From <@VMS.DC.LSOFT.COM:owner-mednews@ASUVM.INRE.ASU.EDU> Sun Aug 27 14:48:06 1995 (LSMTP for OpenVMS v0.1a) with SMTP id A0DF1DD7 ; Sun, 27 Aug 1995 14:34:07 - 1300 release 1.8b) with NJE id 7033 for MEDNEWS@ASUVM.INRE.ASU.EDU; Sun, 27 Aug 1995 11:31:17 -0700 (LMail V1.2a/1.8a) with BSMTP id 2072; Sun, 27 Aug 1995 11:31:16 - 0700 V2R3) with TCP; Sun, 27 Aug 95 11:31:02 MST (8.6.12/8.6.9) with UUCP id LAA08623 for mednews@asuvm.inre.asu.edu; Sun, 27 Aug 1995 11:15:37 -0700 mednews@asuvm.inre.asu.edu Comments: To: asumednews@stat.com HICNet Medical News Digest Sun, 27 Aug 1995 Volume 08 : Issue 29 Today's Topics: [MMWR] Injuries Associated with Self-Unloading Forage Wagons [MMWR] Update: HIV-2 Infection Among Blood and Plasma Donors [MMWR] Monthly Immunization Table [MMWR Aug-11-95] Heat-Related Mortality --- Chicago, July 1995 CancerNet Update for August 1995 Gov't Hotline for Environmental Health Questions Available [MMWR 25-Aug-95] Disabilities among children aged < 17 [MMWR] State and National Vaccination Coverage levels... +------------------------------------------------+ ! ! ! Health Info-Com Network ! ! Medical Newsletter ! +------------------------------------------------+ Editor: David Dodell, D.M.D. 10250 North 92nd Street, Suite 210, Scottsdale, Arizona 85258-4599 USA Telephone +1 (602) 860-1121 FAX +1 (602) 451-1165 Internet: mednews@stat.com Bitnet: ATW1H@ASUACAD Mosaic WWW *Asia/Pacific: http://biomed.nus.sg/MEDNEWS/welcome.html *Americas: http://outland.cardinal.com/hicn *Europe: http://www.dmu.ac.uk/ln/MEDNEWS/ Compilation Copyright 1995 by David Dodell, D.M.D. All rights Reserved. License is hereby granted to republish on electronic media for which no fees are charged, so long as the text of this copyright notice and license are attached intact to any and all republished portion or portions. The Health Info-Com Network Newsletter is distributed biweekly. Articles on a medical nature are welcomed. If you have an article, please contact the editor for information on how to submit it. If you are interested in joining the automated distribution system, please contact the editor. Associate Editors: E. Loren Buhle, Jr. Ph.D. Dept. of Radiation Oncology, Univ of Pennsylvania Tom Whalen, M.D., Robert Wood Johnson Medical School at Camden Douglas B. Hanson, Ph.D., Forsyth Dental Center, Boston, MA Lawrence Lee Miller, B.S. Biological Sciences, UCI Dr K C Lun, National University Hospital, Singapore W. Scott Erdley, MS, RN, SUNY@UB School of Nursing Jack E. Cross, B.S Health Care Admin, 882 Medical Trng Grp, USAF Albert Shar, Ph.D. CIO, Associate Prof, Univ of Penn School of Medicine Stephen Cristol, M.D. MPH, Dept of Ophthalmology, Emory Univ, Atlanta, GA Subscription Requests = mednews@stat.com anonymous ftp = vm1.nodak.edu; directory HICNEWS FAX Delivery = Contact Editor for information ---------------------------------------------------------------------- To: hicnews Injuries Associated with Self-Unloading Forage Wagons -- New York,1991- 1994 In New York, an estimated 3600 injuries occur each year to farmers operating farm machines (1). In October 1993, the Occupational Health Nurses in Agricultural Communities (OHNAC)* program in the New York State Department of Health received a report of a man who sustained severe injuries when he became entangled in the power take-off (PTO) driveline to a self-unloading forage wagon**. Subsequent investigation by OHNAC identified four additional similar incidents in New York that occurred during September 1991-October 1994, including one fatality and one injury to a 9-year-old girl working on a family farm. This report summarizes the results of the investigation of these forage-wagon- related injuries and presents recommendations to reduce the risk for such injuries. On October 1, 1993, a 66-year-old farmer was using a self-unloading forage wagon to unload chopped corn into a blower for transfer into a silo. To unload the corn, he used a tractor to pull the loaded forage wagon next to the blower (which was attached to a second tractor). To reach the speed-control lever, he stepped over the rotating PTO driveline that connected his tractor to the wagon and supplied its power. As he stepped, his pants became entangled around the unprotected rotating driveline. A nearby worker witnessed the incident and turned off the driveline. The farmer's injuries included amputation of the genitalia and deep tissue damage to the buttocks, requiring extensive grafting. He was hospitalized for 2 weeks and unable to work for 1 month. On investigation by OHNAC, with assistance from the Cooperative Extension Service, four other incidents were identified since 1991 involving forage wagons with unprotected drivelines. In September 1991, a 33-year-old farmer sustained multiple fractures of the right leg with amputation of the right foot when his shirt blew into a rotating driveline of a forage wagon while he was working between two drivelines on a windy day. In October 1992, a 41-year-old farm operator sustained avulsion of the entire scrotal area when his pants became entangled while he was stepping over the unprotected PTO driveline. In November 1992, a 9-year-old girl sustained bilateral above-the-knee amputations when her jacket became entangled while she was reaching over the unprotected rotating driveline to operate the speed control of the forage wagon she was unloading. Finally, in an unwitnessed incident in October 1994, a 19-year-old male farmer sustained fatal internal injuries after apparently stepping too close to the driveline of a forage wagon while unloading chopped corn. Reported by: S Roerig, J Melius, MD, J Pollock, MSP, M London, MS, G Casey, New York State Dept of Health. Div of Surveillance, Hazard Evaluations, and Field Studies, National Institute for Occupational Safety and Health, CDC. Editorial Note: In the United States, farm machinery is a leading source of traumatic injuries to farmers, accounting for an estimated 34,000 lost-time work injuries to farmers nationally in 1993 (2). Mechanical devices are associated with approximately 30% of the work-related injuries on farms (2). Forage wagons are used most often on farms that raise large animals and grow their own feed grain. The fatal and severe nonfatal injuries described in this report were caused by a combination of factors. To unload feed grain, the forage wagon and silo blower must be in close proximity, which requires that the two tractors that power these machines also be in close proximity (Figure 1). The speed-control lever for the wagon is often located on the discharge side near the silo blower (i.e., between the two pieces of equipment). Many older tractors are small enough that, when the forage wagon and blower are thus positioned for proper operation, sufficient space remains between the adjacent rear tires of the two tractors to allow the operator to dismount from either tractor seat and walk between the two tractors directly to the forage wagon speed control without crossing over a revolving PTO driveline. However, as both silos and self-unloading forage wagons have increased in capacity, both the size and horsepower of the associated tractors have increased concomitantly. When these larger tractors are used, their rear wheels abut, blocking access between the tractors and requiring the operator to cross over a revolving driveline to operate