
Following is the final electronic text from the Morbidity and Mortality Weekly
Report (MMWR), vol. 44, no. 16, dated April 28, 1995.  The MMWR is published
by the U.S. Department of Health and Human Services, Public Health Service,
Centers for Disease Control and Prevention (CDC), Atlanta, Georgia.
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CONTENTS OF THIS ISSUE:
Pages/Title
    309
        Clean Air Month -- May 1995
    309-312
        Children at Risk from Ozone Air Pollution --
        United States, 1991-1993
    312-315, 321-323
        Fatal and Nonfatal Suicide Attempts Among Adolescents --
        Oregon, 1988-1993
    323-325
        Evaluation of Vaccination Strategies in Public Clinics --
        Georgia, 1985-1993
    325
        -- Notice to Readers: Discontinuation of
           Publication of Figures II-V in MMWR
        -- Addendum: vol. 44, No. 4
        -- Erratum: Vol. 44, No. RR-1
        -- Erratum: Vol. 44, No. 6
    326
        AIDS Map
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Clean Air Month -- May 1995

     The American Lung Association (ALA) sponsors National Clean Air Month
each May to educate the public about the relation between clean air and
respiratory health. This year's theme is "Helping Kids Breathe Easier."
     Air pollution is an important contributor to lung disease, the third
leading cause of death in the United States. ALA is committed to decreasing
lung disease in children by emphasizing the importance of reducing air
pollution. ALA recommends that persons drive less, support state and local
clean air regulations, make their homes and workplaces smoke-free, and test
them for harmful pollutants (e.g., radon and carbon monoxide).
     Efforts planned by local lung associations throughout the country for
Clean Air Month include Clean Commute Days and Clean Air Challenge cycling and
walking fundraising events. This issue of MMWR includes a report that provides
estimates of the number of children potentially at risk from ozone air
pollution.
     Additional information about Clean Air Month and related activities is
available from local ALA offices (telephone [800] 586-4872) or from the
national office (1740 Broadway, New York, NY 10019-4374; telephone [212]
315-8700).


Children at Risk from Ozone Air Pollution --
United States, 1991-1993

     A national health objective for the year 2000 is to reduce exposure to
air pollutants so that at least 85% of persons reside in counties that meet
Environmental Protection Agency (EPA) standards (objective 11.5) (1). Ozone,
the principle component of summer smog, is the most pervasive air pollutant in
the United States. The risks associated with ozone and other air pollutants
are especially increased for children and adults with asthma (2); however,
children with no underlying pulmonary diseases also are at risk for adverse
health effects associated with these pollutants (3). In addition, because
children of racial/ethnic minorities are more likely to reside in areas with
higher air pollution levels, they may be exposed to higher levels of ozone
(4). This report presents the findings of an analysis by the American Lung
Association (ALA) to characterize pediatric populations potentially at risk
for adverse health effects from exposure to ozone air pollution in the United
States during 1991-1993.
     The National Ambient Air Quality Standard for ozone is 0.12 parts per
million (ppm) averaged over 1 hour.* The federal standard is met if this value
is not exceeded more than once per calendar year on average over a 3-year
period. The federal "exceedance" of the 0.12 ppm standard is defined as all
levels greater than or equal to 0.125 ppm.** For this report, both the federal
exceedance level (greater than or equal to 0.125 ppm, averaged over 1 hour)
and an alternative level--used in recent health studies (greater than or equal
to 0.085 ppm, averaged over 8 hours) (5)--were used as cutoff values.
     The 1990 population census provided race/ethnicity-specific data for
persons aged less than or equal to 17 years in each county (Bureau of the
Census, unpublished data, 1992). The number of children with asthma was
estimated by applying age-specific national prevalence rates from CDC's
National Health Interview Survey (6) to age-specific population estimates at
the county level. Information about ozone exposure was based on 1991-1993
monitored ozone data (EPA, unpublished data, 1994), the most recent data
available from EPA. Although individual levels of ozone exposure may vary for
persons who reside in a particular county and differ from those measured by
the monitor in that county, ozone levels generally are consistent within
specific geographic areas (7).
     During 1991-1993, ozone levels exceeded 0.085 ppm over 8 hours on four or
more occasions in 394 counties and cities; an estimated 136 million persons
(54.7% of the U.S. population) resided in these areas. Of the total number of
children aged less than or equal to 13 years in the United States
(50,324,764), approximately 27.1 million (53.9%) resided in these areas. Among
racial/ethnic groups, 61.3% of all black children, 67.7% of all Asian/ Pacific
Islander children, and 69.2% of all Hispanic children resided in these areas
(Table 1). An estimated 2.0 million (5.8%) of the 34.3 million children (aged
less than or equal to 17 years) residing in these areas were affected by
asthma.
     During 1991-1993, a total of 104 counties and cities had ozone levels
greater than 0.125 ppm over a 1-hour period on four or more occasions. An
estimated 60 million persons in the United States (24.1% of the U.S.
population) resided in these areas, including an estimated 12.1 million
children (aged less than or equal to 13 years) (24.1% of all children in this
age group). Among racial/ethnic groups, 23.1% of black children, 39.9% of
Asian/Pacific Islander children, and 44.2% of Hispanic children resided in
these areas (Table 2). Approximately 877,000 children (aged less than or equal
to 17 years) in these areas were affected by asthma.

