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HICNet Medical News Digest Sun, 02 Apr 1995 Volume 08 : 
Issue 10

Today's Topics:

 [MMWR] Self-Treatment with Herbal and Other Plant-Derived Remedies
 [MMWR] Emergence of Penicillin-Resistant Streptococcus pneumoniae
 [MMWR] Update: Vibrio cholerae O1
 [MMWR] Health Insurance Coverage and Receipt of Preventive Health
 [MMWR] Evaluation of Congenital Syphilis Surveillance System

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To: hicnews
Remedies

 Self-Treatment with Herbal and Other Plant-Derived Remedies
 -- Rural Mississippi, 1993

 Herbal and other plant-derived remedies have been estimated by the
World Health Organization (WHO) to be the most frequently used therapies
worldwide (1). Therapeutic agents derived from plants include pure 
chemical
entities available as prescription drugs (e.g., digitoxin, morphine, and
taxol), standardized extracts, herbal teas, and food plants; plant-
derived
remedies can contain chemicals with potent pharmacologic and toxicologic
properties (2,3). Although precise levels of use of these remedies in 
the
United States are unknown, in 1991, herbal products accounted for sales 
of
approximately $1 billion (4). Previous reports about herbal remedies in 
the
rural South have described the use and biologic activities of locally
gathered plant species (5,6) and details of preparation and dosage, but
have not determined the prevalence of use of plant-derived remedies in 
the
study population and the prevalence of use of specific remedies. To 
assess
the prevalence of use of plant-derived remedies (excluding prescription
drugs) and the prevalence of use of specific remedies in rural central
Mississippi, The University of Mississippi conducted a survey during 
March-
June 1993. This report describes two case reports of use of these 
remedies
and summarizes the findings of the survey.

Case Reports
 Case 1. A 55-year-old man who had completed 11 years of education
reported using turpentine during the year preceding the survey to rid
himself of "seed ticks." The man purchased turpentine at a local drug 
store
and, based on the advice of a friend, poured approximately 4 oz of
turpentine onto a sponge and applied the sponge over all surfaces of his
body below the neck. He then bathed in a tub of hot water and had onset 
of
a severe burning sensation. To alleviate the burning, he soaked in a tub
of cold water. The man subsequently developed blistering on all body
surfaces to which he had applied turpentine. He also reported having 
used
aloe as a topical remedy during the preceding year and reported previous
use of briar root, castor, garlic, lemon, and sassafras.
 Case 2. A 46-year-old woman who had completed 7 years of education
reported using castor oil routinely as a laxative and to treat "colds." 
She
purchased castor oil at a discount department store, kept it readily
available in her home, and had used castor oil and acetaminophen to 
treat
a cold in her 18-month-old grandchild. She fed the child 1 teaspoon of
castor oil mixed with one half of a baby bottle of orange juice. The
symptoms resolved. She also reported using aloe, asafetida, catnip, 
garlic,
lemon, and turpentine as remedies during the preceding year and recalled
previous use of briar root, chinaberry, corn shucks, and pine as 
remedies.

Survey
 A 2% random cluster sample of households (n=11,671) was selected 
from
detailed transportation maps for two geographic areas in rural central
Mississippi (1990 rural central Mississippi population: 33,992). Of the 
223
occupied households contacted, one or more adults (persons aged greater
than or equal to 18 years) in 210 (94%) households participated; 251 
adults
were included in the survey. The survey collected information on
demographic, socioeconomic, and health variables; medicinal use and
knowledge of 25 specific plants or plant-derived substances*; and 
diseases
or symptoms treated with these plants. The 25 plants were selected based
on ethnobotanical research conducted in this geographic area. In 
addition,
respondents were asked about their knowledge or use of any other
plant-derived remedies to treat specific diseases or symptoms.
 Of the 251 respondents, 178 (71% [95% confidence interval (CI)=65%-
77%]) reported using at least one plant-derived remedy during the year
preceding the survey. The prevalence of reported use varied among age
groups and was significantly higher among persons aged 45-64 years (81%
[95% CI=72%-90%]) than among those aged 18-44 years (75% [95% CI=65%-
85%])
and among those aged greater than or equal to 65 years (62% [95% CI=53%-
71%]) (p less than 0.05). Of respondents who had used plants during the
preceding year, 31% (95% CI=25%-37%) had used one plant-derived remedy; 
20%
(95% CI=15%-25%), two; and 20% (95% CI=15%-25%), three or more.
 The most frequently used (i.e., used by at least 10% of 
respondents)
plant-derived remedies during the preceding year were lemon (47% [95%
CI=41%-53%]), aloe (27% [95% CI=22%-32%]), castor oil (14% [95% CI=10%-
18%]), turpentine (12% [95% CI=8%-16%]), tobacco (12% [95% CI=8%-16%]), 
and
garlic (10% [95% CI=6%-14%]). Other plants used for self-treatment 
included
poke and sassafras.
 The most common self-reported reasons for using plant-derived 
remedies
during the preceding year included treatment of diseases or symptoms**
associated with the respiratory system (43% [95% CI=38%-48%]), the skin
(20% [95% CI=16%-24%), insect bites or parasite infestations (11% [95%
CI=8%-14%]), the cardiovascular system (9% [95% CI=6%-12%]), and the
gastrointestinal system (6% [95% CI=4%-8%]).

Reported by: DA Frate, PhD, EM Croom, Jr, PhD, JB Frate, JP Juergens, 
PhD,
Research Institute of Pharmaceutical Sciences, School of Pharmacy, The 
Univ
of Mississippi, University; EF Meydrech, PhD, Dept of Preventive 
Medicine,
The Univ of Mississippi Medical Center, Jackson. Health Studies Br, Div 
of
Environmental Hazards and Health Effects, National Center for 
Environmental
Health, CDC.

Editorial Note: In this survey of adults residing in rural areas of
Mississippi, nearly three fourths of respondents reported having used
plant-derived remedies during the preceding year. These data also 
indicate
that plant-derived remedy use was widely distributed among all age 
groups
and was not limited only to older persons in the population. In 
comparison,
in a previous study of herbal remedy use among a national sample of U.S.
residents, only 3% of respondents indicated that they had used such
remedies during the preceding year (7). The substantially higher use
reported in the population surveyed in Mississippi may reflect
methodological differences in the two studies. Specifically, the 
definition
of plant-derived remedies used in this report was more inclusive than 
the
definition of herbal remedies used in the national survey. In addition,
higher use in the population surveyed in Mississippi may be associated 
with
socioeconomic and cultural influences in this population. For example, 
in
rural central Mississippi, only 51% of persons aged greater than or 
equal
to 25 years had a high school diploma or higher education compared with 
64%
for the state (8). Although utilization rates of the health-care system 
in
the survey area are similar to national rates, self-treatment is an
important adjunct to receiving formal care in this area (9).
 Some plant-derived remedies reported in rural central Mississippi
(e.g., poke and sassafras) contain pharmacologically active and 
potentially
toxic compounds (2). For example, both turpentine and castor oil can
produce adverse effects if used inappropriately. Use of externally 
applied
turpentine oil for treatment of parasites has been reported previously 
(6).
Although turpentine oil is a nontoxic and effective counterirritant when
applied to a small area of the skin, cutaneous application of larger
amounts has been associated with vesicular eruptions, urticaria, and
vomiting (10). Castor oil is a stimulant laxative that may cause 
thorough
evacuation of the bowels within 2-6 hours of ingestion (10); the strong
purgative action of castor oil also can cause dehydration and 
electrolyte
imbalance, and long-term use may reduce the absorption of nutrients.
Because the stimulant effects of castor oil may cause uterine 
contraction,
some authorities have recommended that it not be used during pregnancy; 
use
also is not recommended in infants and young children (11).
 The survey findings in this report document the popularity of
self-treatment with plant-derived therapies among persons in rural 
central
Mississippi. Increased interest by health agencies in plant-derived
therapies is reflected through the efforts of both the National 
Institutes
of Health (which established the Office of Alternative Medicine) and the
Food and Drug Administration (which has issued regulations addressing
health claims for foods and dietary supplements). The survey findings 
also
underscore the need for physicians, pharmacists, and other health-care
providers to consider the possibility of plant-derived self-treatments
among their patients and to actively elicit this information when taking
a clinical history. In addition, health-care providers should be aware 
of
potential drug interactions, toxicity, and adverse re- actions as well 
as
possible treatment benefits that may be associated with plant-derived
therapies.

