HICNet Medical News Digest Tue, 11 Apr 1995 Volume 08 : 
Issue 15
 
Today's Topics:
 
 Interleukin-2 Produces CD4+ T Cells In HIV-Infected People
 [MMWR 01-13-95] Injuries Associated with Use of Snowmobiles
 [MMWR] Physician Vaccination Referral Practices for Children
 [MMWR] Differences Maternal Mortality Among Black & White Women
 [MMWR] Mortality from TB Associated with Occupations
 
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To: hicnews
 
P R E S S R E L E A S E
***************************
National Institutes of Health
National Institute of Allergy and Infectious Diseases
March 2, 1995
 
 
 Interleukin-2 Produces Significant, Sustained Increases in
 CD4+ T Cells in HIV-Infected People
 
 In a small number of HIV-infected patients, infusions of an
immune system protein significantly increased levels of the infection-
fighting white blood cells normally destroyed during HIV infection,
according to researchers at the National Institute of Allergy and
Infectious Diseases (NIAID).
 
 As reported in the March 2, 1995 The New England Journal of
Medicine, NIAID Clinical Director H. Clifford Lane, M.D., Joseph A.
Kovacs, M.D., of the NIH Clinical Center's Critical Care Medicine
Department, and their colleagues found that interleukin-2 (IL-2)
boosted levels of CD4+ T cells in some patients for more than two
years, a far longer time than typically seen with currently available
anti-HIV drugs.
 
 "This study provides the strongest evidence so far that it may be
possible to rebuild and maintain the damaged immune systems of HIV-
infected individuals," says Dr. Lane. "Ongoing studies of
intermittent infusions of IL-2 will determine whether the increases in
CD4+ T cell counts seen in this trial will translate into clinical
benefits."
 
 In the NIAID study, patients received IL-2 intravenously for five
consecutive days every two months. All participants took at least one
approved antiretroviral drug such as zidovudine (AZT) or didanosine
(ddI) during the study. CD4+ T cell measurements were made one and
two months after each course of IL-2.
 
 In six of 10 patients who started the study with CD4+ T cell
counts higher than 200 per cubic millimeter (mm3) of blood, CD4+ T cell
counts rose by more than 50 percent after 12 months. The remaining
four had stable CD4+ T cell counts or showed a slight decline.
 
 Of the 15 patients who started the study with CD4+ T cell counts
below 200/mm3, only two showed a 50 percent increase in their CD4+ T
cell count. In the remaining 13, no significant increases in CD4+ T
cell counts were observed, and side effects were considerably more
severe than in the patients with baseline CD4+ T cell counts above
200/mm3.
 
 In several patients, the rise in CD4+ T cells was dramatic -- for
example, one individual's CD4+ T cell count rose from 554 to 1,998
cells/mm3 after 12 months on IL-2. A healthy person usually has 800 to
1,200 CD4+ T cells/mm3.
 
 "Although current anti-HIV drugs have transient benefits,
especially for individuals in late-stage disease, they do not prevent
the immunologic deterioration associated with HIV disease," says Dr.
Lane. "It is increasingly evident that preservation and restoration
of the immune systems of HIV-infected people are necessary if they are
to live for long periods of time. This study shows that IL-2 may help
accomplish this. We believe the principles established here for
augmentation of the T helper cell limb of the immune system might also
benefit patients with other diseases characterized by decreased T cell
function."
 
 Side effects were common in the study, including rash, fever,
lowering of blood pressure, flu-like symptoms, diarrhea and laboratory
abnormalities such as reduced calcium, albumin and magnesium in the
blood.
 
 "While receiving infusions of IL-2, patients are extremely
uncomfortable, often with symptoms worse than a very bad bout with the
flu. Fortunately, none of the side effects we have observed thus far
in these studies appear to be life-threatening," says Dr. Lane. "As
with any treatment, the potential clinical benefits of IL-2 therapy
ultimately will need to be weighed carefully against its potential
side effects."
 
 IL-2, originally called T cell-growth factor, is produced in the
body by T cells and has potent effects on the proliferation and
differentiation of a number of immune cells, including T cells, B
cells and natural killer cells. Commercially, IL-2 is produced by
recombinant DNA technology and is licensed for the treatment of
metastatic renal cell cancer. The recombinant IL-2 used in the NIAID
study was produced by Chiron Corporation of Emeryville, Calif.
 
Background
 The current study builds on more than a decade of NIAID research
into the role of IL-2 in the immune system and its possible use as an
HIV therapy. In 1982, before the identification of HIV as the cause
of AIDS, Dr. Lane and collaborators from the U.S. Food and Drug
Administration demonstrated that IL-2 could enhance the activity of
immune system cells taken from AIDS patients. In 1983, the first AIDS
patients were infused with IL-2, during the same period when cancer
patients were first treated with the substance. Over the next 12
years, Dr. Lane and his group refined their approach to IL-2 therapy
for HIV infection through an ongoing series of laboratory experiments
and small clinical trials.
 
 "The development of this treatment regimen, which involves
alternately stimulating the immune system with IL-2 and then letting
it rest, is the culmination of 13 years of laboratory studies and
clinical research," says Anthony S. Fauci, M.D., NIAID director.
"This work is a model of NIAID's 'bench-to bedside' philosophy of
research: doing laboratory and preclinical studies, learning from
preliminary clinical studies, going back to the laboratory bench for
further refinement, and then treating patients with the improved
regimen. In this instance, the re-circulation of information from the
laboratory bench to the patient's bedside, over a period of 13 years,
has led to unprecedented results."
 