Reported by: R White, MST, National Programs Div, S Rappaport, MPH, K Lieber,
MPH, A Gorman, Epidemiology and Statistics Div, F DuMelle, D Maple, Government
Relations Div, M Bhawnani, Communications Div, N Edelman, MD, American Lung
Association, New York. Air Pollution and Respiratory Health Br, Div of
Environmental Hazards and Health Effects, National Center for Environmental
Health, CDC.

Editorial Note: Ozone pollution results when hydrocarbons and nitrogen oxides
emitted from motor vehicles and other sources react in the presence of
sunlight. Exposure to ozone has been associated with adverse health effects,
including hospital and emergency department visits for asthma and other
respiratory problems; reductions in lung function; and exercise-related
wheezing, coughing, and chest tightness (5). Children are at higher risk for
detrimental effects of ozone than adults because they spend more time outdoors
during summer months when ozone levels are higher and because their lungs are
still developing (8).
     Although air pollution has been recognized as a public health hazard in
the United States since the 1950s, the disproportionate risks for
racial/ethnic minorities with low incomes have only recently been recognized
(4). The findings in this report underscore the increased risk for exposure--particularly among children--for racial/ethnic minorities who reside in areas
where national air quality standards are not met (4). In addition, since the
early 1980s, the risk for asthma-associated mortality and hospitalization has
been consistently higher among young persons who are black (9).
     ALA recently issued Danger Zones: Ozone Air Pollution and Our Children.
The report is a national and county estimate of the number of children who are
at potential risk from exposure to ozone. Copies are available from local
offices of the ALA, telephone (800) 586-4872 or (212) 315-8700.

References
1. Public Health Service. Healthy people 2000: national health promotion and
disease prevention objectives. Washington, DC: US Department of Health and
Human Services, Public Health Service, 1991; DHHS publication no.
(PHS)91-50213.
2. CDC. Populations at risk from air pollution--United States, 1991. MMWR
1993;42:301-4.
3. Committee on Environmental Health. Ambient air pollution: respiratory
hazards to children. Pediatrics 1993;91:1210-3.
4. US Environmental Protection Agency. Environmental equity: reducing risk for
all communities. Volume 1: workgroup report to the Administrator. Washington,
DC: US Environmental Protection Agency, Office of Policy, Planning, and
Evaluation, June 1992; publication no. EPA-230/R-92/008.
5. Lippmann M. Health effects of tropospheric ozone: review of recent research
findings and their implications to ambient air quality standards. J Expo Anal
Care Environ Epidemiol 1993;3:103-29.
6. NCHS. Current estimates from the National Health Interview Survey, 1990.
Hyattsville, Maryland: US Department of Health and Human Services, Public
Health Service, CDC, 1991; DHHS publication no. (PHS)92-1509. (Vital and
health statistics; series 10, no. 181).
7. Curran T, Fitz-Simons T, Freas W, et al. National air quality and emissions
trends report, 1993. Research Triangle Park, North Carolina: US Environmental
Protection Agency, Office of Air Quality Planning and Standards, October 1994;
publication no. EPA-454/R-94/026.
8. World Health Organization. Principles for evaluating health risks from
chemicals during infancy and early childhood: the need for a special approach.
Geneva: World Health Organization, 1986; environmental criteria 59.
9. CDC. Asthma--United States, 1982-1992. MMWR 1995;43:952-5.