References
1. Marini-Bettolo GB. Present aspects of the use of plants in 
traditional
medicine. J Ethnopharmacol 1980;2:183-8.
2. Croom EM Jr. Herbal medicine among the Lumbee Indians. In: Kirkland 
J,
Mathews HF, Sullivan CW III, Baldwin K, eds. Herbal and magical 
medicine.
Durham, North Carolina: Duke University Press, 1992:137-69.
3. Croom EM Jr. Documenting and evaluating herbal remedies. Economic 
Botany
1983;37:13-27.
4. McCaleb RS. Regulation of dietary supplements: hearing before the
Subcommittee on Health and the Environment of the Committee on Energy 
and
Commerce, House of Representatives. Washington, DC: 103rd US Congress,
House of Representatives, 1993; series no. 103-57.
5. Morton JF. Folk remedies of the low country. Miami: Seeman, 1974.
6. Bolyard JC. Medicinal plants and home remedies of Appalachia.
Springfield, Illinois: CC Thomas, 1981.
7. Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco 
TL.
Unconventional medicine in the United States: prevalence, costs, and
patterns of use. N Engl J Med 1993; 328:245-52.
8. Bureau of the Census. 1990 Census of the population and housing: 
summary
social, economic, and housing characteristics--Mississippi. Washington, 
DC:
US Department of Commerce, Bureau of the Census, 1992; publication no.
CPH-5-26.
9. Banahan BF III, Frate DA. Use of home remedies and OTC products among
rural residents at high risk for development of coronary heart disease. 
San
Diego: American Pharmaceutical Association, March 1992.
10. American Pharmaceutical Association. Handbook of nonprescription 
drugs.
10th ed. Washington, DC: American Pharmaceutical Association, 1993.
11. Brunton LL. Agents affecting gastrointestinal water flux and 
motility,
digestants, and bile acids. In: Gilman AG, Rall TW, Nies AS, Taylor P, 
eds.
The pharmacological basis of therapeutics. 8th ed. New York: Pergamon
Press, 1990:914-32.

* Aloe vera, asafetida, briar root/blackberry, castor/castor oil, 
catnip,
chinaberry, corn shucks/corn silks, dock/yellow dock, garlic, American
ginseng, Jimson weed, lemon, life everlasting/rabbit tobacco/rabbit 
grass,
mayapple/bitter apple, milkweed, mistletoe, nutmeg, oak, peach/peach
seed/peach pit, pine/pinetop, poke/poke salad, sassafras, 
sage/horsemint,
tobacco, and turpentine.
** The reported diseases or symptoms treated with plant-derived remedies
were categorized by organ system. For the respiratory system, the 
diseases
or symptoms reported included "colds," sore throat, and cough; for the
skin, rashes and burns; for the cardiovascular system, hypertension and
diabetes; and for the gastrointestinal system, "stomach aches,"
constipation, and diarrhea.


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

To: hicnews
pneumoniae

 Emergence of Penicillin-Resistant Streptococcus pneumoniae --
 Southern Ontario, Canada, 1993-1994

 Streptococcus pneumoniae is a leading cause of infectious
disease-related illness and death in the United States, accounting for 
an
estimated 3000 cases of meningitis, 50,000 cases of bacteremia, 500,000
cases of pneumonia, and 7 million cases of acute otitis media each year
(1). Penicillin has been the antibiotic of choice for the treatment of
infections caused by S. pneumoniae; since the mid-1980s, the prevalence 
of
penicillin-resistant S. pneumoniae has increased substantially worldwide
(2-4). In Canada, a strain of pneumococcus with reduced susceptibility 
to
penicillin was first reported in 1974 (5); based on surveys during 1977-
1990, rates of resistance to penicillin were 2.4%, 1.5%, and 1.3% in the
provinces of Alberta, Ontario, and Quebec, respectively (6-8). To 
determine
whether the prevalence of penicillin resistance had increased among
pneumococcal isolates, investigators from the University of Toronto 
tested
the susceptibility of strains collected from a Toronto hospital and from
a surrounding region in southern Ontario during June-December 1993 and
March-June 1994. This report summarizes the results of this 
investigation.
 During the study period, all nonduplicate S. pneumoniae isolates 
were
obtained from a private community-based laboratory providing services to
physicians, clinics, and nursing homes in metropolitan Toronto, and from
patients assessed in the emergency department of a tertiary-care 
teaching
hospital in Toronto. In vitro susceptibility testing was conducted by a
broth microdilution procedure in accordance with interpretive standards 
of
the U.S. National Committee for Clinical Laboratory Standards (NCCLS) 
(9).
An intermediate level of resistance to penicillin was defined as a 
minimal
inhibitory concentration (MIC) of 0.1-1.0 ug/mL; high-level resistance 
was
defined as an MIC greater than or equal to 2.0 ug/mL.
 A total of 202 isolates (196 from noninvasive sites [i.e., sputum])
of S. pneumoniae were tested, including 122 isolates obtained from the
private laboratory and 80 from the hospital emergency department. Of the
202 isolates, 16 (7.9%) were penicillin-resistant--including four with
high-level resistance; 11 had been obtained from eye, ear, or sputum
samples from children (eight of 68 aged less than 5 years) in outpatient
settings and five from sputum, blood, cerebrospinal fluid, and eye 
samples
from adults in the emergency department.
 Penicillin-susceptible strains generally were susceptible to other
antimicrobial agents. However, high proportions of penicillin-resistant 
S.
pneumoniae isolates were resistant to tetracycline (63%; MIC greater 
than
or equal to 8 ug/mL), trimethoprim/sulfamethoxazole (56%; MIC greater 
than
or equal to 4 ug/mL), erythromycin (50%; MIC greater than or equal to 4
ug/mL), and cefuroxime (38%; MIC greater than or equal to 2 ug/mL).
High-level resistance to ceftriaxone (MIC greater than or equal to 2 
ug/mL)
occurred in four (25%) of 16 penicillin-resistant isolates; high-level
resistance to penicillin was present in three of the four isolates
resistant to ceftriaxone. All isolates were susceptible to vancomycin 
and
imipenem. Serotypes of the penicillin-resistant pneumococci tested in 
the
Canadian Streptococcal Reference Laboratory (Edmonton, Alberta) were 19F
(five isolates), 9V (two), 23F (two), and one each of 6A, 6B, and 19A; 
four
were non-typeable.

Reported by: AE Simor, MD, L Louie, J Goodfellow, M Louie, MD, Dept of
Microbiology, Sunnybrook Health Science Centre, Univ of Toronto; Med-
Chem
Laboratories, Toronto, Ontario, Canada. Adult Vaccine Preventable 
Disease
Br, and Child Vaccine Preventable Disease Br, Div of Epidemiology and
Surveillance, National Immunization Program; Nosocomial Pathogens
Laboratory Br, Hospital Infections Program, and Childhood and 
Respiratory
Diseases Br, Div of Bacterial and Mycotic Diseases, National Center for
Infectious Diseases, CDC.

