HICNet Medical News Digest Thu, 01 Dec 1994 Volume 07 : Issue 57 Today's Topics: News from the Editor [MMWR 5 Nov 94] The Great American Smokeout [MMWR] Attitudes towards Smoking Policies in Eight States [MMWR] Cigarette Smoking Among Women of Reproductive Age [MMWR] Continuing Diabetes Care [MMWR 11 Nov 94] Imported Plague [MMWR] Erythromycin-Resistant Bordetella pertussis [MMWR] Prevalence of Self-Report Epilepsy +------------------------------------------------+ ! ! ! Health Info-Com Network ! ! Medical Newsletter ! +------------------------------------------------+ Editor: David Dodell, D.M.D. 10250 North 92nd Street, Suite 210, Scottsdale, Arizona 85258-4599 USA Telephone +1 (602) 860-1121 FAX +1 (602) 451-1165 Internet: mednews@stat.com Bitnet: ATW1H@ASUACAD Mosaic WWW *Asia/Pacific: http://biomed.nus.sg/MEDNEWS/welcome.html *Americas: http://cancer.med.upenn.edu:3000/ *Europe: http:/www.dmu.ac.uk/0/departments/pharmacy/archive/www/MEDNEWS/welcome .html Compilation Copyright 1994 by David Dodell, D.M.D. All rights Reserved. License is hereby granted to republish on electronic media for which no fees are charged, so long as the text of this copyright notice and license are attached intact to any and all republished portion or portions. The Health Info-Com Network Newsletter is distributed biweekly. Articles on a medical nature are welcomed. If you have an article, please contact the editor for information on how to submit it. If you are interested in joining the automated distribution system, please contact the editor. Associate Editors: E. Loren Buhle, Jr. Ph.D. Dept. of Radiation Oncology, Univ of Pennsylvania Tom Whalen, M.D., Robert Wood Johnson Medical School at Camden Douglas B. Hanson, Ph.D., Forsyth Dental Center, Boston, MA Lawrence Lee Miller, B.S. Biological Sciences, UCI Dr K C Lun, National University Hospital, Singapore W. Scott Erdley, MS, RN, SUNY@UB School of Nursing Jack E. Cross, B.S Health Care Admin, 882 Medical Trng Grp, USAF Albert Shar, Ph.D. CIO, Associate Prof, Univ of Penn School of Medicine Martin I. Herman, M.D., LeBonheur Children's Medical Center, Memphis TN 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 ---------------------------------------------------------------------- Date: Thu, 01 Dec 94 06:25:25 MST From: mednews@stat.com (HICNet Medical News) To: hicnews Subject: News from the Editor Message-ID: <3sPNwc1w165w@stat.com> I have been a little overwelmed lately, thereby causing the tardiness of this issue. I've also converted the machine I compose the newsletter on to IBM's OS/2 Warp. Very nice operating system, but it caused a little incompatibility with my scanner hardware. I have resolved this problem, so articles will be flowing again within a short time. David Dodell, DMD Editor ------------------------------ Date: Thu, 01 Dec 94 06:27:47 MST From: mednews@stat.com (HICNet Medical News) To: hicnews Subject: [MMWR 5 Nov 94] The Great American Smokeout Message-ID: <1wPNwc2w165w@stat.com> The Great American Smokeout, November 17, 1994 Since 1977, the American Cancer Society (ACS) has sponsored the Great American Smokeout to foster community-based activities that encourage cigarette smokers to stop smoking for at least 24 hours. These activities include distributing materials to schools, hospitals, businesses, and other organizations that discourage tobacco use; encouraging restaurants and other businesses to be smoke-free for the day; and promoting media coverage of special events at the national and community level. During the 1993 Great American Smokeout, an estimated 2.4 million (6%) smokers reported quitting, and 6.0 million (15%) reported reducing the number of cigarettes smoked on that day (1). In addition, approximately 1.6 million (4%) smokers quit smoking for 1-10 days after the Smokeout (1). Approximately 10.7 million packs of cigarettes were not smoked, resulting in an estimated $18.1 million not spent on cigarettes (1-3). This year, the Great American Smokeout will be on Thursday, November 17. The goal of the Smokeout is to promote and encourage smoking cessation by helping smokers realize that if they can quit for 1 day, they can quit permanently. Information is available from local chapters of the ACS; for telephone numbers of these local chapters, telephone (800) 227-2345 or (404) 329-7576. Reported by: American Cancer Society, Atlanta. Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. References 1. Lieberman Research, Inc. The 1993 Great American Smokeout study. Atlanta: American Cancer Society, 1993. 2. CDC. Cigarette smoking among adults--United States, 1992, and changes in the definition of current cigarette smoking. MMWR 1994;43:342-6. 3. The Tobacco Institute. The tax burden on tobacco: historical compilation, 1993. Washington, DC: The Tobacco Institute, 1994. ------------------------------ Date: Thu, 01 Dec 94 06:28:51 MST From: mednews@stat.com (HICNet Medical News) To: hicnews Subject: [MMWR] Attitudes towards Smoking Policies in Eight States Message-ID: Attitudes Toward Smoking Policies in Eight States -- United States, 1993 Legislation regulating smoking has at least two functions: to protect nonsmokers from the adverse health effects of environmental tobacco smoke and to prevent young persons from smoking (1). To characterize public attitudes toward such legislation, the National Cancer Institute (NCI) and the American Cancer Society used the Behavioral Risk Factor Surveillance System (BRFSS) to survey persons in eight states* during July-August 1993 as part of the American Stop Smoking Intervention Study for Cancer Prevention (2). This report summarizes the survey findings. BRFSS provides state-specific estimates of the prevalence of selected risk behaviors to be used for planning, implementing, and evaluating public health programs. Each month, state health departments use survey sampling and random-digit-dialing techniques (3) to conduct telephone interviews with adults aged greater than or equal to 18 years. During July-August 1993, a total of 20 questions were added to BRFSS in the eight states to assess support for policies related to cigarette smoking (4). To estimate the state population prevalences (5), data were weighted to the age-, race-, and sex-specific population counts from the most current census (or intercensal estimate) in each state and for the respondent's probability of selection. SUDAAN (6) was used to calculate the 95% confidence intervals for the prevalence estimates. For this study, sample sizes ranged from 252 to 431 per state; state-specific response rates for completed interviews ranged from 63.6% to 93.3%. Current smokers were defined as persons who had smoked at least 100 cigarettes and who reported being a smoker at the time of the interview. Environmental Tobacco Smoke Respondents were given a list of public locations and asked whether, for each setting, smoking should be allowed in all areas (do not restrict), allowed in some areas (restrict), or not allowed at all (ban). Public opinion about whether to restrict or ban smoking varied