* 44 FR 8202.
** 40 CFR 50.


Fatal and Nonfatal Suicide Attempts
Among Adolescents -- Oregon, 1988-1993

     Suicide is the third leading cause of death among adolescents aged 15-19
years in the United States and second among adolescents in Oregon. During
1959-1961 and during 1990-1992, the rate of suicide in Oregon increased
sixfold among 15-19-year-olds. During 1988-1991, the suicide rate for
adolescents in Oregon (15.5 deaths per 100,000) was 39.6% higher than the U.S.
rate (11.1). Because of the magnitude of this problem, in 1987 the state
legislature in Oregon mandated that hospitals treating a child aged less than
or equal to 17 years for injuries resulting from a suicide attempt report the
attempt to the State Health Division, Oregon Department of Human Resources,
and that the patient be referred for counseling; the Oregon Adolescent Suicide
Attempt Data System (ASADS) was established in 1988. This report presents an
analysis of data for adolescents aged less than or equal to 17 years from
ASADS during 1988-1993.
     Notification of suicide attempt is made through a one-page report form,
which is usually completed by emergency department or medical records
personnel and is submitted monthly from all hospitals in the state. Hospitals
use their own criteria to define attempts. Information collected includes age,
race/ethnicity, sex, place of attempt, date of attempt, method of attempt, and
whether the patient was admitted to the hospital. Beginning in 1990, data also
were collected on reasons for the attempt and number of previous attempts.
Data missing from attempt reports were imputed in proportion to known
distributions for the specified variable. The proportion of missing data
ranged from 0.1%-23.5%. In this analysis, fatal attempts were identified using
death certificate data.
     During 1988-1993, a total of 3783 suicide attempts were reported for
persons aged less than or equal to 17 years; of these, 3773 were by persons
aged 10-17 years (Table 1). Sex-specific attempt rates were 326.4 per 100,000
for females and 73.4 for males. Children as young as age 6 years had attempted
suicide. The number of reported attempts increased steadily with age for males
but peaked at age 15 years for females (Figure 1).

Characteristics of Fatal and Nonfatal Suicide Attempts
     During 1988-1993, most (2981 [78.8%]) suicide attempts were made in the
residence of the attempter; 280 (7.4%), in another residence; 178 (4.7%), in
school; and seven (0.2%), in jail. Attempts occurred more commonly during
spring months (March, April, and May) (1106 [29.2%]) and least commonly during
summer months (June, July, and August) (731 [19.3%]). In addition, attempts
occurred most frequently on Mondays (660 [17.4%]) and least often on Saturdays
(414 [11.0%]).
     Among youth aged 10-17 years, 123 (6.4 per 100,000) made a suicide
attempt that resulted in death (Table 1). The rate of fatal suicide attempts
was three times greater for males (9.5) than for females (3.1). In addition,
the proportion of attempts that were fatal was more than 100-fold higher among
males (94 [11.5%]) than among females (29 [0.1%]). Although the risk for
attempts was 3.8 times greater among youth aged 15-17 years than among those
aged 10-14 years, the proportions of fatal attempts were similar among males
and females in both age groups.
     During 1990-1993, of the 2511 persons who attempted suicide, 1042 (41.5%)
reported having made at least one previous attempt during the preceding 5
years. Previous attempts occurred most often among those who indicated their
reason for attempting suicide was rape/sexual abuse (149 [60.7%]), substance
abuse (111 [56.6%]), or physical abuse (46 [54.0%]).

