From <@uga.cc.uga.edu:owner-mednews@ASUACAD.BITNET> Sun Apr 2 13:32:17 1995 with BSMTP id 5840; Sun, 02 Apr 95 13:23:40 EDT UGA.CC.UGA.EDU (LMail V1.2a/1.8a) with BSMTP id 5829; Sun, 2 Apr 1995 13:22:07 -0400 HICNet Medical News Digest Sun, 02 Apr 1995 Volume 08 : Issue 10 Today's Topics: [MMWR] Self-Treatment with Herbal and Other Plant-Derived Remedies [MMWR] Emergence of Penicillin-Resistant Streptococcus pneumoniae [MMWR] Update: Vibrio cholerae O1 [MMWR] Health Insurance Coverage and Receipt of Preventive Health [MMWR] Evaluation of Congenital Syphilis Surveillance System +------------------------------------------------+ ! ! ! 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/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 Remedies Self-Treatment with Herbal and Other Plant-Derived Remedies -- Rural Mississippi, 1993 Herbal and other plant-derived remedies have been estimated by the World Health Organization (WHO) to be the most frequently used therapies worldwide (1). Therapeutic agents derived from plants include pure chemical entities available as prescription drugs (e.g., digitoxin, morphine, and taxol), standardized extracts, herbal teas, and food plants; plant- derived remedies can contain chemicals with potent pharmacologic and toxicologic properties (2,3). Although precise levels of use of these remedies in the United States are unknown, in 1991, herbal products accounted for sales of approximately $1 billion (4). Previous reports about herbal remedies in the rural South have described the use and biologic activities of locally gathered plant species (5,6) and details of preparation and dosage, but have not determined the prevalence of use of plant-derived remedies in the study population and the prevalence of use of specific remedies. To assess the prevalence of use of plant-derived remedies (excluding prescription drugs) and the prevalence of use of specific remedies in rural central Mississippi, The University of Mississippi conducted a survey during March- June 1993. This report describes two case reports of use of these remedies and summarizes the findings of the survey. Case Reports Case 1. A 55-year-old man who had completed 11 years of education reported using turpentine during the year preceding the survey to rid himself of "seed ticks." The man purchased turpentine at a local drug store and, based on the advice of a friend, poured approximately 4 oz of turpentine onto a sponge and applied the sponge over all surfaces of his body below the neck. He then bathed in a tub of hot water and had onset of a severe burning sensation. To alleviate the burning, he soaked in a tub of cold water. The man subsequently developed blistering on all body surfaces to which he had applied turpentine. He also reported having used aloe as a topical remedy during the preceding year and reported previous use of briar root, castor, garlic, lemon, and sassafras. Case 2. A 46-year-old woman who had completed 7 years of education reported using castor oil routinely as a laxative and to treat "colds." She purchased castor oil at a discount department store, kept it readily available in her home, and had used castor oil and acetaminophen to treat a cold in her 18-month-old grandchild. She fed the child 1 teaspoon of castor oil mixed with one half of a baby bottle of orange juice. The symptoms resolved. She also reported using aloe, asafetida, catnip, garlic, lemon, and turpentine as remedies during the preceding year and recalled previous use of briar root, chinaberry, corn shucks, and pine as remedies. Survey A 2% random cluster sample of households (n=11,671) was selected from detailed transportation maps for two geographic areas in rural central Mississippi (1990 rural central Mississippi population: 33,992). Of the 223 occupied households contacted, one or more adults (persons aged greater than or equal to 18 years) in 210 (94%) households participated; 251 adults were included in the survey. The survey collected information on demographic, socioeconomic, and health variables; medicinal use and knowledge of 25 specific plants or plant-derived substances*; and diseases or symptoms treated with these plants. The 25 plants were selected based on ethnobotanical research conducted in this geographic area. In addition, respondents were asked about their knowledge or use of any other plant-derived remedies to treat specific diseases or symptoms. Of the 251 respondents, 178 (71% [95% confidence interval (CI)=65%- 77%]) reported using at least one plant-derived remedy during the year preceding the survey. The prevalence of reported use varied among age groups and was significantly higher among persons aged 45-64 years (81% [95% CI=72%-90%]) than among those aged 18-44 years (75% [95% CI=65%- 85%]) and among those aged greater than or equal to 65 years (62% [95% CI=53%- 71%]) (p less than 0.05). Of respondents who had used plants during the preceding year, 31% (95% CI=25%-37%) had used one plant-derived remedy; 20% (95% CI=15%-25%), two; and 20% (95% CI=15%-25%), three or more. The most frequently used (i.e., used by at least 10% of respondents) plant-derived remedies during the preceding year were lemon (47% [95% CI=41%-53%]), aloe (27% [95% CI=22%-32%]), castor oil (14% [95% CI=10%- 18%]), turpentine (12% [95% CI=8%-16%]), tobacco (12% [95% CI=8%-16%]), and garlic (10% [95% CI=6%-14%]). Other plants used for self-treatment included poke and sassafras. The most common self-reported reasons for using plant-derived remedies during the preceding year included treatment of diseases or symptoms** associated with the respiratory system (43% [95% CI=38%-48%]), the skin (20% [95% CI=16%-24%), insect bites or parasite infestations (11% [95% CI=8%-14%]), the cardiovascular system (9% [95% CI=6%-12%]), and the gastrointestinal system (6% [95% CI=4%-8%]). Reported by: DA Frate, PhD, EM Croom, Jr, PhD, JB Frate, JP Juergens, PhD, Research Institute of Pharmaceutical Sciences, School of Pharmacy, The Univ of Mississippi, University; EF Meydrech, PhD, Dept of Preventive Medicine, The Univ of Mississippi Medical Center, Jackson. Health Studies Br, Div of Environmental Hazards and Health Effects, National Center for Environmental Health, CDC. Editorial Note: In this survey of adults residing in rural areas of Mississippi, nearly three fourths of respondents reported having used plant-derived remedies during the preceding year. These data also indicate that plant-derived remedy use was widely distributed among all age groups and was not limited only to older persons in the population. In comparison, in a previous study of herbal remedy use among a national sample of U.S. residents, only 3% of respondents indicated that they had used such remedies during the preceding year (7). The substantially higher use reported in the population surveyed in Mississippi may reflect methodological differences in the two studies. Specifically, the definition of plant-derived remedies used in this report was more inclusive than the definition of herbal remedies used in the national survey. In addition, higher use in the population surveyed in Mississippi may be associated with socioeconomic and cultural influences in this population. For example, in rural central Mississippi, only 51% of persons aged greater than or equal to 25 years had a high school diploma or higher education compared with 64% for the state (8). Although utilization rates of the health-care system in the survey area are similar to national rates, self-treatment is an important adjunct to receiving formal care in this area (9). Some plant-derived remedies reported in rural central Mississippi (e.g., poke and sassafras) contain pharmacologically active and potentially toxic compounds (2). For example, both turpentine and castor oil can produce adverse effects if used inappropriately. Use of externally applied turpentine oil for treatment of parasites has been reported previously (6). Although turpentine oil is a nontoxic and effective counterirritant when applied to a small area of the skin, cutaneous application of larger amounts has been associated with vesicular eruptions, urticaria, and vomiting (10). Castor oil is a stimulant laxative that may cause thorough evacuation of the bowels within 2-6 hours of ingestion (10); the strong purgative action of castor oil also can cause dehydration and electrolyte imbalance, and long-term use may reduce the absorption of nutrients. Because the stimulant effects of castor oil may cause uterine contraction, some authorities have recommended that it not be used during pregnancy; use also is not recommended in infants and young children (11). The survey findings in this report document the popularity of self-treatment with plant-derived therapies among persons in rural central Mississippi. Increased interest by health agencies in plant-derived therapies is reflected through the efforts of both the National Institutes of Health (which established the Office of Alternative Medicine) and the Food and Drug Administration (which has issued regulations addressing health claims for foods and dietary supplements). The survey findings also underscore the need for physicians, pharmacists, and other health-care providers to consider the possibility of plant-derived self-treatments among their patients and to actively elicit this information when taking a clinical history. In addition, health-care providers should be aware of potential drug interactions, toxicity, and adverse re- actions as well as possible treatment benefits that may be associated with plant-derived therapies. References 1. Marini-Bettolo GB. Present aspects of the use of plants in traditional medicine. J Ethnopharmacol 1980;2:183-8. 