Editorial Note: The findings in this report suggest an increased 
prevalence
of penicillin-resistant S. pneumoniae in metropolitan Toronto compared 
with


 

(Continued from last message)
that in a similar study in Toronto in 1988 (1.5% [8]). By selecting all
pneumococcal isolates from a large outpatient reference laboratory and
hospital emergency department in metropolitan Toronto (97% of which were
obtained from noninvasive sites), the study provided an indication of 
the
antimicrobial resistance patterns among pneumococci circulating in the
community and reflects a trend of emerging pneumococcal drug resistance 
in
North America and other countries (2-4). For example, in the United 
States
during 1987-1992, the prevalence of high-level resistance to penicillin
increased more than 60-fold, from 0.02% to 1.3% in pneumococcal isolates
collected from sentinel sites (3). The proportion of pneumococcal 
isolates
resistant to penicillin has ranged from 2% to 26% in selected 
communities
in the United States, indicating substantial geographic variability in
prevalence of penicillin resistance (3,4; CDC, unpublished data, 1995).
 In communities where pneumococci resistant to extended-spectrum
cephalosporins have been identified, antimicrobial regimens for 
treatment
of life-threatening pneumococcal infection should initially include
vancomycin until the results of susceptibility testing are available.
Although the selection of antimicrobials should be guided by the
region-specific prevalence of drug-resistant S. pneumoniae (DRSP), the
incidence of this problem is unknown for most regions of the country, 
and
community-specific surveillance is needed to determine the incidence of
resistance to antimicrobial drugs (e.g., penicillin and extended-
spectrum
cephalosporins) and to inform clinicians to enable selection of optimal
antimicrobials.
 Appropriate interpretive standards for antimicrobial susceptibility
testing of S. pneumoniae isolates have been updated by the NCCLS (9,10).
All pneumococcal isolates from normally sterile sites should be screened
for penicillin resistance using an NCCLS-approved method. Oxacillin disk
diffusion is a cost-effective and sensitive method for screening;
susceptible isolates have a zone size of greater than or equal to 20 mm.
Nonsusceptible isolates should have MICs determined for penicillin, an
extended-spectrum cephalosporin, chloramphenicol, vancomycin, and other
clinically indicated drugs. MICs should be determined using approved
methods such as broth microdilution, agar disk diffusion, and 
antimicrobial
gradient strips. Automated in vitro methods are not recommended for
determining pneumococcal susceptibility.
 The emergence of DRSP underscores the need for strategies to 
monitor,
prevent, and control DRSP infections. Because inappropriate empiric or
prophylactic therapy facilitates the occurrence of pneumococcal
antimicrobial resistance, prevention and control of DRSP infections 
should
include efforts to promote judicious antimicrobial prescribing practices
among clinicians. In addition, these efforts should promote adherence to
the recommendations of the Advisory Committee on Immunization Practices
that the 23-valent pneumococcal polysaccharide capsular vaccine be
administered to persons aged greater than or equal to 2 years with 
medical
conditions increasing their risk for serious pneumococcal infection and 
to
all persons aged greater than or equal to 65 years. Current pneumococcal
vaccination levels are low; for example, in a 1993 survey, only 27% of
persons aged greater than or equal to 65 years reported having been
vaccinated (CDC, unpublished data, 1995). There is no commercially
available vaccine for children aged less than 2 years; however, clinical
trials are in progress to assess immunogenicity and efficacy of protein
conjugate pneumococcal polysaccharide vaccines in young children.
 To address the factors contributing to increased resistance and to
identify methods for prevention and control of DRSP in the United 
States,
in June 1994, CDC convened a working group comprising public health
practitioners, clinical laboratory professionals, health-care providers,
and representatives of professional societies. This group has developed 
a
strategy with objectives to 1) establish DRSP as a nationally reportable
condition, 2) promote appropriate NCCLS interpretive standards for
pneumococcal antimicrobial susceptibility testing, 3) develop an 
electronic
laboratory-based surveillance system to detect invasive DRSP infections 
and
other laboratory-reportable conditions, 4) establish a group of 
clinicians
and public-health officials to form consensus treatment recommendations 
for
pneumococcal infections based on interpretations of antimicrobial
resistance data, and 5) promote pneumococcal vaccination and judicious
antimicrobial drug use. The goal of this strategy is to minimize
complications of DRSP infection, including increased and prolonged 
illness,
long-term sequelae of infection, health-care expenditures, and death.
Information about activities of the DRSP Working Group can be obtained
through the Childhood and Respiratory Diseases Branch, Division of
Bacterial and Mycotic Diseases, National Center for Infectious Diseases,
CDC, Mailstop C-09, Atlanta, GA 30333; Internet address
drsp@ciddbd1.em.cdc.gov.

References
1. Reichler MR, Allphin AA, Breiman RF, et al. The spread of
multiply-resistant Streptococcus pneumoniae at a day care center in 
Ohio.
J Infect Dis 1992;166:1346-53.
2. Applebaum PC. Antimicrobial resistance in Streptococcus pneumoniae: 
an
overview. Clin Infect Dis 1992;15:77-83.
3. Breiman RF, Butler JC, Tenover FC, Elliott JA, Facklam RR. Emergence 
of
drug resistant pneumococcal infections in the United States. JAMA
1994;271:1831-5.
4. CDC. Drug-resistant Streptococcus pneumoniae--Kentucky and Tennessee,
1993. MMWR 1994; 43:23-5,31.
5. Dixon JMS. Pneumococcus with increased resistance to penicillin. 
Lancet
1974;2:474.
6. Dixon JMS, Lipinski AE, Graham MEP. Detection and prevalence of
pneumococci with increased resistance to penicillin. Can Med Assoc J
1977;117:1159-61.
7. Jette LP, Lamothe F, and the Pneumococcus Study Group. Surveillance 
of
invasive Streptococcus pneumoniae infection in Quebec, Canada, from 1984
to 1986: serotype distribution, antimicrobial susceptibility, and 
clinical
characteristics. J Clin Microbiol 1989;27:1-5.
8. Mazzulli T, Simor AE, Jaeger R, Fuller S, Low DE. Comparative in 
vitro
activities of several new fluoroquinolones and beta-lactam antimicrobial
agents against community isolates of Streptococcus pneumoniae. 
Antimicrob
Agents Chemother 1990;34:467-9.
9. National Committee for Clinical Laboratory Standards. Performance
standards for antimicrobial susceptibility testing [Fifth informational
supplement]. Villanova, Pennsylvania: National Committee for Clinical
Laboratory Standards, 1994; NCCLS document no. M100-S5.
10. Jorgensen JH, Swenson JM, Tenover FC, Ferraro MJ, Hindler JA, Murray
PR. Development of interpretive criteria and quality control limits for
broth microdilution and disk diffusion antimicrobial susceptibility 
testing
of Streptococcus pneumoniae. J Clin Microbiol 1994;32:2448-59.