Methods Used
     During 1988-1993, ingestion of drugs accounted for most (2857 [75.5%])
attempts (Table 2); of the attempts involving drugs, analgesics accounted for
1354 (47.4%) (aspirin and acetaminophen were used most commonly). Cutting and
piercing injuries accounted for 421 (11.1%) of the attempts, of which most
were lacerations of the wrists. Most attempts by multiple methods were
lacerations combined with a drug overdose.
     Drugs were used in 2440 (79.8%) attempts by females, compared with 417
(57.4%) by males (Table 2). Males who attempted suicide were more likely than
females to do so by suffocation/hanging, cutting/piercing, or use of firearms
(Table 2).
     Of all methods used to attempt suicide, those used most commonly were
least likely to result in death (e.g., of attempts by drug overdose, 0.4% were
fatal) (Table 2). In comparison, 78.2% and 35.7% of attempts using firearms or
poisonings with gas, respectively, were fatal. Of the 124 deaths among persons
aged less than or equal to 17 years, most resulted from use of firearms
(63.7%) or suffocation/hanging (18.5%).
     During 1990-1993, persons who had made multiple attempts were more likely
to use suffocation/hanging (4.3%) and cutting/piercing (14.3%) than those
making attempts for the first time (1.2% and 6.9%, respectively).

Reasons for Suicide Attempt
     During 1990-1993, the most commonly reported reasons for attempting
suicide were family discord (1492 [59.4%]), an argument with a
boyfriend/girlfriend (819 [32.6%]), and school-related problems (578 [23.0%])
(Table 3). A higher proportion of females (60.8%) and persons aged less than
or equal to 12 years (73.0%) reported family discord as their reason for
attempting suicide.

Reported by: DD Hopkins, MS, JA Grant-Worley, MS, DW Fleming, MD, State
Epidemiologist, State Health Div, Oregon Dept of Human Resources. National
Center for Injury Prevention and Control, CDC.

Editorial Note: In Oregon, during 1988-1993, for every fatal suicide attempt
by an adolescent, 31 nonfatal attempts were reported. Some attempts may not
have been made with death as a goal but instead may have reflected a desire to
resolve a difficult conflict, indicate an intolerable living situation, or
elicit sympathy or guilt (1,2).
     Oregon is the only state with a legal requirement for reporting suicide
attempts and a surveillance system for monitoring such attempts. The reported
rate of suicide attempts among adolescents in Oregon during 1988-1993 based on
ASADS data is substantially lower than previously reported using survey data.
Based on the 1993 Youth Risk Behavior Survey, 2.7% of U.S. high school
students reported making a suicide attempt during the previous 12 months that
required medical attention (3); 3.2% (i.e., 3200 per 100,000) of Oregon high
school students reported such attempts. Because ASADS is hospital-based and
includes only attempts by persons who actually seek medical care, the findings
may provide more valid information than other sources. For example, data from
surveys often rely on the respondents' definition of attempted suicide, and
only small proportions of respondents who report having attempted suicide
actually have taken a substantive action to injure themselves (4).
Furthermore, YRBS may overestimate the prevalence of suicide attempts among
high school students. However, ADADS probably underestimates the occurrence of
suicide attempts in Oregon for at least four reasons. First, hospital
reporting may be incomplete; in addition, reporting hospitals may use
different criteria in determining whether a patient attempted suicide. Second,
reports of adolescent suicide attempts are not required from clinics or
physicians' offices; some attempters may have been treated in these settings,
especially those living in rural areas. Third, attempts by adolescents who did
not require professional medical care were not reported. Finally, when persons
from Oregon receive treatment in another state for a suicide attempt, the
event is unreported.
     In Oregon, firearms were used most often in fatal suicide attempts, and
most attempts involving firearms were fatal. Nationally, 81% of the increase
in suicide among persons aged 15-19 years during 1980-1992 was related to use
of firearms (5). Controlling access to firearms is an important prevention
measure; however, storing weapons unloaded and locked may not prevent
intentionally inflicted gunshot wounds among suicidal youth (6). Because an
attempt with a gun usually results in death, parents and other persons who
have responsibility for children should ensure that at-risk adolescents have
no access to guns.
     ASADS represents an initial effort to examine the magnitude and
epidemiology of intentionally self-inflicted injury among adolescents. This
surveillance system was the first statewide system established to quantify the
incidence of adolescent suicide attempts and to characterize the attempts and
attempters. Although the system still must undergo vigorous evaluation (7), it
provides essential information that will be useful in applying public health
measures to the problem of suicide (8). Data from ASADS are being used to
develop public and private suicide-education programs. For example, the Oregon
Health Division has formed a task force to review the data and propose
intervention methods. This approach may be adopted for use in other states to
permit characterization of persons attempting suicide and to assist in
refining prevention and early-intervention measures.