2. Croom EM Jr. Herbal medicine among the Lumbee Indians. In: Kirkland J, Mathews HF, Sullivan CW III, Baldwin K, eds. Herbal and magical medicine. Durham, North Carolina: Duke University Press, 1992:137-69. 3. Croom EM Jr. Documenting and evaluating herbal remedies. Economic Botany 1983;37:13-27. 4. McCaleb RS. Regulation of dietary supplements: hearing before the Subcommittee on Health and the Environment of the Committee on Energy and Commerce, House of Representatives. Washington, DC: 103rd US Congress, House of Representatives, 1993; series no. 103-57. 5. Morton JF. Folk remedies of the low country. Miami: Seeman, 1974. 6. Bolyard JC. Medicinal plants and home remedies of Appalachia. Springfield, Illinois: CC Thomas, 1981. 7. Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States: prevalence, costs, and patterns of use. N Engl J Med 1993; 328:245-52. 8. Bureau of the Census. 1990 Census of the population and housing: summary social, economic, and housing characteristics--Mississippi. Washington, DC: US Department of Commerce, Bureau of the Census, 1992; publication no. CPH-5-26. 9. Banahan BF III, Frate DA. Use of home remedies and OTC products among rural residents at high risk for development of coronary heart disease. San Diego: American Pharmaceutical Association, March 1992. 10. American Pharmaceutical Association. Handbook of nonprescription drugs. 10th ed. Washington, DC: American Pharmaceutical Association, 1993. 11. Brunton LL. Agents affecting gastrointestinal water flux and motility, digestants, and bile acids. In: Gilman AG, Rall TW, Nies AS, Taylor P, eds. The pharmacological basis of therapeutics. 8th ed. New York: Pergamon Press, 1990:914-32. * Aloe vera, asafetida, briar root/blackberry, castor/castor oil, catnip, chinaberry, corn shucks/corn silks, dock/yellow dock, garlic, American ginseng, Jimson weed, lemon, life everlasting/rabbit tobacco/rabbit grass, mayapple/bitter apple, milkweed, mistletoe, nutmeg, oak, peach/peach seed/peach pit, pine/pinetop, poke/poke salad, sassafras, sage/horsemint, tobacco, and turpentine. ** The reported diseases or symptoms treated with plant-derived remedies were categorized by organ system. For the respiratory system, the diseases or symptoms reported included "colds," sore throat, and cough; for the skin, rashes and burns; for the cardiovascular system, hypertension and diabetes; and for the gastrointestinal system, "stomach aches," constipation, and diarrhea. ------------------------------ To: hicnews pneumoniae Emergence of Penicillin-Resistant Streptococcus pneumoniae -- Southern Ontario, Canada, 1993-1994 Streptococcus pneumoniae is a leading cause of infectious disease-related illness and death in the United States, accounting for an estimated 3000 cases of meningitis, 50,000 cases of bacteremia, 500,000 cases of pneumonia, and 7 million cases of acute otitis media each year (1). Penicillin has been the antibiotic of choice for the treatment of infections caused by S. pneumoniae; since the mid-1980s, the prevalence of penicillin-resistant S. pneumoniae has increased substantially worldwide (2-4). In Canada, a strain of pneumococcus with reduced susceptibility to penicillin was first reported in 1974 (5); based on surveys during 1977- 1990, rates of resistance to penicillin were 2.4%, 1.5%, and 1.3% in the provinces of Alberta, Ontario, and Quebec, respectively (6-8). To determine whether the prevalence of penicillin resistance had increased among pneumococcal isolates, investigators from the University of Toronto tested the susceptibility of strains collected from a Toronto hospital and from a surrounding region in southern Ontario during June-December 1993 and March-June 1994. This report summarizes the results of this investigation. During the study period, all nonduplicate S. pneumoniae isolates were obtained from a private community-based laboratory providing services to physicians, clinics, and nursing homes in metropolitan Toronto, and from patients assessed in the emergency department of a tertiary-care teaching hospital in Toronto. In vitro susceptibility testing was conducted by a broth microdilution procedure in accordance with interpretive standards of the U.S. National Committee for Clinical Laboratory Standards (NCCLS) (9). An intermediate level of resistance to penicillin was defined as a minimal inhibitory concentration (MIC) of 0.1-1.0 ug/mL; high-level resistance was defined as an MIC greater than or equal to 2.0 ug/mL. A total of 202 isolates (196 from noninvasive sites [i.e., sputum]) of S. pneumoniae were tested, including 122 isolates obtained from the private laboratory and 80 from the hospital emergency department. Of the 202 isolates, 16 (7.9%) were penicillin-resistant--including four with high-level resistance; 11 had been obtained from eye, ear, or sputum samples from children (eight of 68 aged less than 5 years) in outpatient settings and five from sputum, blood, cerebrospinal fluid, and eye samples from adults in the emergency department. Penicillin-susceptible strains generally were susceptible to other antimicrobial agents. However, high proportions of penicillin-resistant S. pneumoniae isolates were resistant to tetracycline (63%; MIC greater than or equal to 8 ug/mL), trimethoprim/sulfamethoxazole (56%; MIC greater than or equal to 4 ug/mL), erythromycin (50%; MIC greater than or equal to 4 ug/mL), and cefuroxime (38%; MIC greater than or equal to 2 ug/mL). High-level resistance to ceftriaxone (MIC greater than or equal to 2 ug/mL) occurred in four (25%) of 16 penicillin-resistant isolates; high-level resistance to penicillin was present in three of the four isolates resistant to ceftriaxone. All isolates were susceptible to vancomycin and imipenem. Serotypes of the penicillin-resistant pneumococci tested in the Canadian Streptococcal Reference Laboratory (Edmonton, Alberta) were 19F (five isolates), 9V (two), 23F (two), and one each of 6A, 6B, and 19A; four were non-typeable. Reported by: AE Simor, MD, L Louie, J Goodfellow, M Louie, MD, Dept of Microbiology, Sunnybrook Health Science Centre, Univ of Toronto; Med- Chem Laboratories, Toronto, Ontario, Canada. Adult Vaccine Preventable Disease Br, and Child Vaccine Preventable Disease Br, Div of Epidemiology and Surveillance, National Immunization Program; Nosocomial Pathogens Laboratory Br, Hospital Infections Program, and Childhood and Respiratory Diseases Br, Div of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, CDC. Editorial Note: The findings in this report suggest an increased prevalence of penicillin-resistant S. pneumoniae in metropolitan Toronto compared with úÿ úÿ(Continued from last message) that in a similar study in Toronto in 1988 (1.5% [8]). By selecting all pneumococcal isolates from a large outpatient reference laboratory and hospital emergency department in metropolitan Toronto (97% of which were obtained from noninvasive sites), the study provided an indication of the antimicrobial resistance patterns among pneumococci circulating in the community and reflects a trend of emerging pneumococcal drug resistance in North America and other countries (2-4). For example, in the United States during 1987-1992, the prevalence of high-level resistance to penicillin increased more than 60-fold, from 0.02% to 1.3% in pneumococcal isolates collected from sentinel sites (3). The proportion of pneumococcal isolates resistant to penicillin has ranged from 2% to 26% in