across settings (Table 1): support was greater for banning smoking in fast-food restaurants (range: 42.5%-63.0%) and at indoor sporting events (55.4%-66.9%) than in sit-down restaurants (39.5%-50.6%) and indoor malls (33.4%-56.5%). Overall, smokers were less likely than nonsmokers to support banning smoking in the different locations. Preventing Teenagers from Smoking Respondents were given a list of five strategies that might prevent teenagers from smoking and asked whether they believed the strategies were not at all effective, somewhat effective, or very effective. Each of the strategies was believed to be effective (i.e., somewhat or very) by most respondents (Table 2): in particular, 65.3%-77.8% of respondents believed that banning all smoking inside and outside school property would be an effective strategy. Most respondents (79.1%-89.6%) favored a ban on smoking inside school buildings that applies to students, visitors, and teachers; 66.2%-85.1% of respondents favored a ban on the use of any tobacco product (including cigarettes, cigars, pipes, and chewing tobacco) at school-sponsored events (e.g., football games and field trips). Banning all cigarette advertising was considered to be an effective strategy in reducing smoking among teenagers by 54.3%- 71.9% of respondents (Table 2). In addition, 49.8%-66.5% of respondents believed that tobacco advertising influences persons to buy tobacco products. The proportion of respondents who supported a ban on advertising tobacco products at sports stadiums and arenas ranged from 67.7% to 78.2%, and the proportion who supported a ban on advertising tobacco products on billboards ranged from 62.6% to 77.2%. High proportions of respondents believed in the effectiveness of selected measures to limit teenager's access to tobacco products, including stronger enforcement of laws prohibiting the sale of cigarettes to minors (77.1% to 85.5%), banning all cigarette vending machines (69.3% to 79.3%), and increasing the price of a pack of cigarettes (55.4% to 67.7%) (Table 2). Most respondents (54.1% to 68.8%) favored increasing the tax on a pack of cigarettes $1 per pack; however, many (47.9% to 66.1%) believed that such an increase would be unfair to cigarette smokers. Belief in the effectiveness of teenage access restrictions was high among both smokers (41.8% to 79.3%) and nonsmokers (60.2% to 88.4%). Reported by the following BRFSS coordinators: D Hargrove-Roberson, MSW, Louisiana; J Jackson-Thompson, PhD, Missouri; G Boeselager, MS, New Jersey; E Capwell, PhD, Ohio; N Hann, MPH, Oklahoma; M Lane, MPH, South Carolina; R Diamond, MPH, Texas; K Holm, MPH, Washington. Surveillance Program, National Cancer Institute, National Institutes of Health. Div of Chronic Disease Control and Community Intervention, Office of Surveillance and Analysis, and Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. Editorial Note: The findings in this report are consistent with previous studies that have documented public support for regulating tobacco use in public places (2). For example, in 1987, 72% of adults in seven Minnesota communities favored prohibiting smoking in public buildings (7). In 1989, findings from a survey conducted for the NCI Community Intervention Trial for Smoking Cessation (COMMIT) (8) indicated that among persons in 10 communities, 62%- 100% supported restricting or banning smoking in selected locations. Most favored restricting smoking in five locations (bars, restaurants, bowling alleys, private worksites, and government buildings) and banning it in three other locations (indoor sports arenas, hospitals, and doctors' offices). These findings also confirm increasing support for banning smoking in restaurants (9). For example, 16.2% to 32.3% of respondents in the COMMIT study (8) favored banning smoking in restaurants, compared with 39.5% to 63.0% of BRFSS respondents. In addition, the BRFSS findings distinguish between fast-food and sit-down restaurants. Support for banning smoking in fast-food restaurants was stronger than support for banning smoking in sit-down restaurants, possibly because of the perception that fast-food restaurants tend to cater to and be frequented by children and adolescents (2). Previous studies (2) have documented high levels of support for measures to prevent teenagers from smoking (7,10). The BRFSS findings indicate widespread belief in the effectiveness of such measures and suggest broad support for banning the use of any tobacco product at school-sponsored events. Finally, the BRFSS findings indicate support for recommendations issued by the Institute of Medicine (2), which include the need to 1) adopt and enforce tobacco-free policies in all public locations, especially those that cater to and are frequented by children and youths; 2) adopt tobacco-free policies that apply to persons attending events sponsored by organizations involved with youths; 3) restrict the advertising and promotion of tobacco products; and 4) increase the excise tax on cigarettes. References 1. Pederson LL, Bull SB, Ashley MJ, Lefcoe NM. A population survey on legislative measures to restrict smoking in Ontario: 3 variables related to attitudes of smokers and nonsmokers. Am J Prev Med 1989;5:313-22. 2. Institute of Medicine. Growing up tobacco free: preventing nicotine addiction in children and youths. Washington, DC: National Academy Press, 1994. 3. Waksburg J. Sampling methods for random digit dialing. J Am Stat Assoc 1978;73:40-6. 4. Remington PL, Smith MY, Williamson DF, Anda RF, Gentry EM, Hogelin GC. Design, characteristics, and usefulness of state-based behavioral risk factor surveillance, 1981-1987. Pub Health Rep 1988;103:366-75. 5. Siegel PZ, Brackbill RM, Frazier EL, et al. Behavioral risk factor surveillance, 1986-1990. In: CDC surveillance summaries (December). MMWR 1991;40(no. SS-4):1-23. 6. Shah BV. Software for Survey Data Analysis (SUDAAN) version 5.5 [Software documentation]. Research Triangle Park, North Carolina: Research Triangle Institute, 1991. 7. Forster JL, McBride C, Jeffery R, Schmid TL, Pirie PL. Support for restrictive tobacco policies among residents of selected Minnesota communities. Am J Health Promot 1991;6:99-104. 8. CDC. Public attitudes regarding limits on public smoking and regulation of tobacco sales and advertising--10 U.S. communities, 1989. MMWR 1991;40:344-5,351-3. 9. CDC. Preventing tobacco use among young people--a report of the Surgeon General. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1994. 