References
1. Bolton IM. Perspectives of youth on preventive intervention strategies. In:
Alcohol, Drug Abuse, and Mental Health Administration. Report of the
Secretary's Task Force on Youth Suicide: Volume 3--prevention and
interventions in youth suicide. Washington, DC: US Department of Health and
Human Services, Public Health Service, 1989:264-75; DHHS publication no.
(ADM)89-1623.
2. Committee on Adolescence, American Academy of Pediatrics. Suicide and
suicide attempts in adolescents and young adults. Pediatrics 1988;81:322-4.
3. Kann L, Warren CW, Harris WA, et al. Youth risk behavior surveillance--United States, 1993. In: CDC surveillance summaries (March). MMWR 1995;44(no.
SS-1).
4. Meehan PJ, Lamb JA, Saltzman LE, O'Carroll PW. Attempted suicide among
young adults: progress towards a meaningful estimate of prevalence. Am J
Psychiatry 1992;149:41-4.
5. CDC. Suicide among children, adolescents, and young adults--United States,
1980-1992. MMWR 1995;44:289-91.
6. Brent DA, Perper JA, Goldstein CE, et al. Risk factors for adolescent
suicide: a comparison of adolescent suicide victims with suicidal inpatients.
Arch Gen Psychiatry 1988;45:581-8.
7. Klaucke DN, Buehler JW, Thacker SB, et al. Guidelines for evaluating
surveillance systems. MMWR 1988;37(no. S-5).
8. Potter L, Powell K, Kachur S. Suicide prevention from a public health
perspective. Suicide Life Threat Behav 1995;25:83-92.


Evaluation of Vaccination Strategies
in Public Clinics -- Georgia, 1985-1993

     From 1987 through 1993, the vaccination coverage levels among children
served in public health clinics in Georgia more than doubled. This increase
followed the implementation of a multifaceted strategy that included routine
measurement of vaccination coverage levels. This report describes this program
and an analysis of increases in vaccination coverage during 1985-1993.
     In 1985, the Georgia Division of Public Health (GDPH) reviewed the
vaccination records of selected public clinics to assess vaccination coverage
levels for the recommended childhood vaccines in relation to the national goal
of 90% up-to-date by age 2 years. The results indicated that less than 40% of
2-year-olds served by the public sector had received a complete set of
recommended vaccinations (i.e., four doses of diphtheria and tetanus toxoids
and pertussis vaccine, three doses of oral poliovirus vaccine, and one dose of
measles-mumps-rubella vaccine). In response, GDPH initiated a statewide annual
assessment of vaccination coverage levels in public clinics. Information from
these assessments assists in a program with four elements: 1) assessment of
coverage levels and missed opportunity rates through analysis of birth and
vaccination dates obtained for a sample of children from each clinic; 2)
feedback of these data to the clinics; 3) issuance of awards (e.g., plaques)
to health districts and clinics meeting coverage goals; and 4) dissemination
of maps of coverage, rank-order lists, and other information to health
district offices and public clinics.
     During 1987-1989, participation in the program increased from zero to
include all of the approximately 220 public clinics and all 19 health
districts in the state; these clinics provide vaccinations to approximately
70% of the state's birth cohort. Among children attending these clinics, the
proportion who were up-to-date increased from 35% in 1987 to 80% in 1993
(Figure 1), while the rate of missed simultaneous vaccination opportunities at
the last visit declined from 15% to less than 1%. In 1987, aggregate coverage
rates were less than 50% in 11 of 12 participating districts; in comparison,
in 1993, aggregate rates were greater than or equal to 50% in all 19
districts, greater than 75% in 16, and greater than 90% in three.
Reported by: M Chaney, Georgia Div of Public Health. National Immunization
Program, CDC.