the forage wagon. Since the 1930s, PTO drivelines have been manufactured with shields. However, shields are often damaged or removed during operation or maintenance of the farm equipment. Of the estimated 29,000 self-unloading wagons in use on New York farms, 3000-5000 are believed to lack shields to protect workers adequately from a revolving PTO driveline (J. Pollock, Cornell University, personal communication, 1995). Entanglement in PTO drivelines, including entanglement in those equipped with intact U-shaped shields that leave one side (generally the underside) unguarded, previously has been recognized as a hazard in the agricultural industry (3-6). Drivelines should be equipped with proper functioning guards in any work situation,*** especially when the worker must work between two operating PTO drivelines. Furthermore, workers must be trained in safe work practices, which include shutting off PTO drivelines whenever possible before dismounting tractors, maintaining warning decals, not wearing loose or bulky clothing around and avoiding close proximity to rotating PTO drivelines, and keeping bystanders--especially children--away from PTO-driven equipment (7). To assist in preventing injuries to children, farmers should recognize that farm equipment is designed for operation by adults; be aware of the physical, emotional, and mental characteristics and abilities of children; and select age-appropriate tasks for children (8). Because of the need for immediate response to serious injuries, workers should not work alone when using hazardous equipment; however, if persons do work alone, they should be monitored frequently to ensure immediate response in the event of injuries (7). The National Institute for Farm Safety is reviewing approaches to reduce the risk for forage-wagon-related injuries. In addition to proper shielding of the drivelines, placement of the speed-control devices to enable operation of such devices from the tractor driver's seat or from another location on the wagon would eliminate the need for the operator to step over the driveline. Leading manufacturers of forage wagons have designed conveyor extensions that allow for an increase in the space between the two tractors; the extension can be supplied with new equipment or used to retrofit some older equipment. An informal survey of forage wagon equipment indicated that conveyor extensions are available for all seven wagons selected in a nonrandom sample; costs for the retrofits ranged from $35 to $600 each. Although these extensions are marketed to promote productivity, not safety, manufacturers and dealers should be made aware that these extensions can contribute to safer operation of the equipment, and farmers should be encouraged to use them to enhance safety as well as increase productivity. In New York, OHNAC, in collaboration with farm groups, have alerted farmers about the hazards associated with PTO drivelines-- especially on forage wagons--through educational presentations and articles in regional agricultural publications. References 1. Pollock J. Perspectives of New York farm safety: workplace injuries and worker opinions [Thesis]. Ithaca, New York: Cornell University, 1990. 68 p. 2. NIOSH. Traumatic injury surveillance of farmers: annual statistical abstract, 1993. Morgantown, West Virginia: US Department of Health and Human Services, Public Health Service, CDC, NIOSH, 1995 (in press). 3. Cogbill TH, Steenlage ES, Landercasper J, Strutt PJ. Death and disability from agricultural injuries in Wisconsin: a 12-year experience with 739 patients. J Trauma 1991;31:1632-7. 4. Heeg M, ten Duis HJ, Klasen HJ. Power take-off injuries. British Journal of Accident Surgery 1986;17:28-30. 5. Roerig S. Scalping accidents with shielded PTO units: four case reports. American Association of Occupational Health Nursing Journal 1993;41:437-9. 6. CDC. Scalping incidents involving hay balers--New York. MMWR 1992;41:489-91. 7. Demmin D, Hallman E. Cornell Cooperative Extension rural health and safety fact sheet: power take-off (PTO) safety. Ithaca, New York: Cornell University, 1995; publication no. 123FSF56. 8. Bean TL, Wojtowicz J. Farm safety for children: what job is right for my child? Columbus, Ohio: Ohio State University, 1992; publication no. AEX-991.1. * OHNAC is a national surveillance program conducted by CDC's National Institute for Occupational Safety and Health that has placed public health nurses in rural communities and hospitals in 10 states (California, Georgia, Iowa, Kentucky, Maine, Minnesota, New York, North Carolina, North Dakota, and Ohio) to conduct surveillance for agriculture-related illnesses and injuries that occur among farmers and their family members. These surveillance data are used to assist in reducing the risk for occupational illness and injury in agricultural populations. ** A forage wagon is used to transport and unload feed into a storage (e.g., silo) or feed area. *** 29 CFR section 1928.57. Occupational Safety and Health Administration (OSHA) Standard for Safety for Agricultural Equipment. Family-run farms with no other employees are exempt from compliance with federal OSHA standards, and those with less than or equal to 10 employees are generally not subject to OSHA inspection. ------------------------------ To: hicnews Update: HIV-2 Infection Among Blood and Plasma Donors -- United States, June 1992-June 1995 Human immunodeficiency virus type 1 (HIV-1) and type 2 (HIV-2) both cause acquired immunodeficiency syndrome (AIDS). Following the licensure of combination HIV-1/HIV-2 screening enzyme immunoassays (EIA), the Food and Drug Administration (FDA) recommended that beginning in June 1992 all donated whole blood, blood components, and source plasma be screened for antibody to HIV-2 because not all persons infected with HIV-2 can be detected by HIV-1 testing (1,2). This report describes the first two cases of HIV-2 infection detected among potential blood donors since the implementation of recommended HIV-2 screening and summarizes national data about persons known to be infected with HIV-2 during December 1987-June 1995.* Donor 1 In June 1994, a blood donation was discarded after it tested positive by combination HIV-1/HIV-2 EIA and indeterminate by HIV-1 Western blot assay (WB). The donor was notified about the test results and consented to an interview and repeat testing. Testing at CDC indicated the specimen was positive by HIV-1 EIA, HIV-1 WB, HIV-2 EIA, and HIV-2 WB for research use only (RUO). Results of RUO synthetic peptide tests indicated cross-reactivity to HIV-1 and were interpreted as HIV-2 infection. The donor was born and resided in the United States. She previously had not donated blood or plasma. She reported no symptoms related to HIV infection and denied injecting-drug use, receipt of transfusions, and travel outside the United States. Since 1982, she had had four male sex partners; all were born in the United States. The HIV status of her partners is unknown, and she was unaware of any HIV-infection risks among them. She has no children. She received HIV counseling--including instructions to refrain from donating blood, blood components, and tissues or organs--and referral to a health-care provider. Donor 2 In November 1994, a plasma donation was destroyed after the serum tested positive by combination HIV-1/HIV-2 EIA and RUO HIV-2 