Study Results
 Twenty-five patients were enrolled in the NIAID study. Of these,
eight HIV-infected men and two HIV-infected women, ranging in age from
29 to 45, had CD4+ T cell counts greater than 200/mm3. These 10
patients received a total of four to 13 courses of IL-2 at the NIH
Clinical Center, and were followed for periods of 22 to 40 months.
The NIAID researchers found that after one year of therapy, CD4+ T
cell counts increased by at least 50 percent in six of these 10
patients. The remaining four patients had no significant increases or
showed a slight decline in CD4+ T cell counts.
 
 In seven of the 10 patients, the proportion of cells that carried
HLA-DR, a marker of aberrant T cell activation, on their surfaces
decreased by at least 25 percent. Increased expression of HLA-DR on
immune cells called CD8+ T cells has been associated with more rapid
disease progression in HIV-infected individuals.
 
 In nine of the 10 patients, the percentage of cells expressing
the high-affinity receptor for IL-2 progressively increased. Cells
with the high-affinity receptor on their surfaces appear to be more
sensitive to IL-2.
 
 One concern of the investigators was that IL-2 would increase the
amount of virus in the body by activating HIV-infected T cells and
thereby boosting viral replication. Although the scientists found no
consistent changes in the amount of virus in the patients' blood using
measurements of an HIV protein called p24, a more sensitive test
called the branched-DNA (bDNA) assay revealed a transient increase in
HIV RNA in the blood of four of the 10 patients with baseline CD4+ T
cell counts greater than 200/mm3 following each infusion of IL-2.
 
 "Although no obvious detrimental effects were associated with the
transient bursts of viral replication seen in these four patients
following IL-2 infusion, it seems prudent to use the best possible
regimen of antiretroviral drugs, perhaps two or more drugs in
combination, as an adjunct to IL-2 therapy," says Dr. Kovacs, a senior
investigator in the Critical Care Medicine Department of NIH's
Clinical Center.
 
 Among the four patients with the most dramatic increases in CD4+
T cell counts, HIV RNA was undetectable throughout therapy. No other
consistent increase in HIV RNA was noted in the one other patient
tested with the bDNA assay.
 
 During the course of therapy, eight of the 10 patients with
baseline CD4+ T cell counts greater than 200/mm3 required reductions in
the dose of IL-2, primarily because of fever and severe flu-like
symptoms. Two of these patients chose to discontinue IL-2 therapy
after four and nine courses, respectively, but continued to be
followed during regular visits to the NIAID AIDS Clinic.
 
 In addition to the 10 patients described above, the investigators
also enrolled 15 patients with CD4+ T cell counts of 200/mm3 or fewer.
In this group of patients, IL-2 therapy was associated with few
improvements in immunologic responses, increased HIV replication and
substantial toxicity. Of the two patients in this group who showed a
sustained increase in their CD4+ T cell counts, both had baseline CD4+
T cell counts above 150 cells/mm3.
 
 "If IL-2 therapy proves to have a beneficial clinical effect in
patients with HIV, it most likely will be in those individuals whose
immune systems are not severely debilitated," says Dr. Kovacs.
 
Further Studies
 Dr. Lane and his collaborators at Chiron Corporation are working
with investigators around the United States and worldwide to build on
the current findings.
 
 "We need to find the lowest effective dose of IL-2," says Dr.
Lane. "There is substantial toxicity associated with the treatment as
it is currently administered."
 
 The investigators are currently recruiting patients for a new
series of studies at NIAID. In the first of these, the timing of IL-2
infusions are linked to changes in a patient's CD4+ T cell count.
Another study is examining the safety and potential effectiveness of
subcutaneous, rather than intravenous, IL-2 therapy. A third trial is
assessing whether blockade of tumor necrosis factor (TNF), production
of which is increased by IL-2, will diminish the side effects and/or
burst in viral replication associated with IL-2 infusions.
 
 Co-authors of Drs. Lane and Kovacs include Susan Vogel, Richard
T. Davey, M.D., Judith Falloon, M.D., Michael A. Polis, M.D., Robert
E. Walker, M.D., and Julia A. Metcalfe, all of the NIAID Laboratory of
Immunoregulation; Henry Masur, M.D., of the Critical Care Medicine
Department of the Warren Grant Magnuson Clinical Center; and Michael
Baseler, Ph.D., Robin J. Dewar, Ph.D., Randy Stevens and Norman P.
Salzman, Ph.D., all of Program Resources Inc., Frederick, Md.
 
 NIAID, a component of NIH, supports investigators and scientific
studies at universities, medical schools, hospitals and research
institutions in the United States and abroad aimed at preventing,
diagnosing and treating such illnesses as AIDS, tuberculosis and
asthma as well as allergies. NIH is an agency of the U.S. Public
Health Service, part of the U.S. Department of Health and Human
Services.
 ###
 
HIV-infected individuals and their physicians interested in NIAID
clinical trials involving interleukin-2 can call 1-800-AIDS-NIH.
Information on other HIV clinical trials is available by calling 1-
800-TRIALS-A.
 