10. Marcus SE, Emont SL, Corcoran RD, et al. Public attitudes about cigarette smoking: results from the 1990 Smoking Activity Volunteer Executed Survey. Pub Health Rep 1994;109:125-34. * Louisiana, Missouri, New Jersey, Ohio, Oklahoma, South Carolina, Texas, and Washington. ------------------------------ Date: Thu, 01 Dec 94 06:29:54 MST From: mednews@stat.com (HICNet Medical News) To: hicnews Subject: [MMWR] Cigarette Smoking Among Women of Reproductive Age Message-ID: Health Objectives for the Nation Cigarette Smoking Among Women of Reproductive Age -- United States, 1987-1992 Women who smoke cigarettes are at increased risk for lung cancer, chronic obstructive pulmonary disease, and complications of oral contraceptive use. During pregnancy, cigarette smoking increases the risks for a low birthweight infant and infant mortality. A national health objective for the year 2000 is to reduce cigarette smoking among women of reproductive age (i.e., 18- 44 years) to a prevalence of no more than 12% (objective 3.4h) (1). This goal is substantially lower than the estimated baseline prevalence of 29% measured by CDC's 1987 National Health Interview Survey (NHIS). To characterize recent trends in cigarette smoking and monitor progress toward the year 2000 objective, data from the NHIS for 1987 through 1992 were analyzed for women aged 18-44 years. The NHIS is an ongoing household survey conducted annually among a nationally representative sample (n=120,000) of the civilian, noninstitutionalized U.S. population. Information about tobacco use was collected through personal interviews with an adult (aged greater than or equal to 18 years) randomly selected from each surveyed household (n=40,000).* Each year during 1987-1992, the sample sizes for the target study group that was asked tobacco-use questions (i.e., women aged 18-44 years) ranged from 3717 to 13,809. Respondents were asked if they ever smoked 100 cigarettes during their lifetimes and whether they currently smoked (2). Annual prevalence estimates and 95% confidence intervals (CIs) were calculated using SUDAAN (3). Data were weighted to provide national estimates. During 1987-1992, the prevalence of cigarette smoking among reproductive-aged women in the United States declined 3.7%, from 29.6% in 1987 to 26.9% in 1992 (Table 1). The prevalence declined substantially from 1987 (29.6%) to 1990 (25.6%) but increased slightly from 1991 (26.7%) to 1992 (26.9%). In 1992, an estimated 14.3 million U.S. women aged 18-44 years were smokers. Smoking prevalence was inversely related to level of education and was consistently highest among women with less than a high school education (Table 1). Among women with less than a high school education, smoking prevalence decreased from 46.5% in 1987 to 40.6% in 1990; in 1992, the rate (40.2%) remained unchanged. For women with 16 or more years of education, smoking prevalence declined from 14.2% in 1987 to 10.5% in 1990; however, in 1992, the rate increased to 12.5%. During 1987-1992, smoking prevalence rates varied by race. During 1987-1990, race-specific declines in smoking prevalence occurred among both black and white women (Table 1). For black women, the rate declined from 31.2% in 1987 to 22.8% in 1990, but increased significantly to 28.1% in 1991 before declining to 22.6% in 1992. For white women, the rate declined from 30.0% in 1987 to 26.5% in 1990, then increased to 27.1% in 1991 and 28.6% in 1992. Among women aged 18-24 years, smoking prevalence among black women declined dramatically during 1987-1992, from 21.8% to 5.9%. In comparison, among white women, the prevalence was unchanged, 27.8% and 27.2% in 1987 and 1992, respectively. Reported by: Div of Health Interview Statistics, National Center for Health Statistics; Epidemiology Br, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. Editorial Note: In 1965 (the first year the NHIS was used to monitor tobacco use), 33% of U.S. women were cigarette smokers (4). Since then, however, the health risks of cigarette smoking have úÿ been widely publicized, and the prevalence of cigarette smoking among women has declined gradually. During 1974-1985, smoking prevalence among women decreased at a rate of 0.3% per year, one third the rate for men (5). While smoking rates declined among women, death rates for lung cancer increased; in 1987, lung cancer surpassed breast cancer as the leading cause of cancer death among U.S. women. By 1990, 25.6% of women aged 18-44 years were current smokers. Two important findings in this report regarding cigarette smoking by women during 1987-1992 are that 1) rates of cigarette smoking for young black women declined substantially during this period, and 2) after a 25-year decline, rates among women of other races and older women of reproductive age stopped declining in 1990. An important factor probably associated with the decline in smoking among younger black females was the decrease in rates of smoking reported by black female high school seniors during 1985- 1989 (6). In addition, cigarette smoking has been suggested to have less functional value for black women (i.e., they may be less likely to use smoking for weight control or social acceptability) (7). However, reasons for the increase in smoking among black women aged 18-44 years in 1991 only have not been determined. At least two factors have been suggested to account for the reduction or termination of declines in cigarette smoking among women of reproductive age: first, tobacco companies used advertising campaigns (8) and other approaches to target women, and second, the increase in rates of smoking initiation by young adolescent females during the early 1970s resulted in a greater number of adult women smokers (9). Although the mean education level** of Hispanic women in this study was lower when compared with non-Hispanic women, the prevalence of cigarette smoking was significantly lower among Hispanic women, possibly reflecting the effect of potential cultural differences that decrease the social acceptability of smoking among Hispanic women. The findings in this report also indicate that, during 1987-1992, smoking rates were significantly higher for women living below the poverty level than those living at or above the poverty level. This inverse association between income and smoking prevalence also has been documented for men and reflects correlations with education level. Comprehensive strategies to discourage tobacco use by women and to achieve the year 2000 national health objective should include four basic components: research, outreach, education, and advocacy. Research efforts should focus on the disparate race-specific trends in smoking by race and translation of successes in efforts to reduce smoking among other groups. Outreach should especially be directed toward providing interventions for the high proportion of women smokers with less than a high school education. Education campaigns that employ paid antismoking advertising have been implemented successfully in California and may be adapted for use in other locations in the United States (10). Examples of measures to strengthen advocacy of tobacco-control policies include increases in the excise taxes on tobacco products and enforcement of laws that restrict access to tobacco products by minors. References 1. 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. 2. CDC. Cigarette smoking among adults--United States, 1992, and changes in the definition of current cigarette smoking. MMWR 1994;43:342-6. 3. Shah BV. Software for Survey Data and Analysis (SUDAAN) version 6.0 [Software documentation]. Research Triangle Park, North Carolina: Research Triangle Institute, 1991. 