
From <@uga.cc.uga.edu:owner-mednews@ASUACAD.BITNET> Mon Mar 6 10:50:22 
1995
 with BSMTP id 0681; Mon, 06 Mar 95 10:44:35 EST
UGA.CC.UGA.EDU
(LMail V1.2a/1.8a) with BSMTP id 1978; Mon, 6 Mar 1995 09:16:58 -0500
 <MEDNEWS%ASUACAD.BITNET@uga.cc.uga.edu>
<MEDNEWS%ASUACAD.BITNET@uga.cc.uga.edu>


HICNet Medical News Digest Mon, 06 Mar 1995 Volume 08 : 
Issue 05

Today's Topics:

 FDA warning"BAMBA SNAC
 Fertility Drugs
 Hepatitis Vaccine Lice
 Pacemaker Leads
 Natures Nutrition Form
 Rules For Spermicides
 Treatment Pancreatic C
 FDA Pesticides Program
 [MMWR] Prevention Program for Reducing Risk for Neural Tube Defects
 [MMWR] Use of Safety Belts -- Madrid Spain
 [MMWR] Monthly Immunization Table
 [MMWR] Vaccination Coverage of 2-year old children
 [MMWR Feb 27, '95] Serogroup B Meningococcal Disease

 +------------------------------------------------+
 ! !
 ! Health Info-Com Network !
 ! Medical Newsletter !
 +------------------------------------------------+
 Editor: David Dodell, D.M.D.
 10250 North 92nd Street, Suite 210, Scottsdale, Arizona 85258-4599 
USA
 Telephone +1 (602) 860-1121
 FAX +1 (602) 451-1165
 Internet: mednews@stat.com
 Bitnet: ATW1H@ASUACAD

 Mosaic WWW
*Asia/Pacific:
 http://biomed.nus.sg/MEDNEWS/welcome.html
*Americas:
 http://cancer.med.upenn.edu:3000/
*Europe:
 
http:/www.dmu.ac.uk/0/departments/pharmacy/archive/www/MEDNEWS/welcome.h
tml

Compilation Copyright 1994 by David Dodell, D.M.D. All rights 
Reserved.
License is hereby granted to republish on electronic media for which 
no
fees are charged, so long as the text of this copyright notice and 
license
are attached intact to any and all republished portion or portions.

The Health Info-Com Network Newsletter is distributed biweekly. 
Articles
on a medical nature are welcomed. If you have an article, please 
contact
the editor for information on how to submit it. If you are interested 
in
joining the automated distribution system, please contact the editor.

 Associate Editors:

E. Loren Buhle, Jr. Ph.D. Dept. of Radiation Oncology, Univ of 
Pennsylvania

 Tom Whalen, M.D., Robert Wood Johnson Medical School at Camden

 Douglas B. Hanson, Ph.D., Forsyth Dental Center, Boston, MA

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

 Dr K C Lun, National University Hospital, Singapore

 W. Scott Erdley, MS, RN, SUNY@UB School of Nursing

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

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

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

 Subscription Requests = mednews@stat.com
 anonymous ftp = vm1.nodak.edu; directory HICNEWS
 FAX Delivery = Contact Editor for information


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

To: hicnews

 FDA WARNING AGAINST CONSUMING "BAMBA SNACKS WITH PEANUTS"

 FDA is issuing a national warning against purchasing or
consuming "Bamba Snacks with Peanuts" manufactured by OSEM Food
Industries Ltd. of Tel Aviv, Israel, because this kosher snack
product has been associated with outbreaks of Salmonella agona in
Europe. FDA is issuing this warning as a precautionary measure,
since it is not known how widely the product is distributed in
the U.S., or whether the product in the U.S. is similarly
contaminated.
 Salmonella agona is an organism which can cause serious and
sometimes fatal infections in small children, frail or elderly
people, and others with weakened immune systems. Healthy
individuals may only suffer short-term symptoms such as high
fever, severe headache, vomiting, nausea, abdominal pain and
diarrhea. Long term complications can include debilitating
arthritis.
 Since December 1, 1994, authorities in England and Wales
have reported 27 cases of Salmonella agona infection in children
under ten years of age who have consumed this snack product.
Authorities in Austria, Germany and Sweden have also reported
similar cases. No cases have yet been reported in the U.S.
 Laboratory examinations of some of the product conducted by
health authorities in the United Kingdom have confirmed the
the presence of the organism. Efforts to recall the product have
been initiated in the United Kingdom and other countries.
 FDA and the U.S. Centers for Disease Control and Prevention
are working to determine whether contaminated product has been
distributed in the U.S. and the extent to which it poses a public
health threat in this country. In the meantime, consumers who
may have this product are urged not to consume it, but to instead
contact their local FDA office.