WB. Attempts by the plasma center to notify the donor were unsuccessful. However, the donor independently sought HIV testing 2 weeks later at a counseling and testing site (CTS). The CTS laboratory results were HIV-1 EIA positive with an atypical HIV-1 WB indeterminate band pattern suggestive of HIV-2 infection. Subsequent testing at CDC indicated the specimen was HIV-1 EIA positive, HIV-1 WB indeterminate, HIV-2 EIA positive, and HIV-2 WB positive. RUO synthetic peptide EIA and dot blots were also positive for HIV-2. These results were interpreted as confirmed HIV-2 infection. During the follow-up interview, the male donor reported no symptoms of HIV infection. He had not previously donated blood or plasma. He was born in France and had lived in several countries in western Africa during 1979-1985 before moving to the United States. While in western Africa, he was vaccinated on two occasions with needles that were wiped with cotton and reused between patients. He also received several tattoos in Africa. Of his estimated 35 lifetime sex partners, most were African. The donor denied having had sex with men, injecting-drug use, and receipt of transfusions. He received HIV counseling--including instructions to refrain from donating blood, blood components, and tissues or organs--and referral to a health-care provider. U.S. Reports of HIV-2 Infection As of June 30, 1995, a total of 62 persons in the United States were reported with HIV-2 infection (Figure 1). Of 58 persons for whom sex data were available, 38 (66%) were male. At least 11 of the 62 persons had an AIDS-defining condition at the time of report, and five are known to have died. Of these 62 persons, 42 (68%) were born in western Africa and two in Europe; for nine, the region of origin was unknown although four had malaria antibody profiles consistent with previous residence in western Africa. Of the nine persons with HIV-2 infection born in the United States, six were adults of whom four had either traveled to or had a sex partner from western Africa, and three were infants born to mothers of unknown national origin. Reported by: MD Herr, HIV/AIDS Epidemiology; AL Hathcock, PhD, State Epidemiologist, Delaware Div of Public Health. DW Hamaker, JM Schulte, DO, D Hoehns, BE Mitchell, MPH, Bur of HIV and STD Prevention; DM Simpson, MD, State Epidemiologist, Texas Dept of Health. Local and state health depts. Office of Blood Research and Review; Div of Transfusion Transmitted Diseases, Center for Biologics Evaluation and Research, Food and Drug Administration. Div of HIV/AIDS, National Center for Infectious Diseases; Div of HIV/AIDS Prevention, National Center for Prevention Svcs, CDC. Editorial Note: In the United States, HIV-2 infection among blood donors is extremely rare. Since the implementation of combination HIV-1/HIV-2 EIA screening of blood and plasma donations, an estimated 74 million donations have been tested for HIV. Including the two cases described in this report, three cases of HIV-2 infection have been detected among blood and plasma donors in the United States; the first case was detected by HIV-1 screening in 1986 (3). These findings are consistent with previous surveys of ·_ approximately 20 million U.S. blood donations during 1987-1989 in which no blood-donor specimens with HIV-2 antibody were detected (4,5). The national blood supply is protected from HIV primarily through two methods: 1) interviewing donors about risk behaviors for HIV infection and 2) laboratory screening donations for HIV (6,7). All donations detected with HIV are excluded from any clinical use,** and donors are deferred from further donations***. For both donors described in this report, although no HIV risk factors were identified during the interview preceding blood donation, laboratory screening of their blood and plasma donations detected HIV infection. Subsequent testing revealed HIV-2 cross-reactivity resulting in a positive HIV-1 EIA (which would have led to exclusion even in the absence of HIV-2 testing) and a positive or indeterminate HIV-1 WB. HIV-1 is distributed worldwide and is prevalent in the United States; however, HIV-2 is endemic in western Africa with limited distribution to other regions of the world. Of the 62 persons reported with HIV-2 infection in the United States, at least 48 (77%) were born in, had traveled to, and/or had a sex partner from western Africa. In addition to detection of HIV-2 cases through blood and plasma donor screening, epidemiologic data about HIV-2 cases are collected through the CDC-supported national HIV/AIDS surveillance system and serosurveys (8,9). Because not all persons who are infected with HIV-2 donate blood or are otherwise tested for HIV-2, the number of persons reported with HIV-2 infection probably is underestimated. Nonetheless, the data from these sources indicate that HIV-2 is uncommon in the United States. Blood centers detecting a repeatedly reactive specimen by combination HIV-1/HIV-2 EIA should follow the recommended CDC/FDA testing algorithm (1). Specimens suspected of being HIV-2 positive may be referred to state health department laboratories or to CDC for confirmatory HIV-2 testing. Cases of HIV-2 infection should be reported to state and local health departments as allowed by law and/or regulation. Periodic updates about the number of persons known to be infected with HIV-2 in the United States are available from the CDC National AIDS Clearinghouse. References 1. CDC. Testing for antibodies to human immunodeficiency virus type 2 in the United States. MMWR 1992;41(no. RR-12). 2. George JR, Rayfield MA, Phillips S, et al. Efficacies of US Food and Drug Administration-licensed HIV-1-screening enzyme immunoassays for detecting antibodies to HIV-2. AIDS 1990;4:321-6. 3. O'Brien TR, Polon C, Schable CA, et al. HIV-2 infection in an American. AIDS 1991;5:85-8. 4. CDC. Surveillance for HIV-2 infection in blood donors--United States, 1987-1989. MMWR 1990;39:829-31. 5. CDC. AIDS due to HIV-2 infection--New Jersey. MMWR 1988;37:33-5. 6. Food and Drug Administration. Revised recommendations for the prevention of human immunodeficiency virus (HIV) transmission by blood and blood products [Memorandum to all registered blood establishments]. Bethesda, Maryland: US Department of Health and Human Services, Public Health Service, Food and Drug Administration, Center for Biologics Evaluation and Research, 1992. 7. Food and Drug Administration. Recommendations for donor screening with a licensed test for HIV-1 antigen [Memorandum to all registered blood and plasma establishments]. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, Food and Drug Administration, Center for Biologics Evaluation and Research, 1995. 8. CDC. HIV/AIDS surveillance report. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, 1995:36-7. (Vol 6, no. 2). 