From <@uga.cc.uga.edu:owner-mednews@ASUACAD.BITNET> Sat May 20 03:44:00 1995 with BSMTP id 0116; Sat, 20 May 95 03:30:41 EDT UGA.CC.UGA.EDU (LMail V1.2a/1.8a) with BSMTP id 1375; Sat, 20 May 1995 02:39:00 -0400 HICNet Medical News Digest Fri, 19 May 1995 Volume 08 : Issue 19 Today's Topics: [MMWR Apr21] Suicide Among Children, Adolescents, and Young Adults [MMWR] Update: Influenza Activity -- United States and Worldwide [MMWR] Local Transmission of Plasmodium vivax Malaria [MMWR] Rates of Cesarean Delivery -- United States, 1993 [MMWR] Notice to Readers: National Notifiable Diseases Reporting [MMWR Apr28] Clean Air Month -- May 1995 [MMWR] Children at Risk from Ozone Air Pollution [MMWR] Fatal and Nonfatal Suicide Attempts Among Adolescents +------------------------------------------------+ ! ! ! 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://lab.xrt.upenn.edu:2000/hicn (good till June 1995) *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 Adults Suicide Among Children, Adolescents, and Young Adults -- United States, 1980-1992 Suicide was the fifth leading cause of years of potential life lost before age 65 years in 1990 (CDC, unpublished data, 1995). During 1980- 1992, a total of 67,369 persons aged less than 25 years (i.e., children, adolescents, and young adults) committed suicide and, in 1992, persons in this age group accounted for 16.4% of all suicides. From 1952 through 1992, the incidence of suicide among adolescents and young adults nearly tripled (1). One of the national health objectives for the year 2000 is to reduce the suicide rate for persons aged 15-19 years by greater than 25% to 8.2 per 100,000 persons (objective 7.2a) (2). This report summarizes trends in suicide among persons aged less than 25 years from 1980 through 1992 (the latest year for which complete data are available). Trends in suicide among young persons were determined using final mortality data from CDC's underlying cause of death files (3). Suicides and methods of fatal injury were determined by using International Classification of Diseases, Ninth Revision, codes. Suicide rates were calculated using population data from the 1980 and 1990 census enumerations and intercensal year estimates compiled by the U.S. Bureau of the Census. From 1980 to 1992, the number and rate of suicides declined among persons aged less than 25 years from 5381 (5.7 per 100,000 persons) to 5007 (5.4). For persons aged 20-24 years, the suicide rate declined 7.2% (from 16.1 to 14.9). In comparison, the rate increased among persons aged 15- 19 years by 28.3% (from 8.5 to 10.9) and among persons aged 10-14 years by 120% (from 0.8 to 1.7). For persons aged 20-24 years, suicide rates declined for all racial and sex groups except black males (Table 1).* For persons aged 15-19 years, the suicide rate increased for all groups except males of other races; in particular, for black males the rate increased 165.3%. For persons aged 10-14 years, suicide rates increased substantially in all racial and sex groups. In 1992, firearm-related deaths accounted for 64.9% of suicides among persons aged less than 25 years. Among persons aged 15-19 years, firearm-related suicides accounted for 81% of the increase in the overall rate from 1980-1992. During 1980-1992, among persons aged less than 25 years, the proportions of suicides by poisoning, cutting, and other methods declined, while the proportions by firearms and hanging increased; hanging was the second most common method of suicide, followed by poisoning. Reported by: Div of Violence Prevention, National Center for Injury Prevention and Control, CDC. Editorial Note: The findings in this report are consistent with previous reports indicating that the risk for suicide is greatest among young white males (4). However, from 1980 through 1992, suicide rates increased most rapidly among young black males. Although suicide among children is a rare event, the dramatic increase in the suicide rate among persons aged 10- 14 years underscores the urgent need for intensifying efforts to prevent suicide among persons in this age group. The causes of suicide are multiple and complex. Potential reasons for the increase in suicides among some groups may reflect increasing interaction of risk factors including substance abuse; mental illness; impulsive, aggressive, and antisocial behavior; family influences, including a history of violence and family disruption; severe stress in school or social life; and rapid sociocultural change (5). The increase in firearm-related suicide probably reflects increased access to firearms by the at-risk population (6). Most youth suicide-prevention programs are directed toward older adolescents and do not include outreach efforts for minorities (6). The recent increases in suicide rates among young black males and children aged 10-14 years especially indicate the need to develop interventions for these groups. In addition, the increasing use of firearms for suicide underscores the need for intensifying the development and assessment of suicide-prevention measures directed toward firearms. Because a previous report suggested that suicide attempts among younger persons have not increased (7), the increased rate of completed suicides may be attributed to the use of more lethal means during attempts. Because attempted suicide is a major risk factor for subsequent suicide, in several states public health surveillance projects have been initiated to improve the quality of information about persons who are at risk for suicide (8). In addition, some health departments have initiated comprehensive youth suicide-prevention activities to improve service to the at-risk population (9). Based on review of programs throughout the United States, CDC has identified strategies for preventing suicide among young persons (6). These strategies include 1) training school and community leaders to identify young persons at highest risk for suicidal thoughts, threats, and attempts; 2) educating young persons about suicide, risk factors, and interventions; 3) implementing screening and referral programs; 4) developing peer- support programs; 5) establishing and operating suicide crisis centers and hotlines; 6) restricting access to highly lethal methods of suicide; and 7) intervening after a suicide to prevent other young persons from attempting or completing suicide. Rigorous evaluation of new and existing prevention programs is essential to identify and establish the most effective interventions for reducing suicide among young persons. National Suicide Prevention Week is May 7-13, 1995. This year's theme is "Stop the whispers...suicidal persons can be helped." For additional information, contact the American Association of Suicidology, telephone (202) 237-2280. References 1. Shaffer D, Garland A, Gould M, Fisher P, Trautman P. Preventing teenage suicide: a critical review. J Am Acad Child Adolesc Psychiatry 1988;27:675- 87. 