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

To: hicnews

 AVAILABILITY OF FERTILITY DRUGS

 We are receiving inquiries concerning the shortage of two
fertility drugs, Pergonal and Metrodin. Both drugs are
manufactured by Serono Laboratories Inc. in Switzerland. Recent
decisions by Serono on the manufacture of these products have
adversely affected worldwide supplies. The following may be used
to answer questions about steps being taken by FDA and the
manufacturer to increase the supply.
 Fertility drugs are used to treat certain types of infertility
in women, and are often prescribed to correct a woman's hormone
imbalance and stimulate ovulation.
 FDA is discussing with Serono how to expedite the return of
these drugs to the United States market. FDA will consider an
additional manufacturing facility application so that production of
the drugs can be resumed.
 In letters issued in December l994 to health professionals and
distributors, Serono said it will reserve the remaining stocks of
the drugs for patients who are currently receiving treatment. If
a doctor has a patient who is in midcycle and has run out of her
drug supply, the doctor can request an additional supply by
contacting Serono's customer service department at 1-800-283-8088.
 FDA approved the infertility drug Humegon manufactured by
Organon Inc., of West Orange, N.J., in September l994. Organon has
agreed to FDA's request to make their drug available and will
release limited quantities soon.
 If doctors cannot obtain the necessary drugs from Serono or
Organon, FDA will not object if patients working closely with their
doctors temporarily import the drugs for personal use from an
alternative source. Unless it is medically necessary, however,
doctors should wait to begin treating new patients until the supply
of approved drugs has increased.
 Serono's U.S. headquarters are located in Norwell, Mass.

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

To: hicnews

 FDA LICENSES HEPATITIS A VACCINE
 We have been receiving inquiries about FDA's licensure of a
hepatitis A vaccine -- the first available to prevent this highly
contagious viral disease. The following may be used to answer
questions.
 More than 23,000 cases of hepatitis A were officially reported
in the United States in 1992, although 100,000 to 150,000 Americans
are estimated to be infected each year.
 Hepatitis A generally is spread by contaminated food or water
and by close personal contact with an infected individual. The
disease can also be contracted by consuming raw or undercooked
shellfish harvested from contaminated waters.
 Outbreaks of hepatitis A sometimes occur in institutional
settings including day-care centers and facilities that house
intellectually impaired children and adults. Military personnel
living in field conditions, crowded barracks and high-risk
geographic areas also are at higher risk for the disease.
Hepatitis A is especially prevalent in developing countries that
have poor sanitary systems and standards of hygiene.
 The new vaccine's effectiveness was demonstrated in a clinical
trial conducted in Thailand under the auspices of the U.S. Armed
Forces Research Institute for Medical Sciences and the Thai
government. In this study, in which more than 19,000 Thai school
children were given the vaccine, the effectiveness rate of the
product was 84 percent.
 Adverse reactions were mild and included redness, hardness and
swelling at the injection site, fatigue, fever, malaise and nausea.
 The vaccine is indicated for international travelers, people
living in or relocating to areas where the disease is endemic, some
military personnel, and certain high-risk individuals such as some
hospital and laboratory personnel.
 On Jan. 28, 1994, FDA's Vaccines and Related Biological
Products Advisory Committee reviewed the safety and efficacy of the
vaccine and recommended approval for use in selected groups
including travelers, the military and laboratory workers.
 The new vaccine is manufactured by SmithKline Beecham of
Philadelphia, Pa., under the trade name Havrix.
 The official date of licensure is Feb. 22, 1995.

