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HICNet Medical News Digest Tue, 21 Mar 1995 Volume 08 : 
Issue 07

Today's Topics:

 NEW TECHNOLOGY USED TO DEVELOP MEDICAL INSTRUMENT
 [MMWR Mar 10] Escherichia coli O157:H7 Outbreak Linked to ...
 [MMWR] Emergency Department Surveillance for Weapon-Related...
 [MMWR] HIV Counseling and Testing -- United States, 1993
 [MMWR] Clarification: Vol. 43, Nos. 51 & 52
 [MMWR] Addendum: Vol. 44, No. 8
 [MMWR] Errata: Vol. 44, No. 8
 [MMWR Mar 17] Diphtheria Epidemic -- New Independent States of the

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NEW TECHNOLOGY USED TO DEVELOP MEDICAL INSTRUMENT

 Technology developed by a team from NASA, a major
university, and a small business is making it possible to
directly and non-invasively measure the stiffness of long
bones. NASA is interested in using the technology to test
the bones of astronauts, who lose calcium from their
weight-bearing bones during space flight.

 The instrument, known as the Mechanical Response Tissue
Analyzer (MRTA), is a portable device that detects the
response of the bone to a brief vibratory stimulus to
measure the bending stiffness of the bones. The bones that
can be tested are the ulna in the forearm and the tibia in
the leg.

 The instrument was developed by NASA's Ames Research
Center, Mountain View, CA, Stanford University, Palo Alto,
CA, and Gait Scan Inc., Ridge, NJ.

 "The major attraction of this technology is the speed
and simplicity with which the measurement gives a complete
picture of bone strength," said Sara Arnaud, M.D., of Ames'
Life Sciences Division. Arnaud said that a long bone will
bend before it breaks, with a stiffer bone requiring more
force to break it. Bending stiffness is a mechanical
property of bone that reflects both the materials in the
bone and its shape. The MRTA is the only instrument that
provides a direct and non-invasive measure of bending
stiffness in the ulna and tibia, she said.

 Among the MRTA's advantages are its safety -- because
it uses no radiation -- and the ease of measurement. A
technician places a small probe on the skin surface of the
limb to be tested, which rests on a stable support. The
patient feels a "buzz" that lasts less than five seconds.
The frequencies from the resonating bone are detected at
the same site as the stimulus and analyzed by unique
software in an attached computer. The result is an
accurate measurement of the bending stiffness of the bone.
In addition, at an approximate cost of $20,000, the MRTA is
fairly inexpensive.

 Arnaud noted that while the MRTA is not yet in clinical
use, it has been used in several research studies of the
forearm bones. She is using the device to measure the
strength of the leg's tibia bone among working women at
Ames. In other research, the MRTA accurately showed the
fragility of bones in patients with osteogenesis
imperfecta, a disease marked by brittle bones and increased
risk of fractures.

 Scientists also have used the device to measure the
strength of bones in the forearms of women with post-
menopausal osteoporosis. Ames' scientists plan to use the
MRTA to measure the suspected decrease in bone strength in
astronauts following space flight.

 Arnaud sees several other potential uses for the MRTA.
One promising application is in follow-up testing of
patients being treated for osteoporosis. It also may be
useful in monitoring the healing of broken bones. The
physician could determine whether a healing bone is strong
enough to allow the patient to resume using the limb.

 The more immediate applications of the MRTA may be in
physical fitness, where long bone strength is essential.
The lack of radiation exposure and simplicity of
measurement make it particularly well-suited to screening
studies used to identify substandard levels of fitness in
large groups, such as military recruits or students.

 "The MRTA doesn't replace the bone density-measuring
technology we now have," Arnaud said, "but it provides an
excellent non-radiation measure of long bone strength. It
will, I am sure, find its place in the resources of
physicians treating bone disease."

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

Michael Braukus
Headquarters, Washington, DC
(Phone: 202/358-1979)

Ann Hutchison
Ames Research Center, Mountain View, CA
(Phone: 415/604-4968)

RELEASE: 95-20



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

To: hicnews

 Escherichia coli O157:H7 Outbreak Linked to Commercially 
Distributed
 Dry-Cured Salami -- Washington and California, 1994

 From November 16 through December 21, 1994, a total of 20
laboratory-confirmed cases of diarrhea caused by Escherichia coli 
O157:H7
were reported to the Seattle-King County Department of Public Health
(SKCDPH). In comparison, three cases were reported during October 1994.
Epidemiologic investigation linked E. coli O157:H7 infection with
consumption of a commercial dry-cured salami product distributed in 
several
western states. Three additional cases subsequently were identified in
northern California. This report summarizes preliminary findings from 
the
outbreak investigation.

