The following are pre-publication drafts of articles from the Morbidity and Mortality Weekly Report 44(06) dated February 17, 1995. Late-breaking articles, and final editorial revisions are not included. Therefore, these articles should not be quoted without consulting the official printed copy that is released to the public, as received from the CDC.--CDC.Also, please refer to the printed copy for any charts or graphically represented data. Table of Contents ----------------- American Heart Month, February 1995 Indicators of Nicotine Addiction Among Women -- United States, 1991-1992 Prevalence of Recommended Levels of Physical Activity Among Women -- Behavioral Risk Factor Surveillance System, 1992 Smokeless Tobacco Use Among American Indian Women -- Southeastern North Carolina, 1991 Update: Dracunculiasis Eradication -- Pakistan, 1994 ----------------- American Heart Month, February 1995 Cardiovascular disease is the most common cause of death in the United States. Although death rates for cardiovascular disease are declining, in 1991 the death rate for this problem among women was approximately five times that for lung or breast cancer (Figure 1). A high proportion of these deaths are preventable by reducing important risk factors for heart disease, including smoking, physical inactivity, and high-fat diet. In conjunction with American Heart Month (February 1995), this issue of MMWR includes reports that address two of these modifiable risk factors among U.S. women. Indicators of Nicotine Addiction Among Women -- United States, 1991-1992 An estimated 22 million U.S. women were current smokers in 1993; of these, 73% wanted to quit smoking (1). However, attempts to quit smoking and to remain abstinent are hindered by nicotine addiction and by the subsequent effects of nicotine withdrawal (2). To assess the prevalence of selected indicators of nicotine addiction among U.S. women, CDC analyzed data from the National Household Survey on Drug Abuse (NHSDA) in 1991 and 1992 (3). This report presents the findings of the analysis. The NHSDA is a household survey of a nationally representative sample of the civilian, noninstitutionalized U.S. population. Combined data from the 1991 and 1992 surveys (n=7137) were used to estimate the prevalences of four indicators of nicotine addiction among women who smoke. Information about these indicators was based on responses to four questions; current smokers* were asked whether, during the 12 months preceding the survey, they 1) "felt [they] needed or were dependent on cigarettes," 2) "needed larger amounts [more cigarettes] to get the same effect," 3) "felt unable to cut down on [their] use even though [they] tried," and 4) "had withdrawal symptoms, that is, felt sick because [they] stopped or cut down on [their] use." The analysis of "unable to cut down" (n=4422) and "felt sick" (n=4646) was restricted to persons who reported trying to reduce their use of cigarettes during the preceding 12 months. In addition, for the indicator "unable to cut down," because of the question design, respondents who reported not trying to reduce any drug use during the preceding 12 months (n=224) also were excluded. Because the likelihood of daily smoking (4; CDC, unpublished data, 1991) and the intensity of smoking (i.e., number of cigarettes smoked per day) (4,5) varies directly with age, respondents were classified into two age groups--12- 24-year-olds and greater than or equal to 25-year-olds. Data were adjusted for nonresponse and weighted to provide national estimates. Standard errors were calculated by using SUDAAN (6). Among female smokers in both age groups, 75% reported feeling dependent on cigarettes (Table 1). The prevalence of feeling dependent varied directly with intensity of smoking; among those who smoked six to 15 cigarettes per day, 80.6% (95% confidence interval [CI]=77.1%-84.2%) of those aged 12-24 years and 76.1% (95% CI=72.3%-79.9%) of those aged greater than or equal to 25 years reported feeling dependent on cigarettes. Female smokers aged 12-24 years were more likely to report needing more cigarettes to attain the same effect than were those aged greater than or equal to 25 years (18.0% [95% CI=15.8%-20.2%] versus 13.2% [95% CI=11.3%- 15.0%]). Among those who had tried to reduce smoking during the preceding 12 months, 81.5% (95% CI=78.9%-84.1%) of 12-24-year-olds and 77.8% (95% CI=75.1%- 80.5%) of greater than or equal to 25-year-olds reported being unable to do so; even among those who smoked six to 15 cigarettes per day, inability to reduce smoking was reported by 82.6% (95% CI=78.7%-86.4%) of 12-24-year-olds and 73.8% (95% CI=68.4%-79.2%) of the greater