9. O'Brien TR, George JR, Holmberg SD. Human immunodeficiency virus type 2 infection in the United States. JAMA 1992;267:2775-9. * Single copies of this report will be available until August 18, 1996, from the CDC National AIDS Clearinghouse, P.O. Box 6003, Rockville, MD 20849-6003; telephone (800) 458-5231 or (301) 217-0023. ** 21 CFR section 610.45(c). *** 21 CFR section 606.160(e). ------------------------------ To: hicnews Monthly Immunization Table To track progress toward achieving the goals of the Childhood Immunization Initiative (CII), CDC publishes monthly a tabular summary of the number of cases of all diseases preventable by routine childhood vaccination reported during the previous month and year-to-date (provisional data). In addition, the table compares provisional data with final data for the previous year and highlights the number of reported cases among children aged less than 5 years, who are the primary focus of CII. Data in the table are reported through the National Electronic Telecommunications System for Surveillance. ------------------------------ To: hicnews Heat-Related Mortality -- Chicago, July 1995 During July 12-16, 1995, Chicago experienced unusually high maximum daily temperatures, ranging from 93 F to 104 F (33.9 C to 40.0 C). On July 13, the heat index* peaked at 119 F (48.3 C)--a record high for the city. This report describes the heat- related deaths reported by the Cook County Medical Examiner's Office (CCMEO) during this heat wave. Deaths classified as heat-related by the CCMEO met one of the following three criteria: 1) core body temperature of the decedent greater than or equal to 105 F ( greater than or equal to 40.6 C) at the time of or immediately after death, 2) substantial environmental or circumstantial evidence of heat as a contributor to death (e.g., decedent found in a room without air conditioning, all windows closed, and a high ambient temperature), or 3) decedent in a decomposed condition without evidence of other cause of death and with evidence that the decedent was last seen alive during the heat wave period. During July 11-27, a total of 465 deaths were certified as heat-related by the CCMEO (Figure 1); during July 4-10, no deaths were certified as heat-related. The highest number of heat-related deaths previously certified by the CCMEO--associated with a heat wave in 1988--was 77. The number of heat-related deaths peaked 2 days after the heat index peaked. Deaths increased from 49 (July 14) to a maximum of 162 (July 15) (Figure 1). Of the 465 decedents, 257 (55%) were male. Based on race-specific data, 229 (49%) decedents were black; 215 (46%), white; and 21 (5%), other racial/ethnic groups.** Within racial categories, 128 (56%) blacks were male, and 114 (53%) whites were male. Of the 437 decedents for whom age could be determined, age ranged from 3 years to 103 years (median: 75 years, mean: 72 years); 222 (51%) were aged greater than or equal to 75 years. During July 13-21 (when most heat-related deaths were certified by the CCMEO), a total of 1177 deaths occurred in Chicago--an 85% increase over the same period in 1994 (637 deaths). Reported by: ER Donoghue, MD, MB Kalelkar, MD, MA Boehmer, Office of the Medical Examiner County of Cook, Chicago; J Wilhelm, MD, S Whitman, PhD, G Good, MS, S Lyne, RSM, Commissioner, City of Chicago Dept of Health; J Lumpkin, MD, L Landrum, MUPP, BJ Francis, MD, State Epidemiologist, Illinois Dept of Public Health. Div of Environmental Hazards and Health Effects, National Center for Environmental Health, CDC. Editorial Note: Excess mortality from hyperthermia and cardiovascular disease during heat waves has been well documented (2,3). The findings in Chicago by the CCMEO that blacks, males, and the elderly appear to be particularly susceptible to heat-related death are similar to previous studies of heat waves. During public health crises such as heat waves, state-specific mortality data are often incomplete or unavailable; therefore, data from medical examiners' (MEs') offices may be used to assess mortality during such crises. Although ME-based surveillance for heat-related deaths can prompt timely public health responses during heat waves, use of ME data is limited because of selection bias. Individual MEs and other persons who certify deaths (e.g., coroners and attending physicians) use varying criteria to determine which deaths are heat-related, largely because no standardized definition exists. In the United States, lack of a uniform definition for heat-related death results in substantial variation in the criteria used to certify such deaths. The most stringent definition of heat-related death is a core body temperature of greater than or equal to 105 F (greater than or equal to 40.6 C) taken at the time of death, with no other reasonable explanation of death. This definition precludes certifying any death as heat-related if core body temperature is not measured before or near the time of death and may underestimate excess heat-related mortality. A nonspecific definition of heat-related death (which could include all deaths that occur during a heat wave) would overestimate this mortality. The definition used by the CCMEO to classify deaths as heat-related has remained unchanged since 1978 and is based on a reasonable approach (i.e., evidence of exposure to high levels of environmental heat). These two factors (as well as the finding that the data about heat-related deaths are consistent with preliminary data about total mortality in Chicago during July 1995) suggest that the CCMEO data did not overestimate heat-related mortality during that period. The differential impact of a heat wave on specific population subgroups cannot be determined based on ME data alone because of incompleteness and potential bias (3,4). For example, based on CCMEO data, a disproportionately high number of heat-related deaths occurred among blacks in Chicago on July 15 (Figure 1). Because CCMEO data do not include all deaths nor equally represent all socioeconomic status (SES) categories, it is not yet possible to completely describe mortality, calculate death rates, or determine whether the race- and sex-specific distribution of the heat-related deaths is disproportionate to overall mortality in Chicago. A case-control study is under way in Chicago to examine the influences of SES and specific environmental factors on heat-related mortality. Despite their limitations, the data in this report confirm that 1) public health information should be directed toward susceptible populations (e.g., the elderly), 2) as in other heat waves (2,3), the time between the beginning of a heat wave and the resulting heat-related deaths (e.g., 2 days in Chicago) should be sufficient to disseminate prevention messages to the public, and 3) a standardized definition of heat-related death is needed. Heat-related mortality is preventable. The most effective measures for preventing heat-related illness and death include reducing physical activity, drinking additional nonalcoholic liquids, and increasing the amount of time spent in air-conditioned environments. In addition, because increased air movement (e.g., fans) has been associated with heat stress when the ambient temperature exceeds approximately 100 F (37.8 C) and because fans are not protective at temperatures greater than 90 F (greater than 32.3 C) with humidity greater than 35% (the exact temperature varies with the humidity), fans should not be used for preventing heat-related illness in areas with high humidity (3,5). To further define information that can be used to identify persons at greatest risk during hot weather, CDC is collaborating with Chicago and Illinois health officials to determine risk factors to better target persons at increased risk for heat-related illness or death. A standard definition for heat-related death will be addressed at the February 1996 meeting of the American Academy of Forensic Sciences. References 1. Rothfusz LP. The heat index "equation" (or, more than you ever wanted to know about heat index). Fort Worth, Texas: National Oceanic and Atmospheric Administration, National Weather Service, Office of Meteorology, 1990; publication no. SR 90-23. 