Washington
 Infection with E. coli O157:H7 has been a reportable disease in
Washington since 1987; cases are identified through routine follow-up of
infections reported from local laboratories to the SKCDPH. Among the 20
case-patients, the median age was 6 years (range: 23 months to 77 
years),
11 (55%) were male, and all resided in King County. Three patients 
required
hospitalization, including a 2-year-old who developed hemolytic uremic
syndrome (HUS).
 Interviews with initial patients suggested that brand A dry-cured
salami purchased at a local grocery chain was associated with illness.
Based on these preliminary findings, during November 23-25, the grocery
chain voluntarily withdrew brand A salami from its King County stores. 
To
assess potential risk factors for infection, the SKCDPH conducted a
case-control study of 16 cases and age-matched controls. A case was 
defined
as culture-confirmed E. coli O157:H7 in a King County resident with 
onset
of illness during November 15-29. Eleven (68%) case-patients and one 
(6%)
control reported eating brand A dry-cured salami within 7 days before 
onset
of illness (Mantel-Haenszel matched odds ratio=undefined; p less than
0.01). No other food item was significantly associated with infection.
 All salami was purchased from the delicatessen counters of the 
local
grocery chain. On November 28 and 29, environmental investigations were
conducted at three of these delicatessens, and food samples were 
collected.
No errors in food-handling practices were identified. E. coli O157:H7 
was
isolated from samples of brand A presliced dry-cured salami from two of 
the
delicatessens on December 2 and subsequently from a sample from a third
delicatessen in the grocery chain. On December 2, the SKCDPH issued a 
press
release informing the public of this problem and notified the U.S.
Department of Agriculture (USDA). On December 6, the manufacturing 
company
voluntarily recalled 10,000 pounds of implicated product labeled "Sell 
by
May 7, 1995," which had been distributed in California, Oregon, and
Washington. In addition, the company requested that their distributors
suspend the sale of all of its products until the source of 
contamination
was determined. The last case-patient had onset of illness on December 
6.
 Restriction fragment length polymorphism (Shiga-like toxin RFLP and
lambda-RFLP) analysis by the University of Washington School of Public
Health and Community Medicine determined that patterns were identical in
15 of 19 clinical isolates and in the three salami isolates. Sources for
the matching isolates included 12 patients who ate salami, two secondary
cases, and one person who ate sliced turkey purchased from a 
delicatessen
where brand A dry-cured salami was sold, suggesting possible
cross-contamination. The four nonmatching isolates were from specimens 
from
patients who did not eat salami. These findings were confirmed at CDC by
pulsed-field gel electrophoresis on a sample of outbreak-related 
isolates.

California
 Three patients with laboratory-confirmed E. coli O157:H7 infection 
who
reported consumption of brand A salami during the week before illness 
onset
were hospitalized in northern California during November. Two patients
resided in Sonoma County and one in Sacramento County. Patients were 
aged
4, 25, and 71 years; the 4-year-old developed HUS. Dates of onset ranged
from November 17 through November 27. In addition, a 20-month-old 
resident
of Sacramento who had consumed brand A dry-cured salami before onset of
illness was hospitalized with postdiarrheal HUS on November 24. Although
cultures of stool from this patient were negative for routine bacterial
pathogens, screening for E. coli O157:H7 had not been performed before
institution of antibiotic therapy. However, serum antibody to O157 
antigen
subsequently was detected at the Microbial Diseases Laboratory of the
California State Department of Health Services (CSDHS).
 CSDHS subsequently cultured E. coli O157:H7 from two samples of
presliced brand A dry-cured salami obtained from stores in California.

Reported by: ER Alexander, MD, J Boase, MSN, M Davis, DVM, L Kirchner, C
Osaki, MSPH, T Tanino, Seattle-King County Dept of Public Health, M
Samadpour, PhD, Univ of Washington, P Tarr, MD, Children's Hospital and
Medical Center, Seattle; M Goldoft, MD, S Lankford, J Kobyashi, MD, P
Stehr-Green, DrPH, State Epidemiologist, Washington Dept of Health. P
Bradley, B Hinton, MD, Sacramento County Health Dept, Sacramento; P 
Tighe,
B Pearson, GR Flores, MD, Sonoma County Health Dept, Santa Rosa; S 
Abbott,
R Bryant, SB Werner, MD, DJ Vugia, MD, State Epidemiologist, California
State Dept of Health Svcs. Food Safety Inspection Svc, US Dept of
Agriculture. Div of Training, Epidemiology Program Office; Foodborne and
Diarrheal Diseases Br, Div of Bacterial and Mycotic Diseases, National
Center for Infectious Diseases, CDC.

Editorial Note: E. coli O157:H7 was first recognized as a human pathogen
in 1982 (1) and is now an important cause of bloody diarrhea and a 
leading
cause of acute renal failure in children (2). Each year in the United
States, E. coli O157:H7 infection accounts for a minimum 20,000 cases of
illness and 250 deaths (CDC, unpublished data, 1995). In 1993, the 
Council
of State and Territorial Epidemiologists recommended that E. coli 
O157:H7
be a nationally reportable disease and that clinical laboratories screen
at least all bloody stools for this pathogen (3). In response to 
increased
culturing, during 1993-1994, a total of 46 clusters of E. coli O157:H7
infections involving an estimated 1300 persons were recognized in the
United States. The outbreak described in this report highlights the
critical role of both microbiologic surveillance for E. coli O157:H7 on
diarrheal stool specimens submitted for bacterial culture and a 
reporting
system to detect evolving communitywide outbreaks (4,5). As of January
1995, 32 states required that E. coli O157:H7 isolates be reported to 
the
state health department, and an additional 16 states were considering
establishing this requirement (CDC, unpublished data, 1995).
 The identification of dry-cured salami as a source of E. coli 
O157:H7
infection in this outbreak extends the spectrum of food vehicles 
associated
with this organism. Previous outbreaks have been associated with other
foods of animal origin--including ground beef, roast beef, and raw milk
(2)--and raw vegetables and apple cider possibly contaminated with cow
feces (6,7). Dry-cured salami is not cooked but is usually produced 
through
fermentation followed by drying. Specific manufacturing processes may 
vary
among companies and for different types of salami. Experimental 
inoculation
of a salami batter with E. coli O157:H7 has demonstrated that the 
organism
survives but does not grow during fermentation, drying, and storage for 
2
months at 39.2 F (4 C) (8).
 On December 9, representatives of the USDA's Food Safety Inspection
Service (FSIS) and 250 dry-sausage makers met to address the isolation 
of
E. coli O157:H7 from this product. Industry representatives agreed to
evaluate their production methods to assess the survival of E. coli
O157:H7. FSIS will review industry findings and initiate any necessary
changes in manufacturing processes (e.g., fermentation or time and
temperature procedures).
 The investigation in this report illustrates the usefulness of
molecular subtyping techniques to distinguish outbreak strains of E. 
coli
O157:H7 from others circulating in the community. Subtyping methods have
included RFLP, pulsed-field gel electrophoresis, and phage typing 
(9,10).
The combined use of methods may assist efforts to determine the 
relatedness
of strains and assess epidemiologic associations (10). Prospective
subtyping of E. coli O157:H7 strains may be used as an adjunct to
microbiologic surveillance to detect clusters of related cases, guide
interviewing, ascertain the source of infection, and prevent additional
cases.