than or equal to 25-year-olds. Of all female smokers aged greater than or equal to 12 years, 35.4% reported withdrawal symptoms (i.e., feeling sick) when they tried to reduce their smoking. Females in both the younger and older age groups were equally likely to report at least one of the four indicators of nicotine addiction (81.2% [95% CI=78.6%-83.8%] and 79.4% [95% CI=77.3%- 81.5%], respectively) (Table 1). Even among females who smoked five or fewer cigarettes per day, 63.1% (95% CI=56.4%-69.8%) of those aged 12-24 years and 53.0% (95% CI=46.9%-59.1%) of those aged greater than or equal to 25 years reported one or more of these indicators. Reported by: J Gfroerer, Prevalence Br, Office of Applied Studies, Substance Abuse and Mental Health Svcs Administration. Office on Smoking and Health, and Div of Chronic Disease Control and Community Intervention, National Center for Chronic Disease Prevention and Health Promotion, CDC. Editorial Note: In 1990, an estimated 61,000 U.S. women aged greater than or equal to 35 years died from cardiovascular diseases attributable to cigarette smoking (7). Because the risk for myocardial infarction can be reduced by 50% after 1 year of abstaining from smoking (8), interventions to encourage smoking cessation are an important strategy to reduce cardiovascular mortality. Although most women smokers want to quit smoking, only 2.5% of all smokers successfully quit each year (9). The finding in this report that approximately 80% of female smokers reported symptoms of nicotine addiction underscores the importance of measures to increase women's access to cessation interventions, including adjunctive nicotine-replacement therapy. The findings in this report are subject to at least two limitations. First, the NHSDA indicators are not comprehensive measures of nicotine addiction and do not include all symptoms of nicotine withdrawal (e.g., anxiety, irritability, anger, difficulty concentrating, hunger, or cravings for cigarettes) (2); as a result, the NHDSA data may underestimate the proportion of smokers who report at least one indicator of nicotine addiction. Second, these findings are based on self-reported data, and perceptions of nicotine addiction were not validated. However, in previous studies, self-reported symptoms of nicotine addiction have been confirmed by observer rating (2). Although manifestations of cardiovascular disease occur primarily during adulthood, related high-risk behaviors, such as tobacco use, often are initiated during adolescence; an estimated 87% of female daily smokers began smoking at less than or equal to 18 years of age (CDC, unpublished data, 1991). Young persons often try using tobacco with a belief that they can quit. However, of adolescent smokers who have intended to not be smoking in 5-6 years, 73% still smoked 5 years later (10). The 1991 and 1992 NHSDA data suggest that an important reason for young smokers' failure to quit smoking is a prevalence of addiction similar to that among older smokers. Because of the difficulty in achieving abstinence and the strength and early onset of nicotine addiction, interventions to prevent smoking initiation are important. School-based programs, combined with community interventions, have been effective in preventing smoking initiation (10). Other measures that can prevent smoking initiation, onset of nicotine addiction, and subsequent morbidity and mortality associated with cardiovascular diseases include enforcement of laws that prohibit sales to minors, counter-advertising campaigns that "deglamorize" smoking to youth, and increases in the real price of cigarettes. References 1. CDC. Cigarette smoking among adults--United States, 1993. MMWR 1994;43:925-30. 2. CDC. The health consequences of smoking: nicotine addiction--a report of the Surgeon General. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1988; DHHS publication no. (CDC)88-8406. 3. Substance Abuse and Mental Health Services Administration. National Household Survey on Drug Abuse: population estimates, 1992. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, Substance Abuse and Mental Health Services Administration, 1993; DHHS publication no. (SMA)93-2053. 4. Moss AJ, Allen KF, Giovino GA, et al. Recent trends in adolescent smoking, smoking-uptake correlates, and expectations about the future. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, NCHS, 1992. (Advance data no. 221). 5. Giovino GA, Schooley MW, Zhu B-P, et al. Surveillance for selected tobacco-use behaviors--United States, 1900-1994. MMWR 1994;43(no. SS-3). 6. Shah BV. Software for survey data analysis (SUDAAN), version 5.50 [Software documentation]. Research Triangle Park, North Carolina: Research Triangle Institute, 1991. 