2. Wainwright S, Buchanan S, Mainzer H. Cardiovascular mortality: the hidden peril of heat waves [Abstract]. In: Program and abstracts of the CDC Epidemic Intelligence Service 43rd annual conference. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, CDC, 1994. 3. Kilbourne EM, Choi K, Jones TS, Thacker SB, and the Field Investigation Team. Risk factors for heat stroke: a case control study. JAMA 1982;247:3332-6. 4. Jones TS, Liang AP, Kilbourne EM, et al. Morbidity and mortality associated with the July 1980 heat wave in St. Louis and Kansas City, Missouri. JAMA 1982;247:3327-31. 5. Lee DH. Seventy-five years of searching for a heat index. Environ Res 1980;22:331-56. * The heat index (i.e., the apparent temperature) is an estimation of the influence of temperature and humidity on the evaporative and radiative transfer of heat between a typical human and the atmosphere. The values can be derived from a chart available through the National Weather Service (1). ** The CCMEO categorizes race of decedents as black, white, or other. ------------------------------ To: hicnews +----------------------------------------------+ | NATIONAL INSTITUTE | | C A N C E R | | INTERNATIONAL INFORMATION | | C E N T E R | +----------------------------------------------+ | CancerNet@icicc.nci.nih.gov | +-------------------------------+ Changes to CancerNet,August 1995 CancerNet was updated on August 1, 1995. PDQ Statements -------------- The following PDQ statements were added or updated in CancerNet with the August update (see the file Monthly PDQ Changes -- cn-405001 for detailed information on the changes in each statement). New Statements: One new cancer screening summary, "Screening for Breast Cancer for Patients" (cn-305499), was added. Changed treatment statements for physicians: Adult Hodgkin's Disease (cn-100003) Adult Non-Hodgkin's Lymphoma (cn-100066) Adult Primary Liver Cancer (cn-101195) Anal Cancer (cn-100022) Bladder Cancer (cn-101206) Breast Cancer (cn-100013) Childhood Acute Lymphocytic Leukemia (cn-100026) Childhood Brain Tumor (cn-100047) Childhood Hodgkin's Disease (cn-103043) Childhood medulloblastoma (cn-100048) Childhood rhabdomyosarcoma (cn-100759) Childhood soft tissue sarcoma (cn-103085) Childhood Supratentorial Primitive Neuroectodermal Tumor (cn-104028) Chronic lymphocytic leukemia (cn-101003) Colon Cancer (cn-100008) Cutaneous T-cell Lymphoma (cn-100098) Esophageal cancer (cn-100089) Gastrointestinal Carcinoid Tumor (cn-101064) Hairy cell leukemia (cn-101651) Melanoma (cutaneous) (cn-101302) Metastatic Squamous Neck Cancer with Occult Primary (cn-101454) Neuroblastoma (cn-100530) Osteosarcoma (cn-100049) Ovarian epithelial cancer (cn-100950) Pancreatic cancer (cn-100046) Plasma Cell Neoplasm (cn-100281) Prostate cancer (cn-101229) Rectal Cancer (cn-100076) Wilms' Tumor (cn-100719) Changed treatment statements for patients: Adult Non-Hodgkin's Lymphoma (cn-200066) Adult Primary Liver Cancer (cn-201195) Anal Cancer (cn-200022) Cervical cancer (cn-200103) Childhood Brain Cancer (cn-200047) Childhood Hodgkin's Disease (cn-203043) Childhood Medulloblastoma (cn-200048) Childhood Rhabdomyosarcoma (cn-200759) Colon Cancer (cn-200008) Hairy Cell Leukemia (cn-201651) Melanoma (cn-201302) Osteosarcoma (cn-200049) Pancreatic Cancer (cn-200046) Prostate Cancer (cn-201229) Rectal Cancer (cn-200076) Changed supportive care statements: Nausea and Vomiting (cn-304466) Changed cancer screening and prevention statements: None. Changed drug information statements: None. Changed CancerNet News The following news bulletin was added: JAMA Publishes Descriptions of Tobacco Company Activities (cn-400105) The following news bulletins were changed: FDA's Mammography Quality Standards Act/Mammography Facility Locator Service (cn-400075) NCI High Priority Clinical Trials (cn-400007) Survival Following Breast-Sparing Surgery vs. Mastectomy (cn-400020) Redistribution of CancerNet and CancerNet Availability (cn-400030) The following news bulletins were deleted: Investigator letter: Secondary AML after dose-intensive therapy (cn- 400061) Mammography Facility Locator Service Opens (cn-400088) - see item cn- 400075 Publications ------------ The following publication information was added: Cancer Research in Hispanic Populations Monograph (cn-400106) Sowing Seeds in the Mountains Monograph (cn-400107) The following publication information was changed: JNCI Monographs Available (cn-400066) The following publication information was deleted: 1992 Oncology Overviews (cn-400057) National Disease Prevention Campaign (cn-400069) NCI Fact Sheets --------------- The following fact sheets were added: PDQ Search Service (cn-600026) Ten Facts to Know About Cancer (cn-600412) Q & A: Mammography and Breast Cancer (cn-600521) The following fact sheets were changed: NCI's Clinical Trials Cooperative Group Program (cn-600014) Patients Needed for Breast Cancer Clinical Trials (cn-600713) NCI's Cancer Centers Program (cn-600012) Personal Use of Hair Coloring Products and Risk of Cancer (cn-600332) Oral Contraceptives and Breast Cancer (cn-600336) No fact sheets were deleted. CANCERLIT Citations and Abstracts: ---------------------------------- ·_ No new CANCERLIT citations and abstract topics were added. The CANCERLIT citations and abstracts for August will be available on August 9, 1995. Instructions: To request the CancerNet Instructions and Contents List, send a mail message, and in the body of the message, enter HELP. Address the mail message to: cancernet@icicc.nci.nih.gov To request the modified statements, follow the above directions, and in the body of the mail message, enter the statement code. When requesting more than one statement, enter each code on a separate line. CancerNet statements are also available in Spanish. To request the Instructions and Contents List in Spanish, enter SPANISH in the body of the mail message. If you would like to request the statements in Spanish, substitute the prefix "cs-" in front of the number (e.g., cs-100022) to receive the statement on anal cancer in Spanish . All of the physician and patient statements are available in Spanish. News items that are available in Spanish have a # next to the statement title. Although both the English and Spanish are updated at the same time each month, the Spanish statements do not reflect the changes made in the English statements until the following month to allow time for translation . If you are interested in requesting CancerNet statements or news articles in Spanish, it is suggested that you request an updated Contents List. If you are redistributing the PDQ information you retrieve from CancerNet to others at your location, or are interested in redistributing the information from CancerNet, request the news article, Redistribution of Cancernet (cn-400030) , to find out about conditions that apply when redistributing the information. This article also has information on other sites providing access to CancerNet information. Please send comments or questions to: Cheryl Burg NCI International Cancer Information Center