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

To: hicnews

 TELECTRONICS PACEMAKER LEADS

 The Food and Drug Administration today is advising doctors
and their patients with certain pacemakers to check their lead
wire for a possible fracture that could result in severe heart
injury or death. If the wire is found to be defective, the
patients and their doctors need to consult about what medical
action is needed.
 The faulty pacemakers are equipped with Accufix atrial "J"
lead wires models 330-801 and 329-701 that were manufactured by
Telectronics Pacing Systems in Englewood, Colo., and implanted in
patients in the United States from 1988 to 1994. Another model,
330-812, which also has been reported as prone to fracture, was
distributed only abroad.
 FDA is advising the doctors of the estimated 25,000 patients
with these models to use fluoroscopy or similar procedures to
determine whether the leads have fractured.
 If a fractured wire is detected, doctors can decide to
replace it or leave it in place and monitor it by fluoroscope.
Most fractured wires are not medical emergencies.
 Following reports of the fractures, Telectronics last
November told hospitals to stop implanting the devices, recalled
the unused products and notified FDA about the problems.
 Today, the manufacturer is sending a letter to doctors
requesting them to contact all patients with the affected leads
and advising on their best treatment. In addition, the firm plans
to contact directly all users of the recalled devices.
 The "J" lead wire contains a coiled electric cable and a
flat, 3 1/2 inch long wire that helps the lead keep its shape.
When the flat wire breaks the conductivity of the lead is not
affected and the pacemaker will continue to function. The flat
wire, however, can protrude through its polyurethane coating and
cut the heart wall or the aorta, thereby causing severe internal
hemorrhage.
 It has not yet been determined how many of the involved
wires are likely to break although preliminary estimates, based
on the manufacturer's analysis, suggest a 12 percent fracture
rate. As of Jan. 14, 1995, 110 confirmed or suspected fractures
have been reported, resulting in two deaths and seven serious
injuries.
 There are more than one million pacemaker patients in the
United States. The "J" leads are used only with dual chamber
pacemakers, although a few patients with single chamber
pacemakers may have had an Accufix "J" lead implanted in case it
was needed later.

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

To: hicnews

 FDA WARNS CONSUMERS AGAINST NATURE'S NUTRITION FORMULA ONE

 The Food and Drug Administration is warning consumers
not to purchase or consume Nature's Nutrition Formula One
products labeled as containing Ma huang (ephedrine) and kola nut
because the product poses a risk to consumers' health. The
products are sold by Alliance U.S.A. of Richardson, Texas.
 FDA has determined that the products can cause severe
injury or death in some people who consume them.
 Nature's Nutrition Formula One is labeled as a dietary
supplement and has been marketed with labeling purporting that it
is useful for weight loss and energy enhancement.
 The potentially dangerous products can be identified by the
listing of Ma huang and kola nut as ingredients and the
appearance of either of the following usage statements on the
label: "Adult Food Supplement Take 1 to 3 capsules at 10:00 AM &
3:00 PM," or "Adult food supplement: one to two capsules mid-
morning and mid-afternoon."
 FDA has received more than 100 reports of injuries and
adverse reactions related to the product during the past year.
Reported reactions range from serious, life-threatening
conditions such as irregular heartbeat, heart attack, stroke,
seizures, hepatitis and psychosis, to relatively minor and
 temporary conditions such as dizziness, headache and
gastrointestinal distress. Several deaths have been associated
with the product.
 FDA and outside medical experts have determined that the
products represent a threat to health because the combination of
Ma huang, a source of ephedrine, and kola nut, a source of
caffeine, can cause severe injury to people even under conditions
of usual or recommended use. Ephedrine is an amphetamine-like
chemical that acts as a stimulant in the body.
 In November 1994, FDA informed Alliance that Nature's
Nutrition Formula One posed a potential health hazard and was in
violation of federal laws designed to protect the public health.
After inadequate response from Alliance, the agency asked the
company to recall the products. Because the company to date has
failed to recall its potentially dangerous products, FDA is
issuing today's warning as a matter of public health protection.
 At this time, FDA's warning is limited to versions of
Nature's Nutrition Formula One that contain both Ma huang and
kola nut. The company has advised FDA that it has reformulated
its product to remove the kola nut. This warning does not apply
to the reformulated version of the product. The agency is
continuing to evaluate the safety of ephedrine-containing
products produced or distributed by Alliance U.S.A. and other
companies.