7. CDC. Cigarette smoking-attributable mortality and years of potential life lost--United States, 1990. MMWR 1993;42:645-9. 8. CDC. The health benefits of smoking cessation: a report of the Surgeon General, 1990. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, 1990; DHHS publication no. (CDC)90-8416. 9. CDC. Smoking cessation during previous year among adults-- United States, 1990 and 1991. MMWR 1993;42:504-7. 10. US Department of Health and Human Services. Preventing tobacco use among young people: a report of the Surgeon General. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1994. *Defined as persons who had ever smoked 100 cigarettes and had smoked during the 30 days preceding the survey. Prevalence of Recommended Levels of Physical Activity Among Women -- Behavioral Risk Factor Surveillance System, 1992 Regular physical activity provides important health benefits for women, including lower risks for coronary heart disease, some cancers, osteoporosis, and other leading causes of death and disability (1-3). Despite such benefits, the proportion of women in the United States reporting regular physical activity has been low (4). Because even moderately intense physical activity has substantial health benefits, public health recommendations for physical activity have been expanded to a broader spectrum of activity, including gardening, walking, and housework in addition to more vigorous aerobic exercise (e.g., jogging) (5,6). To improve estimates of the prevalence of participation in physical activity at levels associated with health benefits among adult women, data about leisure-time physical activity were analyzed from the 1992 Behavioral Risk Factor Surveillance System (BRFSS). This report summarizes the results of these analyses. Data were available for 55,506 women aged greater than or equal to 18 years in 48 states and the District of Columbia who participated in the 1992 BRFSS, a population-based, random-digit- dialed telephone survey. Respondents were asked about the frequency, duration, and intensity of leisure-time physical activities during the preceding month and were categorized as having reported 1) no leisure-time physical activity, 2) irregular activity that did not meet the recommended criteria for either moderate or vigorous physical activity, or 3) regular activity meeting either the previous recommendation for vigorous physical activity (greater than or equal to 20 minutes per day of vigorous physical activity on greater than or equal to 3 days per week) or the newer moderate activity recommendation (greater than or equal to 30 minutes per day of moderate activity on greater than or equal to 5 days per week [6]). Data were weighted and aggregated, and composite estimates and standard errors for selected groups were calculated using SESUDAAN (7). Prevalences and 95% confidence intervals were calculated by age, race/ethnicity, education level, and annual household income of respondents. Overall, 27.1% of adult women reported participation in recommended activity levels, a proportion that was generally consistent across age groups. The prevalence of inactivity increased with age, from 25.6% among women aged 18-34 years to 42.1% among women aged greater than or equal to 65 years (Table 1). Reported participation in recommended levels of physical activity varied substantially among racial/ethnic groups and by education levels and incomes. White non-Hispanic women were more likely to be more active (28.7%) than Hispanic women (24.7%) and black non-Hispanic women (17.5%).* The prevalence of participation in recommended levels was inversely related to education level and family income: women with less than a high school education were less likely to report regular activity (17.4%) than high school graduates (23.8%) and college graduates (33.5%). Women in the lowest income category (less than or equal to $14,999 per year) were least likely to report regular activity (21.4%), and women in the highest income category (greater than or equal to $50,000 per year) were most likely to report regular activity (34.9%). Reported by: State Behavioral Risk Factor Surveillance System coordinators. Health Interventions and Translation Br, and Statistics Br, Div of Chronic Disease Control and Community Intervention, National Center for Chronic Disease Prevention and Health Promotion, CDC. Editorial Note: CDC and the American College of Sports Medicine recently recommended that adults accumulate greater than or equal to 30 minutes of moderate physical activity on greater than or equal to 5 days per week (6). Adherence to