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

To: hicnews

 Update: Vibrio cholerae O1 -- Western Hemisphere,
 1991-1994, and V. cholerae O139 -- Asia, 1994

 The cholera epidemic caused by Vibrio cholerae O1 that began in
January 1991 has continued to spread in Central and South America 
(Figure
1). In southern Asia, the epidemic caused by the newly recognized strain
V. cholerae O139 that began in late 1992 also has continued to spread
(Figure 2). This report updates surveillance findings for both 
epidemics.
 From the onset of the V. cholerae O1 epidemic in January 1991 
through
September 1, 1994, a total of 1,041,422 cases and 9642 deaths (overall
case-fatality rate: 0.9%) were reported from countries in the Western
Hemisphere to the Pan American Health Organization. In 1993, the numbers
of reported cases and deaths were 204,543 and 2362, respectively (Table 
1).
From January 1 through September 1, 1994, a total of 92,845 cases and 
882
deaths were reported. In 1993 and 1994, the number of reported cases
decreased in some countries but continued to increase in several areas 
of
Central America, Brazil, and Argentina (1-3).
 The epidemic of cholera caused by V. cholerae O139 has affected at
least 11 countries in southern Asia. V. cholerae O139 produces severe
watery diarrhea and dehydration that is indistinguishable from the 
illness
caused by V. cholerae O1 (4) and appears to be closely related to V.
cholerae O1 biotype El Tor strains (5). Specific totals for numbers of 
V.
cholerae O139 cases are unknown because affected countries do not report
infections caused by O1 and O139 separately; however, greater than 
100,000
cases of cholera caused by V. cholerae O139 may have occurred (6).
 In the United States during 1993 and 1994, 22 and 47 cholera cases
were reported to CDC, respectively. Of these, 65 (94%) were associated 
with
foreign travel. Three of these were culture-confirmed cases of V. 
cholerae
O139 infection in travelers to Asia.

Reported by: Cholera Task Force, Diarrheal Disease Control Program, 
World
Health Organization, Geneva. Expanded Program for the Control of 
Diarrheal
Diseases, Special Program on Maternal and Child Health and Population, 
Pan
American Health Organization, Washington, DC. Foodborne and Diarrheal
Diseases Br, Div of Bacterial and Mycotic Diseases, National Center for
Infectious Diseases, CDC.

Editorial Note: Cholera is transmitted through ingestion of fecally
contaminated food and beverages. Because cholera remains epidemic in 
many
parts of Central and South America, Asia, and Africa, health-care 
providers
should be aware of the risk for cholera in persons traveling in
cholera-affected countries--particularly those persons who are visiting
relatives or departing from the usual tourist routes because they may be
more likely to consume unsafe foods and beverages.
 Persons traveling in cholera-affected areas should not eat food 
that
has not been cooked and is not hot (particularly fish and shellfish) and
should drink only beverages that are carbonated or made from boiled or
chlorinated water. The licensed parenteral cholera vaccine provides only
limited and brief protection against V. cholerae O1, may not provide any
protection against V. cholerae O139, and has a high cost-benefit ratio 
(7);
therefore, the vaccine is not recommended for travelers (8). New oral
cholera vaccines are being developed and provide more reliable 
protection,
although still at a high cost per case averted. None of these vaccines 
have
attained the combination of high efficacy, long duration of protection,
simplicity of administration, and low cost necessary to make mass
vaccination feasible in cholera-affected countries.
 The diagnosis of cholera should be considered in patients with 
watery
diarrhea who have recently (i.e., within 7 days) returned from
cholera-affected countries (9). Patients with suspected cholera should 
be
reported immediately to local and state health departments. Treatment of
cholera includes rapid fluid and electrolyte replacement with adjunctive
antibiotic therapy. Stool specimens should be cultured on
thiosulfate-citrate-bile salts-sucrose (TCBS) agar. Clinical isolates of
non-O1 V. cholerae should be referred to a state public health 
laboratory
for testing for O139 if the patient traveled in an O139-affected area, 
has
life-threatening dehydration typical of severe cholera, or has been 
linked
to an outbreak of diarrhea.

References
1. CDC. Update: cholera--Western hemisphere, 1992. MMWR 1993;42:89-91.
2. Wilson M, Chelala C. Cholera is walking south. JAMA 1994;272:1226-7.
3. Tauxe R, Seminario L, Tapia R, Libel M. The Latin American epidemic. 
In:
Wachsmuth I, Blake P, Olsvik O, eds. Vibrio cholerae and cholera: 
molecular
to global perspectives. Washington, DC: ASM Press, 1994:321-44.
4. CDC. Imported cholera associated with a newly described toxigenic 
Vibrio
cholerae O139 strain--California, 1993. MMWR 1993;42:501-3.
5. Popovic T, Fields P, Olsvik O, et al. Molecular subtyping of 
toxigenic
Vibrio cholerae O139 causing epidemic cholera in India and Bangladesh,
1992-1993. J Infect Dis 1995;171:122-7.
6. Cholera Working Group, International Center for Diarrheal Diseases
Research, Bangladesh. Large epidemic of cholera-like disease in 
Bangladesh
caused by Vibrio cholerae O139 synonym Bengal. Lancet 1993;342:387-90.
7. MacPherson D, Tonkin M. Cholera vaccination: a decision analysis. Can
Med Assoc J 1992; 146:1947-52.
8. CDC. Cholera vaccine. MMWR 1988;37:617-8,623-4.
9. Besser RE, Feikin DR, Eberhart-Phillips JE, Mascola L, Griffin PM.
Diagnosis and treatment of cholera in the United States: are we 
prepared?
JAMA 1994;272:1203-5.



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

To: hicnews
Health

 Health Insurance Coverage and Receipt of Preventive Health Services
 -- United States, 1993

 In 1992, an estimated 38.5 million U.S. residents aged less than 65
years did not have health insurance (1). Efforts by states to expand
health-care coverage will require surveillance for and state-specific
information about coverage for acute care and the receipt of preventive
services. This report summarizes state-specific and aggregated data from
the 1993 Behavioral Risk Factor Surveillance System (BRFSS) regarding 
the
status of health insurance coverage and the receipt of preventive health
services among adults aged 18-64 years. In addition, findings from the
analysis of supplemental questions added to the BRFSS in Minnesota are
included that address health-care utilization, source of health-care
coverage, and coverage of children.
 In 1993, the District of Columbia and all states except Wyoming
participated in the BRFSS, a population-based, random-digit-dialed
telephone survey of adults aged greater than or equal to 18 years (2). 
All
persons responding to the BRFSS questionnaire were asked whether they 
had
health-care coverage*, which of selected preventive health services they
had received, if they had a usual place of medical care, and how they
perceived their health status. This analysis specifically examined
preventive health services targeted by the national health objectives 
for
the year 2000 (i.e., cholesterol screening, breast and cervical cancer
screening, and colorectal cancer screening) (3). The use of these 
services,
the perception of health status, and absence of a usual place of medical
care were compared between persons who were insured and uninsured by
calculating crude prevalence ratios and adjusted odds ratios (i.e.,
adjusted for age, race, education level, employment status, and income
level). For this analysis, sample estimates were statistically weighted 
to
reflect the noninstitutionalized civilian population in each state, and
standard errors were calculated using SESUDAAN.

Health Insurance Coverage for Persons Aged 18-64 Years
 Of the 102,263 persons who participated in the 1993 BRFSS, 81,794
persons aged 18-64 years responded to the question about health-care
coverage. Of these respondents, 16% reported they were uninsured at the
time of interview (Table 1). The percentages of persons who reported 
being
uninsured ranged from 7% in Hawaii to 26% in Louisiana (Table 1). The
prevalence of being uninsured was higher among persons in states in the
West (20%; 95% confidence interval [CI]=19%-21%) and South (19%; 95%
CI=18%-19%) than in the Northeast (14%; 95% CI=13%-15%) or Midwest (12%;
95% CI=11%-13%).**
 The prevalence of being uninsured was highest among men (18%), 
persons
aged 18-24 years (27%), those with less than a high school education 
(35%),
those with an annual household income less than $10,000 (39%), blacks
(21%), Hispanics (34%), and persons who were unemployed (44%) (Table 2).
Compared with women who were insured, women who were uninsured were 
twofold
more likely to report having no usual place of medical care (10% versus
18%), at least 50% less likely to have had both a mammogram and a 
clinical
breast examination during the previous 2 years (69% versus 35%), and 
less
likely to report having had a digital rectal examination during the
previous 2 years (51% versus 29%) or ever having had a proctoscopy
examination (32% versus 22%) (Table 3). The prevalences of self-
perceived
health status were similar among women who were insured and uninsured.
 When compared with men who were insured, uninsured men were two 
times
more likely to report having no usual place of medical care (18% versus
41%) and half as likely to report having had their cholesterol checked 
(65%
versus 36%) or having had a digital rectal (51% versus 27%) or a
proctoscopy examination (38% versus 20%). The prevalences of self-
perceived
health status were similar among men who were insured and uninsured.