Internet: cheryl@icicc.nci.nih.gov --- Editor, HICNet Medical Newsletter Internet: david@stat.com FAX: +1 (602) 451-6135 ------------------------------ To: hicnews GOVERNMENT HOTLINE PROVIDES ANSWERS TO ENVIRONMENTAL HEALTH QUESTIONS Durham, North Carolina, August 1, 1995 - ENVIRO-HEALTH, a publicly accessible clearinghouse on environmental health effects, is a free information source and referal service sponsored by the National Institute of Environemental Health Sciences (NIEHS), one of the National Institutes of Health. NIEHS created the clearinghouse to provide environmental health information to the general public. ENVIRO-HEALTH also responds to requests from public health officials, environmental justice groups, grassroots environmental organizations, environmental science writers, educators, and students. Since opening in October 1994, the ENVIRO-HEALTH hotline has responded to a broad range of questions regarding the human health effects of electromagnetic fields, pesticides, indoor air quality, multiple chemical exposures, radon, industrial emissions, drinking water, and other health-related topics. Calls and requests to ENVIRO-HEALTH are received by technical information specialists who provide information over the telephone, via fax, and through the mail, or by making referrals to other government clearinghouses. The technical information specialists take calls on weekdays between the hours of 9:00 a.m. and 8:00 p.m. Eastern Time, but callers can leave messages 24 hours a day. ENVIRO-HEALTH can be reached through a toll-free telephone number (1-800-NIEHS-94), by e-mail (envirohealth@niehs.nih.gov) or by fax (919-361-9408). General Information about ENVIRO-HEALTH is located on the NIEHS world wide web home page (http://www.niehs.nih.gov). --- Editor, HICNet Medical Newsletter Internet: david@stat.com FAX: +1 (602) 451-6135 ------------------------------ To: hicnews Disabilities Among Children Aged less than or equal to 17 Years -- United States, 1991-1992 Disabilities among children result in substantial reductions in quality of life and are associated with increased dependence on the health-care and social-service systems. To assess the prevalence of disabilities and their associated health conditions among children, CDC reviewed data from the Survey of Income and Program Participation (SIPP) for 1991-1992, which collected information about chronic conditions, including the functional limitations related to those conditions (1,2). This report summarizes SIPP data for children aged less than or equal to 17 years. From October 1991 through January 1992, SIPP collected information about disabilities during personal household interviews of a sample (n=97,133 persons in 34,100 households) of the U.S. civilian, noninstitutionalized population. Measures of disability were based on definitions from the International Classification of Impairments, Disabilities, and Handicaps (ICIDH)* (3). The ICIDH extends the International Classification of Diseases (ICD) to include the personal and social consequences of diseases. Parents or legal guardians were asked about disabilities among their children aged less than or equal to 14 years. Children aged 15-17 years were asked directly about disabilities when they were available; however, for most children in this age group, information was obtained from their parents or guardians. For children reported to have a disability, parents were asked about the condition(s) that caused the functional limitation. Data were weighted to calculate national estimates representative of the U.S. population. To ensure that the disability data were comprehensive and accounted for all developmental stages of children, the SIPP definitions of disability were varied by age group. For children aged 0-5 years, disability was defined as 1) limitation in the usual kind of activities done by most children the same age, or 2) receipt of therapy or diagnostic services by the child for developmental needs. For children aged greater than or equal to 6 years, disability was any limitation in the ability to do regular school work. Additional indicators of disability included, for children aged 3-14 years, a long-lasting condition that limited the ability to walk, run, or use stairs, and for children aged 15-17 years, measures of problems in personal care, personal management (activities of daily living**), and the use of assistive aids (e.g., wheelchair). During 1991-1992, an estimated 48.9 million persons (19.4% of the total U.S. population of 251.8 million) had a disability; of these, 3.8 million (7.9%) were aged less than or equal to 17 years (1). For children aged less than 3 years, the overall estimated prevalence of disabilities was 2.2%; for those aged 3-5 years, 5.2%; for those aged 6-14 years, 6.3%; and for those aged 15-17 years, 9.3% (Table 1). In all age groups, the prevalence of disabilities was higher among boys than girls; this sex-specific difference was greatest in the 6-14-year age group. The condition most frequently reported as a cause of functional limitation among children aged less than or equal to 17 years was learning disability (29.5%), followed by speech problems (13.1%), mental retardation (6.8%), asthma (6.4%), and mental or emotional problems or disorders (6.3%) (Table 2). Reported by: JM McNeil, Bur of the Census, Economics and Statistics Administration, US Dept of Commerce. Disabilities Prevention Program; Developmental Disabilities Br, Div of Birth Defects and Developmental Disabilities, National Center for Environmental Health; Behavioral Risk Factor Surveillance Br, Office of Surveillance and Analysis, National Center for Chronic Disease Prevention and Health Promotion, CDC. Editorial Note: In the United States, the impact of disabilities is disproportionately higher among children because disabilities with onset during childhood account for approximately one third of the years of disability*** in the U.S. population (4). Improved characterization of the magnitude and distribution of disabilities among children is important to identify needed services and to target appropriate interventions. The findings in this report further document age and sex variations in the prevalence of disabilities among children. The increase in the prevalence of disabilities with advancing age probably reflects the ability to identify more readily academic or behavioral limitations among older children and variations in the way educational systems identify children limited in the ability to do regular school work (5). Reasons for sex-specific differences are unclear and require further study. The approach used in this report to estimate the prevalence of disabilities was based on limitations in function resulting from chronic conditions rather than on the diagnosis of such conditions. Previous studies may have underestimated the prevalence of disabilities among children because the definitions were restricted to certain conditions (6). To improve the precision of estimates of disability, the SIPP definitions were broadened to include the functional consequences of chronic conditions. The inclusion of these functional limitations enables more accurate estimates of the prevalence of disabilities. However, the SIPP data are subject to at least two limitations. First, because children living in institutions or group homes were excluded from