either this recommendation or the previous recommendation (greater than or equal to 20 minutes of vigorous activity on greater than or equal to 3 days per week) should provide substantial health benefits (3,6,8). The findings in this report indicate that leisure-time physical activity levels among women were strongly associated with demographic characteristics and that two measures of socioeconomic status (i.e., education and income) were particularly strong predictors of participation in health-enhancing levels of physical activity. Because physical inactivity accounts for approximately 25% of all deaths from chronic disease in the United States (8), reducing preventable death and disability from disease (e.g., heart disease) attributable to physical inactivity (8,9) will require intervention programs that are directed toward and effective among the approximately 70% of women who are sedentary or irregularly active. These BRFSS data also address a priority surveillance need for information about physical activity among racial/ethnic minorities, as specified by the national health objectives for the year 2000 (5). Interpretation of the findings in this report is subject to at least three limitations. First, because the BRFSS estimates for physical activity levels were based on self-reported data, activity levels may be overestimated. Second, the BRFSS did not ascertain nonleisure-time physical activity (i.e., occupational activity or walking or cycling to work); therefore, estimates restricted to leisure-time activity may underestimate the prevalence of physical activity in some groups. Third, because respondents to the BRFSS can report only two leisure-time activities, physical activity levels will be underestimated for those who participate in multiple activities. Strategies for increasing levels of leisure-time physical activity should include public education about the health benefits of moderate physical activity and education of health-care providers to increase the number of providers who counsel their patients to become more active--levels of physical activity have increased among patients who have been counseled by their physicians to become more active (10). Employers can encourage employees to walk on breaks or at other appropriate periods (e.g., lunch) or provide incentives for employees to participate in community-based programs. Community-based programs should offer opportunities for all women to participate in moderate physical activity, particularly women who are older, have low incomes, or have children. Such programs should address barriers to women for increasing activity levels (e.g., safety; child care; time; and the availability and accessibility of walking and cycling trails, sidewalks, and recreational facilities). References 1. Blair SN, Kohl HW, Paffenbarger RS Jr, Clark DG, Cooper KH, Gibbons LW. Physical fitness and all-cause mortality: a prospective study of healthy men and women. JAMA 1989;262:2395-401. 2. Blair SN, Kohl HW, Gordon NF, Paffenbarger RS Jr. How much physical activity is good for health? Annu Rev Public Health 1992;13:99-126. 3. Krall EA, Dawson HB. Walking is related to bone density and rates of bone loss. Am J Med 1994;96:20-6. 4. CDC. Prevalence of sedentary lifestyle--Behavioral Risk Factor Surveillance System, United States, 1991. MMWR 1993;42:576-9. 5. 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. 6. Pate RR, Pratt M, Blair SN, et al. Physical activity and public health: a recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA 1995;273:402-7. 7. Shah BV. SESUDAAN: standard errors program for computing of standardized rates from sample survey data. Research Triangle Park, North Carolina: Research Triangle Institute, 1981. 8. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993;270:2207-12. 9. Hahn RA, Teutsch SM, Rothenberg RB, Marks JS. Excess deaths from nine chronic diseases in the United States, 1986. JAMA 1990;264:2654-9. 10. Long BJ, Calfas KJ, Sallis JF, et al. Evaluation of patient physical activity after counseling by primary care providers. Med Sci Sports Exerc 1994;26(suppl):S4. *Numbers for other racial/ethnic groups were too small for meaningful analysis. Smokeless Tobacco Use Among American Indian Women -- Southeastern North Carolina, 1991 Rates of smokeless tobacco use among U.S. adults are highest for young males, American Indians/Alaskan Natives, persons residing in the South or rural areas of the country, and those of low socioeconomic status (1). In addition, the prevalence of smokeless tobacco use has been reported to be high in tobacco-producing regions, including rural North Carolina and Kentucky (2,3). In