 
 
------------------------------
 
To: hicnews
 
 Injuries Associated With Use of Snowmobiles -- New Hampshire, 1989-
1992
 
 Recreational use of snowmobiles is popular in New Hampshire during 
the
winter months; from 1982 to 1992, the annual number of registered
snowmobiles ranged from approximately 21,200 to 42,500. During this 
period,
26 deaths associated with use of snowmobiles in New Hampshire accounted 
for
822 years of potential life lost before age 65 years. To assist in the
development and evaluation of injury-prevention programs for users of
off-highway recreational vehicles (OHRVs) (e.g., all-terrain vehicles,
trail bikes, and snowmobiles), the State of New Hampshire Department of
Fish and Game (DFG) and the New Hampshire Department of Health and Human
Services examined reports of injuries resulting from OHRV use in New
Hampshire from January 1989 through February 1992*. This report 
summarizes
information about snowmobile-associated fatal and nonfatal injuries 
during
this period.
 Since 1981, New Hampshire has required reporting of OHRV incidents
resulting in injury. A standard report form must be completed by a 
person
involved in the event or by a law enforcement agent and filed with DFG
within 5 days of the incident. Information collected on the form 
includes
demographic characteristics of the operator, type of vehicle, 
environmental
conditions, date and time of the incident, whether the operator reported
having taken an OHRV safety course, type of injury, excessive speed, and
use of alcohol and helmets.
 During January 1989-February 1992, DFG received reports of 164
snowmobile incidents resulting in injury. Of the 164 incidents, 155
involved 188 vehicles and resulted in 163 nonfatal injuries, and nine
involved 13 vehicles and resulted in 12 fatalities and two nonfatal
injuries (Table 1). All fatal incidents were reported by law enforcement
agents. Of the 155 reports of nonfatal incidents, 103 (66%) were 
completed
by a law enforcement agent.
 All operators involved in fatal (13) and most involved in nonfatal
(161 [86%]) incidents were male. Seven (54%) operators involved in fatal
incidents and 75 (40%) operators involved in nonfatal incidents were 
aged
20-29 years; no operators involved in fatal incidents and 40 (21%) 
involved
in nonfatal incidents were aged less than 20 years. No operator involved
in a fatal incident and 14 (7%) of those involved in a nonfatal incident
were reported to have taken an OHRV safety course.
 Of nine fatal events and 155 nonfatal events, seven (78%) and 64
(46%), respectively, occurred during darker periods (i.e., 4 p.m.-8 
a.m.,
November-March). No fatal and 25 (16%) nonfatal events occurred during
periods of precipitation or other inclement weather (i.e., fog or active
snow, sleet, or rain). Operating on a frozen body of water was reported 
for
five of nine fatal and 36 (23%) of 155 nonfatal events.
 Overall, 67% of fatal incidents were associated with alcohol use 
and
67% with excessive speed. Of the 103 police-reported nonfatal incidents,
16 (16%) involved alcohol use, and 36 (35%) involved excessive speed; in
comparison, of 52 incidents reported only by persons involved in the
incident, one (2%) and three (6%), respectively, reported use of alcohol
or excessive speed.
 Of eight deaths resulting from incidents occurring on a frozen body
of water, three resulted from hypothermia and five from either head and
neck injuries (three) or multiple trauma (two). Three other deaths were
attributed to head and neck trauma and one to multiple trauma.
 Of 165 persons nonfatally injured, 104 (63%) were reported to have
been wearing helmets. Helmets were reported to have been worn by 31 
(57%)
of 54 persons with nonfatal head injuries, compared with four of six
persons with fatal head injuries.
 
Reported by: A Hewitt, State of New Hampshire Dept of Fish and Game; 
Bureau
of Vital Records and Health Statistics; D Solet, M Kiely, Office of 
Chronic
Disease and Health Data, New Hampshire Dept of Health and Human Svcs. 
Div
of Field Epidemiology, Epidemiology Program Office, CDC.
 
Editorial Note: In New Hampshire, most fatal snowmobile incidents 
involved
male operators in their 20s, use of alcohol, or excessive speed; half of
persons killed sustained head injuries. In addition, fatalities 
occurring
as a result of operating on frozen bodies of water were associated with
either severe trauma or events related to falling through the ice (i.e.,
hypothermia). These findings are consistent with previous studies of
fatalities associated with the use of OHRVs (1,2). For example,
contributing factors for nondrowning deaths following incidents on 
frozen
 
úÿ


úÿ(Continued from last message)
water surfaces have included high speeds attained on such open surfaces 
and
unexpected uneven terrain (e.g., ice ridges) (1). The findings in this
report also indicate that some snowmobile drivers and passengers did not
wear helmets. Although this investigation could not assess the
effectiveness of helmet use, a previous study estimated that helmet use 
can
reduce the risk for death among all-terrain vehicle operators by
approximately 42% and can reduce the likelihood of head injury in a
nonfatal incident by approximately 64% (3).
 The findings in New Hampshire are subject to at least three
limitations. First, rates of injury and death could not be determined
because of the lack of an accurate denominator. Although previous 
studies
have used registered OHRVs as a denominator, this number may vary in
relation to season and other environmental factors (e.g., inclement
weather). Second, because approximately one third of nonfatal injury
reports were completed only by persons involved in the incident, some
information reported may not be valid (e.g., helmet use, speed, and 
alcohol
use). Finally, these findings probably underestimate the true incidence 
of
snowmobile-associated injuries because of underreporting. Review of
hospital emergency and discharge records could assist in evaluating the
extent of underreporting.
 Information from the injury reporting system in New Hampshire may 
be
useful for public health surveillance and assessment of snowmobile and
other OHRV injuries (4). In addition, this data source can be used by 
the
New Hampshire Snowmobile Association and other organizations to target
high-risk groups for intervention programs. Since 1975, DFG has operated
a safety training course for OHRV users. State law requires that any 
OHRV
operator driving off their private property either possess a valid 
driver's
license (minimum age: 16 years) or have taken this course. Operators 
aged
less than 30 years should especially be targeted by any intervention
strategy; in particular, young operators with a valid driver's license 
are
encouraged to take the DFG safety course.
 