References
1. Riley LW, Remis RS, Helgerson SD, et al. Hemorrhagic colitis 
associated
with a rare Escherichia coli serotype. N Engl J Med 1983;308:681-5.
2. Griffin PM, Tauxe RV. The epidemiology of infections caused by
Escherichia coli O157:H7, other enterohemorrhagic E. coli, and the
associated hemolytic uremic syndrome. Epidemiol Rev 1991;13:60-98.
3. Council of State and Territorial Epidemiologists. CSTE position
statement #4: national surveillance of Escherichia coli O157:H7. 
Atlanta:
Council of State and Territorial Epidemiologists, June 1993.
4. Alexander ER. Editorial response: surveillance of Escherichia coli
O157:H7--a necessity for the prevention of an emerging infectious 
disease
[Editorial]. Clin Infect Dis 1994;19:844-5.
5. Tarr PI. "4+ Normal flora" (or is it?) [Editorial]. J Pediatr
Gastroenterol Nutr 1994;19:145-7.
6. Cieslak P, Barrett T, Griffin P. Escherichia coli O157:H7 infection 
from
a manured garden. Lancet 1993;342:367.
7. Besser RE, Lett SM, Weber TJ, et al. An outbreak of diarrhea and
hemolytic uremic syndrome from Escherichia coli O157:H7 in fresh-pressed
apple cider. JAMA 1993;269:2217-20.
8. Glass KA, Loeffelholz JM, Ford JP, Doyle MP. Fate of Escherichia coli
O157:H7 as affected by pH or sodium chloride in fermented, dry sausage.
Appl Environ Microbiol 1992;58:2513-6.
9. Samadpour M, Grimm LM, Desai B, Alfi D, Ongerth JE, Tarr PI. 
Molecular
epidemiology of Escherichia coli O157:H7 strains by bacteriophage
restriction fragment length polymorphism analysis: application to a
multistate foodborne outbreak and day-care center cluster. J Clin 
Microbiol
1993;31:3179-83.
10. Barrett TJ, Lior H, Green JH, et al. Laboratory investigation of a
multistate food-borne outbreak of Escherichia coli O157:H7 by using
pulsed-field gel electrophoresis and phage typing. J Clin Microbiol
1994;32:3013-7.


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

To: hicnews

 Emergency Department Surveillance for Weapon-Related Injuries --
Massachusetts,
 November 1993-April 1994

 During 1992, a total of 37,776 firearm-related deaths occurred in 
the
United States (1), and in 1991, firearm-related deaths were the leading 
or
second leading cause of injury death in 15 states (2). Because of
limitations in data, however, the epidemiology of nonfatal firearm- and
other weapon-related injuries has not been well characterized. To 
improve
characterization of these problems, in 1989, the Massachusetts 
Department
of Public Health (MDPH) began a pilot project to develop the first
emergency-department-based statewide Weapon-Related Injury Surveillance
System (WRISS) in the United States (3). All 85 hospital emergency
departments in Massachusetts (1990 population: 6,016,425) now 
participate
in this system. This report summarizes results from the first 6 months 
of
statewide reporting (November 1993-April 1994), including previously


 

(Continued from last message)
unavailable statewide morbidity data on gunshot and stabbing injuries.
 Since 1927, physicians in Massachusetts have been required to 
report
to law enforcement authorities all gunshot wounds (GSWs) and all
violence-related sharp instrument wounds (SIWs).* GSWs are defined as 
"all
injuries resulting from, or caused by, the discharge of a gun, pistol, 
BB
gun, or other air rifle or firearm." Violence-related SIWs are defined 
as
nonself-inflicted "wounds or injuries caused by a knife or sharp or 
pointed
instrument if, in the physician's judgment, a criminal act was 
involved."
Although the statute requires reporting by all physicians, WRISS is a
voluntary reporting system that has been implemented only in hospital-
based
emergency departments. The goal of WRISS is to ascertain all reportable
weapon-related injuries treated in an emergency department regardless of
outcome. WRISS does not ascertain nonfatal injuries treated outside the
emergency department or injuries declared fatal at the scene whose 
victims
are taken directly to the state medical examiner's office.
 To facilitate reporting to WRISS and minimize reporting burden for
providers, the existing police reporting form was modified and variables
were added to a new voluntary reporting portion of the form. Completed
forms are sent periodically from hospitals to the MDPH and state law
enforcement authorities. Variables in WRISS include demographics (age,
race/ethnicity, sex, and community of residence), location of incident,
injury characteristics (type of weapon and location of wound), suspected
drug or alcohol use, and injury severity (treated and released, admitted
to hospital, or died). Reports for GSWs include type of injury
(nonself-inflicted violence related; unintentional; or self-inflicted), 
and
reports for violence-related GSWs and SIWs include victim-offender
relationship and precipitating circumstance. Based on periodic audits of
records, reporting compliance is 70%-80% systemwide. Responses are 
unknown
or missing for less than or equal to 25% of demographic variables, 
injury
characteristics, and injury severity; 32%-68% of victim-offender
relationships; and 26%-57% of precipitating circumstances.
 During November 1993-April 1994, WRISS received reports of 1345
weapon-related injuries, including 451 GSWs and 894 SIWs. Based on these
findings, estimated annual statewide rates were 15 GSWs per 100,000
residents and 30 violence-related SIWs per 100,000 residents. Of the 
1345
injured persons, 1139 (85%) were male. The mean age was 27 years; 613 
(46%)
were aged 15-24 years, 396 (29%) were aged 25-34 years, and 267 (20%) 
were
aged greater than or equal to 35 years. Persons with GSWs were more 
likely
to be hospitalized (240 [53%]) than persons with SIWs (258 [29%]).
 Although 37% of persons in Massachusetts reside in large 
communities
(population greater than or equal to 50,000), 71% (300) of the GSW-
related
injuries occurred among persons who resided in large communities. 
Persons
incurring GSWs in large communities were more likely than those in small
communities to be aged less than 35 years (264 [88%] compared with 94
[76%]). In comparison, persons incurring SIWs in large communities were
more likely than those in small communities to be aged greater than or
equal to 35 years (158 [25%] compared with 39 [17%]). In large 
communities,
most (68%) GSW injuries were violence related, while in small 
communities
30% were violence related and 40% were unintentional (Table 1). 
Community
size was not associated with victim-offender relationship or 
precipitating
circumstances for either GSWs or SIWs. Among violence-related GSW
incidents, when the victim-offender relationship was known, a higher
proportion was associated with a stranger (28% in large communities and 
22%
in small communities) than with someone known by the victim (14% and 
11%,
respectively) while among SIW injuries, the offender was more likely to 
be
known by the victim (34% and 39%) than to be a stranger (24% and 30%). 
For
GSWs for which information on circumstance was known, argument or abuse 
was
involved in 18% of incidents in large communities and 11% in small
communities. Approximately half (46% in large communities and 52% in 
small
communities) of incidents associated with SIWs involved argument or 
abuse.
 The annualized crude rate for GSW injuries was 27 per 100,000 
persons
in large communities, compared with seven per 100,000 persons in small
communities; however, the difference was greatest for violence-related 
GSWs
(Table 2). Of the 451 GSWs, 60 (13%) were associated with BB guns and 
other
nonpowder guns; of these, 45 (75%) occurred in small communities. In
addition, BB guns and other nonpowder guns accounted for 19 (42%) of all
reported weapon-related injuries to children aged less than 15 years. 
Most
(36 [60%]) BB gun injuries were unintentional, and 13 (22%) were 
violence
related; the remaining injuries were self-inflicted or of unknown 
intent.
 Of the 894 SIWs, 636 (71%) occurred among persons in large 
communities
(annualized crude rate: 57 per 100,000 residents), and 225 (25%) 
occurred
in small communities (12 per 100,000 residents); information on 
community
of residence was missing or unknown for 33 (4%). Most (734 [82%] of 894)
injured persons were male, and the mean age was 28 years.