selected communities in the United States, indicating substantial geographic variability in prevalence of penicillin resistance (3,4; CDC, unpublished data, 1995). In communities where pneumococci resistant to extended-spectrum cephalosporins have been identified, antimicrobial regimens for treatment of life-threatening pneumococcal infection should initially include vancomycin until the results of susceptibility testing are available. Although the selection of antimicrobials should be guided by the region-specific prevalence of drug-resistant S. pneumoniae (DRSP), the incidence of this problem is unknown for most regions of the country, and community-specific surveillance is needed to determine the incidence of resistance to antimicrobial drugs (e.g., penicillin and extended- spectrum cephalosporins) and to inform clinicians to enable selection of optimal antimicrobials. Appropriate interpretive standards for antimicrobial susceptibility testing of S. pneumoniae isolates have been updated by the NCCLS (9,10). All pneumococcal isolates from normally sterile sites should be screened for penicillin resistance using an NCCLS-approved method. Oxacillin disk diffusion is a cost-effective and sensitive method for screening; susceptible isolates have a zone size of greater than or equal to 20 mm. Nonsusceptible isolates should have MICs determined for penicillin, an extended-spectrum cephalosporin, chloramphenicol, vancomycin, and other clinically indicated drugs. MICs should be determined using approved methods such as broth microdilution, agar disk diffusion, and antimicrobial gradient strips. Automated in vitro methods are not recommended for determining pneumococcal susceptibility. The emergence of DRSP underscores the need for strategies to monitor, prevent, and control DRSP infections. Because inappropriate empiric or prophylactic therapy facilitates the occurrence of pneumococcal antimicrobial resistance, prevention and control of DRSP infections should include efforts to promote judicious antimicrobial prescribing practices among clinicians. In addition, these efforts should promote adherence to the recommendations of the Advisory Committee on Immunization Practices that the 23-valent pneumococcal polysaccharide capsular vaccine be administered to persons aged greater than or equal to 2 years with medical conditions increasing their risk for serious pneumococcal infection and to all persons aged greater than or equal to 65 years. Current pneumococcal vaccination levels are low; for example, in a 1993 survey, only 27% of persons aged greater than or equal to 65 years reported having been vaccinated (CDC, unpublished data, 1995). There is no commercially available vaccine for children aged less than 2 years; however, clinical trials are in progress to assess immunogenicity and efficacy of protein conjugate pneumococcal polysaccharide vaccines in young children. To address the factors contributing to increased resistance and to identify methods for prevention and control of DRSP in the United States, in June 1994, CDC convened a working group comprising public health practitioners, clinical laboratory professionals, health-care providers, and representatives of professional societies. This group has developed a strategy with objectives to 1) establish DRSP as a nationally reportable condition, 2) promote appropriate NCCLS interpretive standards for pneumococcal antimicrobial susceptibility testing, 3) develop an electronic laboratory-based surveillance system to detect invasive DRSP infections and other laboratory-reportable conditions, 4) establish a group of clinicians and public-health officials to form consensus treatment recommendations for pneumococcal infections based on interpretations of antimicrobial resistance data, and 5) promote pneumococcal vaccination and judicious antimicrobial drug use. The goal of this strategy is to minimize complications of DRSP infection, including increased and prolonged illness, long-term sequelae of infection, health-care expenditures, and death. Information about activities of the DRSP Working Group can be obtained through the Childhood and Respiratory Diseases Branch, Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, CDC, Mailstop C-09, Atlanta, GA 30333; Internet address drsp@ciddbd1.em.cdc.gov. References 1. Reichler MR, Allphin AA, Breiman RF, et al. The spread of multiply-resistant Streptococcus pneumoniae at a day care center in Ohio. J Infect Dis 1992;166:1346-53. 2. Applebaum PC. Antimicrobial resistance in Streptococcus pneumoniae: an overview. Clin Infect Dis 1992;15:77-83. 3. Breiman RF, Butler JC, Tenover FC, Elliott JA, Facklam RR. Emergence of drug resistant pneumococcal infections in the United States. JAMA 1994;271:1831-5. 4. CDC. Drug-resistant Streptococcus pneumoniae--Kentucky and Tennessee, 1993. MMWR 1994; 43:23-5,31. 5. Dixon JMS. Pneumococcus with increased resistance to penicillin. Lancet 1974;2:474. 6. Dixon JMS, Lipinski AE, Graham MEP. Detection and prevalence of pneumococci with increased resistance to penicillin. Can Med Assoc J 1977;117:1159-61. 7. Jette LP, Lamothe F, and the Pneumococcus Study Group. Surveillance of invasive Streptococcus pneumoniae infection in Quebec, Canada, from 1984 to 1986: serotype distribution, antimicrobial susceptibility, and clinical characteristics. J Clin Microbiol 1989;27:1-5. 8. Mazzulli T, Simor AE, Jaeger R, Fuller S, Low DE. Comparative in vitro activities of several new fluoroquinolones and beta-lactam antimicrobial agents against community isolates of Streptococcus pneumoniae. Antimicrob Agents Chemother 1990;34:467-9. 9. National Committee for Clinical Laboratory Standards. Performance standards for antimicrobial susceptibility testing [Fifth informational supplement]. Villanova, Pennsylvania: National Committee for Clinical Laboratory Standards, 1994; NCCLS document no. M100-S5. 10. Jorgensen JH, Swenson JM, Tenover FC, Ferraro MJ, Hindler JA, Murray PR. Development of interpretive criteria and quality control limits for broth microdilution and disk diffusion antimicrobial susceptibility testing of Streptococcus pneumoniae. J Clin Microbiol 1994;32:2448-59. ------------------------------ To: hicnews Update: Vibrio cholerae O1 -- Western Hemisphere, 1991-1994, and V. cholerae O139 -- Asia, 1994 The cholera epidemic caused by Vibrio cholerae O1 that began in January 1991 has continued to spread in Central and South America (Figure 1). In southern Asia, the epidemic caused by the newly recognized strain V. cholerae O139 that began in late 1992 also has continued to spread (Figure 2). This report updates surveillance findings for both epidemics. From the onset of the V. cholerae O1 epidemic in January 1991 through September 1, 1994, a total of 1,041,422 cases and 9642 deaths (overall case-fatality rate: 0.9%) were reported from countries in the Western Hemisphere to the Pan American Health Organization. In 1993, the numbers of reported cases and deaths were 204,543 and 2362, respectively (Table 1). From January 1 through September 1, 1994, a total of 92,845 cases and 882 deaths were reported. In 1993 and 1994, the number of reported cases decreased in some countries but continued to increase in several areas of Central America, Brazil, and Argentina (1-3). The epidemic of cholera caused by V. cholerae O139 has affected at least 11 countries in southern Asia. V. cholerae O139 produces severe watery diarrhea and dehydration that is indistinguishable from the illness caused by V. cholerae O1 (4) and appears to be closely related to V. cholerae O1 biotype El Tor strains (5). Specific totals for numbers of V. cholerae O139 cases are unknown because affected countries do not report infections caused by O1 and O139 separately; however, greater than 100,000 cases of cholera caused by V. cholerae O139 may have occurred (6). In the United States during 1993 and 1994, 22 and 47 cholera cases were reported to CDC, respectively. Of these, 65 (94%) were associated with foreign travel. Three of these were culture-confirmed cases of V. cholerae O139 infection in travelers to Asia. Reported by: Cholera Task Force, Diarrheal Disease Control Program, World Health Organization, Geneva. Expanded Program for the Control of Diarrheal Diseases, Special Program on Maternal and Child Health and Population, Pan American Health Organization, Washington, DC. Foodborne and Diarrheal Diseases Br, Div of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, CDC. Editorial Note: Cholera is transmitted through ingestion of fecally contaminated food and beverages. Because