4. CDC. Reducing the health consequences of smoking: 25 years of progress--a report of the Surgeon General. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, 1989; DHHS publication no. (PHS)89-8411. 5. Fiore MC, Novotny TE, Pierce JP, Hatziandreu EJ, Patel KM, Davis RM. Trends in cigarette smoking in the United States: the changing influence of gender and race. JAMA 1989;261:49-55. 6. Bachman JG, Wallace JM, O'Malley PM, Johnston LD, Kurth CL, Neighbors HW. Racial/ethnic differences in smoking, drinking, and illicit drug use among American high school seniors, 1976-89. Am J Public Health 1991;81:372-7. 7. Camp DE, Klesges RC, Relyea G. The relationship between body weight concerns and adolescent smoking. Health Psychol 1982;12:24- 32. 8. Ernster VL. How tobacco companies target women. In: American Cancer Society. World smoking and health. Atlanta: American Cancer Society, 1991:8-11. 9. Gilpin EA, Lee L, Evans M, Pierce J. Smoking initiation rates in adults and minors: United States, 1944-1988. Am J Epidemiol 1994;140:535-43. 10. Pierce JP, Evans N, Farkas AJ. Tobacco use in California: an evaluation of the tobacco control program, 1989-1993. La Jolla, California: University of California, San Diego, 1994. * Health-topic supplements: Cancer Control and Epidemiology, 1987; Occupational Health, 1988; Diabetes Risk Factors, 1989; Health Promotion and Disease Prevention, 1990 and 1991; and Cancer Control, 1992. ** In this study, the mean number of years of education completed by Hispanic women was 11.3 years and for non-Hispanic women, 13.1 years. ------------------------------ Date: Thu, 01 Dec 94 06:30:45 MST From: mednews@stat.com (HICNet Medical News) To: hicnews Subject: [MMWR] Continuing Diabetes Care Message-ID: Continuing Diabetes Care -- Rhode Island, 1991 The annual economic impact of diabetes mellitus in the United States is an estimated $92 billion (1), primarily reflecting the treatment of both acute (e.g., diabetic ketoacidosis and hypoglycemic coma) and chronic (e.g., atherosclerotic cardiovascular disease, blindness, renal failure, neuropathy, and amputation of extremities) complications (2). The complications of diabetes may be prevented or delayed through intensive treatment (3) and through early detection and treatment of complications (4,5). To characterize continuing care of diabetes in Rhode Island in 1991, the Rhode Island Department of Health initiated a Diabetes Care Survey (DCS) in conjunction with its statewide Health Interview Survey (HIS) in 1990. This report summarizes the results of that survey. Questions about the frequency of continuing diabetes care were based on standards published in 1989 that recommend persons using insulin visit a physician at least quarterly and persons not using insulin visit a physician at least semiannually. The standards also recommend examination by an "eye doctor" at least annually for persons aged 12-30 years with a diagnosis of diabetes of at least a 5-year duration and for all persons aged greater than or equal to 30 years with diabetes (4). CDC has defined such examinations as "dilated eye examinations" (5). The 1990 HIS used random-digit-dialing to survey 3118 households in Rhode Island; 2588 (83%) persons responded. One adult (aged greater than or equal to 18 years) respondent in each household was asked about the sociodemographic characteristics, health status, and health-related behaviors of all household members. In 1991, 150 (71%) of 212 adult HIS respondents who reported having been told by a doctor that they had diabetes in 1990 were recontacted for the DCS and asked about health status and diabetes care. Of the 150 respondents, 89% were aged greater than or equal to 40 years, 52% were aged greater than or equal to 65 years, and 54% were women. Forty-three percent had not graduated from high school, and 45% had family incomes at or less than 200% of the poverty level*. In approximately one third (34%), diabetes had been diagnosed within the preceding 5 years. Almost all (95%) received diabetes care from a physician. Almost half (48%) used oral hypoglycemic agents; 31% used insulin. Of the 84 respondents with noninsulin-treated diabetes, nearly all (99%) had visited a health-care provider at least twice during the preceding year. Of the 54 respondents with insulin-treated diabetes, 61% had visited a provider four times during the preceding year. During the preceding year, 72% of the respondents who were eligible for a dilated eye examination had received one. Respondents aged less than 40 years were less likely to have visited a health-care provider for regular diabetes care (53%) than were respondents aged 40-64 years (86%) or greater than or equal to 65 years (95%) (Table 1). Men were less likely than woman to have had a dilated eye examination during the preceding year (60% versus 84%, respectively). Reported by: D Goldman, MPH, J Fulton, PhD, D Perry, J Feldman, MD, Rhode Island Diabetes Control Program, Rhode Island Dept of Health. Epidemiology and Statistics Br, Div of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, CDC. Editorial Note: The control of complications and costs of diabetes requires that persons with diabetes have access to continuing medical care for this disease. The findings in this report indicate that in Rhode Island, most persons with diabetes reported receiving dilated eye examinations in accordance with current recommendations. In comparison, other recent assessments indicate that during 1989, only 49% of adults with diagnosed diabetes in the United States had dilated eye examinations during the preceding year (6); in addition, during 1992, 33%-60% of patients with diabetes who were receiving care at three of the largest health maintenance organizations in the United States also had received yearly eye examinations (7 ). Since 1979, efforts of the Rhode Island Diabetes Control Program have been directed toward reducing barriers to care and ensuring eye examinations for persons with diabetes; the program has especially focused on persons with low income and those with no health insurance. Components of the multifaceted campaign to ensure eye care for persons with diabetes include 1) distribution of information, including materials developed by the National Institutes of Health as a part of the National Eye Health Education Program, through sites (e.g., the offices of primary-care physicians and podiatrists, clinics, emergency rooms, hospitals, worksites, pharmacies, and Lions clubs) that promote annual eye examinations among persons with diabetes; 2) distribution of national standards for eye care by mail to all primary-care providers, through presentations to selected medical staff at all Rhode Island hospitals, and through publication of articles assessing and promoting diabetic eye care in Rhode Island; and 3) direct diabetes-care interventions through neighborhood health centers associated with the Providence Ambulatory Health Care Foundation. The findings in this report