Reported by: V Ozonoff, C Barber, B Hume, L Jannelli, M Schuster, H
McLaughlin, Massachusetts Dept of Public Health. Div of Violence
Prevention, National Center for Injury Prevention and Control, CDC.

Editorial Note: National injury-control priorities include reductions in
intentional, unintentional, and self-inflicted firearm injuries (4).
Surveillance for weapon-related injuries--which involves the systematic
collection of data about both fatal and nonfatal injuries--is an 
essential
component in the development of a science-based approach to preventing
these injuries and can assist in efforts to provide public education,
develop legislation to reduce risks for weapon-related injuries, 
identify
groups and communities at highest risk for such injuries, and evaluate
prevention initiatives (5).
 In Massachusetts, findings from WRISS routinely have been 
disseminated
throughout the state to violence-prevention groups, hospitals, and
policymakers through newsletters, presentations, and staff training. 
These
data have been used by hospitals to obtain funding for victim services
programs, design violence-prevention educational materials, and train
postgraduate medical staff. WRISS data also were used by an adolescent
violence-prevention coalition to select neighborhoods for a teen 
mentoring
program and by a community coalition in Boston in planning a gun buy-
back
initiative and related public education efforts. In addition, data have
been requested by mayors and city councils and cited by the governor in 
a
newspaper editorial addressing gun access.
 Analysis of the statewide findings in Massachusetts indicates
important variations in injury patterns that cannot be discerned based 
only
on findings from localities. For example, the types of weapons and 
related
injuries differed substantially between small and large communities. In
addition, this emergency-department-based system enabled recognition of 
the
magnitude of childhood injuries associated with BB guns. Although BB 
guns
and other nonpowder guns are an important cause of injury among children
(6), data about these injuries are not otherwise available because the
injuries rarely cause death or result in hospital admission.
 The MDPH is using WRISS data to establish an enhanced firearm
surveillance system by linking it with mortality and hospital discharge
data to estimate weapon-related injury costs, identifying potential risk
factors through interviews with victims of unintentional GSWs, and
interviewing violence-related GSW victims to assess data validity and
provide additional information on victim-offender relationships and
precipitating circumstances. In addition, WRISS data will be used for a 
new
MDPH initiative to develop statewide surveillance for violence against
women; data on victim-offender relationship and precipitating 
circumstance
will be particularly important for that project.
 The development of WRISS in Massachusetts has established the
feasibility and utility of a statewide, emergency-department-based
surveillance system for weapon-related injury. In addition, this system 
may
provide guidance in developing surveillance systems in other states. In
Massachusetts, implementation of a voluntary, emergency-department-based
system for reporting to MDPH was facilitated by the pre-existing police
reporting requirement. At least 40 other states (7) have mandatory
reporting requirements for GSWs that could be used in developing and
implementing surveillance systems similar to WRISS.

