly report. Surveillance summaries / CDC 11/2002; 51(7):1-10.
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ABSTRACT: In 1969, CDC began abortion surveillance to document the number and characteristics of women obtaining legal induced abortions, to monitor unintended pregnancy, and to assist efforts to identify and reduce preventable causes of morbidity and mortality associated with abortions. This report summarizes and reviews information reported to CDC regarding legal induced abortions obtained in the United States in 1998. For each year since 1969, CDC has compiled abortion data by occurrence. From 1973 to 1997, data were received from or estimated for 52 reporting areas in the United States: 50 states, the District of Columbia, and New York City. In 1998, CDC compiled abortion data from only 48 reporting areas; Alaska, California, New Hampshire, and Oklahoma did not report. In 1998, 884,273 legal induced abortions were reported to CDC, representing a 2% decrease from the 900,171 legal induced abortions reported by the same 48 reporting areas for 1997. The abortion ratio, defined as the number of abortions per 1,000 live births, was 264, compared with 274 in 1997 (for the same 48 areas); the abortion rate for these 48 areas was 17 per 1,000 women aged 15-44 years for both 1997 and 1998. The availability of information about characteristics of women who obtained an abortion in 1998 varied by state and by the number of states reporting each characteristic. The total number of legal induced abortions by state is reported by state of residence and state of occurrence; characteristics of women obtaining abortions in 1998 are reported by state of occurrence. Women undergoing an abortion were likely to be young (i.e., age < 25 years), white, and unmarried; slightly more than one half were obtaining an abortion for the first time. Of all abortions for which gestational age was reported, 56% were performed at < or = 8 weeks of gestation, and 88% were performed before 13 weeks. Overall, 19% of abortions were performed at the earliest weeks of gestation (< or = 6 weeks), 18% at 7 weeks, and 19% at 8 weeks. From 1992 (when this information was first collected) through 1998, an increasing percentage of abortions were performed at the very early weeks of gestation. Few abortions were provided after 15 weeks of gestation; 4% were obtained at 16-20 weeks, and 1.4% were obtained at > or = 21 weeks. A total of 24 reporting areas submitted information stating that they performed medical (nonsurgical) procedures (two of these areas categorized medical abortions with "other" procedures), making up < 1% of all procedures reported from all states. From 1993 through 1997 (years for which data have not been published previously and the most recent years for which such data are available), 36 women died as a result of complications from known legal induced abortion, and three deaths were associated with known illegal abortion. The annual case-fatality rate of legal induced abortion ranged from 0.3 to 0.8 abortion-related deaths per 100,000 reported legal induced abortions. From 1990 through 1995, the number of abortions declined each year; in 1996, the number increased slightly, but in 1997, it declined to its lowest level since 1978. In 1998, the number of abortions continued to decrease when comparing the 48 reporting areas. In 1997, as in previous years, deaths related to legal induced abortions occurred rarely. PUBLIC HEALTH ACTIONS TAKEN: The number and characteristics of women who obtain abortions in the United States should continue to be monitored so that trends in induced abortion can be assessed and efforts to prevent unintended pregnancy can be evaluated.MMWR. Surveillance summaries: Morbidity and mortality weekly report. Surveillance summaries / CDC 06/2002; 51(3):1-32.