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 mortality data, underlying cause of death, 1991 [Machine-readable public-use data tapes]. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1993. 4. CDC. Youth suicide--United States, 1970-1980. MMWR 1987;36:87-9. 5. Goodwin FK, Brown GL. Risk factors for youth suicide. In: Alcohol, Drug Abuse, and Mental Health Administration. Report of the Secretary's Task Force on Youth Suicide. Volume 2. Washington, DC: US Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, 1989; DHHS publication no. (ADM)89-1622. 6. CDC. Youth suicide prevention programs: a resource guide. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1992. 7. Mocicki EK, O'Carroll P, Locke BZ, Rae DS, Roy AG, Regier DA. Suicidal ideation and attempts: the epidemiologic catchment area study. In: Alcohol, Drug Abuse, and Mental Health Administration. Report of the Secretary's Task Force on Youth Suicide. Volume 4: strategies for the prevention of youth suicide. Washington, DC: US Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, 1989; DHHS publication no. (ADM)87-1624. 8. Colorado Department of Public Health and Environment. Violence in Colorado: trends and resources. Denver: Colorado Department of Public Health and Environment, 1994. 9. Eggert LL, Thompson EA, Randall BP, McCauley E. Youth suicide prevention plan for Washington state. Olympia, Washington: Washington Department of Health, 1995. * Because data for racial groups other than black and white were too small for separate analysis, data for these groups were combined. Data on ethnicity were not analyzed because they were not available for the entire study period. ------------------------------ To: hicnews Worldwide Update: Influenza Activity -- United States and Worldwide, 1994-95 Season, and Composition of the 1995-96 Influenza Vaccine In collaboration with the World Health Organization (WHO) and the international network of collaborating laboratories and with state and local health departments in the United States, CDC conducts surveillance to monitor influenza activity and to detect antigenic changes in the circulating strains of influenza viruses. This report summarizes surveillance for influenza in the United States and worldwide during the 1994-95 season and describes the composition of the 1995-96 influenza vaccine. United States Influenza activity began in the Northeast in late November 1994 and from late January to early February spread to other regions of the country. Activity peaked during March and continues to decline. From November 27, 1994, through January 14, 1995, regional or widespread influenza activity* was reported only from northeastern states. Regional activity was first reported outside this area for the week ending January 21, and by February 11 regional or widespread activity had been reported from every region in the country. Based on reports from state and territorial epidemiologists, peak activity occurred the week ending March 11, 1995, when 26 states reported either regional or widespread activity. The number of states reporting regional or widespread activity has declined every week since March 12. For the week ending April 8, four states reported regional activity, and none reported widespread activity. Of total deaths reported through CDC's 121-city mortality surveillance system, the proportion attributed to pneumonia and influenza exceeded the epidemic threshold** for 11 of the 27 weeks from October 2, 1994, through April 8, 1995. Pneumonia and influenza deaths exceeded the epidemic threshold for 2 consecutive weeks twice during this interval. Of the 3423 influenza virus isolates reported to CDC from WHO collaborating laboratories in the United States through April 8, a total of 2654 (78%) were type A and 769 (22%) were type B. Of the 1337 type A viruses that have been subtyped, 1318 (99%) were type A(H3N2) and 19 (1%) were type A(H1N1). Worldwide Influenza activity has occurred at low to moderate levels in most parts of the world. Although a few countries reported epidemic activity, sporadic activity or localized outbreaks were reported more frequently. Influenza activity was usually associated with cocirculation of influenza A(H3N2) and influenza B viruses. Influenza A(H1N1) activity was reported only in association with sporadic cases. Influenza A(H3N2) viruses were first detected during October in Europe and North America. Outbreaks associated with influenza A(H3N2) were subsequently reported in the People's Republic of China, Finland, Hungary, Italy, Spain, the United Kingdom, and the United States. Although influenza A and influenza B cocirculated, influenza A(H3N2) viruses predominated in Canada, Finland, France, Italy, Spain, and the United States. Influenza type B viruses were first detected this season in Europe in association with a secondary school outbreak in Portugal during October. Outbreaks caused by influenza B were reported subsequently in China, Iran, Italy, and the United States. Epidemic activity associated with influenza B was reported in Italy and Russia. In Germany, the Netherlands, Portugal, Russia, and the United Kingdom, influenza B viruses were isolated more frequently than influenza A(H3N2) viruses. Influenza A(H1N1) viruses have been reported in association with sporadic activity from Canada, China, Hong Kong, the Netherlands, Norway, Poland, Singapore, Switzerland, Thailand, the United Kingdom, and the United States during the 1994-95 season. Composition of the 1995-96 Vaccine The Food and Drug Administration Vaccines and Related Biologicals Advisory Committee (VRBAC) has recommended that the 1995-96 trivalent influenza vaccine for the United States contain A/Johannesburg/33/94- like (H3N2), A/Texas/36/91-like (H1N1) and B/Beijing/184/93-like viruses. This recommendation was based on the antigenic analysis of recently isolated influenza viruses and the antibody responses of persons vaccinated with the 1994-95 vaccine. Although many of the influenza type A(H3N2) viruses that have been antigenically characterized are similar to the A/Shangdong/09/93 strain, some recently isolated A(H3N2) strains from Asia, Europe, and North America are more similar to the antigenic variant A/Johannesburg/33/94 (Table 1). Vaccines containing the A/Shangdong/09/93(H3N2)-like virus induced a good antibody response to the vaccine strain but induced lower and less frequent antibody responses to recent type A(H3N2) strains such as A/Johannesburg/33/94 (1). Therefore, VRBAC recommended changing the influenza type A(H3N2) vaccine component to an A/Johannesburg/33/94-like strain for the 1995-96 season. Many recent influenza B viruses isolated from Asia, Europe, and North America are antigenically distinguishable from the B/Panama/45/90 strain included in the 1994-95 vaccine. These recent