southeastern North Carolina, reports from physicians and dentists suggested a high prevalence of smokeless tobacco use in the local American Indian population, the Lumbee--particularly among women and children. In response to these reports, the Department of Family and Community Medicine at the Bowman Gray School of Medicine of Wake Forest University analyzed data from a National Cancer Institute-sponsored cervical cancer prevention program to estimate the prevalence of smokeless tobacco use during 1991 among Lumbee women aged greater than or equal to 18 years residing in Robeson County, North Carolina (1990 population: 105,179). This analysis was based on responses to a survey conducted as part of the cancer-prevention program; these data are the most complete on tobacco use for this population. The survey included questions about cervical cancer knowledge, attitudes, and practices; demographic characteristics; social support; and health behavior, including use of tobacco and alcohol. A random sample of 479 women was selected from the official Lumbee tribal enrollment database using a computer-generated list of phone numbers; the database lists approximately 43,000 persons (86% of the estimated 1990 population of the Lumbee tribe). A telephone number was listed for 99% of the Lumbee tribal members in the database. The survey was conducted in respondents' homes during August-October 1991 by nine Lumbee women who had been trained as research assistants. Smokeless tobacco use was classified as ever or never use based on the question, "Have you ever used chewing tobacco or snuff?" Ever use was further subdivided into current use (those who reported using smokeless tobacco at the time of the survey) and former use (those who reported not using smokeless tobacco at the time of the survey). Early initiation (defined as beginning use at age less than 6 years) was based on the question, "How old were you when you began using chewing tobacco or snuff regularly?" The survey also assessed smoking status (never, former [smoked at least 100 cigarettes during their lifetime but did not smoke at the time of the survey], and current [smoked at least 100 cigarettes during their lifetime and smoked at the time of the survey]), self-reported health status (excellent, good, fair, or poor), social or church group participation, number of close friends, and reported use of medical services. Chi-square analysis was used to assess differences in smokeless tobacco use by demographic, social support, and health behavior categories and to assess the frequency of early initiation of smokeless tobacco use in relation to age group. Of the 479 women surveyed, 307 (64%) reported never using smokeless tobacco, 64 (13%) reported former use, and 108 (23%) reported current use. The prevalence of current smokeless tobacco use was greatest among women aged greater than or equal to 65 years (51%) and lowest among those aged 25-34 years (6%) and 18-24 years (11%) (Table 1). Current use also was high among women who had less than 12 years of education (42%), whose annual income was less than $11,000 (31%), who were widowed (42%), who had never smoked cigarettes (30%), and who perceived their health as poor or fair (39%). Current smokeless tobacco use was not associated with alcohol use, use of medical services, church or social group participation, or number of close friends. Age at initiation of smokeless tobacco use was unknown for 18 (10%) of the 172 ever users; although demographic characteristics of these women were similar to those for whom complete initiation data were available, these respondents were excluded from analyses of age at initiation of use. The median age at initiation of smokeless tobacco use was 10 years; of the ever users for whom data were available, 90% initiated smokeless tobacco use before age 18 years. Median duration of smokeless tobacco use among all current users was 37 years. Because women in older age groups had a greater chance of beginning smokeless tobacco use at age greater than or equal to 18 years, women who initiated smokeless tobacco use at age greater than or equal to 18 years (n=16) were eliminated from the analysis of women who initiated smokeless tobacco use at an early age to ensure comparability between the youngest and older age groups; the women who were excluded did not differ from the others by income or education. The prevalence of early initiation of smokeless tobacco use was highest among those aged 18-24 years (77%) (Table 2). The prevalence of early initiation in other age groups ranged from 18% to 30%. Based on analysis of aggregated data, 35% of women aged less than or equal to 44 years began smokeless tobacco use before age 6 years, compared with 22% of women aged greater than or equal to 45 years. Reported by: JG Spangler, MD, MB Dignan, PhD, R Michielutte, PhD, Dept of Family and Community Medicine, Bowman Gray School of Medicine of Wake Forest Univ, Winston-Salem, North Carolina. Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. Editorial Note: Based on the findings of this survey, the prevalence of smokeless tobacco use among Lumbee women in North Carolina in 1991 was nine times the national mean prevalence for American Indian women (2.5%) and 38 times that for women in the total U.S. population (0.6%) (1). Robeson County, where most of the Lumbee reside, is the third largest tobacco-producing county in North Carolina (E. Davis, Robeson County [North Carolina] Agricultural Extension Service, personal communication, 1994), and the high prevalence of smokeless tobacco use among the Lumbee women may reflect, in part, the tobacco-based local economy. High prevalences of smokeless tobacco use also have been documented in other tobacco-producing regions of the United States (2,3). However, the prevalence of smokeless tobacco use among these women was more than twice that of women in Pitt County, North Carolina (3), the leading tobacco-producing county in the United States, and approximates the prevalence among some male adolescent populations (4). Cultural factors specific to American Indians and the economic impact of tobacco on residents of this region may be associated with this unusually high prevalence of smokeless tobacco use. For example, use of tobacco has been a part of American Indian culture, including medicinal uses such as treatment of gastrointestinal symptoms (5), since before the arrival of Europeans (6,7). Such uses of tobacco, combined with the availability of tobacco leaf among tobacco-farming families, may be associated with initiation of nicotine addiction in young children. The findings in this study are subject to at least two limitations. First, respondents were asked to recall their use of smokeless tobacco as children; because early age at initiation among younger women was more recent and, therefore, more likely to be remembered, the high prevalence of early onset of use among younger women may partly reflect this bias. Second, family use of tobacco and family or personal involvement in tobacco production were not analyzed. Employment in tobacco production may play a role in attitudes toward smokeless tobacco use (3) because personal involvement in growing tobacco has been associated with a high prevalence of smokeless tobacco use among adolescents (2). The high prevalence of smokeless tobacco use among Lumbee women increases the risk for health hazards, including gingival recession, tooth loss, leukoplakia, and oral cancer. Nicotine use may also increase the risk for cardiovascular disease (8) and reproductive risks such as low birthweight, premature delivery, and spontaneous abortion (9). Further assessment of parents' attitudes toward childhood smokeless tobacco use, the anthropologic characteristics of smokeless tobacco use among the Lumbee, and the influence of a tobacco-based economy on early initiation and high prevalence of smokeless tobacco use should assist in the development of culturally and economically acceptable interventions. References 1. CDC. Use of smokeless tobacco among adults--United States, 1991. MMWR 1993;42:263-6. 2. Noland MP, Kryscio RJ, Riggs RS, Linville LH, Perritt LJ, Tucker TC. Use of snuff, chewing tobacco, and cigarettes among adolescents in a tobacco-producing area. Addict Behav 1990; 15:517-30. 3. Glover ED, O'Brien K, Holbert D. Prevalence of smokeless tobacco use in Pitt County, North Carolina. Int J Addict 1987;22:557-65. 4. Kann L, Warren W, Collins JL, Ross J, Collins B, Kolbe LJ. Results from the national school-based 1991 Youth Risk Behavior Survey and progress toward achieving related health objectives for the nation. Public Health Rep 1993;108(suppl 1):47-55. 5. Vogel V. American Indian medicine. Norman, Oklahoma: University of Oklahoma Press, 1994. 6. Christen AG, Swanson BZ, Glover ED, Henderson AH. Smokeless tobacco: folklore and social history of snuffing, sneezing, dipping, and chewing. J Am Dent Assoc 1982;105:821-9. 7. CDC. Smoking and health in the Americas: a 1992 report of the Surgeon General, in collaboration with the Pan American Health Organization. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1992; DHHS publication no. (CDC)92-8419. 8. Bolinder G, Alfredsson L, Englund A, de Faire U. Smokeless tobacco use and increased cardiovascular mortality among Swedish construction workers. Am J Public Health 1994;84: 399-404. 