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ABSTRACT: Various maternal behaviors and experiences before, during, and after pregnancy (e.g., unintended pregnancy, late entry into prenatal care, cigarette smoking, not breast-feeding) are associated with adverse health outcomes for both the mother and the infant. Information regarding maternal behaviors and experiences is needed to monitor trends, to enhance the understanding of the relations between behaviors and health outcomes, to plan and evaluate programs, to direct policy decisions, and to monitor progress toward Healthy People 2000 and 2010 objectives. This report covers data from 1993 through 1999. The Pregnancy Risk Assessment Monitoring System (PRAMS) is an ongoing, state- and population-based surveillance system designed to monitor selected self-reported maternal behaviors and experiences that occur before, during, and after pregnancy among women who deliver a live-born infant. PRAMS employs a mixed-mode data collection methodology; up to three self-administered surveys are mailed to a sample of mothers, and nonresponders are followed up with a telephone interview. Self-reported survey data are linked to selected birth certificate data and weighted for sample design, nonresponse, and noncoverage to create annual PRAMS analysis data sets. PRAMS generates statewide estimates of various perinatal health topics among women delivering a live infant. Data for 1999 from 17 states are examined. In addition, trend data are examined for 12 states that had at least 3 years of data during 1993-1999. In 1999, the prevalence of unintended pregnancy resulting in a live birth ranged from 33.7% to 52% across the 17 states. During 1993-1999, only one state reported a decreasing trend in the prevalence of unintended pregnancy. Women aged <20 years, black women, women with less than or equal to a high school education, and women receiving Medicaid were more likely to report unintended pregnancy. The prevalence of late or no entry into prenatal care ranged from 16.1% to 29.9%. The prevalence of late or no entry into prenatal care significantly decreased over time in seven of the 12 states with trend data. In general, women aged <20 years, black women, women with less than a high school education, and women receiving Medicaid were more likely to report late or no entry into prenatal care. The prevalence of smoking during the last 3 months of pregnancy ranged from 6.2% to 27.2%, and the prevalence decreased in five states from 1993 to 1999. Overall, smoking during the last 3 months of pregnancy was associated with younger age (<25 years), non-Hispanic ethnicity, having less than or equal to a high school education, receiving Medicaid, and delivering a low birthweight infant. The prevalence of physical abuse by a husband or partner during pregnancy ranged from 2.1% to 6.3%. No trends were observed for physical abuse from 1996 to 1999, the only years for which these data were available. Across the 17 states, only Medicaid status was consistently associated with experiencing physical abuse during pregnancy. The prevalence of breast-feeding initiation ranged from 48% to 89%. Ten of 12 states with trend data reported increases in the prevalence of breast-feeding initiation. Overall, women aged <20 years, women with less than or equal to a high school education, and women receiving Medicaid were less likely to breast-feed. The prevalence of breast-feeding duration for at least 4 weeks ranged from 34.9% to 78.1%. From 1993 to 1999, increases in levels of breast-feeding for at least 4 weeks were observed in eight states. Women aged <25 years, black women, women with less than or equal to a high school education, and women receiving Medicaid were generally less likely to breast-feed for at least 4 weeks. The prevalence of back sleep position for infants ranged from 35.1% to 74.6%. Increases in the use of the back sleep position were observed in all 12 states with trend data from 1996 to 1999. Black race and having less than or equal to a high school education were consistently associated with not using the back sleep position. For surveillance during 1993-1999, the majority or all states observed increases in breast-feeding initiation, breast-feeding for at least 4 weeks, and back sleep position. Approximately one half of the states observed decreases for late or no entry into prenatal care and smoking during the last 3 months of pregnancy. Little or no progress was observed in the prevalence of unintended pregnancy or physical abuse during pregnancy. With few exceptions, the 17 states failed to meet the Healthy People 2000 objectives for the seven reported behaviors in 1999. Certain deMMWR. Surveillance summaries: Morbidity and mortality weekly report. Surveillance summaries / CDC 05/2002; 51(2):1-27.