viruses are similar to the B/Beijing/184/93, B/Shanghai/04/94, and B/Harbin/07/94 strains. These strains, which are themselves antigenically indistinguishable, have been used as reference strains for antigenic analysis (Table 2). Although vaccines containing B/Panama/45/90 virus induced antibodies at a similar frequency and titer as the vaccine virus for some recent influenza B strains, in some studies the antibody response in adults and the elderly was reduced to the B/Beijing/ 184/93-like strain, B/Shanghai/04/94. VRBAC recommended changing the influenza B component to a B/Beijing/184/93- like virus for the 1995-96 season. The actual strain used by U.S. vaccine manufacturers will be B/Harbin/07/94 because of its growth properties. Since the 1992-93 influenza season, isolation of influenza type A(H1N1) virus has been sporadic worldwide (2). Nine recent viruses from China and the United States have been characterized as being related to the reference strains A/Taiwan/01/86 and A/Texas/36/91. Vaccines containing the A/Texas/36/91 strain induced antibodies with similar frequency and titer to the vaccine virus and to type A(H1N1) strains isolated in 1993 and 1994. Therefore, VRBAC recommended retaining an A/Texas/36/91-like strain in the 1995-96 vaccine. Reported by: Participating state and territorial health dept epidemiologists and state public health laboratory directors. M Chakraverty, PhD, Central Public Health Laboratory, A Hay, PhD, National Institute for Medical Research, London; G Schild, PhD, J Wood, PhD, National Institute for Biological Standards and Control, Hertfordshire, England. I Gust, MD, A Hampson, Commonwealth Serum Laboratories, Parkville, Australia. J Weber, Laboratory Center for Disease Control, Ottawa, Ontario. J Kim, PhD, K Park, PhD, National Institute of Health, Seoul, Korea. E Claas, PhD, Eramus University, Rotterdam, The Netherlands. World Health Organization National Influenza Centers, Program on Bacterial, Viral Diseases, and Immunology, Geneva. Div of Virology, Center for Biologics Evaluation and Research, Food and Drug Administration. Influenza Br, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases, CDC. Editorial Note: During the 1994-95 season, the impact of influenza in most ·_ parts of the United States and in most other countries in the Northern Hemisphere was less severe than during the previous season, when A/Beijing/32/92-like (H3N2) viruses predominated. Although approximately 75% of influenza viruses circulating in the United States during the 1994- 95 season have been type A(H3N2), compared with the 1993-94 season, influenza spread more slowly and was associated with less severe illness. The results of mortality surveillance based on the 121-city system suggest relatively low influenza-associated mortality in the United States this season and are consistent with other influenza surveillance findings. Strains to be included in next season's influenza vaccine are selected usually during the preceding January through March because of scheduling requirements for production, quality control, packaging, and distribution of vaccine for administration before onset of the next influenza season. Recommendations of the Advisory Committee on Immunization Practices for the use of vaccine and antiviral agents for prevention and control of influenza have been published in the MMWR Recommendations and Reports (3). References 1. World Health Organization. Recommended composition of influenza virus vaccines for use in the 1995-96 season. Wkly Epidemiol Rec 1995;70:53-6. 2. CDC. Update: influenza activity--United States and worldwide, 1993-94 season, and composition of the 1994-95 influenza vaccine. MMWR 1994;43:179- 83. 3. CDC. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1995;44(no. RR-3). * Levels of activity are 1) sporadic--sporadically occurring influenza- like illness (ILI) or culture-confirmed influenza, with no outbreaks detected; 2) regional--outbreaks of ILI or culture-confirmed influenza in counties having a combined population of less than 50% of the state's total population; and 3) widespread--outbreaks of ILI or culture-confirmed influenza in counties having a combined population of greater than or equal to 50% of the state's total population. ** The epidemic threshold is 1.645 standard deviations above the seasonal baseline. The expected seasonal baseline is projected using a robust regression procedure in which a periodic regression model is applied to observed percentages of deaths from pneumonia and influenza since 1983. ------------------------------ To: hicnews Local Transmission of Plasmodium vivax Malaria -- Houston, Texas, 1994 Malaria was endemic in the United States until the late 1940s; since then, most cases of malaria reported in the United States has been acquired during international travel or has occurred in persons who had resided in countries where malaria is endemic. This report summarizes the investigation of three persons who acquired Plasmodium vivax infection in Houston, Texas, by presumed mosquitoborne transmission during 1994. Case Reports Case 1. On July 8, a 62-year-old man was hospitalized with an 8-day history of fever chills, sweats, and vomiting. His temperature on admission was 104.0 F (40.0 C). P. vivax parasites were identified on a blood smear on July 11. The patient recovered after treatment with chloroquine and primaquine. Case 2. On July 18, a 37-year-old man sought care in an emergency department at another hospital because of a temperature of 102.8 F (39.3 C) and a 3-week history of nausea, vomiting, fever, chills, sweats, headache, and shortness of breath. P. vivax parasites were identified on a routine peripheral blood smear on July 18. He recovered after treatment with chloroquine; although primaquine was not initially prescribed, he received it during the investigation in August. Case 3. On December 4, a 50-year-old man was admitted to the same hospital as in case 2 because of altered mental status, fever, and headache of 2 weeks' duration; his temperature on admission was 100.0 F (37.8 C). P. vivax parasites were identified on a routine peripheral blood smear on December 6. He recovered after treatment with chloroquine and primaquine. He had had similar symptoms with onset during late July and early August and had been admitted to two different hospitals during August. During the second hospitalization, viral meningitis was presumptively diagnosed; evaluation included one thick blood smear on August 23 (which was reported as negative for malaria parasites), and acute and convalescent immunoglobulin M enzyme-linked immunosorbent assay titers for St. Louis encephalitis (both titers were 1:10). The blood smears from August 23 were unavailable for review. However, tests of serum specimens from the August and December hospitalizations for malaria antibody by an indirect