Minnesota-Specific Data for Persons Aged 18-64 Years
 The Minnesota Department of Health asked all respondents 12
supplemental questions about health insurance coverage. Among the 2494
persons who were insured, 1852 (75%; 95% CI=73%-77%) reported their
employer was their primary source of coverage for health insurance.
Overall, 9% (95% CI=8%-10%) of employed persons were uninsured and 20% 
(95%
CI=15%-25%) of those employed in service occupational groups were
uninsured. In addition, 44% (95% CI=37%-50%) of uninsured persons and 
21%
(95% CI=19%-23%) of insured persons reported no visits to a physician
during the previous year.
 Of the 253 persons who were uninsured, 178 (69%; 95% CI=63%-75%)
reported the primary reason they lacked health insurance was cost. In
addition, of the 102 uninsured persons with children, 53 (53%; 95% 
CI=35%-
55%) reported that their children did not have health-care coverage.

Reported by: N Salem, PhD, Minnesota Dept of Health. 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, 
MPA,
Connecticut; F Breukelman, Delaware; C Mitchell, District of Columbia; D
McTague, MS, Florida; E Pledger, MPA, Georgia; F Newfield, MPA, Hawaii; 
C
Johnson, MPH, Idaho; B Steiner, MS, Illinois; R Guest, MPA, 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; 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, 
VMD,
North Carolina; D Young, MS, North Dakota; E Capwell, PhD, Ohio; N Hann,
MPH, Oklahoma; J Grant-Worley, 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 Risk Factor
Surveillance Br, Office of Surveillance and Analysis, National Center 
for
Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note: This report documents substantial variation in the
state-specific prevalences of persons who report being uninsured. In
addition, persons who were uninsured were less likely to have recently
received preventive health services or have a regular place of medical
care. The 1993 BRFSS findings are consistent with results from previous
national studies indicating that uninsured persons are less likely to
receive preventive health services (4). Lack of health-care coverage 
also


 

(Continued from last message)
has been associated with delayed medical care and use of fewer medical
services (5,6).
 The findings in this report indicate that uninsured persons are 
more
likely to be younger, less educated, of races other than white, 
unemployed,
and of low income. These persons are less likely to engage in preventive
practices that can be effectively encouraged in the primary health-care
setting. Because lack of insurance is associated with limited access to
important preventive health-care services, improvements in health 
insurance
coverage through health-care reform at the state level may improve 
access
to preventive health services.
 The state-added questions from Minnesota are assisting in 
identifying
uninsured groups and estimating the percentage of children who are
uninsured. These findings are critical for targeting specific 
populations
that are uninsured and developing health-care reform and managed-care
strategies.
 The findings in this report are subject to at least three 
limitations.
First, because the BRFSS includes only households with a telephone, 
these
findings probably underestimate the prevalence of being uninsured among
persons not residing in households with telephones (e.g., persons living
below the poverty level, less educated persons, and unemployed persons).
Second, nonrespondents or refusals in households with a telephone may be
younger and less educated persons who are more likely to be uninsured.
Third, because estimates are based on self-reported data, responses 
cannot
be validated and are subject to recall bias.
 The BRFSS can be used to provide routinely available, timely,
state-specific data on health insurance coverage and receipt of 
preventive
health services that may be used to monitor the progress of health-care
reform efforts in each state. This information may assist state planners
in evaluating progress toward the national health objectives for the 
year
2000 related to chronic diseases and disabling conditions. In addition, 
the
BRFSS enables states to add specific questions, such as those included 
in
Minnesota, to expand health-related information for use in planning and
evaluating state-based strategies for all groups.

References
1. Snider S, Boyce S. Sources of health insurance and characteristics of
the uninsured: analysis of the March 1993 Current Population Survey.
Washington, DC: Employee Benefit Research Institute, January 1994. (EBRI
special report no. SR-20; issue brief no. 145).
2. Frazier EL, Franks AL, Sanderson LM. Behavioral risk factor data. In:
CDC. Using chronic disease data: a handbook for public health
practitioners. Atlanta: US Department of Health and Human Services, 
Public
Health Service, CDC, 1992:4-1-4-17.
3. Public Health Service. Healthy people 2000: national health promotion
and disease prevention objectives--full report, with commentary.
Washington, DC: US Department of Health and Human Services, Public 
Health
Service, 1991; DHHS publication no. (PHS)91-50212.
4. Makuc DM, Freid VM, Parsons PE. Health insurance and cancer screening
among women. Hyattsville, Maryland: US Department of Health and Human
Services, Public Health Service, CDC, NCHS, 1994. (Advance data no. 
254).
5. Woolhandler S, Himmelstein DU. Reverse targeting of preventive care 
due
to lack of health insurance. JAMA 1988;259:2872-4.
6. Weissmann JS, Stern R, Fielding SL, Epstein AM. Delayed access to 
health
care: risk factors, reasons, and consequences. Ann Intern Med 
1991;114:325-
31.

* All respondents were asked, "Do you have any kind of health care
coverage, including health insurance, prepaid plans such as HMOs (health
maintenance organizations), or government plans such as Medicare?" 
Persons
who reported having no health-care coverage at the time of the interview
were considered to be uninsured.
** West=Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana,
Nevada, New Mexico, Oregon, Utah, and Washington; South=Alabama, 
Arkansas,
Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana,
Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, 
Tennessee,
Texas, Virginia, and West Virginia; Northeast=Connecticut, Maine,
Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode
Island, and Vermont; and Midwest=Illinois, Indiana, Iowa, Kansas, 
Michigan,
Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and
Wisconsin.