References
1. Rowe B, Milner R, Johnson C, Bota G. Snowmobile-related deaths in
Ontario: a 5-year review. Can Med Assoc J 1992;146:147-52.
2. Hargarten SW. All-terrain vehicle mortality in Wisconsin: a case 
study
in injury control. Am J Emerg Med 1991;9:149-52.
3. Rodgers GB. The effectiveness of helmets in reducing all-terrain 
vehicle
injuries and deaths. Accid Anal Prev 1990;22:47-58.
4. Smith SM, Middaugh JP. An assessment of potential injury surveillance
data sources in Alaska using an emerging problem: all-terrain
vehicle-associated injuries. Public Health Rep 1989; 104:493-8.
 
* Because the standard reporting form was changed in 1992, comparison 
with
later years was not possible.
 
 
 
------------------------------
 
To: hicnews
 
 Physician Vaccination Referral Practices and Vaccines for Children
 -- New York, 1994
 
 Although vaccinations are among the most effective preventive 
public
health measures available, many children are not vaccinated on time (1).
One identified barrier to timely vaccination is referral of children by
primary-care physicians to other medical settings for vaccination (2). 
This
report summarizes a survey by the New York State Department of Health of
vaccination referral practices among New York physicians and describes 
the
implementation in New York of Vaccines for Children (VFC), a national
program making federally purchased vaccines available at no cost to
health-care providers for administration to eligible children (3).
 During April 1993, a random sample of 1137 licensed pediatricians 
and
family-practice physicians (from a total n=5392) in New York were 
surveyed
by mail about vaccination practices. Of 752 (66%) responses, 502 (67%) 
were
from actively practicing primary-care physicians. Of these, 250 (50%)
referred all or some of their patients elsewhere for vaccinations. Of
referring physicians, 228 (91%) referred patients to a local health
department clinic; 109 (44%) had increased the number of patient 
referrals
during 1983-1993, while seven (3%) had decreased referrals. In addition,
63 (25%) reported that the number of well-child-care visits had 
decreased
during 1983-1993, while five (2%) reported increases during that time. 
Of
the 250 referring physicians, 246 provided reasons for referral and 
rated
those reasons as "very important," "somewhat important," or "not 
important"
(Table 1). Financial hardship was a "very important" reason for referral
for 217 (88%) of those surveyed; the lack of vaccination coverage by
private insurance was "very important" for 132 (54%). Physicians also 
were
asked whether the government should underwrite the cost of mandatory
vaccinations. Overall, 409 (54%) respondents indicated that some or all 
of
the costs of childhood vaccination should be underwritten.
 Since October 1, 1994, free vaccine has been available to VFC
participating providers in New York. Categories of federally eligible
children aged less than 19 years include those on Medicaid, those who 
are
uninsured, those who are underinsured who visit federally qualified 
health
centers, and American Indians/Alaskan Natives. New York also provided 
free
vaccine to underinsured children who receive care in any medical setting
and any child served at a local health department.
 Medical-care providers were recruited for VFC through articles
published in professional organization newsletters and by mailing of
registration packets to licensed pediatricians, family physicians,
osteopathic physicians, and medical facilities. As of December 27, 1994,
a total of 1378 physician practices in New York (including at least 1972
individual physicians and at least 362 health-care facilities) were
participating in VFC.
 To determine the extent of enrollment by Medicaid providers, the 
list
of VFC enrollees was compared to a list of providers who billed Medicaid
for childhood vaccines during federal fiscal year 1993. Of 2169 
physicians
who billed Medicaid for childhood vaccines in 1993, a total of 1213 
(56%)
had enrolled. Among the 166 physicians who submitted a minimum of 1000
claims for individual vaccines, 143 (86%) had enrolled, while 653 (68%) 
of
956 physicians not yet enrolled had submitted fewer than 50 claims.
 In September 1994, the New York State Department of Health 
conducted
a telephone survey of health-care providers who had returned 
registration
forms and declined participation in the program to determine reasons for
nonparticipation and to guide future recruitment efforts. Of the 41
physicians who had declined, 29 (71%) were contacted. Of these, five 
(17%)
were retired, five (17%) did not accept patients aged less than 19 
years,
six (21%) were subspecialists or in academic medicine and did not 
provide
vaccinations, six (21%) indicated that most of their patients would not 
be
eligible, one (2%) had multiple reasons for not registering, and the six
(21%) with patients who could benefit from VFC agreed to register as a
result of the phone call.
 From September 15, 1994 (the first date vaccines could be ordered),
through December 27, 1994, a minimum of 2,496,000 doses of vaccine had 
been
ordered and approximately 2,456,000 doses were shipped to VFC 
participants.
The average time between placement of orders and receipt of vaccine by
providers was 1 week.
 