immunofluorescent assay were positive for P. vivax (titer of 1:64 on August 23, 1:256 on August 30, and 1:256 on December 6). These results indicate P. vivax malaria infection before December, and that the December episode most likely was a relapse from dormant liver stages (hypnozoite), which result only from mosquitoborne inoculation with sporozoites and not from person-to-person transmission (e.g., through blood transfusions or injecting drugs). Case Investigations Case-patients 2 and 3 had never traveled outside of the United States; case-patient 1 had traveled outside the United States only before 1956. None had a history of blood transfusions, tattoos, malariotherapy for Lyme disease, recent injecting-drug use, or previous malaria infection. They lived within a 3-mile radius, were not acquainted, and had not been in the same locations. However, all had prolonged nighttime exposure to mosquitoes, either through working outdoors at night or sleeping in housing without window panes and/or with unscreened windows and doors. They lived 10 miles from the nearest international airport, and there are no prevailing winds in Houston that would carry anophelines beyond their maximal flight range of 1-2 miles (1). Active Case-Finding Medical record reviews at all clinical laboratories and hospitals and contacts with infectious disease physicians identified 21 additional malaria patients in Houston and Harris County during June 1-August 22. At the time of the investigation, four (19%) of these patients had been reported through the existing passive surveillance system; 17 (81%) were identified by contacting laboratories in the Houston area. All 21 had traveled to countries where malaria is endemic; however, two of the 21 had visited only parts of northern Mexico where malaria transmission has not been reported. Of the 24 total patients, 10 (including cases 1-3) were infected with P. vivax; three of the 10 were treated with chloroquine only and had not received primaquine to prevent a relapse infection. The Harris County Mosquito Control District identified adult female Anopheles quadrimaculatus, a competent vector of malaria, in mosquito traps placed near the residences of patients 1 and 2 on August 4. Although possible breeding sites were identified near these residences, mosquito larvae were not found. Rainfall was below average during July-August, and many potential breeding sites were dry. Reported by: R Bell, PhD, J Cousins, W McNeely, MPH, P Rogers, PhD, A Payne, DrPH, M desVignes-Kendrick, MD, Houston Dept of Health and Human Svcs; J Billodeaux, R Jones, Harris County Mosquito Control District, Houston; J Taylor, MPH, K Hendricks, MD, J Perdue, Bur of Communicable Disease Control, D Simpson, MD, State Epidemiologist, Texas Dept of Health. Div of Field Epidemiology, Epidemiology Program Office; Div of Parasitic Diseases, National Center for Infectious Diseases, CDC. Editorial Note: The findings of the Houston investigation indicate that the P. vivax infections for patients 1-3 most likely were acquired locally (in Houston) as the result of mosquitoborne transmission. The course of illness in case 3 strongly supports mosquitoborne transmission and possible secondary transmission. Airport malaria (i.e., inadvertent transportation of infective anophelines on airplanes) is unlikely. This cluster of patients with locally acquired P. vivax malaria in an urban setting occurred 1 year after identification of an outbreak of locally acquired P. falciparum infection in New York City (M. Layton, New York City Department of Health, personal communication, 1994). Local transmission in densely populated areas represents a change in the epidemiologic pattern of malaria: until 1991, when local transmission was reported in a suburban area of New Jersey (2-4), local transmission had occurred predominantly in rural areas. Although malaria is a notifiable disease in all states, only seven (29%) of the 24 cases identified in this investigation had been reported to the health department in Houston. The lack of reporting of and information about these cases delayed the investigation and efforts to identify other possible locally acquired cases. For example, the two cases in persons who had traveled only to northern Mexico may have been either imported or locally acquired; however, because they had not been reported, they were not investigated promptly. In addition, although most hospital laboratories have the capacity to conduct malaria smear examinations, limitations in the experience of staff may decrease the likelihood of detection. To improve surveillance of all notifiable conditions, the Texas Department of Health has begun an educational campaign and is implementing an enhanced toll-free telephone reporting system aimed at all health- care practitioners; in addition, the Houston Health Department has distributed newsletters to physicians and infection-control practitioners informing them of the locally acquired cases, the proper treatment for cases, and the importance of reporting. The Harris County Mosquito Control District will enhance vector surveillance for anopheline vectors, which will be linked to active malaria case detection this summer. Malaria continues to be a leading cause of morbidity and mortality worldwide, particularly because of the development of drug-resistant strains, and is a continuing concern in the United States because of increased international migration, travel, and commerce. The basic requirements for local transmission of malaria--including persons (who may or may not be ill) with malarial gametocytes in their blood (as was documented in Houston), competent vectors, and conducive weather conditions--exist in many areas of the United States. Important strategies for preventing the re-establishment of malaria as an endemic disease in the United States are prompt recognition and reporting of cases of malaria; appropriate treatment of all malaria cases, including primaquine for P. vivax and P. ovale infections to prevent relapse; and implementation of appropriate control measures. References 1. Isaacson M. Airport malaria: a review. Bull World Health Organ 1989;67:737-43. 2. CDC. Transmission of Plasmodium vivax malaria--San Diego County, California, 1988 and 1989. MMWR 1990;39:91-4. 3. CDC. Mosquito-transmitted malaria--California and Florida, 1990. MMWR 1991;40:106-8. 