References
1. NCHS. Vital statistics mortality data, underlying cause-of-death 
detail,
1992 [Machine-readable public-use data tape]. Hyattsville, Maryland: US
Department of Health and Human Services, Public Health Service, CDC, 
1994.
2. Fingerhut LA, Jones C, Makuc DM. Firearm and motor vehicle injury
mortality--variations by state, race, and ethnicity: United States, 1990-
91. Hyattsville, Maryland: US Department of Health and Human Services,
Public Health Service, CDC, 1994. (Advance data no. 242).
3. Ozonoff VV, Barber CW, Spivak H, Hume B, Jannelli L, Scott NJ.
Weapon-related injury surveillance in the emergency department. Am J 
Public
Health 1994;84:2024-5.
4. CDC/National Highway Traffic Safety Administration. Position papers 
from
the Third National Injury Control Conference: setting the national 
agenda
for injury control in the 1990s. Atlanta: US Department of Health and 
Human
Services, Public Health Service, CDC, 1992.
5. CDC. Deaths resulting from firearm- and motor-vehicle-related 
injuries--
United States, 1968-91. MMWR 1994;43:37-42.
6. Christoffel T, Christoffel K. Nonpowder firearm injuries: whose job 
is
it to protect children? Am J Public Health 1987;77:735-8.
7. Lee RK, Waxweiler RJ, Dobbins JG, Paschetag T. Incidence rates of
firearm injuries in Galveston, Texas, 1979-1981. Am J Epidemiol
1991;134:511-21.

* Mass. Gen. L. ch. 112, Section 12A (1986).


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To: hicnews

 HIV Counseling and Testing -- United States, 1993

 Counseling and testing (CT) are important components of state and
local human immunodeficiency virus (HIV)-prevention programs (1). 
Analysis
of national data sources indicates that HIV-antibody tests are obtained
from a variety of testing sites, including private physicians, 
hospitals,
and outpatient clinics (66.7%), and publicly funded sites (33.1%) (2). 
This
report uses data from CDC's 1993 Behavioral Risk Factor Surveillance 
System
(BRFSS) to examine variations in rates of use of private and public HIV 
CT
sites by state.
 In 1993, a total of 49 states and the District of Columbia
participated in the BRFSS, a state-specific population-based, random-
digit-
dialed telephone survey that collects information monthly from U.S. 
adults
aged greater than or equal to 18 years. Thirteen questions about
HIV/AIDS-related knowledge and attitudes and HIV-antibody testing 
history
during the preceding year were asked only to respondents aged less than 
or
equal to 65 years. In 1993, a total of 84,039 persons responded to these
questions (state-specific range: 993 to 3667). The state-specific median
percentage of 82% of eligible respondents completed interviews (3). Data
for each state were weighted by demographic characteristics and by
selection probability; results are representative of persons aged 18-65
years in each state. Confidence intervals for percentages and estimated
numbers of persons tested were based on standard errors that accounted 
for
complex survey design (4).
 A median of 25.5% of persons (range: 14.4% [Iowa] to 37.5% 
[Alaska])
answered yes to the question: "Except for donating or giving blood, have
you ever had your blood tested for the AIDS virus infection?" (Table 1).
The number (weighted estimate) of adults who had ever been tested for 
HIV
was highest in California (6.3 million).
 A median of 9.6% of persons (range: 4.1% [Maine and South Dakota] 
to
16.9% [District of Columbia]) reported obtaining HIV-antibody tests
primarily for diagnostic reasons* (Table 1). Persons categorized as 
having
obtained diagnostic HIV-antibody tests were identified by one of three
responses to the question "What was the main reason you had your last 
AIDS
blood test?": "to find out if infected," "because of referral by a 
doctor
or health department or sex partner," or "for routine checkup**."
 In 43 states and the District of Columbia, at least 50.0% (median:
60.9%) of respondents had obtained their last diagnostic test from a
private physician, health maintenance organization, or private 
outpatient
clinic (Table 2). A median of 16.2% of persons (range: 5.0% [North 
Dakota]
to 37.6% [Mississippi]) had obtained their last diagnostic test at a
publicly funded prevention site (including health departments; AIDS,
sexually transmitted disease [STD], or tuberculosis clinics; and
drug-treatment programs).
 The estimated number of persons who obtained a diagnostic test at a
publicly funded site during the preceding year correlated with the 
number
of tests reported to CDC's HIV Counseling and Testing System by publicly
funded sites in each state (5) (correlation coefficient=0.96; p less 
than
0.01).
 A median of 60.7% of persons who had obtained their most recent
diagnostic HIV-antibody test at a publicly funded site (range: 30.8% 
[New
Jersey] to 95.7% [Oklahoma]) received counseling with their test results
(Table 2). In comparison, a median of 28.2% of persons who had obtained
their tests from a private site (range: 7.7% [Kentucky] to 77.3%
[Oklahoma]) also received counseling. In most (90%) of the reporting 
areas,
the number of persons who received counseling with their HIV test 
results
was greater than or equal to 1.5 times greater for persons tested at
publicly funded sites than those tested at private sites.

Reported by the following BRFSS coordinators: S Jackson, MPA, Alabama; P
Owen, Alaska; B Bender, Arizona; J Senner, PhD, Arkansas; B Davis, PhD,
California; M Leff, MSPH, Colorado; M Adams, MS, Connecticut; F 
Breukelman,
Delaware; C Mitchell, District of Columbia; D McTague, MS, Florida; E
Pledger, MPA, Georgia; F Newfield, MPH, Hawaii; C Johnson, MPH, Idaho; B
Steiner, MS, Illinois; R Guest, MPH, Indiana; P Busick, Iowa; M Perry,
Kansas; K Bramblett, Kentucky; D Hargrove-Roberson, MSW, Louisiana; D
Maines, Maine; A Weinstein, MA, Maryland; R Lederman, MPH, 
Massachusetts;
H McGee, MPH, Michigan; N Salem, PhD, Minnesota; E Jones, MS, 
Mississippi;
J Jackson-Thompson, PhD, Missouri; P Smith, Montana; S Huffman, 
Nebraska;
E DeJan, Nevada; K Zaso, MPH, New Hampshire; G Boeselager, MS, New 
Jersey;
P Jaramillo, MPA, New Mexico; C Maylahn, MPH, New York; G Lengerich, MD,
North Carolina; D Young, MS, North Dakota; E Capwell, PhD, Ohio; N Hann,
MPH, Oklahoma; J Grant-Worley, MS, Oregon; J Romano, MPH, Pennsylvania; 
J
Hesser, PhD, Rhode Island; M Lane, MPH, South Carolina; B Miller, South
Dakota; D Ridings, Tennessee; R Diamond, MPH, Texas; R Giles, Utah; R
McIntyre, PhD, Vermont; S Carswell, MA, Virginia; K Holm, MPH, 
Washington;
F King, West Virginia; E Cautley, MS, Wisconsin. Behavioral and 
Prevention
Research Br, Div of Sexually Transmitted Diseases and HIV Prevention,
National Center for Prevention Svcs; Behavioral Risk Factor Surveillance
Br, Office of Surveillance and Analysis, National Center for Chronic
Disease Prevention and Health Promotion, CDC.