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

To: hicnews

 RULES PROPOSED FOR SPERMICIDES

 FDA today published a proposed rule that would ask
manufacturers of over-the-counter spermicide products to submit
data demonstrating that the final formulations of the products are
effective as contraceptives. The agency has already concluded that
the active ingredients in marketed spermicides generally are safe,
but their effectiveness in final product formulations is highly
variable. Therefore, the agency is proposing that manufacturers
submit new drug applications for all individual spermicide
products.
 The following can be used to answer questions.
 Spermicide contraceptives are available in foam, gel, cream,
film and suppository formulations. They work by forming a physical
and chemical barrier to sperm in the vagina. The active ingredient
in most products is nonoxynol-9; some products contain octoxynol-9.
 There is evidence that some formulations of spermicide
products can lose effectiveness during use. For this reason FDA
believes that clinical data are needed to ensure that over-the-
counter spermicide products remain effective as contraceptives
during actual use.
 Vaginal contraceptives also are sometimes associated with
vaginal irritation, which may play a role in transmission of
sexually transmitted diseases. Therefore the proposal asks
manufacturers to collect information on the occurrence of vaginal
irritation during the clinical trials on their products, and to
present these data as part of the NDA.
 Although the proposal is not intended to cover claims for
prevention of sexually transmitted diseases (STDs) including HIV,
the agency strongly encourages manufacturers to evaluate products
for prevention of infectious diseases. While none of these
products currently has an approved indication for prevention of
STDs, FDA is aware of literature reports and other data suggesting
they may play a role. Separate clinical trials need to be conducted
before such claims could be made for the products. Manufacturers
have been asked to consult with the agency on the data
requirements.
 Marketing status of over-the-counter spermicide products would
not be immediately affected by the proposed rule. To assure
continued availability of affected products after a final rule is
published, FDA is encouraging manufacturers to contact the agency
as soon as possible so that clinical studies can be conducted and
applications approved as quickly as feasible.
 Products that fail to meet the requirements of the final rule
would be considered unapproved new drugs and subject to regulatory
action.
 Comments on the proposal may be sent within 120 days to
Dockets Management Branch (HFA-305), Food and Drug Administration,
Rm. 1-23, 12420 Parklawn Drive, Rockville, Md. 20857.

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

To: hicnews

 FDA AUTHORIZES TREATMENT IND FOR ADVANCED PANCREATIC CANCER


 

(Continued from last message)