Editorial Note: National health objectives for the year 2000 include the goal
that at least 90% of children should have completed the basic vaccination
series by age 24 months (objective 20.11) (1). However, based on the National
Health Interview Survey, in 1993, only 67% of 2-year-olds were up-to-date (2).
Although national coverage levels have increased since 1991, intensified
efforts are needed to improve provider practices and to encourage parents to
ensure their children are vaccinated on schedule.
     The findings in this report suggest that institution of the multifaceted
program in Georgia was associated with increased vaccination coverage.
Preliminary findings from other states (e.g., Colorado and South Carolina)
employing similar programs are consistent with findings in Georgia and
indicate increases in coverage levels (CDC, unpublished data, 1995).
     Assessment of vaccination coverage levels of both public and private
providers is specified in the Standards for Pediatric Immunization Practices
(3), and federal funding is provided to each state and local grant program to
support assessments in the public and private sectors. States receiving
vaccination grant funds during 1995 are required to assess all public health
clinics annually.* To assist with these assessments, Clinic Assessment
Software Application (4) is available at no charge to public and private
providers from the National Immunization Program, CDC, telephone (404)
639-8392.
     Efforts are in progress to adapt the assessment methodology to assist
private providers in self-assessment. To ensure up-to-date vaccination for
children, a high priority is the development and widespread use in the private
sector of programs that have been associated in Georgia and other states with
increases in vaccination coverage.

References
1. Public Health Service. Healthy people 2000: national health promotion and
disease prevention objectives. Washington, DC: US Department of Health and
Human Services, Public Health Service, 1991; DHHS publication no.
(PHS)91-50213.
2. CDC. Vaccination coverage of 2-year-old children--United States, 1993. MMWR
1994;43:705-9.
3. Ad Hoc Working Group for the Development of Standards of Immunization
Practices. Standards for pediatric immunization practices. JAMA 1993;269:1817-22.
4. CDC. Clinic Assessment Software Application (CASA): user's guide. Atlanta:
US Department of Health and Human Services, Public Health Service, CDC, 1994.
* Public Law 103-333.


Notice to Readers
Discontinuation of Publication of Figures II-V in MMWR

Figures II-V, which depict reported cases of acquired immunodeficiency
syndrome, tuberculosis, gonorrhea, and syphilis, respectively, and have been
published quarterly in the MMWR, will no longer be published. CDC is
evaluating other methods of representing surveillance data in graphs.


Addendum: Vol. 44, No. 4
     In the article, "Occupational Silicosis--Ohio, 1989-1994" the following
name should be added to the credits ("reported by") on page 63: RJ Blinkhorn,
Jr, MD, Cuyahoga County Tuberculosis Program, Cleveland, Ohio.


Erratum: Vol. 44, No. RR-1
     In the article "Injury Control Recommendations: Bicycle Helmets," on the
inside front cover, David A. Sleet, Ph.D., should be listed as the Acting
Director of the Division of Unintentional Injuries Prevention. In addition, on
page iv, Nancy Dean Nowak should be listed as Nancy Dean Nowak, R.N., M.P.H.,
and Benjamin Moore, M.P.H., should be listed without an M.P.H.


Erratum: Vol. 44, No. 6
     In the article, "Prevalence of Recommended Levels of Physical Activity
Among Women--Behavioral Risk Factor Surveillance System, 1992," the fifth
sentence on page 106 should read "The prevalence of participation in
recommended levels was directly related to education level and family income .
. . ."


AIDS Map
     The following map provides information on the reported number of acquired
immunodeficiency syndrome (AIDS) cases per 100,000 population, by person's
state of residence from January 1994 through December 1994. More detailed
information on AIDS cases is provided in the HIV/AIDS Surveillance Report,
single copies of which are available free from the CDC National AIDS
Clearinghouse, P.O. Box 6003, Rockville, MD 20849-6003; telephone (800)
458-5231 or (301) 217-0023.
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Centers for Disease Control and Prevention, Atlanta, GA 30333; telephone (404)
332-4555.

The MMWR is available on a paid subscription basis for paper copy and free of
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All material in the MMWR Series is in the public domain and may be used and
reprinted without special permission; citation of source, however, is
appreciated.
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Director, Centers for Disease Control and Prevention
     David Satcher, M.D., Ph.D.
Deputy Director, Centers for Disease Control and Prevention
     Claire V. Broome, M.D.
Director, Epidemiology Program Office
     Stephen B. Thacker, M.D., M.Sc.
Editor, MMWR Series
     Richard A. Goodman, M.D., M.P.H.
Managing Editor, MMWR (weekly)
     Karen L. Foster, M.A.
Writers-Editors, MMWR (weekly)
     David C. Johnson         Darlene D. Rumph-Person
     Patricia A. McGee        Caran R. Wilbanks
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