9. National Institutes of Health. Smokeless tobacco or health: an international perspective. Bethesda, Maryland: US Department of Health and Human Services, Public Health Service, National Institutes of Health, 1992; NIH publication no. 93-3461. Update: Dracunculiasis Eradication -- Pakistan, 1994 Dracunculiasis (Guinea worm disease)--a disabling infection that affects persons in 16 African and three Asian countries--has been targeted by the World Health Organization (WHO) for global eradication by the end of 1995. A total of 221,055 cases were reported to WHO for 1993 (1). Efforts to eradicate dracunculiasis in each of the 19 affected countries are focused on interrupting all transmission. This report summarizes the impact of Pakistan's Guinea Worm Eradication Program (GWEP). The eradication program in Pakistan began in 1986 as a collaborative effort involving Pakistan's National Institute of Health, the Global 2000 project of the Carter Center, and CDC. A nationwide village-by-village survey estimated a total of 2400 incident cases for 1987; cases were detected in three areas including North West Frontier, Punjab, and Sindh provinces (2). Active surveillance and control measures were implemented in February 1988 in all 408 villages at risk for or characterized by endemic dracunculiasis. Village-based "implementors" were identified and trained in each village to report cases monthly, promote filtration of unsafe drinking water through use of cloth filters, and distribute cloth filters. Other health workers applied temephos (Abate[Registered]*) to unsafe sources of drinking water monthly in each affected village to reduce populations of the intermediate copepod hosts. Because in areas with endemic dracunculiasis most underground sources of water are brackish, development of such sources was not a substantial component of the program in Pakistan. Measures introduced in 1990 to help ensure rapid detection, thorough investigation, and complete control of each case included more intensive surveillance and case-containment measures (e.g., close supervision of the village implementors) (3). A cash reward of 1000 rupees (approximately $40 U.S.) for reporting the first case in a village was first offered in 1991. In 1993, other incentives (i.e., 3000 rupees for each patient who complied with case-containment measures and 500 rupees for the person reporting the case) were added and publicized. A registry of reports of potential cases was established, and all claims of cases were promptly investigated by staff of the national eradication program. For each calendar year during 1988-1994, the numbers of villages in Pakistan with endemic dracunculiasis were 156, 146, 56, 35, seven, one, and zero, respectively, and the number of cases detected through village-based surveillance were 1110, 534, 160, 106, 23, two, and zero, respectively (Figure 1). Reported by: M Azam, National Institute of Health, Pakistan. Global 2000, Inc, The Carter Center, Atlanta. World Health Organization Collaborating Center for Research, Training, and Eradication of Dracunculiasis, Div of Parasitic Diseases, National Center for Infectious Diseases, CDC. Editorial Note: Because no cases were reported in 1994, Pakistan is the first of the countries with known endemic dracunculiasis during the 1980s to have eliminated indigenous transmission of the disease for 1 year. In addition, dracunculiasis-eradication methods pioneered by the Pakistan GWEP (e.g., use of village-based health workers and case containment) have been effectively incorporated into all GWEPs in Africa (1). In 1992, the United Nations Childrens' Fund (UNICEF) began providing support to the Pakistan GWEP. In 1993, WHO began assisting Pakistan in maintaining appropriate surveillance activities for the WHO-required 3-year period without indigenous cases for certification of eradication. The WHO Collaborating Center for Research, Training, and Eradication of Dracunculiasis at CDC continues to provide technical assistance to Pakistan regarding surveillance and containment of cases. References 1. WHO. Dracunculiasis: global surveillance summary. Wkly Epidemiol Rec 1994;69:121-8. 2. WHO. Dracunculiasis: Pakistan. Wkly Epidemiol Rec 1988;63:177- 80. 3. CDC. Update: dracunculiasis eradication--Pakistan, 1990. MMWR 1991;40:5-7. *Use of trade names and commercial sources is for identification only and does not imply endorsement by the Public Health Service or the U.S. Department of Health and Human Services. * DISTRIBUTED BY GENA/aegis, your online global gateway to a world of people, information, and resources. 714.248.2836 * 8N1/Full Duplex * v.34