4. Brook JH, Genese CA, Bloland PB, Zucker JR, Spitalny KC. Brief report: malaria probably locally acquired in New Jersey. N Engl J Med 1994;331:22- 3. ------------------------------ To: hicnews Rates of Cesarean Delivery -- United States, 1993 The rate of cesarean delivery in the United States is among the highest for developed nations (1). Because increased risks for maternal death and morbidity and perinatal morbidity are associated with cesarean delivery, a national health objective for the year 2000 is to reduce the overall rate of cesarean delivery to less than or equal to 15.0 per 100 deliveries (1987 baseline: 24.4 per 100 deliveries) (objective 14.8) (2)- -a level last observed in 1978 (3). This report uses data from CDC's National Hospital Discharge Survey (NHDS) to characterize cesarean deliveries during 1993, compares these rates with rates for 1970-1992, and assesses progress toward the national health objective for the year 2000. Since 1965, NHDS has collected data annually on discharges from short-stay, nonfederal hospitals. For 1993, medical and demographic information were abstracted from a sample of 235,411 inpatients discharged from the 466 participating hospitals. In this analysis, data about the number of cesareans and vaginal births after a previous cesarean (VBAC) are based on weighted national estimates from the NHDS sample of approximately 27,000 (11.5%) women discharged after delivery. The estimated numbers of live births by type of delivery were calculated by applying cesarean rates from the NHDS to the number of live births from national vital registration data. Stated differences in this report are significant at the 95% confidence level. In 1993, of the estimated 4,039,000 live births, approximately 585,000 (14.5%) were primary cesareans, 336,000 (8.3%) repeat cesareans, 115,000 (2.9%) VBACs, and 3,003,000 (74.4%) other vaginal deliveries. The overall rate of cesarean delivery in 1993 was 22.8 per 100 deliveries, the lowest rate since 1985 but approximately four times the rate in 1970 (5.5) (Table 1). The primary cesarean rate (i.e., number of first cesareans per 100 deliveries to women who had no previous cesarean) for 1993 (16.3) also was the lowest rate since 1985 but approximately four times the rate in 1970 (4.2). Declines in the overall and primary cesarean delivery rates from the mid-1980s to 1993 were not statistically significant. In 1993, of the women who had a previous cesarean birth, approximately one fourth gave birth vaginally (VBAC rate: 25.4); the VBAC rate in 1993 more than doubled from 1988 (12.6). In 1993, the overall rate of cesarean delivery differed by region, maternal age, hospital size and ownership, and expected source of payment (Table 2). Rates were higher in the South*, for mothers aged greater than or equal to 30 years (especially those aged greater than or equal to 35 years), for hospitals containing less than 100 beds, for proprietary hospitals, and for mothers with Blue Cross/Blue Shield** or other private insurance. The rate of cesarean delivery varied by the complications of pregnancy or delivery that preceded the cesarean. Rates were highest for women who had fetopelvic disproportion (98.5 per 100 deliveries) or failed induction of labor (94.3). Common medical complications were breech presentation (rate: 87.1); history of previous cesarean (74.6); antepartum hemorrhage, abruptio placenta, and placenta previa (64.1); obstructed labor (63.5); and multiple gestation (57.8). In 1993, of all women who had a cesarean, 36.5% had a previous cesarean delivery, 17.4% had an abnormal labor, and 17.0% had fetopelvic disproportion. Of all women who delivered, 11.2% had a previous cesarean, 8.7% each had abnormal labor or uterine inertia, and 7.6% were anemic. Reported by: Natality, Marriage, and Divorce Statistics Br, Div of Vital Statistics, National Center for Health Statistics, CDC. Editorial Note: The findings in this report indicate that the overall and primary cesarean rates have remained relatively stable since the mid- 1980s. Although the VBAC rate increased twofold during 1988-1993, the anticipated reduction in the overall rate of cesarean delivery was offset by trends among women giving birth that are associated with higher risk for cesarean delivery (i.e., increases in maternal age at birth and in first order and plural births [4]). In particular, maternal age is an independent risk factor for cesarean delivery even after adjustments for other potential confounding factors (e.g., race, education, and complications of labor and delivery) (5). In this study, rates of cesarean delivery were analyzed separately by region, hospital size and ownership, and expected source of payment; therefore, simultaneous effects of the other variables could not be analyzed. For example, the study could not assess whether the higher rates of cesarean delivery in small hospitals (i.e., less than 100 beds) reflected the increased likelihood of proprietary ownership of these hospitals. The overall cesarean delivery rate is directly associated with the primary cesarean rate and the VBAC rate. Therefore, in addition to establishing year 2000 national health objective 14.8 to assist in monitoring trends in the overall cesarean delivery rate, two more specific objectives were established to monitor trends in primary cesarean and VBAC rates. The objectives are to reduce the primary cesarean delivery rate to less than or equal to 12.0 per 100 deliveries (1987 baseline: 17.4 per 100 deliveries) (objective 14.8a) and to increase the number of VBACs to greater than or equal to 35.0 per 100 women who had a previous cesarean (objective 14.8b) (2). If the VBAC rate continues to increase at the rate observed during 1988-1993, the national health objective may be met by the year 2000; however, the most recent data indicate the rate stabilized during 1991-1993. Even with a VBAC rate of 35.0, the primary rate must decline by nearly half (to 8.4) to achieve the year 2000 target rate for overall cesarean deliveries (15.0). Based on the stability of the primary cesarean delivery rates during 1985-1993, the overall cesarean rate probably will not decline to meet the objective by the year 2000. In many countries with demographic profiles similar to the United States, cesarean rates are less than or equal to 15.0 per 100 deliveries (1). Strategies to achieve this rate in the United States will require the widespread use of four obstetrical practices that have been successful in reducing cesarean delivery rates in many hospitals: 1) active management of labor; 2) public dissemination of physician-specific cesarean delivery rates to increase public awareness of differences in practices; 3) implementation of standardized protocols for repeat cesareans, dystocia, and fetal distress; and 4) establishment of reduction of the rate as an institutional priority (6-8). References 1. Notzon FC. International differences in the use of obstetric interventions. JAMA 1990;263:3286-91. 2. 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. 3. CDC. Rates of cesarean delivery--United States, 1991. MMWR 1993;42:285- 9. 4. Ventura SJ, Martin JA, Taffel SM, et al. Advance report of final natality statistics, 1992. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1994. (Monthly vital statistics report; vol 43, no. 4, suppl). 