also indicate that in Rhode Island, persons with insulin-treated diabetes visit health-care providers less frequently than is recommended; persons aged less than 40 years were least likely to visit providers at regular intervals. Possible reasons for lack of continuing care in this age group include lack of health insurance, self-perceived good health, and short duration of disease--and therefore, fewer complications (5). The Rhode Island Diabetes Control Program and its Diabetes Professional Advisory Council have used these and other findings to develop a statewide diabetes control plan. These findings also may be used as a baseline for evaluating interventions. To facilitate this process, the advisory council has established a surveillance committee to develop an overall surveillance plan to be coordinated with the statewide diabetes control plan. Although public health surveillance is integral to the control of infectious diseases, the role of state-based surveillance is less well established in the control of diabetes and other chronic conditions. The Rhode Island DCS is an innovative and useful tool for the surveillance of diabetes health-care patterns and practices and may serve as a model for other states with diabetes control programs. References 1. American Diabetes Association, Inc. Direct and indirect costs of diabetes in the United States in 1992. Alexandria, Virginia: American Diabetes Association, Inc, 1993. 2. Herman WH, Teutsch SM, Geiss LS. Diabetes mellitus. In: Amler W, Dull HB, eds. Closing the gap: the burden of unnecessary illness. New York: Oxford University Press, 1987. 3. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. New Engl J Med 1993;329:977-86. 4. Committee on Professional Practice. Position statement: standards of medical care for patients with diabetes mellitus. Diabetes Care 1989;12:365-8. 5. CDC. The prevention and treatment of complications of diabetes mellitus. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1991. 6. Brechner RJ, Cowie CC, Howie LJ, Herman WH, Will JC, Harris MI. Ophthalmic examination among adults with diagnosed diabetes mellitus. JAMA 1993;270:1714-8. 7. Herman WH, Dasbach EJ. Diabetes, health insurance, and health-care reform. Diabetes Care 1994;17:611-3. * Poverty statistics are based on a definition originated by the Social Security Administration in 1964, subsequently modified by federal interagency committees in 1969 and 1980, and prescribed by the Office of Management and Budget as the standard to be used by federal agencies for statistical purposes. ------------------------------ Date: Thu, 01 Dec 94 06:32:14 MST From: mednews@stat.com (HICNet Medical News) To: hicnews Subject: [MMWR 11 Nov 94] Imported Plague Message-ID: Detection of Notifiable Diseases Through Surveillance for Imported Plague -- New York, September-October 1994 Recent reports of bubonic and pneumonic plague outbreaks in India (1,2) prompted the New York City Department of Health (NYCDOH) and the New York State Department of Health (NYSDOH), in conjunction with CDC, to develop an emergency response plan to detect and manage suspected cases imported by international air travel. This report describes the surveillance system implemented by CDC on September 27 and supplemental efforts by NYC/NYSDOH to guide and inform physicians about the outbreak, and summarizes clinical findings for 11 travelers who had symptoms suggestive of plague. CDC Surveillance System The CDC surveillance protocol included instructions to staff of international air carriers to notify U.S. quarantine officials before landing of passengers or crew with illness suggestive of plague. All passengers arriving on direct flights from India were provided a plague alert notice that described the symptoms of plague and urged them to seek medical attention if they developed a febrile illness within 7 days of disembarkation. Once passengers were in the United States, the surveillance system relied on physicians and other hospital staff to report suspected plague cases to local health departments, which would then notify CDC. Supplemental Efforts by NYCDOH/NYSDOH A primary role of NYCDOH/NYSDOH, in conjunction with CDC, was to determine whether the clinical presentation of persons with suspected cases was consistent with plague and to arrange for immediate hospitalization in facilities with respiratory isolation rooms. In addition, because of the high volume of air travel from India (approximately 2000 passengers arrive daily at John F. Kennedy International Airport on flights from India), NYCDOH/NYSDOH supplemented CDC's surveillance plan by using two approaches to disseminate information to heighten awareness of plague, focusing on emergency department physicians. First, a fact sheet describing the clinical presentation of plague and emphasizing the need to assess travel history among patients with suggestive symptoms was transmitted by fax or electronic mail to emergency department physicians and infection-control practitioners at 102 hospitals in New York City and to all acute-care hospitals and county health departments in the state. Second, a special plague advisory issue of City Health Information, NYCDOH's bulletin, was distributed to 20,000 physicians in New York City within 2 weeks of CDC's plague alert. To directly reach persons who recently may have arrived from India and were at increased risk for plague, leaflets in English and Hindi describing plague symptoms and urging ill persons to seek medical attention were distributed by NYCDOH at a heavily attended Indian cultural fair on October 8 and 9. Clinical Findings for Travelers As of October 27 (when the plague alert was terminated), 10 persons with suspected plague had been reported to NYCDOH and one to the Albany County Health Department and NYSDOH. None were confirmed as having plague. Patients ranged in age from 31 to 80 years; six were men. All 11 patients reported having recently been in India. One suspected case was recognized by an airline crew member during a flight; two by customs officials in the airport; and one by airline officials at check-in for a connecting domestic flight at a different airport. The remaining seven suspected cases were reported by hospital emergency departments. Nine of the 11 patients were admitted to a hospital isolation unit for observation while awaiting consultation with CDC and/or confirmatory laboratory testing. Ten patients had clinical presentations that were not consistent with pneumonic plague. One patient, who developed adult respiratory distress syndrome and coma, required serologic and microbiologic testing to rule out plague. The final diagnoses for 10 of the suspected cases were viral syndrome (four patients), malaria (three), concurrent malaria and dengue (one), and typhoid and liver disease (one each); one person had no illness. Reported by: B Mojica, MD, R Heffernan, MPH, C Lowe, MFA, S Matthews, New York City Dept of Health; T Briggs, Albany County Health Dept, Albany; F Guido, E Wender, MD, Westchester County Health Dept, Hawthorne; S