 FDA has authorized a treatment IND (investigational new drug)
for gemcitabine HCL for patients with advanced pancreatic cancer
who are not candidates for surgery. The following can be used to
answer questions.
 FDA's treatment IND regulations offer a mechanism that allows
drug developers to provide earlier and wider access to
investigational therapies for patients with immediately life-
threatening or otherwise serious diseases for which there is no
satisfactory alternative treatment, while review of the new drug
application for the same indication is completed.
 About 27,000 people in the United States were diagnosed with
pancreatic cancer in l994. Pancreatic cancer is generally
asymptomatic until late in the course of the disease. It is among
the most difficult cancers to treat and is rarely curable.
 FDA authorized the treatment IND for gemcitabine to provide a
promising treatment of locally advanced or metastatic pancreatic
cancer. Patients may have had either one prior chemotherapy
regimen or none. No therapies have been approved specifically for
this disease.
 A preliminary review by FDA of two clinical trials of
gemcitabine suggests that it may have some effectiveness in the
treatment of this disease. The sponsor, Eli Lilly and Co. of
Indianapolis, Ind., carried out two trials in patients with
pancreatic cancer, one a comparison with 5 fluorouracil (5-FU) in
previously untreated patients; the other a study in 5-FU failures.
The studies measured tumor shrinkage, survival and an overall
estimate of clinical benefit (pain and ability to function).
 Both studies showed a small rate of tumor shrinkage (about 7
percent); there was a small (about one and a half months)
improvement in median survival in the study comparing gemcitabine
with 5-FU. In both studies gemcitabine treated patients
experienced an approximately 25 percent rate of clinical response.
The 1 year survival rates in the comparative trial were 18 percent
and 2 percent for gemcitabine and 5-FU respectively.
 A second phase II trial included patients who had not
responded to 5-FU treatment. Symptoms improved in 27 percent of
patients, with a median survival time of 3.85 months and a one year
survival rate of 4 percent. A partial response rate (50 percent or
greater decrease in tumor size) was observed in 7.9 percent with
disease stabilization reported in 31.7 percent.
 The major side effects of gemcitabine included neutropenia, a
decrease in white blood cells, which increases susceptibility to
infection; thrombocytopenia, a decrease in blood platelets, which
can cause excessive bleeding; and elevation of liver enzymes.
Nausea, vomiting, rash, flu-like symptoms, breathing difficulties
and traces of blood and protein in the urine have been reported.
Rarely, hemolytic-uremic syndrome (anemia associated with kidney
failure) was reported.
 The drug is manufactured under the trade name Gemzar.

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

To: hicnews

 FDA PESTICIDES PROGRAM

 FDA has been receiving inquiries about its pesticide residue
monitoring program in light of a recently released report prepared
by the Environmental Working Group, a public advocacy group based
in Washington, D.C. The following may be used to answer questions.
 The FDA is committed to reducing the risks associated with
pesticides for all Americans, and especially to ensuring
appropriate protection for children. After reviewing portions of
the report in draft and a draft executive summary, FDA believes
that the draft materials reviewed include constructive
recommendations for increasing public health protection against
potentially harmful pesticide residues on food.
 Specific examples include:
o controlling residue through a Hazard Analysis Critical Control
 Points (HACCP) approach. HACCP principles have been
 successfully adopted by the U.S. seafood industry, and FDA is
 seeking comments about extending HACCP principles to other
 segments of the food industry
o improving record keeping
o reducing use of pesticides
o enhancing computer availability of EPA tolerance information.
 Nevertheless, other recommendations in the report -- such as
the suggestion that all food shipments be sampled and tested for
pesticides -- are impractical and are likely to prove unworkable.
 Unfortunately, the report itself exhibits two fundamental
shortcomings: it overstates the incidence of illegal pesticide
residues in domestic and imported foods, and it fails to represent
accurately the effectiveness of the FDA's residue monitoring
program.
 The EWG's report seems to misinterpret the complex data FDA
gathers on pesticide residues. In reviewing FDA's data, the EWG
has apparently interpreted every finding of both "trace" and very
low level pesticide residues as intentional violations of U.S.
pesticide tolerances -- the allowable levels established by the
Environmental Protection Agency and enforced by FDA.
 This approach skews the data, inflating purported violation
rates and suggesting adverse public health consequences when in
fact the potential risk is extremely low or even nil.
 Findings of "trace" levels arise when FDA analysis of fresh or
processed food shows a slight "blip" on the chromatogram, a finding
that could simply represent a so-called false positive.
 In such cases, FDA cannot state with certainty what pesticide
may be present, or even whether any pesticide is present. These
trace levels are not violations of the law. If the FDA were to
contemplate any regulatory action in such cases, it would have to
confirm the possible trace residue with a "check analysis" --
another, separate, test performed by a different analyst.
 In other cases, if an extremely low level of illegal pesticide
residue can be measured, FDA considers that produce sample positive
and an apparent violation of the law.
 In affording "trace" or "apparent violation" figures the same
regulatory and public health significance as clearly intentional
pesticide residue violations, the EWG report does not advance the
important public policy discussion of pesticide residues in food.
 The FDA's extensive monitoring program for pesticide residues
in foods, both domestic and imported, has repeatedly demonstrated
that the overall incidence of illegal pesticides in food is low:
about one percent for domestically produced foods, approximately
three to five percent for imported foods. These violation rates
have remained consistently low for the last decade or so.
 FDA's pesticide monitoring shows that foods do contain low
levels of pesticide residues, generally in the parts-per-billion
range. These residues are nearly always well below the EPA
tolerances, which are based on conservative estimates of risk.
Moreover, FDA's violation rate estimates are quite consistent with
those of the U.S. Department of Agriculture's Pesticide Data
Program, and with those of other states.
 Finally, the FDA measures pesticide residues in another way
besides direct sampling of food. The FDA's Total Diet Study
measures the actual dietary intake of food as U.S. consumers
actually eat it -- ready for the table. FDA buys "market baskets"
of food around the U.S. and ships the food to one location, where
it is prepared according to home recipes and then analyzed for
pesticide residues.
 The Total Diet Study, which includes restaurant food, has
consistently shown that the actual dietary intake of pesticide
residues by Americans is less than one percent of the levels deemed
safe by the World Health Organization.
 To further reduce risks from pesticides, the EPA, the USDA,
and the FDA are working on the recommendations of the 1993 National
Academy of Sciences report on pesticides in the diets of infants
and children. By 1997, a National Pesticide Residue Database,
designed to consolidate the extensive pesticide residue monitoring
data from industry and government, is expected to be in place. FDA
and USDA are also cooperating to organize the National Laboratory
Accreditation Program, which will enhance the quality of residue
data from laboratories around the country.
 The FDA welcomes independent review of findings from its
pesticide residue monitoring program. Reports summarizing FDA's
pesticide residue program are available from FDA Public Affairs
(202-205-4144). The residue data on which these summaries are
based are available for a fee from the National Technical
Information Service (703-487-4650).