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

To: hicnews

 Evaluation of Congenital Syphilis Surveillance System -- New Jersey, 
1993

 To monitor disease burden and trends associated with congenital
syphilis (CS), effective prevention programs require a surveillance 
system
that identifies CS cases in an accurate and timely manner. Before 1988,
comprehensive CS surveillance was difficult for health departments to
conduct because documentation of infection in infants required complex 
and
costly long-term follow-up for up to 1 year after delivery; follow-up 
often
was incomplete, and many infected infants were not identified. To 
estimate
the public health burden of CS more accurately and eliminate long-term
follow-up of infants by health department personnel, in 1988 CDC
implemented a new CS case definition (1). Rather than relying on
documentation of infection in the infant, the new case definition 
presumes
that an infant is infected if it cannot be proven that an infected 
mother
was adequately treated for syphilis before or during pregnancy (2). 
During
1993-1994, the Sexually Transmitted Disease Prevention and Control 
Program
of the New Jersey Department of Health (NJDOH) evaluated its CS
surveillance system to assess the accuracy and completeness of reporting
using the new case definition and to determine the personnel costs
associated with identifying and classifying CS cases. This report
summarizes the results of the evaluation.
 New Jersey statutes mandate that all pregnant women receive a
serologic test for syphilis (STS) during pregnancy or at delivery if no
test was done during pregnancy. Newborns also routinely receive a STS at
birth if born to a mother with a reactive STS. Laboratories are required
to report all reactive STSs (including maternal, delivery, and newborn) 
to
the NJDOH, and all such reports are investigated by NJDOH. Investigation
activities include reviewing infant and maternal medical records to
determine whether syphilis was previously diagnosed, reviewing 
laboratory
results and health department records to determine the mother's 
treatment
status, and verifying missing information by contacting the patient 
and/or
provider by telephone or field visit.
 For this analysis, reports of all reactive STSs for newborns 
received
by NJDOH during January 1-December 31, 1993, were reviewed manually to
assess the completeness and accuracy of case classification and 
reporting.
Infants with reactive STSs had been classified using the four categories
recommended by CDC: 1) not infected, 2) syphilitic stillbirth, 3) 
confirmed
case of CS, and 4) presumptive case of CS (1,2). Costs associated with
investigation and follow-up of reactive STSs for newborns were estimated
by multiplying the average time spent at each task by the hourly wage
(excluding benefits) of the person performing the task. Time spent on an
investigation was determined by interviewing the persons who performed 
the
tasks.
 During 1993, a total of 497 reactive STSs for newborns were 
reported
to NJDOH. Of these reports, 266 (53%) had been classified as not 
infected,
but reactive secondary to passive transfer of maternal syphilis 
antibodies
from a mother adequately treated for syphilis before or during 
pregnancy,
and 143 (29%) as presumptive cases. In addition, a total of 10 (2%) 
reports
initially classified as not infected were reclassified as presumptive
cases, and 78 (16%) reports were still under investigation.
 For 1993, the estimated average cost of investigating one reactive 
STS
for a newborn using routine surveillance methods was $183. Based on an
average of 41 reactive STSs for newborns reported to NJDOH each month in
1993, the estimated costs for investigation and follow-up were $7500 per
month or $90,000 per year.

Reported by: L Finelli, E Napolitano, J Carolina, STD Prevention and
Control Program; K Spitalny, MD, State Epidemiologist, New Jersey State
Dept of Health. Surveillance and Information Systems Br, Div of Sexually
Transmitted Diseases and HIV Prevention, National Center for Prevention
Svcs; Div of Field Epidemiology, Epidemiology Program Office, CDC.

Editorial Note: CS is a serious and totally preventable disease that
results from in utero infection of the fetus with Treponema pallidum, a
thin, motile spirochete. Complications of CS include intrauterine growth
retardation, bone abnormalities, and failure to thrive. Up to 40% of
pregnancies in women with untreated syphilis result in fetal or 
perinatal
death (3,4). CS can be prevented by screening and treating women for
syphilis before or during early pregnancy (1,5). CDC recommends 
screening
women at high risk for syphilis during the first and third trimesters of
pregnancy (1). Screening for syphilis at delivery primarily ensures that
infants born to women in whom syphilis previously was either 
unidentified
or untreated are identified and treated.
 The new CS case definition was implemented to provide a more 
accurate
measure of the impact of CS by eliminating long-term follow-up of STSs 
and
by including asymptomatic infants at risk for CS (i.e., who require
treatment but who were not counted by the previous case definition).
However, the existing reporting infrastructure in many health 
departments
may need to be changed to allow full benefit from the new case 
definition
(6). Despite use of the new case definition for CS, the findings in the
NJDOH study indicate that the number of CS cases in New Jersey may still
be underestimated because of inaccuracy and incompleteness of CS
surveillance data. In this report, the presumptive cases incorrectly
classified as not infected and the incomplete case reports accounted for
nearly 20% of all reported STSs for newborns during 1993. Reasons for
misclassification of cases and incomplete reporting may reflect a lack 
of
understanding by health department staff of the epidemiology of CS, the 
new
CS surveillance case definition, and CS reporting instructions (2).
 In response to the findings of this study, NJDOH initiated an
intervention trial in March 1994 to improve the timeliness, accuracy, 
and
completeness of CS surveillance data. As part of the intervention, NJDOH
collaborated with three local hospitals that provided delivery services 
to
women at high risk for syphilis. These hospitals established a policy to
notify NJDOH within 24 hours of admission of each pregnant woman with a
positive STS who was admitted for delivery. On notification and before 
the
patient was discharged from the hospital, NJDOH performed medical record
reviews and patient/provider interviews. Using these procedures, the 
time
required for health department staff to complete investigations was 
reduced
from an average of 10 hours to 3 hours per investigation. If this policy
were expanded to most hospitals that deliver high-risk infants, NJDOH
personnel costs associated with CS case investigations could be reduced
substantially, and accuracy and timeliness of reporting could be 
improved.

References
1. CDC. Guidelines for the prevention and control of congenital 
syphilis.
MMWR 1988; 37(suppl no. S-1).
2. CDC. Congenital syphilis case investigation and reporting 
instructions.
Atlanta: US Department of Health and Human Services, Public Health 
Service,
CDC, 1992.
3. CDC. Congenital syphilis--New York City, 1986-1988. MMWR 1989;38:825-
9.
4. Schultz KF, Cates W, O'Mara PR. Pregnancy loss, infant death, and
suffering: the legacy of syphilis and gonorrhea in Africa. Genitourin 
Med
1987;63:320-5.
5. Petrone ME, Teter MJ, Freund CG, Porter J, Parkin WE, Spitalny KC.
Epidemiology of congenital syphilis. N J Med 1989;86:965-9.
6. Zenker PN, Berman SB. Congenital syphilis: reporting and reality
[Editorial]. Am J Public Health 1990;80:271-2.
 Health Insurance Coverage and Receipt of Preventive Health Services
 -- United States, 1993

 In 1992, an estimated 38.5 million U.S. residents aged less than 65
years did not have health insurance (1). Efforts by states to expand
health-care coverage will require surveillance for and state-specific
information about coverage for acute care and the receipt of preventive
services. This report summarizes state-specific and aggregated data from
the 1993 Behavioral Risk Factor Surveillance System (BRFSS) regarding 
the
status of health insurance coverage and the receipt of preventive health
services among adults aged 18-64 years. In addition, findings from the
analysis of supplemental questions added to the BRFSS in Minnesota are
included that address health-care utilization, source of health-care
coverage, and coverage of children.
 In 1993, the District of Columbia and all states except Wyoming
participated in the BRFSS, a population-based, random-digit-dialed
telephone survey of adults aged greater than or equal to 18 years (2). 
All
persons responding to the BRFSS questionnaire were asked whether they 
had
health-care coverage*, which of selected preventive health services they
had received, if they had a usual place of medical care, and how they
perceived their health status. This analysis specifically examined
preventive health services targeted by the national health objectives 
for
the year 2000 (i.e., cholesterol screening, breast and cervical cancer
screening, and colorectal cancer screening) (3). The use of these 
services,
the perception of health status, and absence of a usual place of medical
care were compared between persons who were insured and uninsured by
calculating crude prevalence ratios and adjusted odds ratios (i.e.,
adjusted for age, race, education level, employment status, and income
level). For this analysis, sample estimates were statistically weighted 
to
reflect the noninstitutionalized civilian population in each state, and
standard errors were calculated using SESUDAAN.