5. Peipert JF, Bracken M. Maternal age: an independent risk factor for cesarean delivery. Obstet Gynecol 1993;81:200-5. 6. Sanchez-Ramos L, Kaunitz AM, Peterson HB, et al. Reducing cesarean section rates at a teaching hospital. Am J Obstet Gynecol 1990;163:1081- 8. 7. Socol ML, Garcia PM, Peaceman AM, Dooley SL. Reducing cesarean births at a primarily private university hospital. Am J Obstet Gynecol 1993;168:1748-58. 8. Myers SA, Gleicher N. A successful program to lower cesarean-section rates. N Engl J Med 1988;319:1511-6. * South=Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia ** 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. ------------------------------ To: hicnews Reporting National Notifiable Diseases Reporting -- United States, 1995 Beginning with the April 28, 1995, MMWR, the following modifications will be incorporated in Tables I and II, Cases of Notifiable Diseases, United States, and Figure I, Notifiable Disease Reports: 1) diseases recently deleted from the nationally notifiable diseases list by the Council of State and Territorial Epidemiologists will no longer appear in Tables I and II and Figure I (i.e., aseptic meningitis, primary and postinfectious encephalitis, unspecified hepatitis, leptospirosis, and tularemia) and 2) the column in Table II labeled NA,NB hepatitis will be relabeled "C/NA,NB" hepatitis. ------------------------------ To: hicnews Clean Air Month -- May 1995 The American Lung Association (ALA) sponsors National Clean Air Month each May to educate the public about the relation between clean air and respiratory health. This year's theme is "Helping Kids Breathe Easier." Air pollution is an important contributor to lung disease, the third leading cause of death in the United States. ALA is committed to decreasing lung disease in children by emphasizing the importance of reducing air pollution. ALA recommends that persons drive less, support state and local clean air regulations, make their homes and workplaces smoke-free, and test them for harmful pollutants (e.g., radon and carbon monoxide). Efforts planned by local lung associations throughout the country for Clean Air Month include Clean Commute Days and Clean Air Challenge cycling and walking fundraising events. This issue of MMWR includes a report that provides estimates of the number of children potentially at risk from ozone air pollution. Additional information about Clean Air Month and related activities is available from local ALA offices (telephone [800] 586-4872) or from the national office (1740 Broadway, New York, NY 10019-4374; telephone [212] 315-8700). ------------------------------ To: hicnews Children at Risk from Ozone Air Pollution -- United States, 1991- 1993 A national health objective for the year 2000 is to reduce exposure to air pollutants so that at least 85% of persons reside in counties that meet Environmental Protection Agency (EPA) standards (objective 11.5) (1). Ozone, the principle component of summer smog, is the most pervasive air pollutant in the United States. The risks associated with ozone and other air pollutants are especially increased for children and adults with asthma (2); however, children with no underlying pulmonary diseases also are at risk for adverse health effects associated with these pollutants (3). In addition, because children of racial/ethnic minorities are more likely to reside in areas with higher air pollution levels, they may be exposed to higher levels of ozone (4). This report presents the findings of an analysis by the American Lung Association (ALA) to characterize pediatric populations potentially at risk for adverse health effects from exposure to ozone air pollution in the United States during 1991-1993. The National Ambient Air Quality Standard for ozone is 0.12 parts per million (ppm) averaged over 1 hour.* The federal standard is met if this value is not exceeded more than once per calendar year on average over a 3- year period. The federal "exceedance" of the 0.12 ppm standard is defined as all levels greater than or equal to 0.125 ppm.** For this report, both the federal exceedance level (greater than or equal to 0.125 ppm, averaged over 1 hour) and an alternative level--used in recent health studies (greater than or equal to 0.085 ppm, averaged over 8 hours) (5)--were used as cutoff values. The 1990 population census provided race/ethnicity-specific data for persons aged less than or equal to 17 years in each county (Bureau of the Census, unpublished data, 1992). The number of children with asthma was estimated by applying age-specific national prevalence rates from CDC's National Health Interview Survey (6) to age-specific population estimates at the county level. Information about ozone exposure was based on 1991- 1993 monitored ozone data (EPA, unpublished data, 1994), the most recent data available from EPA. Although individual levels of ozone exposure may vary for persons who reside in a particular county and differ from those measured by the monitor in that county, ozone levels generally are consistent within specific geographic areas (7). During 1991-1993, ozone levels exceeded 0.085 ppm over 8 hours on four or more occasions in 394 counties and cities; an estimated 136 million persons (54.7% of the U.S. population) resided in these areas. Of the total number of children aged less than or equal to 13 years in the United States (50,324,764), approximately 27.1 million (53.9%) resided in these areas. Among racial/ethnic groups, 61.3% of all black children, 67.7% of all Asian/ Pacific Islander children, and 69.2% of all Hispanic children resided in these areas (Table 1). An estimated 2.0 million (5.8%) of the 34.3 million children (aged less than or equal to 17 years) residing in these areas were affected by asthma. During 1991-1993, a total of 104 counties and cities had ozone levels greater than 0.125 ppm over a 1-hour period on four or more occasions. An estimated 60 million persons in the United States (24.1% of the U.S. population) resided in these areas, including an estimated 12.1 million children (aged less than or equal to 13 years) (24.1% of all children in this age group). Among racial/ethnic groups, 23.1% of black children, 39.9% of Asian/Pacific Islander children, and 44.2% of Hispanic children resided in these areas (Table 2). Approximately 877,000 children (aged less than or equal to 17 years) in these areas were affected by asthma. Reported by: R White, MST, National Programs Div, S Rappaport, MPH, K Lieber, MPH, A Gorman, Epidemiology and Statistics Div, F DuMelle, D Maple, Government Relations Div, M Bhawnani, Communications Div, N Edelman, MD, American Lung Association, New York. Air Pollution and Respiratory Health Br, Div of Environmental Hazards and Health Effects, National Center for Environmental Health, CDC. Editorial Note: Ozone pollution results when hydrocarbons and nitrogen oxides emitted from