the study, the prevalence of disabilities among children probably is underestimated. Second, age-group-specific variations in the definitions of disability limit the basis for comparison across age groups. In SIPP, health conditions associated with disabilities comprise a combination of diseases (e.g., asthma or diabetes), impairments (e.g., missing extremities or paralysis), and primary conditions considered to be disabilities (e.g., mental retardation or cerebral palsy). Efforts to improve the precision of national estimates of disabilities among children should distinguish between those impairments, disabilities, and handicaps that are consequences of the disabling process. One such effort is the 1999 revision of the ICIDH, which will emphasize measures of disability and handicap among children (7) and assist in standardizing collection of information about disabilities among children. Improved estimates of the prevalence of disabilities and their associated health consequences among children are needed to develop and evaluate prevention strategies. Estimates based on analysis of data from SIPP can assist public health planners in identifying primary services for children with disabilities and in projecting long-range needs of these children. In addition, the linking of data about primary disabling conditions among children with the functional consequences of these conditions enables more precise estimation of costs required to meet the continuing needs of these children. References 1. McNeil JM. Americans with disabilities, 1991-1992. Washington, DC: US Department of Commerce, Economics and Statistics Administration, Bureau of the Census, 1993. (Current population reports; series p70, no. 33). 2. CDC. Prevalence of disabilities and associated health conditions. MMWR 1994;43:730-1,737-9. 3. World Health Organization. International classification of impairments, disabilities, and handicaps. Geneva: World Health Organization, 1980. 4. Houk VN, Thacker SB. Program to prevent primary and secondary disabilities in the United States. Public Health Rep 1989;104:226-31. 5. US Department of Education. 11th Annual report to Congress on the implementation of the Individuals with Disability Education Act. Washington, DC: US Department of Education, Office of Special Education and Rehabilitative Services, Office of Special Education Programs, 1989. 6. Verbrugge LM. The disability supplement to the 1994-95 National Health Interview Survey (NHIS-Disability). Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, NCHS, 1993. 7. Badley EM. An introduction to the concepts and classifications of the International Classification of Impairments, Disabilities, and Handicaps. Disabil Rehabil 1993;15:161-78. * Based on the ICIDH, an impairment is an abnormality of an organ system, a disability is a person's limitation in function resulting from an impairment, and a handicap is the social consequence(s) or disadvantage(s) resulting from impairment and disability that a person experiences while interacting in the physical and social environment. ** Ability to 1) "get around inside the home"; 2) "get in and out of bed or a chair"; 3) "take a bath or shower, dress, and eat;" and 4) "get to and use the toilet." *** Years of disability are calculated by multiplying the number of persons with new cases of disabilities by the expected lifespan of each person with a disability per year. Because years of disability reflect both prevalence and duration of disability, it is useful in assessing the impact of preventive interventions. ------------------------------ To: hicnews State and National Vaccination Coverage Levels Among Children Aged 19-35 Months -- United States, April-December 1994 The National Immunization Survey (NIS) is a single survey providing state and national estimates of vaccination coverage levels among children aged 19-35 months. CDC implemented the NIS in April 1994 as one element of the five-part Childhood Immunization Initiative (CII) (1), a national strategy to achieve and maintain high vaccination levels among children during the first 2 years of life. NIS collects quarterly data from the 50 states, the District of Columbia, and 27 urban areas considered to have populations at high risk for undervaccination. This report of initial NIS findings provides the results of both national and state vaccination coverage levels for April-December 1994. The NIS uses a two-phase sample design. For the first phase, a quarterly random sample of telephone numbers for each survey area is called, and a screening questionnaire is administered to locate households with one or more children aged 19-35 months. Vaccination information is collected for age-eligible children. All respondents are requested to refer to written records. During April-December 1994, approximately 1.2 million telephone numbers were called, and 25,247 interviews were completed (an average of 110 interviews per area per quarter). The overall response rate for eligible households was 71% (range: 60%-88% among the individual states). In the second phase, vaccination information is requested from health-care providers of children in surveyed households because parents tend to underestimate the number of doses received for multiple-dose vaccines and to overestimate coverage for single-dose vaccines (2,3). Households excluded from phase two include those that use records indicating their children received all of the recommended doses for at least four vaccines* because such recorded histories are highly accurate (CDC, unpublished data, 1995). Based on these exclusions, 18,479 (73%) households were eligible for phase two. Of these, vaccination information was obtained from providers for 7594 (41%) children. The demographic characteristics and the reported vaccination histories were similar for children in households with provider information and households with parental reports only. Overall, 57% of the children in the survey had either written records of having received all of the required doses for at least four vaccines, or had vaccination information based on provider records. The data obtained from provider records were used to improve the accuracy of the vaccination coverage estimates for the entire sample. Standard two-phase estimation procedures (4) were used to estimate vaccination coverage for each surveyed area. The estimates were adjusted using natality data to create a weighted sample representative of children aged 19-35 months in the United States; in addition, adjustments were made for nonresponse and for exclusion of households without a telephone to account for the finding that children in households without telephones are less likely to be vaccinated than children in households with a telephone (CDC, unpublished data, 1995) (5). Based on the NIS, among children who were born during May 1991-May 1993 and who were aged 19-35 months (median: 27 months) when surveyed, estimated vaccination coverage was 75% (confidence interval [CI]= plus or minus 1.2%) for receipt of at least four doses of diphtheria and tetanus toxoids and pertussis vaccine (DTP), three doses of poliovirus vaccine, and one dose of measles-mumps-rubella vaccine (MMR) (4:3:1 series) (Table 1). However, except for hepatitis B, coverage levels for each of the vaccines individually were substantially higher: coverage with three or more doses