cholera remains epidemic in many parts of Central and South America, Asia, and Africa, health-care providers should be aware of the risk for cholera in persons traveling in cholera-affected countries--particularly those persons who are visiting relatives or departing from the usual tourist routes because they may be more likely to consume unsafe foods and beverages. Persons traveling in cholera-affected areas should not eat food that has not been cooked and is not hot (particularly fish and shellfish) and should drink only beverages that are carbonated or made from boiled or chlorinated water. The licensed parenteral cholera vaccine provides only limited and brief protection against V. cholerae O1, may not provide any protection against V. cholerae O139, and has a high cost-benefit ratio (7); therefore, the vaccine is not recommended for travelers (8). New oral cholera vaccines are being developed and provide more reliable protection, although still at a high cost per case averted. None of these vaccines have attained the combination of high efficacy, long duration of protection, simplicity of administration, and low cost necessary to make mass vaccination feasible in cholera-affected countries. The diagnosis of cholera should be considered in patients with watery diarrhea who have recently (i.e., within 7 days) returned from cholera-affected countries (9). Patients with suspected cholera should be reported immediately to local and state health departments. Treatment of cholera includes rapid fluid and electrolyte replacement with adjunctive antibiotic therapy. Stool specimens should be cultured on thiosulfate-citrate-bile salts-sucrose (TCBS) agar. Clinical isolates of non-O1 V. cholerae should be referred to a state public health laboratory for testing for O139 if the patient traveled in an O139-affected area, has life-threatening dehydration typical of severe cholera, or has been linked to an outbreak of diarrhea. References 1. CDC. Update: cholera--Western hemisphere, 1992. MMWR 1993;42:89-91. 2. Wilson M, Chelala C. Cholera is walking south. JAMA 1994;272:1226-7. 3. Tauxe R, Seminario L, Tapia R, Libel M. The Latin American epidemic. In: Wachsmuth I, Blake P, Olsvik O, eds. Vibrio cholerae and cholera: molecular to global perspectives. Washington, DC: ASM Press, 1994:321-44. 4. CDC. Imported cholera associated with a newly described toxigenic Vibrio cholerae O139 strain--California, 1993. MMWR 1993;42:501-3. 5. Popovic T, Fields P, Olsvik O, et al. Molecular subtyping of toxigenic Vibrio cholerae O139 causing epidemic cholera in India and Bangladesh, 1992-1993. J Infect Dis 1995;171:122-7. 6. Cholera Working Group, International Center for Diarrheal Diseases Research, Bangladesh. Large epidemic of cholera-like disease in Bangladesh caused by Vibrio cholerae O139 synonym Bengal. Lancet 1993;342:387-90. 7. MacPherson D, Tonkin M. Cholera vaccination: a decision analysis. Can Med Assoc J 1992; 146:1947-52. 8. CDC. Cholera vaccine. MMWR 1988;37:617-8,623-4. 9. Besser RE, Feikin DR, Eberhart-Phillips JE, Mascola L, Griffin PM. Diagnosis and treatment of cholera in the United States: are we prepared? JAMA 1994;272:1203-5. ------------------------------ To: hicnews Health Health Insurance Coverage and Receipt of Preventive Health Services -- United States, 1993 In 1992, an estimated 38.5 million U.S. residents aged less than 65 years did not have health insurance (1). Efforts by states to expand health-care coverage will require surveillance for and state-specific information about coverage for acute care and the receipt of preventive services. This report summarizes state-specific and aggregated data from the 1993 Behavioral Risk Factor Surveillance System (BRFSS) regarding the status of health insurance coverage and the receipt of preventive health services among adults aged 18-64 years. In addition, findings from the analysis of supplemental questions added to the BRFSS in Minnesota are included that address health-care utilization, source of health-care coverage, and coverage of children. In 1993, the District of Columbia and all states except Wyoming participated in the BRFSS, a population-based, random-digit-dialed telephone survey of adults aged greater than or equal to 18 years (2). All persons responding to the BRFSS questionnaire were asked whether they had health-care coverage*, which of selected preventive health services they had received, if they had a usual place of medical care, and how they perceived their health status. This analysis specifically examined preventive health services targeted by the national health objectives for the year 2000 (i.e., cholesterol screening, breast and cervical cancer screening, and colorectal cancer screening) (3). The use of these services, the perception of health status, and absence of a usual place of medical care were compared between persons who were insured and uninsured by calculating crude prevalence ratios and adjusted odds ratios (i.e., adjusted for age, race, education level, employment status, and income level). For this analysis, sample estimates were statistically weighted to reflect the noninstitutionalized civilian population in each state, and standard errors were calculated using SESUDAAN. Health Insurance Coverage for Persons Aged 18-64 Years Of the 102,263 persons who participated in the 1993 BRFSS, 81,794 persons aged 18-64 years responded to the question about health-care coverage. Of these respondents, 16% reported they were uninsured at the time of interview (Table 1). The percentages of persons who reported being uninsured ranged from 7% in Hawaii to 26% in Louisiana (Table 1). The prevalence of being uninsured was higher among persons in states in the West (20%; 95% confidence interval [CI]=19%-21%) and South (19%; 95% CI=18%-19%) than in the Northeast (14%; 95% CI=13%-15%) or Midwest (12%; 95% CI=11%-13%).** The prevalence of being uninsured was highest among men (18%), persons aged 18-24 years (27%), those with less than a high school education (35%), those with an annual household income less than $10,000 (39%), blacks (21%), Hispanics (34%), and persons who were unemployed (44%) (Table 2). Compared with women who were insured, women who were uninsured were twofold more likely to report having no usual place of medical care (10% versus 18%), at least 50% less likely to have had both a mammogram and a clinical breast examination during the previous 2 years (69% versus 35%), and less likely to report having had a digital rectal examination during the previous 2 years (51% versus 29%) or ever having had a proctoscopy examination (32% versus 22%) (Table 3). The prevalences of self- perceived health status were similar among women who were insured and uninsured. When compared with men who were insured, uninsured men were two times more likely to report having no usual place of medical care (18% versus 41%) and half as likely to report having had their cholesterol checked (65% versus 36%) or having had a digital rectal (51% versus 27%) or a proctoscopy examination (38% versus 20%). The prevalences of self- perceived health status were similar among men who were insured and uninsured. Minnesota-Specific Data for Persons Aged 18-64 Years The Minnesota Department of Health asked all respondents 12 supplemental questions about health insurance coverage. Among the 2494 persons who were insured, 1852 (75%; 95% CI=73%-77%) reported their employer was their primary source of coverage for health insurance. Overall, 9% (95% CI=8%-10%) of employed persons were uninsured and 20% (95% CI=15%-25%) of those employed in service occupational groups were uninsured. In addition, 44% (95% CI=37%-50%) of uninsured persons and 21% (95% CI=19%-23%) of insured persons reported no visits to a physician during the previous year. Of the 253 persons who were uninsured, 178 (69%; 95% CI=63%-75%) reported the primary reason they lacked health insurance was cost. In addition, of the 102 uninsured persons with children, 53 (53%; 95% CI=35%- 55%) reported that their children did not have health-care coverage. Reported by: N Salem, PhD, Minnesota Dept of Health. BRFSS coordinators S Jackson, MPA, Alabama; P Owen, Alaska; B Bender, Arizona; J Senner, PhD, Arkansas; B Davis, PhD, California; M Leff, MSPH, Colorado; M Adams, MPA, Connecticut; F Breukelman, Delaware; C Mitchell, District of Columbia; D McTague, MS, Florida; E Pledger, MPA, Georgia; F Newfield, MPA, Hawaii; C Johnson, MPH, Idaho; B Steiner, MS, Illinois; R Guest, MPA, Indiana; P Busick, Iowa; M Perry, Kansas; K Bramblett, Kentucky; D