Reported by: HG Cicirello, MD, GA Bunn, DR Lynch, SC Meldrum, MS, GS
Birkhead, MD, D Morse, MD, State Epidemiologist, New York State Dept of
Health. S Freidman, MD, N Jenkusky, MPH, New York City Dept of Health. 
EE
Schulte, MD, Albany Medical Center, Albany, New York. National 
Immunization
Program, CDC.
 
Editorial Note: In the United States, approximately 2 million children 
need
one or more doses of recommended vaccines (4). In a 1993 retrospective
survey of children entering kindergarten in New York, only 53% had been
appropriately vaccinated with the recommended vaccines by age 2 years 
(5).
Important barriers to timely vaccination include missed opportunities to
vaccinate at each health-care visit, inconvenient clinic hours, 
inadequate
parental awareness of the need for timely vaccination, inadequate
vaccination tracking, the costs of vaccines, and the referral of 
children
from the private sector to the public sector. This report demonstrates 
that
vaccination referrals, in part attributable to vaccine costs, are common
among New York primary-care providers. Implementation of VFC is expected
to reduce these financial barriers.
 The actual number of VFC participants in New York probably is
underestimated by VFC enrollment figures because many physicians work in
facilities or in group practices where only the physician-in-chief is
registered in the program. In addition, the impact of the program on
vaccination coverage and overall occurrence of vaccine-preventable 
diseases
cannot be determined yet. However, VFC has allowed New York to increase
provision of vaccine to more children in primary-care settings where 
they
first seek care. In states where vaccines have been made available for 
all
children, vaccination rates of preschoolers are approximately 10% higher
than the national average (AG Holtmann, University of Miami, unpublished
data, 1993).
 The Childhood Immunization Initiative (CII) has designated 
vaccination
of preschool-aged children a national priority and has established 1996 
and
year 2000 goals of vaccinating at least 90% of children by age 2 years 
with
the recommended number of doses of diphtheria and tetanus toxoids and
pertussis, polio, Haemophilus influenzae type b, hepatitis B, measles,
mumps, and rubella vaccines. The five strategies of CII, which address 
both
financial and nonfinancial barriers to vaccination, are to 1) improve 
the
delivery of vaccines; 2) reduce the cost of vaccines for parents (VFC); 
3)
enhance awareness, partnerships, and community participation; 4) monitor
vaccination coverage and disease; and 5) improve vaccines and their use.
VFC, as an integral part of this initiative, will assist physicians and
other health-care providers in reaching these national goals.
 
References
1. NCHS. Health, United States, 1993. Hyattsville, Maryland: US 
Department
of Health and Human Services, Public Health Service, CDC, 1994; DHHS
publication no. (PHS)94-1232.
2. Bordley WC, Freed GL, Garrett JM, Byrd CA, Meriwether R. Factors
responsible for immunization referrals to health departments in North
Carolina. Pediatrics 1994;94:376-80.
3. CDC. Vaccines for Children program, 1994. MMWR 1994;43:705.
4. CDC. Vaccination coverage of 2-year-old children--United States, 
1993.
MMWR 1994;43:705-9.
5. Hamburg BG, Dowling TP, Kramer JI, Randles RH, Rodewald LE. 
Immunization
of pre-school children. New York: New York State Public Health Council, 
Ad
Hoc Immunization Committee, March 1993.
 
 
 
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To: hicnews
 
 Differences in Maternal Mortality Among Black and White Women
 -- United States, 1990
 
 The risk for maternal mortality has consistently been higher among
black women than white women. The 1990 national health objective of
reducing maternal mortality to no more than five deaths per 100,000 live
births for any racial/ethnic group was nearly achieved for white women, 
for
whom the maternal mortality ratio* was 5.7 in 1990 (1); for black women,
however, the ratio was 18.6. The year 2000 national health objectives
include reducing the overall maternal mortality ratio to no more than 
3.3
deaths per 100,000 live births and to no more than five for blacks
(objective 14.3) (2). This report summarizes race-specific differences 
in
maternal mortality among black and white women for 1990 and compares 
these
with trends in mortality from 1940-1990.
 Maternal mortality ratios were calculated at 10-year intervals from
1940 to 1990 using data contained on death certificates filed in state
vital statistics offices and compiled by CDC in a national database 
(3,4).
Maternal deaths were defined as those for which a maternal condition was
designated as the underlying cause of death, as recorded on the death
certificate by the attending physician, medical examiner, or coroner.**
This report compares maternal mortality only for black and white women
because data for other racial/ethnic groups were not available for all
years; data for Hispanic women are included in the totals for both 
blacks
and whites.
 In 1990, the overall maternal mortality ratio was 8.0 deaths per
100,000 live births, a 98% decline from 363.9 in 1940. From 1940 to 
1990,
race-specific ratios declined substantially, from 319.8 to 5.7 for white
women and from 781.7 to 18.6 for black women. Although the percentage
decline was similar for black women and white women (97.6% and 98.2%,
respectively), the ratios for black women were consistently two to four
times higher than those for white women. For example, compared with that
for white women, the maternal mortality ratio for black women was 2.4 
times
greater in 1940, 3.6 times greater in 1950, 4.1 times greater in 1960, 
3.9
times greater in 1970, 3.4 times greater in 1980, and 3.3 times greater 
in
1990 (Figure 1, page 13).
 From 1960 through 1990 (years for which more detailed data were
available), the maternal mortality ratio was higher for black women in 
all
age groups and for each of the major causes of death. The black-white
differential was greatest for pregnancies that did not end in a live 
birth,
such as ectopic pregnancy, spontaneous abortion, induced abortion, and
gestational trophoblastic disease.***
 
Reported by: Div of Reproductive Health, National Center for Chronic
Disease Prevention and Health Promotion; Div of Vital Statistics, 
National
Center for Health Statistics, CDC.
 