motor vehicles and other sources react in the presence of sunlight. Exposure to ozone has been associated with adverse health effects, including hospital and emergency department visits for asthma and other respiratory problems; reductions in lung function; and exercise-related wheezing, coughing, and chest tightness (5). Children are at higher risk for detrimental effects of ozone than adults because they spend more time outdoors during summer months when ozone levels are higher and because their lungs are still developing (8). Although air pollution has been recognized as a public health hazard in the United States since the 1950s, the disproportionate risks for racial/ethnic minorities with low incomes have only recently been recognized (4). The findings in this report underscore the increased risk for exposure--particularly among children--for racial/ethnic minorities who reside in areas where national air quality standards are not met (4). In addition, since the early 1980s, the risk for asthma-associated mortality and hospitalization has been consistently higher among young persons who are black (9). ALA recently issued Danger Zones: Ozone Air Pollution and Our Children. The report is a national and county estimate of the number of children who are at potential risk from exposure to ozone. Copies are available from local offices of the ALA, telephone (800) 586-4872 or (212) 315-8700. References 1. 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. 2. CDC. Populations at risk from air pollution--United States, 1991. MMWR 1993;42:301-4. 3. Committee on Environmental Health. Ambient air pollution: respiratory hazards to children. Pediatrics 1993;91:1210-3. 4. US Environmental Protection Agency. Environmental equity: reducing risk for all communities. Volume 1: workgroup report to the Administrator. Washington, DC: US Environmental Protection Agency, Office of Policy, Planning, and Evaluation, June 1992; publication no. EPA-230/R-92/008. 5. Lippmann M. Health effects of tropospheric ozone: review of recent research findings and their implications to ambient air quality standards. J Expo Anal Care Environ Epidemiol 1993;3:103-29. 6. NCHS. Current estimates from the National Health Interview Survey, 1990. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1991; DHHS publication no. (PHS)92-1509. (Vital and health statistics; series 10, no. 181). 7. Curran T, Fitz-Simons T, Freas W, et al. National air quality and emissions trends report, 1993. Research Triangle Park, North Carolina: US Environmental Protection Agency, Office of Air Quality Planning and Standards, October 1994; publication no. EPA-454/R-94/026. 8. World Health Organization. Principles for evaluating health risks from chemicals during infancy and early childhood: the need for a special approach. Geneva: World Health Organization, 1986; environmental criteria 59. 9. CDC. Asthma--United States, 1982-1992. MMWR 1995;43:952-5. * 44 FR 8202. ** 40 CFR 50. ------------------------------ To: hicnews Fatal and Nonfatal Suicide Attempts Among Adolescents -- Oregon, 1988- 1993 Suicide is the third leading cause of death among adolescents aged 15-19 years in the United States and second among adolescents in Oregon. During 1959-1961 and during 1990-1992, the rate of suicide in Oregon increased sixfold among 15-19-year-olds. During 1988-1991, the suicide rate for adolescents in Oregon (15.5 deaths per 100,000) was 39.6% higher than the U.S. rate (11.1). Because of the magnitude of this problem, in 1987 the state legislature in Oregon mandated that hospitals treating a child aged less than or equal to 17 years for injuries resulting from a suicide attempt report the attempt to the State Health Division, Oregon Department of Human Resources, and that the patient be referred for counseling; the Oregon Adolescent Suicide Attempt Data System (ASADS) was established in 1988. This report presents an analysis of data for adolescents aged less than or equal to 17 years from ASADS during 1988-1993. Notification of suicide attempt is made through a one-page report form, which is usually completed by emergency department or medical records personnel and is submitted monthly from all hospitals in the state. Hospitals use their own criteria to define attempts. Information collected includes age, race/ethnicity, sex, place of attempt, date of attempt, method of attempt, and whether the patient was admitted to the hospital. Beginning in 1990, data also were collected on reasons for the attempt and number of previous attempts. Data missing from attempt reports were imputed in proportion to known distributions for the specified variable. The proportion of missing data ranged from 0.1%-23.5%. In this analysis, fatal attempts were identified using death certificate data. During 1988-1993, a total of 3783 suicide attempts were reported for persons aged less than or equal to 17 years; of these, 3773 were by persons aged 10-17 years (Table 1). Sex-specific attempt rates were 326.4 per 100,000 for females and 73.4 for males. Children as young as age 6 years had attempted suicide. The number of reported attempts increased steadily with age for males but peaked at age 15 years for females (Figure 1). Characteristics of Fatal and Nonfatal Suicide Attempts During 1988-1993, most (2981 [78.8%]) suicide attempts were made in the residence of the attempter; 280 (7.4%), in another residence; 178 (4.7%), in school; and seven (0.2%), in jail. Attempts occurred more commonly during spring months (March, April, and May) (1106 [29.2%]) and least commonly during summer months (June, July, and August) (731 [19.3%]). In addition, attempts occurred most frequently on Mondays (660 [17.4%]) and least often on Saturdays (414 [11.0%]). Among youth aged 10-17 years, 123 (6.4 per 100,000) made a suicide attempt that resulted in death (Table 1). The rate of fatal suicide attempts was three times greater for males (9.5) than for females (3.1). In addition, the proportion of attempts that were fatal was more than 100-fold higher among males (94 [11.5%]) than among females (29 [0.1%]). Although the risk for attempts was 3.8 times greater among youth aged 15-17 years than among those aged 10-14 years, the proportions of fatal attempts were similar among males and females in both age groups. During 1990-1993, of the 2511 persons who attempted suicide, 1042 (41.5%) reported having made at least one previous attempt during the preceding 5 years. Previous attempts occurred most often among those who indicated their reason for attempting suicide was rape/sexual abuse (149 [60.7%]), substance abuse (111 [56.6%]), or physical abuse (46 [54.0%]). Methods Used During 1988-1993, ingestion of drugs accounted for most (2857 [75.5%]) attempts (Table 2); of the attempts involving drugs, analgesics accounted for 1354 (47.4%) (aspirin and acetaminophen were used most commonly). Cutting