Hargrove- Roberson, MSW, Louisiana; D Maines, Maine; A Weinstein, MA, Maryland; R Lederman, MPH, Massachusetts; H McGee, MPH, Michigan; E Jones, MS, Mississippi; J Jackson-Thompson, PhD, Missouri; P Smith, Montana; S Huffman, Nebraska; E DeJan, Nevada; K Zaso, MPH, New Hampshire; G Boeselager, MS, New Jersey; P Jaramillo, MPA, New Mexico; C Maylahn, MPH, New York; G Lengerich, VMD, North Carolina; D Young, MS, North Dakota; E Capwell, PhD, Ohio; N Hann, MPH, Oklahoma; J Grant-Worley, Oregon; J Romano, MPH, Pennsylvania; J Hesser, PhD, Rhode Island; M Lane, MPH, South Carolina; B Miller, South Dakota; D Ridings, Tennessee; R Diamond, MPH, Texas; R Giles, Utah; R McIntyre, PhD, Vermont; S Carswell, MA, Virginia; K Holm, MPH, Washington; F King, West Virginia; E Cautley, MS, Wisconsin. Behavioral Risk Factor Surveillance Br, Office of Surveillance and Analysis, National Center for Chronic Disease Prevention and Health Promotion, CDC. Editorial Note: This report documents substantial variation in the state-specific prevalences of persons who report being uninsured. In addition, persons who were uninsured were less likely to have recently received preventive health services or have a regular place of medical care. The 1993 BRFSS findings are consistent with results from previous national studies indicating that uninsured persons are less likely to receive preventive health services (4). Lack of health-care coverage also úÿ úÿ(Continued from last message) has been associated with delayed medical care and use of fewer medical services (5,6). The findings in this report indicate that uninsured persons are more likely to be younger, less educated, of races other than white, unemployed, and of low income. These persons are less likely to engage in preventive practices that can be effectively encouraged in the primary health-care setting. Because lack of insurance is associated with limited access to important preventive health-care services, improvements in health insurance coverage through health-care reform at the state level may improve access to preventive health services. The state-added questions from Minnesota are assisting in identifying uninsured groups and estimating the percentage of children who are uninsured. These findings are critical for targeting specific populations that are uninsured and developing health-care reform and managed-care strategies. The findings in this report are subject to at least three limitations. First, because the BRFSS includes only households with a telephone, these findings probably underestimate the prevalence of being uninsured among persons not residing in households with telephones (e.g., persons living below the poverty level, less educated persons, and unemployed persons). Second, nonrespondents or refusals in households with a telephone may be younger and less educated persons who are more likely to be uninsured. Third, because estimates are based on self-reported data, responses cannot be validated and are subject to recall bias. The BRFSS can be used to provide routinely available, timely, state-specific data on health insurance coverage and receipt of preventive health services that may be used to monitor the progress of health-care reform efforts in each state. This information may assist state planners in evaluating progress toward the national health objectives for the year 2000 related to chronic diseases and disabling conditions. In addition, the BRFSS enables states to add specific questions, such as those included in Minnesota, to expand health-related information for use in planning and evaluating state-based strategies for all groups. References 1. Snider S, Boyce S. Sources of health insurance and characteristics of the uninsured: analysis of the March 1993 Current Population Survey. Washington, DC: Employee Benefit Research Institute, January 1994. (EBRI special report no. SR-20; issue brief no. 145). 2. Frazier EL, Franks AL, Sanderson LM. Behavioral risk factor data. In: CDC. Using chronic disease data: a handbook for public health practitioners. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1992:4-1-4-17. 3. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives--full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212. 4. Makuc DM, Freid VM, Parsons PE. Health insurance and cancer screening among women. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, NCHS, 1994. (Advance data no. 254). 5. Woolhandler S, Himmelstein DU. Reverse targeting of preventive care due to lack of health insurance. JAMA 1988;259:2872-4. 6. Weissmann JS, Stern R, Fielding SL, Epstein AM. Delayed access to health care: risk factors, reasons, and consequences. Ann Intern Med 1991;114:325- 31. * All respondents were asked, "Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs (health maintenance organizations), or government plans such as Medicare?" Persons who reported having no health-care coverage at the time of the interview were considered to be uninsured. ** West=Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, and Washington; South=Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia; Northeast=Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont; and Midwest=Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin. ------------------------------ To: hicnews Evaluation of Congenital Syphilis Surveillance System -- New Jersey, 1993 To monitor disease burden and trends associated with congenital syphilis (CS), effective prevention programs require a surveillance system that identifies CS cases in an accurate and timely manner. Before 1988, comprehensive CS surveillance was difficult for health departments to conduct because documentation of infection in infants required complex and costly long-term follow-up for up to 1 year after delivery; follow-up often was incomplete, and many infected infants were not identified. To estimate the public health burden of CS more accurately and eliminate long-term follow-up of infants by health department personnel, in 1988 CDC implemented a new CS case definition (1). Rather than relying on documentation of infection in the infant, the new case definition presumes that an infant is infected if it cannot be proven that an infected mother was adequately treated for syphilis before or during pregnancy (2). During 1993-1994, the Sexually Transmitted Disease Prevention and Control Program of the New Jersey Department of Health (NJDOH) evaluated its CS surveillance system to assess the accuracy and completeness of reporting using the new case definition and to determine the personnel costs associated with identifying and classifying CS cases. This report summarizes the results of the evaluation. New Jersey statutes mandate that all pregnant women receive a serologic test for syphilis (STS) during pregnancy or at delivery if no test was done during pregnancy. Newborns also routinely receive a STS at birth if born to a mother with a reactive STS. Laboratories are required to report all reactive STSs (including maternal, delivery, and newborn) to the NJDOH, and all such reports are investigated by NJDOH. Investigation activities include reviewing infant and maternal medical records to determine whether syphilis was previously diagnosed, reviewing laboratory results and health department records to determine the mother's treatment status, and verifying missing information by contacting the patient and/or provider by telephone or field visit. For this analysis, reports of all reactive STSs for newborns received by NJDOH during January 1-December 31, 1993, were reviewed manually to assess the completeness and accuracy of case classification and reporting. Infants with reactive STSs had been classified using the four categories recommended by CDC: 1) not infected, 2) syphilitic stillbirth, 3) confirmed case of CS, and 4) presumptive case of CS (1,2). Costs associated with investigation and follow-up of reactive STSs for newborns were estimated by multiplying the average time spent at each task by the hourly wage (excluding benefits) of the person performing the task. Time spent on an investigation was determined by interviewing the persons who performed the tasks. During 1993, a total of 497 reactive STSs for newborns were reported to NJDOH. Of these reports, 266 (53%) had been classified as not infected, but reactive secondary to passive transfer of maternal syphilis antibodies from a mother adequately treated for syphilis before or during pregnancy, and 143 (29%) as presumptive cases. In addition, a total of 10 (2%) reports initially classified as not infected were