Kondracki, G Birkhead, MD, D Morse, MD, State Epidemiologist, New York State Dept of Health. Div of Quarantine, National Center for Prevention Svcs; Bacterial Zoonoses Br, Div of Vector-Borne Infectious Diseases, National Center for Infectious Diseases; Div of Field Epidemiology, Epidemiology Program Office, CDC. Editorial Note: This report illustrates the ongoing potential for importation of emerging infectious diseases into the United States and the need for prompt reporting of cases to local and state health departments for an appropriate public health response (3). The Institute of Medicine has identified international travel and commerce as a major factor associated with emerging infections (4). The protocols described in this report--highlighting the close cooperation between federal, state, and local public health officials; the medical community; and the airline industry-- represent the coordinated, comprehensive prevention-oriented response needed to guard against the threat of emerging and resurgent infections. In addition, the evaluation of suspected plague cases in New York revealed limitations in recognizing cases of disease only at the point of disembarkation; in New York, approximately half of the suspected cases were brought to the NYCDOH/NYSDOH's attention by local physicians. The importance of obtaining a travel history when evaluating persons presenting with fever was underscored by the detection of cases of dengue and nationally notifiable disease conditions (i.e., malaria and typhoid) (5). References 1. CDC. Human plague--India, 1994. MMWR 1994;43:689-91. úÿ 2. CDC. Update: human plague--India, 1994. MMWR 1994;43:722-3. 3. Berkelman RL, Bryan RT, Osterholm MT, LeDuc JW, Hughes JM. Infectious disease surveillance: a crumbling foundation. Science 1994;264:368-70. 4. Institute of Medicine. Emerging infections: microbial threats to health in the United States. Washington, DC: National Academy Press, 1992. 5. CDC. National notifiable diseases reporting--United States, 1994. MMWR 1994;43:800-1. ------------------------------ Date: Thu, 01 Dec 94 06:33:44 MST From: mednews@stat.com (HICNet Medical News) To: hicnews Subject: [MMWR] Erythromycin-Resistant Bordetella pertussis Message-ID: Erythromycin-Resistant Bordetella pertussis -- Yuma County, Arizona, May-October 1994 In 1993, a total of 6586 cases of pertussis was reported in the United States, including 70 in Arizona. On June 27, 1994, a case of Bordetella pertussis disease caused by a strain resistant to erythromycin was reported to the Arizona Department of Health Services (ADHS) from Yuma County (1990 population: 106,895). Susceptibility testing at CDC confirmed that the isolate was highly resistant to erythromycin with a minimum inhibitory concentration (MIC) greater than 64 ug/mL. The MIC of erythromycin against B. pertussis usually ranges from 0.02 ug/mL to 0.1 ug/mL, and resistant isolates have not been previously reported (1). This report summarizes the case investigation and describes efforts to enhance surveillance for pertussis in Arizona. Case Report The erythromycin-resistant strain was isolated from a 2-month-old male infant living in Yuma County, Arizona, who had onset of cough on May 16, 1994. The illness was initially diagnosed as bronchitis, and treatment with amoxicillin was initiated on May 23. The infant had no history of previous antibiotic therapy, and the parents reported he had not received pertussis vaccine before the onset of illness. On May 26, he was hospitalized with severe paroxysmal cough, inspiratory whoop, posttussive vomiting, and episodes of cyanosis and apnea. B. pertussis infection was diagnosed by direct fluorescent antibody (DFA) testing; oral erythromycin estolate therapy (50 mg per kg body weight per day) was initiated on May 26 and continued for 12 days. Because of persistent paroxysmal cough and episodes of cyanosis, apnea, and bradycardia, on June 8 he was transferred to a pediatric intensive-care facility. Both a DFA test and culture performed on nasopharyngeal secretions obtained on June 8 confirmed the persistence of pertussis organisms, and intravenous erythromycin therapy (30 mg/kg/day) was initiated. On June 13, a repeat DFA test and culture were positive, and the erythromycin dosage was increased to 40 mg/kg/day. Despite sequential oral and parenteral erythromycin therapy, nasopharyngeal cultures obtained from the infant on June 16 and 20 grew B. pertussis, and his condition remained unchanged. Susceptibility testing at the hospital laboratory suggested that the isolate was resistant to erythromycin but sensitive to trimethoprim-sulfamethoxazole (TMP-SMZ). On June 20, erythromycin therapy was discontinued, and therapy with TMP-SMZ was initiated; the infant's condition improved rapidly. A nasopharyngeal culture obtained on June 25 was negative, and he was discharged from the hospital on June 29. Approximately 2 weeks before the infant's onset of illness, his 17-year-old mother had developed a spasmodic cough illness associated with posttussive vomiting. A nasopharyngeal culture specimen obtained from the mother on June 28 was negative. She had no history of recently receiving antibiotic treatment. Enhanced Surveillance for Pertussis Because of the case in the 2-month-old infant, in late June, the Yuma County Department of Public Health enhanced surveillance to detect pertussis illness and to obtain B. pertussis isolates from county residents. State and federal public health officials visited all primary-care providers and health-care facilities in Yuma County to disseminate culture kits and instructions for obtaining appropriate culture specimens. In particular, providers were asked to obtain nasopharyngeal cultures from all Yuma County residents with an unexplained acute cough illness lasting 7 or more days. In addition, ADHS mailed letters to approximately 2500 primary-care providers in Arizona to encourage collection of nasopharyngeal cultures for diagnosis of pertussis. Health officials in two California counties near Yuma County (Imperial and San Diego counties) were alerted to the isolation of an erythromycin-resistant pertussis strain in Yuma County. The first person with a culture-confirmed case of B. pertussis in Yuma County in 1994 had onset on April 9. A total of 18 confirmed cases (eight culture-confirmed and 10 epidemiologically linked to a culture-confirmed case) and 57 probable cases (defined as unexplained acute cough for 14 or more days) were identified during April 30-October 1. During the period of enhanced surveillance (late June-October 1), a total of 127 nasopharyngeal culture specimens were obtained from Yuma County residents and sent to the ADHS laboratory. In addition to the index case, B. pertussis was isolated from the specimens of seven persons. Of these seven isolates, one was inadvertently discarded, and the remaining six were susceptible to erythromycin. In addition, all 22 B. pertussis strains isolated during June-August from persons in other Arizona counties and all 13 B. pertussis strains isolated