Editorial Note: The findings from the 1993 BRFSS document a high degree 
of
state-specific variability in self-reported HIV-antibody tests in the
United States. This variability may reflect state-specific differences 
in
such factors as the prevalence of HIV infection and HIV testing in
high-risk groups, the presence and impact of HIV-prevention programs, 
and
age distribution. The BRFSS estimates of the number of persons last 
tested
for voluntary or diagnostic reasons at a publicly funded clinic 
correlated
highly with estimates from CDC's HIV Counseling and Testing System, and 
the
median percentage of respondents ever tested for HIV (25%) is consistent
with estimates based on CDC's National Health Interview Survey (22%).
 Health-care visits to seek and obtain HIV tests are important
opportunities to counsel persons about the risk for HIV infection and
methods to reduce such risk (1). The data in this report indicate that, 
in
most states, approximately threefold more persons reported having 
obtained
their HIV test from a private provider than from a public site; however,
persons who had obtained their test from a private provider were
substantially less likely to have reported receiving counseling than 
those
who obtained tests at a public site. This finding underscores the need 
for
physicians and other health-care providers in private settings to offer 
HIV
counseling at the time patients receive their HIV test results.
 The findings in this report are subject to at least two 
limitations.
First, the sample size of persons who reported having had an HIV-
antibody
test in individual states did not enable stratification by other 
respondent
characteristics. For example, state-specific sample sizes precluded
analysis to determine whether specific high-risk populations that 
obtained
HIV-antibody testing also received counseling. Second, because the BRFSS
is a telephone-based system, some persons at high risk for HIV infection
most likely were excluded from the survey.
 The BRFSS is a unique source for information about HIV-antibody
testing behaviors of U.S. adults--particularly patterns of HIV testing
outside of public clinics--and can be used both at the federal and state
levels to improve HIV-prevention and intervention programs. Questions 
about
CT in the 1993 BRFSS were developed based on input from state health
departments; subsequent BRFSS surveys may incorporate additional
HIV-related behavioral questions.

References
1. Hinman AR. Strategies to prevent HIV infection in the United States. 
Am
J Public Health 1991;81:1557-9.
2. CDC. HIV counseling and testing services from public and private
providers--United States, 1990. MMWR 1992;41:743,749-52.
3. CDC. 1993 BRFSS quality control report. Atlanta: US Department of 
Health
and Human Services, Public Health Service, CDC, 1994.
4. Shah BV. Software for Survey Data Analysis (SUDAAN) version 5.30
[Software documentation]. Research Triangle Park, North Carolina: 
Research
Triangle Institute, 1989.
5. CDC. HIV counseling and testing data system: national profile, 1993.
Atlanta: US Department of Health and Human Services, Public Health 
Service,
CDC, 1994.

* For this study, diagnostic HIV-antibody tests were defined as those
administered primarily to learn infection status rather than voluntary
tests to qualify for insurance, military induction, immigration, 
marriage
license application, or employment.
** This response was included in "diagnostic" reasons to avoid excluding
respondents who initiated a routine examination to determine whether 
they
were infected with HIV.


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

To: hicnews

 Clarification: Vol. 43, Nos. 51 & 52

 The notice to readers "Recommended Childhood Immunization Schedule--
United States, January 1995" (pages 959-960) stated that infants born to
hepatitis B surface antigen (HBsAg)-positive mothers should receive
immunoprophylaxis with 0.5 mL of hepatitis B immune globulin (HBIG) and 
0.5


 

(Continued from last message)
mL of hepatitis B vaccine administered at separate sites. Hepatitis B
vaccines licensed in the United States are produced by Merck and Co., 
Inc.
(Rahway, New Jersey), and SmithKline Beecham (Philadelphia) and are
available in various concentrations. The recommended dose of hepatitis B
vaccine for infants varies by manufacturer and HBsAg status of the 
mother
(Table 1). Merck and Co., Inc., recommends 2.5 ug of Recombivax HB
(registered) for infants of HBsAg-negative mothers and 5.0 ug for 
infants
of HBsAg-positive mothers; SmithKline Beecham recommends 10 ug of 
Engerix-B
(registered) regardless of the mother's HBsAg status. Providers should 
know
the HBsAg status of an infant's mother and consult the product package
insert for the recommended vaccine dose.
 Providers also should be aware that the Food and Drug 
Administration
recently lowered the age-appropriate dose of Engerix-B (registered) from
20 ug to 10 ug for adolescents 11-19 years of age (Table 1) (1).

Reference
1. Smithkline Beecham Pharmaceuticals. Brief summary of prescribing
information: Engerix-B (registered) [Package insert]. Philadelphia:
Smithkline Beecham Pharmaceuticals, 1995.


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

To: hicnews

 Addendum: Vol. 44, No. 8

 In the article, "Exposure of Passengers and Flight Crew to
Mycobacterium tuberculosis on Commercial Aircraft, 1992-1995," the
following names should be added to the credits ("reported by") on the 
sixth
line on page 139: A Ignacio, MD, D Morishige, RL Vogt, MD, State
Epidemiologist, Communicable Disease Div, Hawaii Dept of Health.