of DTP was greater than 90%; coverage for one dose of MMR, three or more doses of polio, and three or more doses of Haemophilus influenzae type B vaccine (Hib) ranged from 83% to 89%. The lower overall coverage for the 4:3:1 series was accounted for primarily by low coverage for the fourth dose of DTP (77%). State-specific estimated coverage levels for the 4:3:1 series ranged from 61% (CI= plus or minus 6.2%) to 88% (CI= plus or minus 4.6%) (Table 2). Coverage levels were less than 65% in three states, greater than or equal to 85% in three states, and were higher in the northeastern and southeastern regions (Figure 1). To assess the validity of estimates from the NIS, findings were compared with previously reported data from the National Health Interview Survey (NHIS) (6,7), a national household survey of the U.S. civilian, noninstitutionalized population. For January-June 1994, NHIS data had been supplemented with provider information in the same manner as in the NIS survey. The estimated coverage level of 75% in the NIS survey was similar to the 72% estimate obtained from the NHIS, and vaccine coverage levels for each individual vaccine (except for hepatitis B) were nearly identical (Table 1). In addition, estimates of vaccination coverage derived independently by selected states for 1994 were similar to those reported in the NIS (CDC, unpublished data, 1995). Reported by: National Center for Health Statistics; Assessment Br, Data Management Div, National Immunization Program, CDC. Editorial Note: The NIS data provide the first current, population-based, state-specific estimates of vaccination coverage produced by a standard methodology for the United States. These findings enable valid comparisons of state efforts to deliver vaccination services. The NIS has obtained the most reliable estimates of vaccination coverage through the use of health-care provider records and the use of data from the NHIS to adjust for households without telephones. The estimate of the coverage for the 4:3:1 series based on NIS (75%) was substantially higher than that previously reported through the NHIS (67%), probably reflecting improvements in the accuracy of both NIS and NHIS data with the inclusion of information from providers rather than a true increase in coverage. CDC will continue to assess and improve the quality of national vaccination data. The vaccination coverage rates reported in the NIS and in recent reports from the NHIS are the highest ever recorded in the United States. In particular, the findings in the NIS indicate that ·_ the CII goal for 90% coverage with three doses of DTP was exceeded, and that the 90% coverage goals for polio, measles, and Hib were nearly attained (1). Coverage for hepatitis B, the vaccine most recently added to the pediatric schedule, was the lowest because many children were born before the recommendations for vaccination were made. Coverage for four doses of DTP is the lowest of the three vaccines included in the combined series. The Advisory Committee on Immunization Practices recently reaffirmed its recommendation for a fourth dose of DTP for all children aged 12-18 months (8). Efforts to ensure timely administration of the fourth dose of DTP vaccine must be intensified to further reduce the incidence of pertussis and should include simultaneous administration with other vaccines recommended for children aged 12-18 months. The substantial variation in state-specific coverage levels for the 4:3:1 series underscores the need for vaccination efforts targeted at children aged less than 2 years; in addition, more than one million children still lack one or more doses of the recommended vaccines. One of the national health objectives for the year 2000 is to achieve series-complete coverage for at least 90% of 2-year-old children for all recommended vaccines** (objective 20.11) (9). Implementation of the five-part CII strategy will be essential to meet this goal and to build a national system that maintains high coverage levels. Potential limitations of NIS include the possible biases associated with exclusion of households without telephones, household nonresponse, and inaccurate reporting from households and small sample sizes for some states. An adjustment for exclusion of households without telephones was made to account for findings in the 1992-1993 NHIS that coverage levels for the 4:3:1 series are approximately 10 percentage points lower among children in households without telephones (CDC, unpublished data, 1995). Although provider information was not available for all children, those children whose providers were not included in the survey were similar to children whose provider was included, suggesting that use of provider data did not introduce a bias. In addition, estimates based on small sample sizes have a larger variance; future analyses will include data for four quarters, thereby reducing the size of the sampling error. CDC will use the NIS, with data from the NHIS, to evaluate progress toward national vaccination goals and, because of the comparability of the information in the NIS, to identify states with the highest rates (whose programs may be models for other states) and states with lower rates (which may need special attention). These coverage estimates are being used to distribute $33 million in incentive funds, with the greatest funding per fully vaccinated child to states that achieve the highest levels of coverage. References 1. CDC. Reported vaccine-preventable diseases--United States, 1993, and the Childhood Immunization Initiative. MMWR 1994;43:57-60. 2. Goldstein KP, Kviz FJ, Daum RS. Accuracy of immunization histories provided by adults accompanying preschool children to a pediatric emergency department. JAMA 1993;270:2190-4. 3. Valadez JJ, Weld LH. Maternal recall error of child vaccination status in a developing nation. Am J Public Health 1992:82:120-2. 4. Cochran WG. Double sampling. In: Cochran WG. Sampling techniques. 3rd ed. New York: John Wiley & Sons, Inc, 1977:327-58. 5. Massey JT, Botman SL. Weighting adjustments for random digit dialed surveys. In: Groves RM, Biemer PP, Lyberg LE, Massey JT, Nicholls WL, Waksberg J. Telephone survey methodology. New York: John Wiley & Sons, Inc, 1988:143-60. 6. CDC. Vaccination coverage of 2-year-old children--United States, January-March, 1994. MMWR 1995:44:142-3,149-50. 7. CDC. Vaccination coverage levels among children aged 19-35 months--United States, April-June 1994. MMWR 1995:44:396-8. 8. CDC. Recommended childhood immunization schedule--United States, 1995. MMWR 1995; 44(no. RR-5). 9. 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. * Vaccines in this series include four doses of diphtheria and tetanus toxoids and pertussis vaccine (DTP), three doses of poliovirus vaccine, one dose of measles-mumps-rubella vaccine (MMR), and three doses of Haemophilus influenzae type B vaccine (Hib). Children may or may not have received three doses of hepatitis B vaccine. ** Series-complete coverage of all currently recommended vaccines include four doses of DTP, three doses of polio, one dose of MMR, and three doses each of Hib and hepatitis B vaccine. ------------------------------ End of HICNet Medical News Digest V08 Issue #29 *********************************************** --- Editor, HICNet Medical Newsletter Internet: david@stat.com FAX: +1 (602) 451-6135