reclassified as presumptive cases, and 78 (16%) reports were still under investigation. For 1993, the estimated average cost of investigating one reactive STS for a newborn using routine surveillance methods was $183. Based on an average of 41 reactive STSs for newborns reported to NJDOH each month in 1993, the estimated costs for investigation and follow-up were $7500 per month or $90,000 per year. Reported by: L Finelli, E Napolitano, J Carolina, STD Prevention and Control Program; K Spitalny, MD, State Epidemiologist, New Jersey State Dept of Health. Surveillance and Information Systems Br, Div of Sexually Transmitted Diseases and HIV Prevention, National Center for Prevention Svcs; Div of Field Epidemiology, Epidemiology Program Office, CDC. Editorial Note: CS is a serious and totally preventable disease that results from in utero infection of the fetus with Treponema pallidum, a thin, motile spirochete. Complications of CS include intrauterine growth retardation, bone abnormalities, and failure to thrive. Up to 40% of pregnancies in women with untreated syphilis result in fetal or perinatal death (3,4). CS can be prevented by screening and treating women for syphilis before or during early pregnancy (1,5). CDC recommends screening women at high risk for syphilis during the first and third trimesters of pregnancy (1). Screening for syphilis at delivery primarily ensures that infants born to women in whom syphilis previously was either unidentified or untreated are identified and treated. The new CS case definition was implemented to provide a more accurate measure of the impact of CS by eliminating long-term follow-up of STSs and by including asymptomatic infants at risk for CS (i.e., who require treatment but who were not counted by the previous case definition). However, the existing reporting infrastructure in many health departments may need to be changed to allow full benefit from the new case definition (6). Despite use of the new case definition for CS, the findings in the NJDOH study indicate that the number of CS cases in New Jersey may still be underestimated because of inaccuracy and incompleteness of CS surveillance data. In this report, the presumptive cases incorrectly classified as not infected and the incomplete case reports accounted for nearly 20% of all reported STSs for newborns during 1993. Reasons for misclassification of cases and incomplete reporting may reflect a lack of understanding by health department staff of the epidemiology of CS, the new CS surveillance case definition, and CS reporting instructions (2). In response to the findings of this study, NJDOH initiated an intervention trial in March 1994 to improve the timeliness, accuracy, and completeness of CS surveillance data. As part of the intervention, NJDOH collaborated with three local hospitals that provided delivery services to women at high risk for syphilis. These hospitals established a policy to notify NJDOH within 24 hours of admission of each pregnant woman with a positive STS who was admitted for delivery. On notification and before the patient was discharged from the hospital, NJDOH performed medical record reviews and patient/provider interviews. Using these procedures, the time required for health department staff to complete investigations was reduced from an average of 10 hours to 3 hours per investigation. If this policy were expanded to most hospitals that deliver high-risk infants, NJDOH personnel costs associated with CS case investigations could be reduced substantially, and accuracy and timeliness of reporting could be improved. References 1. CDC. Guidelines for the prevention and control of congenital syphilis. MMWR 1988; 37(suppl no. S-1). 2. CDC. Congenital syphilis case investigation and reporting instructions. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1992. 3. CDC. Congenital syphilis--New York City, 1986-1988. MMWR 1989;38:825- 9. 4. Schultz KF, Cates W, O'Mara PR. Pregnancy loss, infant death, and suffering: the legacy of syphilis and gonorrhea in Africa. Genitourin Med 1987;63:320-5. 5. Petrone ME, Teter MJ, Freund CG, Porter J, Parkin WE, Spitalny KC. Epidemiology of congenital syphilis. N J Med 1989;86:965-9. 6. Zenker PN, Berman SB. Congenital syphilis: reporting and reality [Editorial]. Am J Public Health 1990;80:271-2. Health Insurance Coverage and Receipt of Preventive Health Services -- United States, 1993 In 1992, an estimated 38.5 million U.S. residents aged less than 65 years did not have health insurance (1). Efforts by states to expand health-care coverage will require surveillance for and state-specific information about coverage for acute care and the receipt of preventive services. This report summarizes state-specific and aggregated data from the 1993 Behavioral Risk Factor Surveillance System (BRFSS) regarding the status of health insurance coverage and the receipt of preventive health services among adults aged 18-64 years. In addition, findings from the analysis of supplemental questions added to the BRFSS in Minnesota are included that address health-care utilization, source of health-care coverage, and coverage of children. In 1993, the District of Columbia and all states except Wyoming participated in the BRFSS, a population-based, random-digit-dialed telephone survey of adults aged greater than or equal to 18 years (2). All persons responding to the BRFSS questionnaire were asked whether they had health-care coverage*, which of selected preventive health services they had received, if they had a usual place of medical care, and how they perceived their health status. This analysis specifically examined preventive health services targeted by the national health objectives for the year 2000 (i.e., cholesterol screening, breast and cervical cancer screening, and colorectal cancer screening) (3). The use of these services, the perception of health status, and absence of a usual place of medical care were compared between persons who were insured and uninsured by calculating crude prevalence ratios and adjusted odds ratios (i.e., adjusted for age, race, education level, employment status, and income level). For this analysis, sample estimates were statistically weighted to reflect the noninstitutionalized civilian population in each state, and standard errors were calculated using SESUDAAN. Health Insurance Coverage for Persons Aged 18-64 Years Of the 102,263 persons who participated in the 1993 BRFSS, 81,794 persons aged 18-64 years responded to the question about health-care coverage. Of these respondents, 16% reported they were uninsured at the time of interview (Table 1). The percentages of persons who reported being uninsured ranged from 7% in Hawaii to 26% in Louisiana (Table 1). The prevalence of being uninsured was higher among persons in states in the West (20%; 95% confidence interval [CI]=19%-21%) and South (19%; 95% CI=18%-19%) than in the Northeast (14%; 95% CI=13%-15%) or Midwest (12%; 95% CI=11%-13%).** The prevalence of being uninsured was highest among men (18%), persons aged 18-24 years (27%), those with less than a high school education (35%), those with an annual household income less than $10,000 (39%), blacks (21%), Hispanics (34%), and persons who were unemployed (44%) (Table 2). Compared with women who were insured, women who were uninsured were twofold more likely to report having no usual place of medical care (10% versus 18%), at least 50% less likely to have had both a mammogram and a clinical breast examination during the previous 2 years (69% versus 35%), and less likely to report having had a digital rectal examination during the previous 2 years (51% versus 29%) or ever having had a proctoscopy examination (32% versus 22%) (Table 3). The prevalences of self- perceived health status were similar among women who were insured and uninsured. When compared with men who were insured, uninsured men were two times more likely to report having no usual place of medical care (18% versus 41%) and half as likely to report having had their cholesterol checked (65% versus 36%) or having had a digital rectal (51% versus 27%) or a proctoscopy examination (38% versus 20%). The prevalences of self- perceived health status were similar among men who were insured and uninsured. Minnesota-Specific Data for Persons Aged 18-64 Years The Minnesota Department of Health asked all respondents 12 supplemental questions about health insurance coverage. Among the 2494 persons who were insured, 1852 (75%; 95% CI=73%-77%) reported their employer was their primary source of coverage for health