Health Insurance Coverage for Persons Aged 18-64 Years
 Of the 102,263 persons who participated in the 1993 BRFSS, 81,794
persons aged 18-64 years responded to the question about health-care
coverage. Of these respondents, 16% reported they were uninsured at the
time of interview (Table 1). The percentages of persons who reported 
being
uninsured ranged from 7% in Hawaii to 26% in Louisiana (Table 1). The
prevalence of being uninsured was higher among persons in states in the
West (20%; 95% confidence interval [CI]=19%-21%) and South (19%; 95%
CI=18%-19%) than in the Northeast (14%; 95% CI=13%-15%) or Midwest (12%;
95% CI=11%-13%).**
 The prevalence of being uninsured was highest among men (18%), 
persons
aged 18-24 years (27%), those with less than a high school education 
(35%),
those with an annual household income less than $10,000 (39%), blacks
(21%), Hispanics (34%), and persons who were unemployed (44%) (Table 2).
Compared with women who were insured, women who were uninsured were 
twofold
more likely to report having no usual place of medical care (10% versus
18%), at least 50% less likely to have had both a mammogram and a 
clinical
breast examination during the previous 2 years (69% versus 35%), and 
less
likely to report having had a digital rectal examination during the
previous 2 years (51% versus 29%) or ever having had a proctoscopy
examination (32% versus 22%) (Table 3). The prevalences of self-
perceived
health status were similar among women who were insured and uninsured.
 When compared with men who were insured, uninsured men were two 
times
more likely to report having no usual place of medical care (18% versus
41%) and half as likely to report having had their cholesterol checked 
(65%
versus 36%) or having had a digital rectal (51% versus 27%) or a
proctoscopy examination (38% versus 20%). The prevalences of self-
perceived
health status were similar among men who were insured and uninsured.

Minnesota-Specific Data for Persons Aged 18-64 Years
 The Minnesota Department of Health asked all respondents 12
supplemental questions about health insurance coverage. Among the 2494
persons who were insured, 1852 (75%; 95% CI=73%-77%) reported their
employer was their primary source of coverage for health insurance.
Overall, 9% (95% CI=8%-10%) of employed persons were uninsured and 20% 
(95%
CI=15%-25%) of those employed in service occupational groups were
uninsured. In addition, 44% (95% CI=37%-50%) of uninsured persons and 
21%
(95% CI=19%-23%) of insured persons reported no visits to a physician
during the previous year.
 Of the 253 persons who were uninsured, 178 (69%; 95% CI=63%-75%)
reported the primary reason they lacked health insurance was cost. In
addition, of the 102 uninsured persons with children, 53 (53%; 95% 
CI=35%-
55%) reported that their children did not have health-care coverage.

Reported by: N Salem, PhD, Minnesota Dept of Health. 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, 
MPA,
Connecticut; F Breukelman, Delaware; C Mitchell, District of Columbia; D
McTague, MS, Florida; E Pledger, MPA, Georgia; F Newfield, MPA, Hawaii; 
C
Johnson, MPH, Idaho; B Steiner, MS, Illinois; R Guest, MPA, 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; 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, 
VMD,
North Carolina; D Young, MS, North Dakota; E Capwell, PhD, Ohio; N Hann,
MPH, Oklahoma; J Grant-Worley, 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 Risk Factor
Surveillance Br, Office of Surveillance and Analysis, National Center 
for
Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note: This report documents substantial variation in the
state-specific prevalences of persons who report being uninsured. In
addition, persons who were uninsured were less likely to have recently
received preventive health services or have a regular place of medical
care. The 1993 BRFSS findings are consistent with results from previous
national studies indicating that uninsured persons are less likely to
receive preventive health services (4). Lack of health-care coverage 
also
has been associated with delayed medical care and use of fewer medical
services (5,6).
 The findings in this report indicate that uninsured persons are 
more
likely to be younger, less educated, of races other than white, 
unemployed,
and of low income. These persons are less likely to engage in preventive
practices that can be effectively encouraged in the primary health-care
setting. Because lack of insurance is associated with limited access to
important preventive health-care services, improvements in health 
insurance
coverage through health-care reform at the state level may improve 
access
to preventive health services.
 The state-added questions from Minnesota are assisting in 
identifying
uninsured groups and estimating the percentage of children who are
uninsured. These findings are critical for targeting specific 
populations


 

(Continued from last message)
that are uninsured and developing health-care reform and managed-care
strategies.
 The findings in this report are subject to at least three 
limitations.
First, because the BRFSS includes only households with a telephone, 
these
findings probably underestimate the prevalence of being uninsured among
persons not residing in households with telephones (e.g., persons living
below the poverty level, less educated persons, and unemployed persons).
Second, nonrespondents or refusals in households with a telephone may be
younger and less educated persons who are more likely to be uninsured.
Third, because estimates are based on self-reported data, responses 
cannot
be validated and are subject to recall bias.
 The BRFSS can be used to provide routinely available, timely,
state-specific data on health insurance coverage and receipt of 
preventive
health services that may be used to monitor the progress of health-care
reform efforts in each state. This information may assist state planners
in evaluating progress toward the national health objectives for the 
year
2000 related to chronic diseases and disabling conditions. In addition, 
the
BRFSS enables states to add specific questions, such as those included 
in
Minnesota, to expand health-related information for use in planning and
evaluating state-based strategies for all groups.

References
1. Snider S, Boyce S. Sources of health insurance and characteristics of
the uninsured: analysis of the March 1993 Current Population Survey.
Washington, DC: Employee Benefit Research Institute, January 1994. (EBRI
special report no. SR-20; issue brief no. 145).
2. Frazier EL, Franks AL, Sanderson LM. Behavioral risk factor data. In:
CDC. Using chronic disease data: a handbook for public health
practitioners. Atlanta: US Department of Health and Human Services, 
Public
Health Service, CDC, 1992:4-1-4-17.
3. Public Health Service. Healthy people 2000: national health promotion
and disease prevention objectives--full report, with commentary.
Washington, DC: US Department of Health and Human Services, Public 
Health
Service, 1991; DHHS publication no. (PHS)91-50212.
4. Makuc DM, Freid VM, Parsons PE. Health insurance and cancer screening
among women. Hyattsville, Maryland: US Department of Health and Human
Services, Public Health Service, CDC, NCHS, 1994. (Advance data no. 
254).
5. Woolhandler S, Himmelstein DU. Reverse targeting of preventive care 
due
to lack of health insurance. JAMA 1988;259:2872-4.
6. Weissmann JS, Stern R, Fielding SL, Epstein AM. Delayed access to 
health
care: risk factors, reasons, and consequences. Ann Intern Med 
1991;114:325-
31.

* All respondents were asked, "Do you have any kind of health care
coverage, including health insurance, prepaid plans such as HMOs (health
maintenance organizations), or government plans such as Medicare?" 
Persons
who reported having no health-care coverage at the time of the interview
were considered to be uninsured.
** West=Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana,
Nevada, New Mexico, Oregon, Utah, and Washington; South=Alabama, 
Arkansas,
Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana,
Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, 
Tennessee,
Texas, Virginia, and West Virginia; Northeast=Connecticut, Maine,
Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode
Island, and Vermont; and Midwest=Illinois, Indiana, Iowa, Kansas, 
Michigan,
Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and
Wisconsin.
 Health Insurance Coverage and Receipt of Preventive Health Services
 -- United States, 1993

 In 1992, an estimated 38.5 million U.S. residents aged less than 65
years did not have health insurance (1). Efforts by states to expand
health-care coverage will require surveillance for and state-specific
information about coverage for acute care and the receipt of preventive
services. This report summarizes state-specific and aggregated data from
the 1993 Behavioral Risk Factor Surveillance System (BRFSS) regarding 
the
status of health insurance coverage and the receipt of preventive health
services among adults aged 18-64 years. In addition, findings from the
analysis of supplemental questions added to the BRFSS in Minnesota are
included that address health-care utilization, source of health-care
coverage, and coverage of children.
 In 1993, the District of Columbia and all states except Wyoming
participated in the BRFSS, a population-based, random-digit-dialed
telephone survey of adults aged greater than or equal to 18 years (2). 
All
persons responding to the BRFSS questionnaire were asked whether they 
had
health-care coverage*, which of selected preventive health services they
had received, if they had a usual place of medical care, and how they
perceived their health status. This analysis specifically examined
preventive health services targeted by the national health objectives 
for
the year 2000 (i.e., cholesterol screening, breast and cervical cancer
screening, and colorectal cancer screening) (3). The use of these 
services,
the perception of health status, and absence of a usual place of medical
care were compared between persons who were insured and uninsured by
calculating crude prevalence ratios and adjusted odds ratios (i.e.,
adjusted for age, race, education level, employment status, and income
level). For this analysis, sample estimates were statistically weighted 
to
reflect the noninstitutionalized civilian population in each state, and
standard errors were calculated using SESUDAAN.