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ABSTRACT: Malaria is caused by four species of intraerythrocytic protozoa of the genus Plasmodium (i.e., P. falciparum, P. vivax, P. ovale, or P. malariae). Malaria is transmitted by the bite of an infective female Anopheles sp. mosquito. The majority of malaria infections in the United States occur in persons who have traveled to areas with ongoing transmission. In the United States, cases can occur through exposure to infected blood products, by congenital transmission, or locally through mosquitoborne transmission. Malaria surveillance is conducted to identify episodes of local transmission and to guide prevention recommendations for travelers. Cases with onset of illness during 1999. Malaria cases confirmed by blood films are reported to local and state health departments by health-care providers or laboratory staff. Case investigations are conducted by local and state health departments, and reports are transmitted to CDC through the National Malaria Surveillance System (NMSS). Data from NMSS serve as the basis for this report. CDC received reports of 1,540 cases of malaria with an onset of symptoms during 1999 among persons in the United States or one of its territories. This number represents an increase of 25.5% from the 1,227 cases reported for 1998. P. falciparum, P. vivax, P. malariae, and P. ovale were identified in 46.0%, 30.7%, 4.6%, and 3.6% of cases, respectively. More than one species was present in 12 patients (0.8% of total). The infecting species was unreported or undetermined in 223 (14.5%) cases. The number of reported malaria cases acquired in Africa increased 27.6% (n = 901), compared with 1998, and an increase of 2.9% (n = 246) occurred in cases acquired in Asia, compared with 1998. Cases from the Americas increased by 19.7% (n = 274) from 1998. Of 831 U.S. civilians who acquired malaria abroad, 159 (19.1%) reported that they had followed a chemoprophylactic drug regimen recommended by CDC for the area to which they had traveled. Three patients became infected in the United States, all through probable local mosquitoborne transmission. Five deaths were attributed to malaria, all caused by P. falciparum. The 25.5% increase in malaria cases in 1999, compared with 1998, resulted primarily from increases in cases acquired in Africa and the Americas. This increase is possibly related to a change in the system by which states report to CDC, but it could also have resulted from local changes in disease transmission, increased travel to these regions, improved reporting to state and local health departments, or a decreased use of effective antimalarial chemoprophylaxis. In the majority of reported cases, U.S. civilians who acquired infection abroad were not on an appropriate chemoprophylaxis regimen for the country where they acquired malaria. Additional information was obtained concerning the five fatal cases and the three infections acquired in the United States. The NMSS surveillance form was modified to gather more detailed information regarding compliance with prescribed chemoprophylaxis regimens. Persons traveling to a malarious area should take one of the recommended chemoprophylaxis regimens appropriate to the region of travel, and travelers should use personal protection measures to prevent mosquito bites. Any person who has been to a malarious area and who subsequently develops a fever or influenza-like symptoms should seek medical care immediately; investigation should include a blood-film test for malaria. Malaria infections can be fatal if not diagnosed and treated promptly. Recommendations concerning prevention of malaria can be obtained from CDC.MMWR. Surveillance summaries: Morbidity and mortality weekly report. Surveillance summaries / CDC 04/2002; 51(1):15-28.
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ABSTRACT: Asthma, a chronic disease occurring among both children and adults, has been the focus of clinical and public health interventions during recent years. In addition, CDC has outlined a strategy to improve the timeliness and geographic specificity of asthma surveillance as part of a comprehensive public health approach to asthma surveillance. This report presents national data regarding self-reported asthma prevalence, school and work days lost because of asthma, and asthma-associated activity limitations (1980-1996); asthma-associated outpatient visits, asthma-associated hospitalizations, and asthma-associated deaths (1980-1999); asthma-associated emergency department visits (1992-1999); and self-reported asthma episodes or attacks (1997-1999). CDC's National Center for Health Statistics (NCHS) conducts the National Health Interview Survey annually, which includes questions regarding asthma and asthma-related activity limitations. NCHS collects physician office-visit data in the National Ambulatory Medical Care Survey, emergency department and hospital outpatient data in the National Hospital Ambulatory Medical Care Survey, hospitalization data in the National Hospital Discharge Survey, and death data in the Mortality Component of the National Vital Statistics System. During 1980-1996, asthma prevalence increased. Annual rates of persons reporting asthma episodes or attacks, measured during 1997-1999, were lower than the previously reported asthma prevalence rates, whereas the rates of lifetime asthma, also measured during 1997-1999, were higher than the previously reported rates. Since 1980, the proportion of children and adults with asthma who report activity limitation has remained stable. Since 1995, the rate of outpatient visits and emergency department visits for asthma increased, whereas the rates of hospitalization and death decreased. Blacks continue to have higher rates of asthma emergency department visits, hospitalizations, and deaths than do whites. Since the previous report in 1998 (CDC. Surveillance for Asthma--United States, 1960-1995. MMWR 1998;47[No. SS-1]:1-28), changes in asthma-associated morbidity and death have been limited. Asthma remains a critical clinical and public health problem. Although data in this report indicate certain early indications of success in current asthma intervention programs (e.g., limited decreases in asthma hospitalization and death rates), the continued presence of substantial racial disparities in these asthma endpoints highlights the need for continued surveillance and targeted interventions.MMWR. Surveillance summaries: Morbidity and mortality weekly report. Surveillance summaries / CDC 04/2002; 51(1):1-13.
- MMWR. Surveillance summaries: Morbidity and mortality weekly report. Surveillance summaries / CDC 01/1997;
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