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

To: hicnews
Defects

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

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

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

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

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


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

To: hicnews

 Use of Safety Belts -- Madrid, Spain, 1994

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

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

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


 

(Continued from last message)

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

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

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

* 57 FR 28899-904.


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

To: hicnews

 Monthly Immunization Table

 To track progress toward achieving the goals of the Childhood
Immunization Initiative (CII), CDC publishes monthly a tabular summary 
of
the number of cases of all diseases preventable by routine childhood
vaccination reported during the previous month and year-to-date
(provisional data). In addition, the table compares provisional data 
with
final data for the previous year and highlights the number of reported
cases among children aged less than 5 years, who are the primary focus 
of
CII. Data in the table are derived from CDC's National Notifiable 
Diseases
Surveillance System.


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

To: hicnews

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

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

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

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

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

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


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

To: hicnews

 Serogroup B Meningococcal Disease -- Oregon, 1994

 In Oregon, the incidence of meningococcal disease has increased
substantially, more than doubling from 2.2 cases per 100,000 persons in
1992 to 4.6 per 100,000 in 1994--the highest incidence in Oregon since
1943. This incidence was almost fivefold higher than recent estimates 
for
the United States during 1989-1991 (approximately one case per 100,000
persons annually) (1). This report describes meningococcal disease
surveillance data from 1994 and summarizes epidemiologic and laboratory
data on serogroup B meningococcal disease in Oregon during 1987-1994.
 During 1994, a total of 143 cases of meningococcal disease was
reported to the State Health Division. In 124 cases, Neisseria 
meningitidis
was isolated from a normally sterile site (confirmed cases); in four 
cases,
gram-negative diplococci were detected in specimens obtained from a
normally sterile site or in persons who had classic symptoms after 
contact
with a confirmed case (presumed cases). Characteristic symptoms 
(including
petechial rash and hypotension) occurred in 14 cases; however, these 
cases
were not culture confirmed (suspected cases). Of 115 isolates for which
serogroup was known, 70 (61%) were serogroup B, 40 (35%) were serogroup 
C,
four were serogroup Y, and one was serogroup W-135. When compared with 
1992
and 1993, the serogroup-specific incidence in 1994 was higher for both
serogroups B and C.
 Of the 70 culture-confirmed cases of serogroup B infection, 34 
(49%)
occurred in females. Seven (10%) cases were fatal; of these, one 
occurred
in a child aged 2 years, and four deaths occurred in persons aged 55-88
years.
 During 1987-1992, 63% (84 of 133) of cases of serogroup B occurred 
in
children aged less than 5 years; in comparison, in 1994, 27% (19 of 70)
occurred in this age group. When compared with 1987-1992, the incidence 
of
reported serogroup B disease in 1994 increased modestly among those aged
less than 5 years (from 6.9 to 8.4), approximately 14-fold among those 
aged
15-19 years (from 0.4 to 5.4), and approximately fourfold among those 
aged
greater than or equal to 60 years (from 0.3 to 1.1) (Figure 1).
 In 1994, serogroup B cases occurred in 17 of the 36 counties in
Oregon; these counties account for 83% of the total population of 
Oregon.
The risk for disease was highest in counties in the Willamette Valley in
the northwestern part of the state. Based on investigation of serogroup 