insurance. Overall, 9% (95% CI=8%-10%) of employed persons were uninsured and 20% (95% CI=15%-25%) of those employed in service occupational groups were uninsured. In addition, 44% (95% CI=37%-50%) of uninsured persons and 21% (95% CI=19%-23%) of insured persons reported no visits to a physician during the previous year. Of the 253 persons who were uninsured, 178 (69%; 95% CI=63%-75%) reported the primary reason they lacked health insurance was cost. In addition, of the 102 uninsured persons with children, 53 (53%; 95% CI=35%- 55%) reported that their children did not have health-care coverage. Reported by: N Salem, PhD, Minnesota Dept of Health. BRFSS coordinators S Jackson, MPA, Alabama; P Owen, Alaska; B Bender, Arizona; J Senner, PhD, Arkansas; B Davis, PhD, California; M Leff, MSPH, Colorado; M Adams, MPA, Connecticut; F Breukelman, Delaware; C Mitchell, District of Columbia; D McTague, MS, Florida; E Pledger, MPA, Georgia; F Newfield, MPA, Hawaii; C Johnson, MPH, Idaho; B Steiner, MS, Illinois; R Guest, MPA, Indiana; P Busick, Iowa; M Perry, Kansas; K Bramblett, Kentucky; D Hargrove- Roberson, MSW, Louisiana; D Maines, Maine; A Weinstein, MA, Maryland; R Lederman, MPH, Massachusetts; H McGee, MPH, Michigan; E Jones, MS, Mississippi; J Jackson-Thompson, PhD, Missouri; P Smith, Montana; S Huffman, Nebraska; E DeJan, Nevada; K Zaso, MPH, New Hampshire; G Boeselager, MS, New Jersey; P Jaramillo, MPA, New Mexico; C Maylahn, MPH, New York; G Lengerich, VMD, North Carolina; D Young, MS, North Dakota; E Capwell, PhD, Ohio; N Hann, MPH, Oklahoma; J Grant-Worley, Oregon; J Romano, MPH, Pennsylvania; J Hesser, PhD, Rhode Island; M Lane, MPH, South Carolina; B Miller, South Dakota; D Ridings, Tennessee; R Diamond, MPH, Texas; R Giles, Utah; R McIntyre, PhD, Vermont; S Carswell, MA, Virginia; K Holm, MPH, Washington; F King, West Virginia; E Cautley, MS, Wisconsin. Behavioral Risk Factor Surveillance Br, Office of Surveillance and Analysis, National Center for Chronic Disease Prevention and Health Promotion, CDC. Editorial Note: This report documents substantial variation in the state-specific prevalences of persons who report being uninsured. In addition, persons who were uninsured were less likely to have recently received preventive health services or have a regular place of medical care. The 1993 BRFSS findings are consistent with results from previous national studies indicating that uninsured persons are less likely to receive preventive health services (4). Lack of health-care coverage also has been associated with delayed medical care and use of fewer medical services (5,6). The findings in this report indicate that uninsured persons are more likely to be younger, less educated, of races other than white, unemployed, and of low income. These persons are less likely to engage in preventive practices that can be effectively encouraged in the primary health-care setting. Because lack of insurance is associated with limited access to important preventive health-care services, improvements in health insurance coverage through health-care reform at the state level may improve access to preventive health services. The state-added questions from Minnesota are assisting in identifying uninsured groups and estimating the percentage of children who are uninsured. These findings are critical for targeting specific populations úÿ úÿ(Continued from last message) that are uninsured and developing health-care reform and managed-care strategies. The findings in this report are subject to at least three limitations. First, because the BRFSS includes only households with a telephone, these findings probably underestimate the prevalence of being uninsured among persons not residing in households with telephones (e.g., persons living below the poverty level, less educated persons, and unemployed persons). Second, nonrespondents or refusals in households with a telephone may be younger and less educated persons who are more likely to be uninsured. Third, because estimates are based on self-reported data, responses cannot be validated and are subject to recall bias. The BRFSS can be used to provide routinely available, timely, state-specific data on health insurance coverage and receipt of preventive health services that may be used to monitor the progress of health-care reform efforts in each state. This information may assist state planners in evaluating progress toward the national health objectives for the year 2000 related to chronic diseases and disabling conditions. In addition, the BRFSS enables states to add specific questions, such as those included in Minnesota, to expand health-related information for use in planning and evaluating state-based strategies for all groups. References 1. Snider S, Boyce S. Sources of health insurance and characteristics of the uninsured: analysis of the March 1993 Current Population Survey. Washington, DC: Employee Benefit Research Institute, January 1994. (EBRI special report no. SR-20; issue brief no. 145). 2. Frazier EL, Franks AL, Sanderson LM. Behavioral risk factor data. In: CDC. Using chronic disease data: a handbook for public health practitioners. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1992:4-1-4-17. 3. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives--full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212. 4. Makuc DM, Freid VM, Parsons PE. Health insurance and cancer screening among women. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, NCHS, 1994. (Advance data no. 254). 5. Woolhandler S, Himmelstein DU. Reverse targeting of preventive care due to lack of health insurance. JAMA 1988;259:2872-4. 6. Weissmann JS, Stern R, Fielding SL, Epstein AM. Delayed access to health care: risk factors, reasons, and consequences. Ann Intern Med 1991;114:325- 31. * All respondents were asked, "Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs (health maintenance organizations), or government plans such as Medicare?" Persons who reported having no health-care coverage at the time of the interview were considered to be uninsured. ** West=Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, and Washington; South=Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia; Northeast=Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont; and Midwest=Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin. Health Insurance Coverage and Receipt of Preventive Health Services -- United States, 1993 In 1992, an estimated 38.5 million U.S. residents aged less than 65 years did not have health insurance (1). Efforts by states to expand health-care coverage will require surveillance for and state-specific information about coverage for acute care and the receipt of preventive services. This report summarizes state-specific and aggregated data from the 1993 Behavioral Risk Factor Surveillance System (BRFSS) regarding the status of health insurance coverage and the receipt of preventive health services among adults aged 18-64 years. In addition, findings from the analysis of supplemental questions added to the BRFSS in Minnesota are included that address health-care utilization, source of health-care coverage, and coverage of children. In 1993, the District of Columbia and all states except Wyoming participated in the BRFSS, a population-based, random-digit-dialed telephone survey of adults aged greater than or equal to 18 years (2). All persons responding to the BRFSS questionnaire were asked whether they had health-care coverage*, which of selected preventive health services they had received, if they had a usual place of medical care, and how they perceived their health status. This analysis specifically examined preventive health services targeted by the national health objectives for the year 2000 (i.e., cholesterol screening, breast and cervical cancer screening, and colorectal cancer screening) (3). The use of these services, the perception of health status, and absence of a usual place of medical care were compared between persons who were insured and uninsured by calculating crude prevalence ratios and adjusted odds ratios (i.e., adjusted for age, race, education level, employment status, and income level). For this analysis, sample estimates were statistically weighted to reflect the noninstitutionalized civilian population in each state, and standard errors were calculated using SESUDAAN. Health Insurance Coverage for Persons Aged 18-64 Years Of the 102,263 persons who participated in the 1993 BRFSS, 81,794 persons aged 18-64 years responded to the question about health-care coverage. Of these respondents, 16% reported they were uninsured at the time of interview (Table 1). The percentages of persons who reported being uninsured ranged from 7% in Hawaii to 26% in Louisiana (Table 1). The prevalence of being uninsured was higher among persons in states in the West (20%; 95% confidence interval [CI]=19%-21%) and South (19%; 95% CI=18%-19%) than in the Northeast (14%; 95% CI=13%-15%) or Midwest (12%; 95% CI=11%-13%).