Editorial Note: Despite overall improved maternal survival during 1940-
1990, black women were more than three times more likely than white 
women
to die from complications of pregnancy, childbirth, and the puerperium.
Although the reasons for this disparity are unclear, possible 
explanations
include differences in pregnancy-related morbidity, access to and use of
health-care services, and content and quality of care.
 Maternal hospitalization, except when associated with delivery, can
serve as a marker for severe maternal morbidity. For example, during 
1987-
1988, a study of pregnancy-related hospitalizations indicated the ratio 
for
black women was 1.4 times that for white women (6); during the same 
period,
the black-white maternal mortality ratio was 3.1. However, in a study of
women in the military--who have unrestricted access to prenatal care--
there
was virtually no difference between black and white women in the overall
prevalence of antenatal hospitalization and in the indications for
hospitalization (7).
 Early entry into prenatal care (i.e., during the first trimester)--
one
indicator of access to and use of pregnancy-related health care--has 
been
assessed for women whose pregnancies ended in a live birth. During 1980-
1990, although 76% of all mothers received early prenatal care, the
percentage of black women who did not receive early prenatal care was
nearly twice that for white women (8). In 1990, 39.4% of black mothers 
did
not receive early prenatal care, compared with 20.8% of white mothers. 
Once
women enter prenatal care, studies indicate differences between black 
and
white women in the advice given to them and use of technology (9,10).
 Data describing access to pregnancy-related health care other than
prenatal care (e.g., gynecologic services) or the content and quality of
health care once women obtain these services are limited. Narrowing
discrepancies in maternal mortality between black and white women will
require evaluating and addressing race-specific differences in morbidity
and in access to and use and content of pregnancy-related care. 
Addressing
discrepancies in maternal mortality also may improve maternal morbidity 
and
infant survival.
 
References
1. Public Health Service. Promoting health/preventing disease: 
objectives
for the nation. Washington, DC: US Department of Health and Human 
Services,
Public Health Service, 1980.
2. Public Health Service. Healthy people 2000: national health promotion
and disease prevention objectives. Washington, DC: US Department of 
Health
and Human Services, Public Health Service, 1991; DHHS publication no.
(PHS)91-50213.
3. NCHS. Vital statistics of the United States, for years 1939-1991. Vol
I-natality. Hyattsville, Maryland: US Department of Health and Human
Services, Public Health Service, CDC.
4. NCHS. Vital statistics of the United States, for years 1939-1991. Vol
II-mortality, part A. Hyattsville, Maryland: US Department of Health and
Human Services, Public Health Service, CDC.
5. NCHS. Estimates of selected comparability ratios based on dual coding
of 1976 death certificates by the eighth and ninth revisions of the
International Classification of Diseases. Hyattsville, Maryland: US
Department of Health and Human Services, Public Health Service, CDC, 
1980.
(Monthly vital statistics report; vol 28, no. 11, suppl).
6. Franks AL, Kendrick JS, Olson DR, Atrash HK, Saftlas AF, Moein M.
Hospitalization for pregnancy complications, United States, 1986-1987. 
Am
J Obstet Gynecol 1992;166:1339-44.
7. Adams MM, Harlass FE, Sarno AP, Read JA, Rawlings JS. Antenatal
hospitalization among enlisted servicewomen, 1987-1990. Obstet Gynecol
1994;84:35-9.
8. NCHS. Health, United States, 1993. Hyattsville, Maryland: US 
Department
of Health and Human Services, Public Health Service, CDC, 1994; DHHS
publication no. (PHS)94-1232.
9. Kogan MD, Kotelchuck M, Alexander GR, Johnson WE. Racial disparities 
in
reported prenatal care advice from health care providers. Am J Public
Health 1994;84:82-8.
10. Brett KM, Schoendorf KC, Kiely JK. Differences between black and 
white
women in the use of prenatal care technologies. Am J Obstet Gynecol
1994;170:41-6.
 
* The maternal mortality ratio is the number of maternal deaths per 
100,000
live births. CDC's National Center for Health Statistics (NCHS) uses the
term maternal mortality rate as required by the World Health 
Organization.
In this report, the term "ratio" is used because the numerator includes
some maternal deaths that were not related to live births, and thus were
not included in the denominator. For this analysis, 3 years of data were
combined to calculate maternal mortality ratios to promote statistical
reliability and stability in the estimates. For example, 1990 ratios are
based on data from 1989 through 1991. In addition, beginning with the 
1989
data year, NCHS began using race of mother instead of race of child to
tabulate live birth and fetal death data by race. In this analysis, race
for live births is tabulated by the race of the child for maternal
mortality to maintain comparability of ratios.
 An underlying cause of death is defined by the International
Classification of Diseases, Ninth Revision (ICD-9), as "a) the disease 
or
injury which initiated the train of morbid events leading directly to
death, or b) the circumstances of the accident or violence which 
produced
the fatal injury.~ In 1979, the ICD-9 provided the first formal 
definition
of maternal mortality, defining maternal death as the death of a woman
while pregnant or within 42 days of termination of pregnancy. This
definition differed from that used previously by NCHS, which included
deaths up to 1 year after termination of pregnancy. However, the change
from the 1-year limit used in the eighth revision to the 42-day limit 
used
in the ninth revision did not greatly affect the comparability of 
maternal
 