Health Insurance Coverage for Persons Aged 18-64 Years
 Of the 102,263 persons who participated in the 1993 BRFSS, 81,794
persons aged 18-64 years responded to the question about health-care
coverage. Of these respondents, 16% reported they were uninsured at the
time of interview (Table 1). The percentages of persons who reported 
being
uninsured ranged from 7% in Hawaii to 26% in Louisiana (Table 1). The
prevalence of being uninsured was higher among persons in states in the
West (20%; 95% confidence interval [CI]=19%-21%) and South (19%; 95%
CI=18%-19%) than in the Northeast (14%; 95% CI=13%-15%) or Midwest (12%;
95% CI=11%-13%).**
 The prevalence of being uninsured was highest among men (18%), 
persons
aged 18-24 years (27%), those with less than a high school education 
(35%),
those with an annual household income less than $10,000 (39%), blacks
(21%), Hispanics (34%), and persons who were unemployed (44%) (Table 2).
Compared with women who were insured, women who were uninsured were 
twofold
more likely to report having no usual place of medical care (10% versus
18%), at least 50% less likely to have had both a mammogram and a 
clinical
breast examination during the previous 2 years (69% versus 35%), and 
less
likely to report having had a digital rectal examination during the
previous 2 years (51% versus 29%) or ever having had a proctoscopy
examination (32% versus 22%) (Table 3). The prevalences of self-
perceived
health status were similar among women who were insured and uninsured.
 When compared with men who were insured, uninsured men were two 
times
more likely to report having no usual place of medical care (18% versus
41%) and half as likely to report having had their cholesterol checked 
(65%
versus 36%) or having had a digital rectal (51% versus 27%) or a
proctoscopy examination (38% versus 20%). The prevalences of self-
perceived
health status were similar among men who were insured and uninsured.

Minnesota-Specific Data for Persons Aged 18-64 Years
 The Minnesota Department of Health asked all respondents 12
supplemental questions about health insurance coverage. Among the 2494
persons who were insured, 1852 (75%; 95% CI=73%-77%) reported their
employer was their primary source of coverage for health insurance.
Overall, 9% (95% CI=8%-10%) of employed persons were uninsured and 20% 
(95%
CI=15%-25%) of those employed in service occupational groups were
uninsured. In addition, 44% (95% CI=37%-50%) of uninsured persons and 
21%
(95% CI=19%-23%) of insured persons reported no visits to a physician
during the previous year.
 Of the 253 persons who were uninsured, 178 (69%; 95% CI=63%-75%)
reported the primary reason they lacked health insurance was cost. In
addition, of the 102 uninsured persons with children, 53 (53%; 95% 
CI=35%-
55%) reported that their children did not have health-care coverage.

Reported by: N Salem, PhD, Minnesota Dept of Health. 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, 
MPA,
Connecticut; F Breukelman, Delaware; C Mitchell, District of Columbia; D
McTague, MS, Florida; E Pledger, MPA, Georgia; F Newfield, MPA, Hawaii; 
C
Johnson, MPH, Idaho; B Steiner, MS, Illinois; R Guest, MPA, 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; 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, 
VMD,
North Carolina; D Young, MS, North Dakota; E Capwell, PhD, Ohio; N Hann,
MPH, Oklahoma; J Grant-Worley, 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 Risk Factor
Surveillance Br, Office of Surveillance and Analysis, National Center 
for
Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note: This report documents substantial variation in the
state-specific prevalences of persons who report being uninsured. In
addition, persons who were uninsured were less likely to have recently
received preventive health services or have a regular place of medical
care. The 1993 BRFSS findings are consistent with results from previous
national studies indicating that uninsured persons are less likely to
receive preventive health services (4). Lack of health-care coverage 
also
has been associated with delayed medical care and use of fewer medical
services (5,6).
 The findings in this report indicate that uninsured persons are 
more
likely to be younger, less educated, of races other than white, 
unemployed,
and of low income. These persons are less likely to engage in preventive
practices that can be effectively encouraged in the primary health-care
setting. Because lack of insurance is associated with limited access to
important preventive health-care services, improvements in health 
insurance
coverage through health-care reform at the state level may improve 
access
to preventive health services.
 The state-added questions from Minnesota are assisting in 
identifying
uninsured groups and estimating the percentage of children who are
uninsured. These findings are critical for targeting specific 
populations
that are uninsured and developing health-care reform and managed-care
strategies.
 The findings in this report are subject to at least three 
limitations.
First, because the BRFSS includes only households with a telephone, 
these
findings probably underestimate the prevalence of being uninsured among
persons not residing in households with telephones (e.g., persons living
below the poverty level, less educated persons, and unemployed persons).
Second, nonrespondents or refusals in households with a telephone may be
younger and less educated persons who are more likely to be uninsured.
Third, because estimates are based on self-reported data, responses 
cannot
be validated and are subject to recall bias.
 The BRFSS can be used to provide routinely available, timely,
state-specific data on health insurance coverage and receipt of 
preventive
health services that may be used to monitor the progress of health-care
reform efforts in each state. This information may assist state planners
in evaluating progress toward the national health objectives for the 
year
2000 related to chronic diseases and disabling conditions. In addition, 
the
BRFSS enables states to add specific questions, such as those included 
in
Minnesota, to expand health-related information for use in planning and
evaluating state-based strategies for all groups.

References
1. Snider S, Boyce S. Sources of health insurance and characteristics of
the uninsured: analysis of the March 1993 Current Population Survey.
Washington, DC: Employee Benefit Research Institute, January 1994. (EBRI
special report no. SR-20; issue brief no. 145).
2. Frazier EL, Franks AL, Sanderson LM. Behavioral risk factor data. In:
CDC. Using chronic disease data: a handbook for public health
practitioners. Atlanta: US Department of Health and Human Services, 
Public
Health Service, CDC, 1992:4-1-4-17.
3. Public Health Service. Healthy people 2000: national health promotion
and disease prevention objectives--full report, with commentary.
Washington, DC: US Department of Health and Human Services, Public 
Health
Service, 1991; DHHS publication no. (PHS)91-50212.
4. Makuc DM, Freid VM, Parsons PE. Health insurance and cancer screening
among women. Hyattsville, Maryland: US Department of Health and Human
Services, Public Health Service, CDC, NCHS, 1994. (Advance data no. 
254).
5. Woolhandler S, Himmelstein DU. Reverse targeting of preventive care 
due
to lack of health insurance. JAMA 1988;259:2872-4.
6. Weissmann JS, Stern R, Fielding SL, Epstein AM. Delayed access to 
health
care: risk factors, reasons, and consequences. Ann Intern Med 
1991;114:325-
31.

* All respondents were asked, "Do you have any kind of health care
coverage, including health insurance, prepaid plans such as HMOs (health
maintenance organizations), or government plans such as Medicare?" 
Persons
who reported having no health-care coverage at the time of the interview
were considered to be uninsured.
** West=Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana,
Nevada, New Mexico, Oregon, Utah, and Washington; South=Alabama, 
Arkansas,
Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana,
Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, 
Tennessee,
Texas, Virginia, and West Virginia; Northeast=Connecticut, Maine,
Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode
Island, and Vermont; and Midwest=Illinois, Indiana, Iowa, Kansas, 
Michigan,
Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and
Wisconsin.


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

End of HICNet Medical News Digest V08 Issue #10
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