and piercing injuries accounted for 421 (11.1%) of the attempts, of which most were lacerations of the wrists. Most attempts by multiple methods were lacerations combined with a drug overdose. Drugs were used in 2440 (79.8%) attempts by females, compared with 417 (57.4%) by males (Table 2). Males who attempted suicide were more likely than females to do so by suffocation/hanging, cutting/piercing, or use of firearms (Table 2). Of all methods used to attempt suicide, those used most commonly were least likely to result in death (e.g., of attempts by drug overdose, 0.4% were fatal) (Table 2). In comparison, 78.2% and 35.7% of attempts using firearms or poisonings with gas, respectively, were fatal. Of the 124 deaths among persons aged less than or equal to 17 years, most resulted from use of firearms (63.7%) or suffocation/hanging (18.5%). During 1990-1993, persons who had made multiple attempts were more likely to use suffocation/hanging (4.3%) and cutting/piercing (14.3%) than those making attempts for the first time (1.2% and 6.9%, respectively). Reasons for Suicide Attempt During 1990-1993, the most commonly reported reasons for attempting suicide were family discord (1492 [59.4%]), an argument with a boyfriend/girlfriend (819 [32.6%]), and school-related problems (578 [23.0%]) (Table 3). A higher proportion of females (60.8%) and persons aged less than or equal to 12 years (73.0%) reported family discord as their reason for attempting suicide. Reported by: DD Hopkins, MS, JA Grant-Worley, MS, DW Fleming, MD, State Epidemiologist, State Health Div, Oregon Dept of Human Resources. National Center for Injury Prevention and Control, CDC. Editorial Note: In Oregon, during 1988-1993, for every fatal suicide attempt by an adolescent, 31 nonfatal attempts were reported. Some attempts may not have been made with death as a goal but instead may have reflected a desire to resolve a difficult conflict, indicate an intolerable living situation, or elicit sympathy or guilt (1,2). Oregon is the only state with a legal requirement for reporting suicide attempts and a surveillance system for monitoring such attempts. The reported rate of suicide attempts among adolescents in Oregon during 1988-1993 based on ASADS data is substantially lower than previously reported using survey data. Based on the 1993 Youth Risk Behavior Survey, 2.7% of U.S. high school students reported making a suicide attempt during the previous 12 months that required medical attention (3); 3.2% (i.e., 3200 per 100,000) of Oregon high school students reported such attempts. Because ASADS is hospital-based and includes only attempts by persons who actually seek medical care, the findings may provide more valid information than other sources. For example, data from surveys often rely on the respondents' definition of attempted suicide, and only small proportions of respondents who report having attempted suicide actually have taken a substantive action to injure themselves (4). Furthermore, YRBS may overestimate the prevalence of suicide attempts among high school students. However, ADADS probably underestimates the occurrence of suicide attempts in Oregon for at least four reasons. First, hospital reporting may be incomplete; in addition, reporting hospitals may use different criteria in determining whether a patient attempted suicide. Second, reports of adolescent suicide attempts are not required from clinics or physicians' offices; some attempters may have been treated in these settings, especially those living in rural areas. Third, attempts by adolescents who did not require professional medical care were not reported. Finally, when persons from Oregon receive treatment in another state for a suicide attempt, the event is unreported. In Oregon, firearms were used most often in fatal suicide attempts, and most attempts involving firearms were fatal. Nationally, 81% of the increase in suicide among persons aged 15-19 years during 1980-1992 was related to use of firearms (5). Controlling access to firearms is an important prevention measure; however, storing weapons unloaded and locked may not prevent intentionally inflicted gunshot wounds among suicidal youth (6). Because an attempt with a gun usually results in death, parents and other persons who have responsibility for children should ensure that at-risk adolescents have no access to guns. ASADS represents an initial effort to examine the magnitude and epidemiology of intentionally self-inflicted injury among adolescents. This surveillance system was the first statewide system established to quantify the incidence of adolescent suicide attempts and to characterize the attempts and attempters. Although the system still must undergo vigorous evaluation (7), it provides essential information that will be useful in applying public health measures to the problem of suicide (8). Data from ASADS are being used to develop public and private suicide-education programs. For example, the Oregon Health Division has formed a task force to review the data and propose intervention methods. This approach may be adopted for use in other states to permit characterization of persons attempting suicide and to assist in refining prevention and early-intervention measures. References 1. Bolton IM. Perspectives of youth on preventive intervention strategies. In: Alcohol, Drug Abuse, and Mental Health Administration. Report of the Secretary's Task Force on Youth Suicide: Volume 3--prevention and interventions in youth suicide. Washington, DC: US Department of Health and ·_ Human Services, Public Health Service, 1989:264-75; DHHS publication no. (ADM)89-1623. 2. Committee on Adolescence, American Academy of Pediatrics. Suicide and suicide attempts in adolescents and young adults. Pediatrics 1988;81:322- 4. 3. Kann L, Warren CW, Harris WA, et al. Youth risk behavior surveillance--United States, 1993. In: CDC surveillance summaries (March). MMWR 1995;44(no. SS-1). 4. Meehan PJ, Lamb JA, Saltzman LE, O'Carroll PW. Attempted suicide among young adults: progress towards a meaningful estimate of prevalence. Am J Psychiatry 1992;149:41-4. 5. CDC. Suicide among children, adolescents, and young adults--United States, 1980-1992. MMWR 1995;44:289-91. 6. Brent DA, Perper JA, Goldstein CE, et al. Risk factors for adolescent suicide: a comparison of adolescent suicide victims with suicidal inpatients. Arch Gen Psychiatry 1988;45:581-8. 7. Klaucke DN, Buehler JW, Thacker SB, et al. Guidelines for evaluating surveillance systems. MMWR 1988;37(no. S-5). 8. Potter L, Powell K, Kachur S. Suicide prevention from a public health perspective. Suicide Life Threat Behav 1995;25:83-92. ------------------------------ End of HICNet Medical News Digest V08 Issue #19 *********************************************** --- Editor, HICNet Medical Newsletter Internet: david@stat.com FAX: +1 (602) 451-6135