úÿ


 
 
 
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To: hicnews
 
 Proportionate Mortality from Pulmonary Tuberculosis Associated
 With Occupations -- 28 States, 1979-1990
 
 The risk for occupational exposure to tuberculosis (TB) is 
increased
among health-care and other workers exposed to persons with active TB,
workers exposed to silica or other agents that increase the risk of
progression from latent infection to active TB, and workers in 
occupations
associated with low socioeconomic status (SES). Accurate estimates of 
and
surveillance for occupationally associated TB are limited because 
reports
of incident TB cases lack comprehensive occupational data (1). Although
occupation is routinely recorded on death certificates, this information
is not routinely coded and entered into vital statistics data files. To
identify occupations associated with increased risk for TB mortality, 
CDC's
National Institute for Occupational Safety and Health (NIOSH) used data
from the National Occupational Mortality Surveillance (NOMS) database* 
to
conduct a proportionate mortality study of persons with pulmonary TB by
occupation for 1979-1990 (the most recent year for which data were
available). This report presents the findings of the study.
 Data collected in the NOMS database include each decedent's usual
industry and occupation, coded using 1980 U.S. census codes (2). During
1979-1990, approximately 3.4 million mortality records that included a
usual occupation (excluding "housewife") were reported to NOMS. For this
study, data for blacks and whites were analyzed separately because of
substantial differences in race-specific rates of pulmonary TB (1,3);
numbers of deaths for other racial groups were too small to calculate
stable estimates. Ethnicity was not routinely coded on death 
certificates
until 1989 and could not be analyzed.
 Indirectly age-standardized, race- and sex-specific proportionate
mortality ratios (PMRs) were calculated by comparing the proportion of
pulmonary TB deaths (International Classification of Diseases, Ninth
Revision, code 011) among decedents in each occupational group to the
proportion of pulmonary TB deaths among all decedents with a coded
occupation (4). Confidence intervals (CIs) were calculated using the
Mantel-Haenszel chi-square test or, when less than 1000 deaths were
observed, the variance from a Poisson distribution. This analysis 
examined
a total of 458 separate or combined occupational groups, comprising all 
503
census occupational codes; of these 458 groups, 329 (71.8%) had one or 
more
deaths attributed to pulmonary TB. Data are presented for the 21
occupational groups in which at least one of the race- and sex-specific
categories had both 1) four or more pulmonary TB deaths and 2) either a 
PMR
greater than 200 or a PMR with a 95% CI that did not include 100.
 From 1979 through 1990, a total of 2206 deaths was attributed to
pulmonary TB. Of these deaths, 1024 (46.4%) occurred among workers in 
the
21 occupational groups that met the selection criteria. The 21 
occupational
groups were categorized into four risk groups (Table 1): 1) high 
potential
for exposure to persons with TB (based on published reports and NIOSH
health hazard evaluations [HHEs]**); 2) potential for substantial 
exposure
to silica (determined using unpublished data from the National 
Occupational
Exposure Survey [5] and the National Occupational Health Survey of 
Mining
[6]); 3) low SES occupation (defined as a Nam-Powers socioeconomic index
score less than 30 [where 1 signifies the lowest possible SES occupation
and 100 the highest]) (7) without other recognized risk factors; and 4)
unknown risk factors.
 Of the 21 occupational groups that met the selection criteria, two
race- and sex- specific groups were associated with potential workplace
exposure to persons with TB: white male health services workers (health 
and
nursing aides, orderlies, and attendants) (PMR=350; seven deaths)*** and
white male funeral directors (PMR=299; four deaths) (Table 1). Six of 
the
21 occupational groups were associated with potential for high silica
exposure. For white males, these groups comprised mining machine 
operators;
operators of machinery used to grind, abrade, buff, or polish;
nonconstruction laborers; and construction workers (particularly brick 
and
stone masons, construction laborers, carpenters, and roofers); PMRs 
ranged
from 134 (169 deaths) to 290 (six deaths). For black males, these groups
comprised construction workers (particularly construction laborers); 
mixing
and blending machine operators; and furnace, kiln, and oven operators,
except food; PMRs ranged from 128 (105 deaths) to 376 (five deaths).
 For two of the occupations associated with low SES that met the
selection criteria (food preparation and service workers [particularly
bartenders and cooks] and farm workers), previous reports have 
documented
increased risk for TB (8). The other low SES occupations that met the
selection criteria (e.g., housekeepers and butlers and nonfarm animal
caretakers) have not previously been associated with increased risk for 
TB.
 
Reported by: Surveillance Br, Div of Surveillance, Hazard Evaluations 
and
Field Studies, and Epidemiological Investigations Br, Div of Respiratory
Disease Studies, National Institute for Occupational Safety and Health,
CDC.
 