B
cases, six (9%) were linked to other cases. Two co-primary cases 
(disease
in a close contact within 24 hours of disease onset in a primary case) 
were
linked to a single primary case. Four secondary cases (disease in a 
close
contact greater than 24 hours after disease onset in a primary case) 
were
identified; at least two occurred in patients for whom appropriate
chemoprophylaxis had been prescribed but who were noncompliant with
therapy.
 Of the 114 N. meningitidis serogroup B strains isolated in Oregon
during 1993-1994, a total of 64 (56%) has been characterized at CDC by
multilocus enzyme electrophoresis. Of these, 55 (86%) belong to the 
enzyme
type-5 (ET-5) complex, a group of genetically related serogroup B
meningococcal strains associated with epidemic meningococcal disease in
other countries (2). Twelve of these isolates also have been serotyped,
serosubtyped, and immunotyped; all are serotype 4 or 15, serosubtype
P1.7,16, and immunotype L3,7,9,8,10.

Reported by: K Hedberg, MD, F Hoesly, MD, D Fleming, MD, State
Epidemiologist, State Health Div, Oregon Dept of Human Resources. K
Steingart, MD, Southwest Washington Health District; M Goldoft, MD, P
Stehr-Green, DrPH, State Epidemiologist, Washington Dept of Health. Div 
of
Field Epidemiology, Epidemiology Program Office; Childhood and 
Respiratory
Diseases Br, Div of Bacterial and Mycotic Diseases, National Center for
Infectious Diseases, CDC.

Editorial Note: The recent increased occurrence of serogroup B
meningococcal disease in Oregon has been associated with a group of 
closely
related strains belonging to the ET-5 clonal complex. These strains were
first identified as the cause of a serogroup B meningococcal epidemic in
Norway that began in 1974 and persisted through 1991 (3). After its
identification in 1974, serogroup B meningococci belonging to the ET-5
complex subsequently caused epidemics in Europe, Cuba, and South America
(2). Endemic meningococcal disease typically is caused by a 
heterogeneous
mix of strains. In comparison, the predominance of closely related 
strains,
or clones, in Oregon is characteristic of epidemic disease, as is the
disproportionate increase in age-specific incidence among young adults. 
The
latter pattern has been suggested as a reliable predictor of the 
transition
from endemic to epidemic meningococcal disease (4,5).
 Although serogroup C meningococcal outbreaks have occurred with
increasing frequency nationwide since 1991 (6), Oregon is the only state
to report substantially increased rates of serogroup B meningococcal
disease. While Washington state had only a slight increase in the 
overall
rate of meningococcal disease in 1994, rates of serogroup B 
meningococcal
disease in Clark County, Washington (1994 population: 280,800) (across 
the
Columbia River from metropolitan Portland, Oregon), have increased 
almost
fivefold (from 1.5 per 100,000 in 1987 to 7.1 per 100,000 in 1994). 
These
increasing rates underscore the need for determining the serogroup of 
all
isolates to assist in assessing trends in the occurrence of 
meningococcal
disease and serogroup distribution of invasive N. meningitidis in other
states.
 The primary means for the control and prevention of serogroup B
meningococcal disease is chemoprophylaxis of close contacts. The
meningococcal vaccine licensed in the United States provides protection
against serogroups A, C, Y, and W-135 but does not provide protection
against serogroup B meningococcal disease. Meningococcal capsular
polysaccharides determine serogroup and are used in purified form to
produce the A/C/Y/W-135 vaccine. Unlike the other major meningococcal
serogroups, however, serogroup B capsular polysaccharide is poorly
immunogenic in humans. Alternate approaches to the development of a
serogroup B meningococcal vaccine have focused on use of outer-membrane
proteins from specific epidemic serogroup B meningococcal strains.
 Three outer-membrane protein-based serogroup B meningococcal 
vaccines
employing two-dose regimens have been effective among older children and
young adults in large clinical trials outside the United States (7-9);
estimated efficacies ranged from 57% to 83%. The only vaccine available
commercially is not licensed for use in the United States but has been 
used
in some South American countries to control serogroup B meningococcal
epidemics. In Sao Paulo, Brazil, approximately 2.4 million children aged