during January- August from patients in San Diego County were susceptible to erythromycin. ADHS has continued enhanced surveillance and has recommended that providers in Arizona obtain nasopharyngeal culture specimens from all persons--regardless of age or vaccination status--with unexplained acute cough of 14 or more days' duration and at least one of the following symptoms: paroxysms of cough, inspiratory whoop, or posttussive vomiting. Health-care providers also have been urged to report all suspected cases to local health departments and to send B. pertussis culture specimens to the ADHS laboratory. Preliminary results of studies at CDC suggest that the mechanism of B. pertussis resistance to erythromycin does not involve ribosomal riboneucleic acid methylation, which has been documented in streptococcal and staphylococcal resistance to erythromycin. Studies are ongoing at CDC to elucidate the mechanism of B. pertussis resistance to erythromycin. Reported by: S Lewis, MPH, Public Health Nursing Staff, Yuma County Dept of Public Health, Yuma; B Erickson, PhD, G Cage, MS, G Harter, State Public Health Laboratory; C Kioski, MPH, S Barefoot, L Carmody, MA, H Houser, L Sands, DO, State Epidemiologist, Arizona Dept of Health Svcs; M Saubolle, PhD, Good Samaritan Regional Medical Center, K Lewis, MD, S Barbour, MD, M Rudinsky, MD, Children's Hospital, Phoenix. Hospital Infections Program, and Div of Bacterial and Mycotic Diseases, National Center for Infectious Diseases; National Immunization Program, CDC. Editorial Note: Erythromycin is the drug of choice for treating persons with B. pertussis disease and for postexposure prophylaxis of all household members and other close contacts as recommended by the Advisory Committee on Immunization Practices (2-6). For adults who are susceptible to pertussis because of a decrease in vaccine-induced immunity or for infants who are too young to be adequately vaccinated and are at risk for severe disease, erythromycin prophylaxis and treatment are the primary control measures. Because of the limited number of isolates subjected to susceptibility testing (n=41), the proportion of resistant strains of B. pertussis cannot be estimated accurately for Yuma County or other areas in the region. However, the absence of additional erythromycin-resistant strains in Arizona and San Diego County, California, suggests that antimicrobial resistance is not widespread. Ongoing surveillance and collection of B. pertussis isolates should assist in more accurate assessment of the extent of transmission of the resistant strain in the area. Failure of erythromycin to eradicate B. pertussis has been associated with poor absorption of some preparations of the antibiotic (4,7). Among the three esterified oral erythromycin formulations (estolate, ethylsuccinate, and stearate), erythro- mycin estolate has superior bioavailability and achieves higher concentrations in serum and respiratory secretions. TMP-SMZ is an alternative for treatment and for chemoprophylaxis, but its efficacy as a chemoprophylactic agent has not been evaluated (8). Nasopharyngeal cultures should be obtained from persons with pertussis who do not improve with erythromycin therapy. Criteria for assessing treatment failure are 1) persistence or worsening of the typical symptoms* of pertussis disease, 2) initiation of erythromycin therapy within 2 weeks of onset of illness, 3) completion of erythromycin therapy in the recommended dosage, and 4) verification of patient compliance with therapy. Most persons who meet these criteria will not be culture-positive for B. pertussis; however, isolates obtained from patients with erythromycin therapy failure should be sent to CDC (Pertussis Laboratory, Childhood Respiratory Diseases Branch, Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, CDC, Mailstop C-02, 1600 Clifton Road, NE, Atlanta, GA 30333) for further testing. Tests to evaluate antimicrobial susceptibility of B. pertussis have not been standardized and are not widely available. In collaboration with ADHS, efforts to standardize B. pertussis susceptibility testing are ongoing at CDC. All health-care providers in the United States are encouraged to obtain nasopharyngeal cultures from patients in whom pertussis is suspected. These include persons with unexplained acute cough of 14 or more days' duration and at least one of the following symptoms: paroxysms of cough, inspiratory whoop, or posttussive vomiting, regardless of the patient's age or vaccination status. All probable and confirmed cases of pertussis should be reported promptly to local or state health departments. References 1. Hoppe JE, Haug A. Antimicrobial susceptibility of Bordetella pertussis (Part I). Infection 1988;16(suppl):126-30. 2. ACIP. Diphtheria, tetanus, and pertussis: recommendations for vaccine use and other preventive measures--recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1991;40(no. RR-10). 3. American Academy of Pediatrics. Pertussis. In: Peter G, ed. 1994 Red book: report of the Committee on Infectious Diseases. 23rd ed. Elk Grove Village, Illinois: American Academy of Pediatrics, 1994:355-67. 4. Bass JW. Erythromycin for treatment and prevention of pertussis. Pediatr Infect Dis 1986;5: 154-7. 5. Sprauer MA, Cochi SL, Zell ER, et al. Prevention of secondary transmission of pertussis in households with early use of erythromycin. Am J Dis Child 1992;146:177-81. 6. Steketee RW, Wassilak SGF, Adkins WN Jr, et al. Evidence for a high attack rate and efficacy of erythromycin prophylaxis in a pertussis outbreak in a facility for the developmentally disabled. J Infect Dis 1988;157:434-40. 7. Hoppe JE, the Erythromycin Study Group. Comparison of erythromycin estolate and erythro-mycin ethylsuccinate for treatment of pertussis. Pediatr Infect Dis J 1992;11:189-93. 8. Hoppe JE, Halm U, Hagedorn HJ, Kraminer-Hagedorn A. Comparison of erythromycin ethylsuccinate and co-trimoxazole for treatment of pertussis. Infection 1989;17:227-31. *Prolonged paroxysms of cough associated with apnea, cyanosis, or bradycardia in young infants or prolonged paroxysms of cough associated with whoop and/or posttussive vomiting in older children and adults. ------------------------------ Date: Thu, 01 Dec 94 06:36:53 MST From: mednews@stat.com (HICNet Medical News) To: hicnews Subject: [MMWR] Prevalence of Self-Report Epilepsy Message-ID: <7BqNwc8w165w@stat.com> Prevalence of Self-Reported Epilepsy -- United States, 1986-1990 Epilepsy is a chronic neurologic condition characterized by abnormal electrical discharges in the brain manifested as two or more unprovoked seizures (1). Risk factors for epilepsy include vascular disease, head trauma, congenital or perinatal factors, central nervous system infections, and neoplasms; however, the etiology of epilepsy is unknown for approximately three fourths of cases (2). Epilepsy frequently causes impaired physical, psychological, and social functioning, which results in substantial disability, economic loss, and diminished quality of life (3). To examine the burden of