Editorial Note: In comparison with surveillance for TB based on incident
symptomatic cases or TB skin-test conversions, mortality-based 
surveillance
may be a relatively insensitive indicator of current occupational risks.
However, except for studies of selected occupations, the findings in 
this
report comprise the only available information about possible 
associations
between occupation and TB infection. Furthermore, these findings 
identify
several additional occupations associated with increased risk for TB, 
for
which there are biologically plausible explanations. For example, the
increased risk for funeral directors may reflect increased likelihood of
exposure to infection from cadavers, and for mining machine operators, 
may
reflect exposure to silica, which increases the risk of progression from
latent infection to active TB. For occupational groups categorized 
"unknown
risk," reasons for their elevated PMRs cannot be explained. These groups
may be at increased risk through factors other than the three recognized
in this analysis or may show elevated PMRs by chance alone.
 The findings in this report are subject to at least four 
limitations.
First, mortality-based surveillance data are not sensitive indicators of
risk for disease because mortality is affected by a combination of 
several
interacting factors. In particular, mortality from TB reflects exposure,
infection, SES, access to and adequacy of medical care, and underlying
medical conditions. Overall, such factors probably contributed to the
approximately threefold greater proportion of pulmonary TB-related
mortality among blacks than among whites in this study (0.18% and 0.05%,
respectively). Second, the method of death certificate-based PMR 
analysis
described in this report is subject to possible misclassification of 
usual
occupation and cause of death and to potential biases inherent in the 
use
of the PMR statistic as a risk estimator (4) and fails to compensate
statistically for multiple comparisons. Third, death certificates lack
information about lifestyle and other risk factors; therefore, no
adjustment was made for possible confounding. Fourth, the timeliness of
death certificates as a source of data is constrained by processing 
delays.
Despite these limitations, these findings are important because of the
strength and biological plausibility of many of the reported 
associations.
 The recent increase in TB incidence and the occurrence of
multidrug-resistant TB have focused attention on particular populations 
at
high risk for disease and on the potential for transmission of infection
to health-care workers. Occupation-based surveillance for TB can assist 
in
identifying groups at high risk and indicate trends in the occurrence of
infection in these workers. These surveillance findings also can assist 
in
evaluating the effectiveness of prevention measures for groups 
previously
established to be at risk, such as miners and agricultural workers.
 To improve the detection and control of TB among occupational 
groups,
CDC has proposed two surveillance activities (9): 1) collection and
analysis of occupational information from TB case reports and 2) serial
cross-sectional surveys of known high-risk populations (including 
selected
occupations) to determine the prevalence of TB skin-test positivity. 
These
data, in combination with ongoing collection and analysis of 
occupational
information from death certificates, will enable comprehensive 
surveillance
for monitoring recognized high-risk populations and identifying new at-
risk
groups.
 
References
1. CDC. Tuberculosis morbidity--United States, 1992. MMWR 1993;42:696-
7,703-4.
2. Bureau of the Census. 1980 Census of population: alphabetical index 
of
industries and occupations--final edition. Washington, DC: US Department
of Commerce, Bureau of the Census, 1982; publication no. PHC80-R3.
3. CDC. Prevention and control of tuberculosis in U.S. communities with
at-risk minority populations: recommendations of the Advisory Council 
for
the Elimination of Tuberculosis. MMWR 1992;41(no. RR-5):1-11.
4. Decoufle P, Thomas T, Pickle L. Comparison of the proportionate
mortality ratio and standardized mortality ratio risk measures. Am J
Epidemiol 1980;111:263-9.
5. Seta JA, Sundin DS, Pedersen DH. National Occupational Exposure 
Survey,
Vol 1. Cincinnati: US Department of Health and Human Services, Public
Health Service, CDC, NIOSH, 1988; DHHS publication no. (NIOSH)88-106.
6. Groce DW, Carr WG, Hearl FJ. The National Occupational Health Survey 
of
Mining. In: CDC surveillance summaries (August). MMWR 1986;35(no. SS-
2):17.
7. Nam CB, Terrie EW. Comparing the Nam-Powers and Duncan SEI 
occupational
scores. Tallahassee, Florida: Florida State University, Center for the
Study of Population, 1986.
8. Weeks JL, Levy BS, Wagner GN, eds. Tuberculosis. In: Preventing
occupational disease and injury. Washington, DC: American Public Health
Association, 1991:572-81.
9. CDC. National action plan to combat multidrug-resistant tuberculosis.
MMWR 1992;41(no. RR-11):1-48.
 
* Through a collaborative project with CDC (specifically NIOSH and the
National Center for Health Statistics) and the National Cancer 
Institute,
the following 28 states contributed occupation-coded death certificate 
data
to NOMS for 1 year or more during 1979--1990: Alaska, California, 
Colorado,
Georgia, Idaho, Indiana, Kansas, Kentucky, Maine, Missouri, Nebraska,
Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina,
Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Tennessee,
Utah, Vermont, Washington, West Virginia, and Wisconsin.
 The NIOSH HHE program is a federally mandated program for investigation
of suspected hazardous exposures or disease outbreaks in the workplace. 
As
of March 1994, a total of 50 HHE requests related to TB had been 
received
by NIOSH and 25 completed (NIOSH, unpublished data, 1994).
* Based on the criteria used in this analysis, no other health-care
workers had elevated PMRs.
 
 
 
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End of HICNet Medical News Digest V08 Issue #15
*********************************************
 
 
---
Editor, HICNet Medical Newsletter
Internet: david@stat.com FAX: +1 (602) 451-6135