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

To: hicnews

 Errata: Vol. 44, No. 8

 In the article, "Exposure of Passengers and Flight Crew to
Mycobacterium tuberculosis on Commercial Aircraft, 1992-1995," on page 
138
in the first sentence under investigation 3, the length of flight is
incorrect. The sentence should read, "In March 1993, a foreign-born
passenger with pulmonary TB traveled on a 4 1/2-hour flight from Mexico 
to
San Francisco."
 In the article, "Use of Safety Belts--Madrid, Spain, 1994," the 
first
sentence on page 151 should read, "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 the phone number 
was
commercial, 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)."


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

To: hicnews
the

 Diphtheria Epidemic -- New Independent States of the Former Soviet 
Union,
 1990-1994

 Although diphtheria was controlled for approximately 30 years after
the institution of childhood vaccination with diphtheria toxoid in the 
late
1950s, epidemic diphtheria has reemerged in the New Independent States
(NIS) of the former Soviet Union (1,2) (Figures 1 and 2). The epidemic
began in 1990 in the Russian Federation and spread to Ukraine in 1991 
and,
during 1993-1994, to 12 of the 13 remaining NIS. In most affected
countries, the incidence rate of reported diphtheria has increased 
twofold
to 10-fold each year. This report summarizes data provided to the World
Health Organization (WHO) about diphtheria in the NIS during 1989-1994.*
 Overall, reported cases of diphtheria in the NIS increased from 839
in 1989 to 47,802 in 1994 (Figure 1). In 1994, a total of 1746 persons
died; case-fatality rates ranged from 2.8% (Russian Federation) to 23.0%
(Lithuania and Turkmenistan).
 In the Russian Federation, reported diphtheria cases increased from
603 in 1989 (0.4 per 100,000 population) to 15,229 (10.3) in 1993, then
increased 161% to 39,703 (26.6) in 1994; a total of 1104 (2.8%) persons
died. The epidemic has progressively spread to involve all 89
administrative regions. Throughout the epidemic, approximately 70% of 
cases
have been reported among persons aged greater than or equal to 15 years.
The highest age-specific incidence rates were among persons aged 4-10
years, 15-17 years, and 40-49 years. Reported nationwide coverage with a
primary series (three doses) of diphtheria toxoid among children aged 12-
23
months increased from 72.6% in 1992 to 79.2% in 1993, but coverage 
remains
low (less than 60%) in some regions. During 1992-1993, at least 90% of
children aged less than or equal to 5 years had received a primary 
series
with diphtheria and tetanus toxoids and pertussis vaccine (DTP) or
pediatric (DT) or adult (Td) formulation diphtheria and tetanus toxoids,
and approximately 80% had received at least one booster. Up to 50% of
infants in some areas may have received a primary series with Td rather
than DTP or DT.
 In Ukraine, reported cases increased 27-fold, from 109 in 1990 to 
2990
(5.7 per 100,000) in 1994; 111 (3.7%) persons died. In 1994, 80% of 
cases
occurred among persons aged greater than or equal to 15 years. In 
Belarus,
reported cases increased 97%, from 120 in 1993 to 236 (2.3) in 1994. In
Moldova, reported cases increased 10-fold, from 35 in 1993 to 372 (8.5) 
in
1994; 19 (5.1%) persons died. In Latvia, reported cases increased 21-
fold,
from 12 in 1993 to 250 (9.4) in 1994 and, in Lithuania, from eight in 
1993
to 39 (1.0) in 1994. In Estonia, seven cases (0.4) were reported in 
1994.
 In Tajikistan, reported cases increased 180%, from 680 in 1993 to 
1907
(31.8 per 100,000) in 1994. Most cases were reported from the southern
region of Kurgan Tyube, which borders Afghanistan. For other central 
Asian
republics, case counts for 1994 were Kazakhstan, 489 (2.8); Kyrgyzstan, 
303
(6.5); Turkmenistan, 61 (1.5); and Uzbekistan, 232 (1.0). These totals
represent increases of twofold to 20-fold over 1993. Approximately 50% 
of
cases in these countries have occurred among persons aged less than or
equal to 14 years.
 In Georgia, 294 cases (5.4 per 100,000) were reported in 1994, a
10-fold increase over 1993. Forty-two (14%) persons died, and 43% of 
cases
occurred among persons aged greater than or equal to 15 years. In
Azerbaijan, 685 cases (9.2) were reported in 1994, compared with 141 in
1993. Armenia reported no cases during 1991-1993 but 36 (1.0) cases in
1994.

Reported by: Regional Office for Europe, World Health Organization,
Copenhagen. Global Program on Vaccines and Immunization, World Health
Organization, Geneva. Regional Office for Eastern Europe and Central 
Asia,
United Nations Children's Fund, New York and Geneva. Child Survival 
Unit,
United Nations Children's Fund, New York. Childhood and Respiratory
Diseases Br, Div of Bacterial and Mycotic Diseases, National Center for
Infectious Diseases; International Health Program Office; Child Vaccine
Preventable Disease Br, Div of Epidemiology and Surveillance, National
Immunization Program, CDC.