** The prevalence of being uninsured was highest among men (18%), persons aged 18-24 years (27%), those with less than a high school education (35%), those with an annual household income less than $10,000 (39%), blacks (21%), Hispanics (34%), and persons who were unemployed (44%) (Table 2). Compared with women who were insured, women who were uninsured were twofold more likely to report having no usual place of medical care (10% versus 18%), at least 50% less likely to have had both a mammogram and a clinical breast examination during the previous 2 years (69% versus 35%), and less likely to report having had a digital rectal examination during the previous 2 years (51% versus 29%) or ever having had a proctoscopy examination (32% versus 22%) (Table 3). The prevalences of self- perceived health status were similar among women who were insured and uninsured. When compared with men who were insured, uninsured men were two times more likely to report having no usual place of medical care (18% versus 41%) and half as likely to report having had their cholesterol checked (65% versus 36%) or having had a digital rectal (51% versus 27%) or a proctoscopy examination (38% versus 20%). The prevalences of self- perceived health status were similar among men who were insured and uninsured. Minnesota-Specific Data for Persons Aged 18-64 Years The Minnesota Department of Health asked all respondents 12 supplemental questions about health insurance coverage. Among the 2494 persons who were insured, 1852 (75%; 95% CI=73%-77%) reported their employer was their primary source of coverage for health insurance. Overall, 9% (95% CI=8%-10%) of employed persons were uninsured and 20% (95% CI=15%-25%) of those employed in service occupational groups were uninsured. In addition, 44% (95% CI=37%-50%) of uninsured persons and 21% (95% CI=19%-23%) of insured persons reported no visits to a physician during the previous year. Of the 253 persons who were uninsured, 178 (69%; 95% CI=63%-75%) reported the primary reason they lacked health insurance was cost. In addition, of the 102 uninsured persons with children, 53 (53%; 95% CI=35%- 55%) reported that their children did not have health-care coverage. Reported by: N Salem, PhD, Minnesota Dept of Health. BRFSS coordinators S Jackson, MPA, Alabama; P Owen, Alaska; B Bender, Arizona; J Senner, PhD, Arkansas; B Davis, PhD, California; M Leff, MSPH, Colorado; M Adams, MPA, Connecticut; F Breukelman, Delaware; C Mitchell, District of Columbia; D McTague, MS, Florida; E Pledger, MPA, Georgia; F Newfield, MPA, Hawaii; C Johnson, MPH, Idaho; B Steiner, MS, Illinois; R Guest, MPA, Indiana; P Busick, Iowa; M Perry, Kansas; K Bramblett, Kentucky; D Hargrove- Roberson, MSW, Louisiana; D Maines, Maine; A Weinstein, MA, Maryland; R Lederman, MPH, Massachusetts; H McGee, MPH, Michigan; E Jones, MS, Mississippi; J Jackson-Thompson, PhD, Missouri; P Smith, Montana; S Huffman, Nebraska; E DeJan, Nevada; K Zaso, MPH, New Hampshire; G Boeselager, MS, New Jersey; P Jaramillo, MPA, New Mexico; C Maylahn, MPH, New York; G Lengerich, VMD, North Carolina; D Young, MS, North Dakota; E Capwell, PhD, Ohio; N Hann, MPH, Oklahoma; J Grant-Worley, Oregon; J Romano, MPH, Pennsylvania; J Hesser, PhD, Rhode Island; M Lane, MPH, South Carolina; B Miller, South Dakota; D Ridings, Tennessee; R Diamond, MPH, Texas; R Giles, Utah; R McIntyre, PhD, Vermont; S Carswell, MA, Virginia; K Holm, MPH, Washington; F King, West Virginia; E Cautley, MS, Wisconsin. Behavioral Risk Factor Surveillance Br, Office of Surveillance and Analysis, National Center for Chronic Disease Prevention and Health Promotion, CDC. Editorial Note: This report documents substantial variation in the state-specific prevalences of persons who report being uninsured. In addition, persons who were uninsured were less likely to have recently received preventive health services or have a regular place of medical care. The 1993 BRFSS findings are consistent with results from previous national studies indicating that uninsured persons are less likely to receive preventive health services (4). Lack of health-care coverage also has been associated with delayed medical care and use of fewer medical services (5,6). The findings in this report indicate that uninsured persons are more likely to be younger, less educated, of races other than white, unemployed, and of low income. These persons are less likely to engage in preventive practices that can be effectively encouraged in the primary health-care setting. Because lack of insurance is associated with limited access to important preventive health-care services, improvements in health insurance coverage through health-care reform at the state level may improve access to preventive health services. The state-added questions from Minnesota are assisting in identifying uninsured groups and estimating the percentage of children who are uninsured. These findings are critical for targeting specific populations that are uninsured and developing health-care reform and managed-care strategies. The findings in this report are subject to at least three limitations. First, because the BRFSS includes only households with a telephone, these findings probably underestimate the prevalence of being uninsured among persons not residing in households with telephones (e.g., persons living below the poverty level, less educated persons, and unemployed persons). Second, nonrespondents or refusals in households with a telephone may be younger and less educated persons who are more likely to be uninsured. Third, because estimates are based on self-reported data, responses cannot be validated and are subject to recall bias. The BRFSS can be used to provide routinely available, timely, state-specific data on health insurance coverage and receipt of preventive health services that may be used to monitor the progress of health-care reform efforts in each state. This information may assist state planners in evaluating progress toward the national health objectives for the year 2000 related to chronic diseases and disabling conditions. In addition, the BRFSS enables states to add specific questions, such as those included in Minnesota, to expand health-related information for use in planning and evaluating state-based strategies for all groups. References 1. Snider S, Boyce S. Sources of health insurance and characteristics of the uninsured: analysis of the March 1993 Current Population Survey. Washington, DC: Employee Benefit Research Institute, January 1994. (EBRI special report no. SR-20; issue brief no. 145). 2. Frazier EL, Franks AL, Sanderson LM. Behavioral risk factor data. In: CDC. Using chronic disease data: a handbook for public health practitioners. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1992:4-1-4-17. 3. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives--full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212. 4. Makuc DM, Freid VM, Parsons PE. Health insurance and cancer screening among women. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, NCHS, 1994. (Advance data no. 254). 5. Woolhandler S, Himmelstein DU. Reverse targeting of preventive care due to lack of health insurance. JAMA 1988;259:2872-4. 6. Weissmann JS, Stern R, Fielding SL, Epstein AM. Delayed access to health care: risk factors, reasons, and consequences. Ann Intern Med 1991;114:325- 31. * All respondents were asked, "Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs (health maintenance organizations), or government plans such as Medicare?" Persons who reported having no health-care coverage at the time of the interview were considered to be uninsured. ** West=Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, and Washington; South=Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia; Northeast=Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont; and Midwest=Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin. ------------------------------ End of HICNet Medical News Digest V08 Issue #10 *********************************************** --- Editor, HICNet Medical Newsletter Internet: david@stat.com FAX: +1 (602) 451-1165 Bitnet : ATW1H@ASUACAD