 

(Continued from last message)
3 months to 6 years were vaccinated during 1989 and 1990, and the 
vaccine
was estimated to be 74% effective in children aged 4-6 years (10). 
Efforts
to initiate studies in the United States to evaluate available vaccines
under an investigational new drug application are in progress.
 Oregon and three other states (California, Connecticut, and 
Minnesota)
are participating in a cooperative agreement with CDC to study emerging
infectious diseases. One focus of this program in Oregon is disease 
caused
by N. meningitidis serogroup B; a study of potentially modifiable risk
factors for meningococcal disease is under way.

References
1. Jackson LA, Wenger JD, Meningococcal Disease Study Group.
Laboratory-based surveillance for meningococcal disease in selected 
areas,
United States--1989-1991. In: CDC surveillance summaries (June). MMWR
1993;42(no. SS-2):21-30.
2. Caugant DA, Froholm LO, Bovre K, et al. Intercontinental spread of a
genetically distinctive complex of clones of Neisseria meningitidis 
causing
epidemic disease. Proc Natl Acad Sci U S A 1986;83:4927-31.
3. Lystad A, Aasen S. The epidemiology of meningococcal disease in 
Norway,
1975-91. NIPH Ann 1991;14:57-66.
4. Peltola H, Kataja JM, Makela PH. Shift in the age-distribution of
meningococcal disease as predictor of an epidemic? Lancet 1982;2:595-7.
5. Jones DM, Mallard RH. Age incidence of meningococcal infection 
England
and Wales, 1984-1991. J Infect 1993;27:83-8.
6. Jackson LA, Schuchat A, Reeves MW, Wenger JD. Serogroup C 
meningococcal
outbreaks in the United States: an emerging threat. JAMA 1995;273:383-
94.
7. Sierra GVG, Campa HC, Varcacel NM, et al. Vaccine against group B
Neisseria meningitidis: protection trial and mass vaccination results in
Cuba. NIPH Ann 1991;14:195-207.
8. Bjune G, Hoiby EA, Gronnesby JK, et al. Effect of outer membrane 
vesicle
vaccine against group B meningococcal disease in Norway. Lancet
1991;338:1093-6.
9. Boslego JB, Garcia J, Cruz C, et al. Efficacy, safety, and
immunogenicity of a meningococcal group B (15:P1.3) outer membrane 
protein
vaccine in Iquique, Chile. Vaccine 1995 (in press).
10. de Moraes JC, Perkins BA, Camargo MCC, et al. Protective efficacy of
a serogroup B meningococcal vaccine in Sao Paulo, Brazil. Lancet
1992;340:1074-8.


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

End of HICNet Medical News Digest V08 Issue #05
***********************************************


---
Editor, HICNet Medical Newsletter
Internet: david@stat.com FAX: +1 (602) 451-1165
Bitnet : ATW1H@ASUACAD

 