Editorial Note: WHO considers the rapidly expanding diphtheria epidemic 
in
the NIS an international public health emergency. In the Russian
Federation, the epidemic has intensified each successive year. In the
central Asian and Transcaucasian republics, epidemic diphtheria is
established in all eight countries; in some of these countries, many 
cases
have occurred among refugees or persons displaced by internal conflict.
Previous reports of diphtheria epidemics underscore the potential for
further increase in the magnitude of this epidemic (3).
 Although the reasons for the diphtheria epidemic in the NIS are not
fully understood, one important factor is the presence of a large number
of susceptible children and adults--which enabled introduction or
reemergence of toxigenic strains of Corynebacterium diphtheriae. Spread 
of
the organism may have been facilitated by crowding and population 
migration
resulting from the dissolution of the Soviet Union. In addition, 
adequate
control measures (particularly aggressive mass vaccination in affected
areas) were not implemented during the early phase of the epidemic.
Increases in the number of susceptible children in the NIS probably
resulted from a combination of low vaccination coverage in many areas 
and
inappropriate primary vaccination of substantial numbers of infants with
Td, a formulation for adults containing decreased amounts of diphtheria
toxoid. The existence of large numbers of susceptible adults is a new
phenomenon in the vaccine era. In the prevaccine era, most persons 
acquired
immunity to diphtheria naturally before adulthood through exposure to C.
diphtheriae. Following the introduction of childhood vaccination with
diphtheria toxoid, circulation of toxigenic C. diphtheriae decreased
substantially. In addition, vaccine-induced immunity wanes over time 
unless
periodic boosters are administered. Serologic studies in the NIS, 
Western
Europe, and the United States indicate that 20%-60% of adults aged 
greater
than or equal to 20 years are susceptible to diphtheria (4-7).
 Lack of effectiveness of diphtheria toxoid is not considered to be 
an
important contributing factor for this epidemic. Recent assessments of
vaccine effectiveness in children conducted in the Russian Federation 
and
Ukraine have documented high clinical effectiveness of diphtheria toxoid
produced in the Russian Federation.
 A plan formulated jointly by WHO and the United Nations Children's
Fund (UNICEF), in collaboration with CDC, the U.S. Agency for 
International
Development, and the International Federation of Red Cross and Red 
Crescent
Societies, has outlined the strategies necessary to control the 
diphtheria
epidemic in the NIS. This plan was approved in January and February 1995
by representatives of the affected countries. Key elements of the plan 
are
to achieve and maintain high levels of routine childhood vaccination 
with
diphtheria toxoid (i.e., greater than or equal to 95% coverage with four
doses of DTP by age 2 years in all districts and the same levels for
booster doses according to national vaccination schedules) and to 
rapidly
vaccinate greater than or equal to 90% of adolescents and adults with Td
(8,9) in all areas of the NIS affected by the epidemic. Because of
widespread transmission among the entire population of the NIS, attempts
to control the epidemic through vaccination of targeted subgroups (e.g.,
adults in selected occupations and children) have not been effective.
 In 1994, at least 20 imported cases of diphtheria were reported in
countries in Europe, including Bulgaria, Finland, Germany, Norway, and
Poland. This demonstrates the potential for the diphtheria epidemic in 
the
NIS to spread to neighboring countries in Europe, the Middle East, and
Asia. Although no cases have been directly imported into the United 
States,
CDC has received reports of two cases of diphtheria among U.S. citizens 
who
reside in or who traveled to the NIS, and considers the epidemic to pose
a risk for importation into the United States.
 This report underscores the importance of maintaining high levels 
of
diphtheria immunity among the total populations of the United States and
other countries, regardless of whether international travel is planned. 
The
Advisory Committee on Immunization Practices recommends that all 
children
receive a routine series of five doses of DTP (or DT if pertussis 
vaccine
is contraindicated) with doses at ages 2, 4, 6, and 12-15 months and 4-6
years; Td boosters should then be administered every 10 years (10). For
persons aged greater than or equal to 7 years who have not been 
previously
vaccinated against diphtheria, the primary series consists of three 
doses
of Td, with intervals of 1-2 months between the first two doses and 6-12
months between the second and third doses. Persons traveling to areas 
with
diphtheria activity should have completed the primary series and should
have received the most recent dose of vaccine (either primary series or
booster) within the previous 10 years.
 Control of the epidemic in the NIS requires immediate efforts to 
raise
levels of immunity through extensive mass vaccination of adolescents and
adults. Shortages of vaccine, antitoxin, and antibiotics exist in the 
NIS
(except the Russian Federation); these needs should immediately be
addressed through coordinated efforts of international public health and
donor agencies. An Interagency Immunization Coordinating Committee was
convened in 1994 and is scheduled to meet again in April 1995 to 
coordinate
donor activities in support of disease control and primary vaccination 
of
children in the NIS.

References
1. Expanded Program on Immunization, World Health Organization. Outbreak
of diphtheria, update. Wkly Epidemiol Rec 1993;19:134-7.
2. CDC. Diphtheria outbreak--Russian Federation, 1990-1993. MMWR
1993;42:840-1,847.
3. Stuart G. A note on diphtheria incidence in certain European 
countries.
Br Med J 1945;2:613-5.
4. Crossley K, Irvine P, Warren JB, Lee BK, Mead K. Tetanus and 
diphtheria
immunity in urban Minnesota adults. JAMA 1979;242:2298-3000.
5. Christenson B, Bottiger M. Serological immunity to diphtheria in 
Sweden
in 1978 and 1984. Scand J Infect Dis 1986;18:227-33.
6. Rix BA, Zhobakas A, Wachmann CH, Bakasenas B, Ronne T. Immunity from
diphtheria, tetanus, poliomyelitis, measles, mumps, and rubella among
adults in Lithuania. Scand J Infect Dis 1994;26:459-67.
7. Ad Hoc Working Group. Susceptibility to diphtheria. Lancet 1978;1:428-
30.
8. Expanded Program on Immunization, Pan American Health Organization.
Diphtheria epidemic in Ecuador. EPI Newsletter 1994;16:5-6,8.
9. Youwang Y, Jianming D, Yong X, Pong Z. Epidemiological features of an
outbreak of diphtheria and its control with diphtheria toxoid 
immunization.
Int J Epidemiol 1992;21:807-11.
10. ACIP. Diphtheria, tetanus, and pertussis: recommendations for 
vaccine
use and other preventive measures--recommendations of the Immunization
Practices Advisory Committee (ACIP). MMWR 1991;40(no. RR-10).

* Data for 1994 are provisional.


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

End of HICNet Medical News Digest V08 Issue #07
***********************************************


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