epilepsy in the United States, the prevalence of self-reported epilepsy was estimated by using data from 1986 through 1990 from the National Health Interview Survey (NHIS) (4). This report summarizes the results of this analysis. The NHIS is a nationally representative household survey of the U.S. civilian, noninstitutionalized population conducted annually by CDC. Respondents were asked whether they or any household family member had epilepsy or repeated seizures, convulsions, or blackouts during the preceding 12 months. Self-reported epilepsy was categorized according to the International Classification of Diseases, Ninth Revision, Clinical Modification, codes 345.0-345.9. Age-specific and age-adjusted prevalences for the 12-month period preceding the interview and associated standard errors were estimated; the direct method was used to age-adjust the estimates, using the 1980 U.S. resident population as the standard (5). To increase the stability of the estimates, data were combined for 1986-1990. Confidence intervals (CIs) were based on the standard errors of the estimates, taking into account the survey design. During 1986-1990, approximately 1.1 million persons in the United States annually reported having epilepsy. The overall prevalence of epilepsy was 4.7 cases per 1000 persons. The prevalence was lowest (3.1) for persons aged greater than or equal to 65 years and highest (5.2) for persons aged 15-64 years (Table 1). The prevalence for persons aged less than 15 years was 4.0. The age-adjusted prevalence was similar for women and men (5.1 and 4.2, respectively), and the age-specific pattern was consistent for both sexes. The age- and race-adjusted prevalence of epilepsy was similar among the regions of the country (4.0 in the West, 4.4 in the Northeast, 4.9 in the Midwest, and 5.0 in the South)*. The age-adjusted prevalence of epilepsy was higher for blacks (6.7 [95% CI=4.9-8.5]) than whites (4.5 [95% CI=3.9-5.1]).** Compared with whites, prevalence rates among blacks were especially higher for persons aged 35-44 years and 45-54 years (prevalence ratios=3.0 and 2.3, respectively) (Figure 1, page 817). This pattern was similar for both black males and black females. Reported by: Statistics Br, Div of Chronic Disease Control and Community Intervention, National Center for Chronic Disease Prevention and Health Promotion; National Center for Health Statistics, CDC. Editorial Note: The findings in this report indicate that epilepsy is a common neurologic condition in the United States. However, the overall age-adjusted prevalence in this report (4.7) is lower than estimates from previous studies (6.0-7.0), which were based on rigorous case ascertainment efforts (i.e., record review or neurologic examination) in more clearly defined local populations (2,6). Epileptic seizures can be classified by etiology or clinical manifestation. Seizures with a presumptive cause (e.g., head trauma, stroke, or neoplasm) are classified as symptomatic seizures or secondary epilepsy; repeated seizures with no presumed cause are classified as idiopathic epilepsy (7). Symptomatic seizures can be either acute or temporally remote from the triggering event and can be prevented by reducing the prevalence of the predisposing event. However, even if all known risk factors for epilepsy were removed from the population, approximately 70% of cases would still occur (2). The findings in this report are subject to at least two limitations. First, estimates are based on self-reported data and may be subject to reporting bias. For example, because a social stigma is associated with epilepsy, persons may be reluctant to report the condition (8). Second, epilepsy manifests itself with varying seizure frequency throughout life. Persons whose seizures are controlled with medication or who have not had a recent seizure may not have reported epilepsy as a medical problem in this survey. The higher reported prevalence of epilepsy for blacks than for whites is consistent with previous reports (6,9). Among blacks, the higher prevalences in middle-aged groups (i.e., 35-44 years and 45- 54 years) may reflect differences in the epidemiology of epilepsy in middle life (e.g., trauma and cerebrovascular disease). Because most previous studies have reported a higher prevalence of epilepsy among males, the detection of similar prevalences for men and women in this report warrants further assessment (9). Prompt detection and early medical intervention can greatly improve seizure control and enhance the quality of life for persons with epilepsy; however, epilepsy remains undiagnosed or inadequately treated in many persons. To address these issues, CDC is collaborating with professional and voluntary organizations to design provider and consumer education materials to improve awareness, detection, and appropriate treatment of persons with epilepsy. November is National Epilepsy Month. For additional information about epilepsy management or referral to local resources, contact the Epilepsy Foundation of America, telephone (800) 332-1000 or (301) 459-3700. References 1. Adams RD, Victor M. Principles of neurology. 4th ed. New York: McGraw-Hill, 1989. 2. Hauser WA, Kurland LT. The epidemiology of epilepsy in Rochester, Minnesota, 1935 through 1967. Epilepsia 1975;16:1-66. 3. Hartshorn JC, Byers VL. Impact of epilepsy on quality of life. J Neurosci Nurs 1992;24:24-9. 4. NCHS. Current estimates from the National Health Interview Survey: data from the national health survey, 1989. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1990; DHHS publication no. (PHS)90-1504. (Vital and health statistics; series 10, no. 176). 5. Fleiss JL. Statistical methods for rates and proportions. 2nd ed. New York: John Wiley & Sons, 1981. 6. Haerer AF, Anderson DW, Schoenberg BS. Prevalence and clinical features of epilepsy in a biracial United States population. Epilepsia 1986;27:66-75. 7. Commission on Classification and Terminology, International League Against Epilepsy. Proposal for revised clinical and electroencephalographic classification of epileptic seizures. Epilepsia 1981;22:489-501. 8. Jacoby A. Felt versus enacted stigma: a concept revisited-- evidence from a study of people with epilepsy in remission. Soc Sci Med 1994;38:269-74. 9. Hauser WA, Hesdorffer DC. Epilepsy: frequency, causes and consequences. New York: Epilepsy Foundation of America, 1990. *Northeast=Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont; Midwest=Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin; South=Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia; West=Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming. **Numbers for races other than black and white were too small for meaningful analysis. ------------------------------ End of HICNet Medical News Digest V07 Issue #57 úÿ (continued next message) ÿ@FROM :david@STAT.COM úÿ(Continued from last message) *********************************************** --- Editor, HICNet Medical Newsletter Internet: david@stat.com FAX: +1 (602) 451-1165 Bitnet : ATW1H@ASUACAD