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HICNet Medical News Digest      Fri, 18 Mar 1994        Volume 07 : Issue 08

Today's Topics:

  [MMWR 4 March 94] Health Risk Among Adolescents Who Do/Don't Attend School
  [MMWR] Physical Violence During the 12 Months Preceding Childbirth
  [MMWR] Clostridium Gastroenteritis Associated with Corned Beef
  [MMWR] Progress Elimination Haemophilus influenzae type b
  [MMWR 11 March 94] Injuries Associated with Soccer Goalposts
  [MMWR] Heterosexually Acquired AIDS

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----------------------------------------------------------------------

Date: Fri, 18 Mar 94 23:20:51 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR 4 March 94] Health Risk Among Adolescents Who Do/Don't Attend
 School
Message-ID: <[e-mail]>

                    Health Risk Behaviors Among Adolescents
            Who Do and Do Not Attend School -- United States, 1992

     High proportions of U.S. high school students engage in behaviors that
place them at increased risk for the leading causes of death and morbidity
(e.g., motor-vehicle crashes and other unintentional injuries, homicide,
suicide, heart disease, and cancer [1]), unintended pregnancy, and infection
with human immunodeficiency virus (HIV) and other sexually transmitted
diseases (2). Because efforts to measure health-risk behaviors among
adolescents throughout the United States have not included those who do not
attend school, the prevalences of those behaviors are probably underestimated
for the total adolescent population. To characterize more accurately the
prevalence of selected health-risk behaviors among adolescents aged 12-19
years who do and do not attend school, CDC analyzed self-reported national
data from the Youth Risk Behavior Survey (YRBS), conducted as part of the 1992
National Health Interview Survey (NHIS). This report summarizes the results of
the analysis.
     The 1992 NHIS was conducted among a representative sample of the civilian
noninstitutionalized U.S. population using a multistage cluster-area
probability design of approximately 120,000 persons representing approximately
49,000 households. The YRBS was conducted as a followback survey to the NHIS
among a representative sample of adolescents in the sampled households. In
each household with at least one person aged 12-21 years, the current school
enrollment status of each adolescent was determined as either "in-school"
(i.e., attending school or on vacation from school at the time of the
interview) or "out-of-school" (i.e., not attending school and had not
graduated from high school or attained General Educational Development
credentials at the time of the interview). Out-of-school adolescents were
over-sampled. During April 1992-March 1993, adolescent respondents listened to
a tape recording of the questionnaire and recorded their responses on a
standardized answer sheet. Questionnaires were completed by 10,645 (77.2%)
eligible adolescents. Information was analyzed for the 6969 respondents who
were aged 12-19 years and had not completed high school. Among these
respondents, 91% were classified as in-school and 9% as out-of-school. Results
were standardized by age by using the age distribution of the total population
participating in the YRBS. SUDAAN was used to compute all standard errors for
the estimates and for differences between the estimates (3). All estimates
were based on weighted data.
     In-school adolescents were significantly more likely than out-of-school
adolescents to have reported "always" using safety belts when riding in a car
or truck as a passenger (33.2% versus 23.2%) and were significantly less
likely to have reported riding during the 30 days preceding the survey with a
driver who had been drinking alcohol (18.9% versus 28.4%), having been
involved in a physical fight during the 12 months preceding the survey (44.2%
versus 51.0%), and having carried a weapon (e.g., gun, knife, or club) during
the 30 days preceding the survey (15.5% versus 22.9%) (Table 1). Use of
motorcycle helmets did not vary by school enrollment status.
     Out-of-school adolescents were significantly more likely than in-school
adolescents to have reported smoking cigarettes during the 30 days preceding
the survey (33.7% versus 20.4%) and to have reported ever having smoked
cigarettes (57.7% versus 50.9%) or used alcohol (62.9% versus 55.2%),
marijuana (31.4% versus 15.9%), or cocaine (7.1% versus 2.1%) (Table 1). Use
of chewing tobacco or snuff during the 30 days preceding the survey, episodic
heavy drinking*, and injecting-drug use did not vary by school enrollment
status.
     Out-of-school adolescents aged 14-19 years were significantly more likely
than in-school adolescents to have reported ever having had sexual intercourse
(70.1% versus 45.4%) and to have had four or more sexual partners (36.4%
versus 14.0%) (Table 1)**. Among adolescents who reported having had sexual
intercourse during the 3 months preceding the survey, use of condoms at last
sexual intercourse did not vary by school enrollment status.
     In-school adolescents were significantly more likely than out-of-school
adolescents to have reported eating five or more servings of fruits and
vegetables during the day preceding the survey (14.5% versus 10.1%) (Table 1).
Eating foods typically high in fat content and participating in moderate
physical activity did not vary by school enrollment status.

Reported by: Div of Adolescent and School Health, National Center for Chronic
Disease Prevention and Health Promotion; Div of Health Interview Statistics,
National Center for Health Statistics, CDC.

Editorial Note: The findings in this report indicate that out-of-school
adolescents were more likely to engage in behaviors (e.g., sexual intercourse
and cigarette smoking) with potentially severe adverse health outcomes than
were adolescents in school. In 1991, 13% of all persons aged 16-24 years in
the United States were high school dropouts (4). Some health-risk behaviors
(e.g., alcohol use and other drug use and sexual intercourse resulting in
unintended pregnancy) may have preceded and contributed to the decision of
some adolescents to quit school, and these risk behaviors may increase after
adolescents quit school (5).
     Because health education can assist adolescents who remain in school to
develop skills to avoid or modify health-risk behaviors, two national goals
(National Education Goal 2 [4] and year 2000 national health objective 8.2
[5]) are to increase the high school graduation rate to at least 90% by the
year 2000. In addition, health objective 8.4 is to increase to at least 75%
the proportion of elementary and secondary schools that provide planned and
sequential school health education from kindergarten through 12th grade (5).
     The findings in this report are being used by public health and education
officials to highlight the special needs of out-of-school adolescents and to
develop innovative approaches to provide accessible prevention services to
adolescents who are not in school. Such approaches may include partnerships
among or between schools, health departments, voluntary health organizations,
community organizations, religious organizations, families, and adolescents.
In 1991, CDC expanded efforts to intensify public health and education
programs among out-of-school adolescents and others in high-risk situations
(e.g., runaways, homeless adolescents, juvenile offenders, and migrant youth).
This initiative is assisting local health departments in Chicago, the District
of Columbia, Los Angeles, and New York City to strengthen their capacity to
prevent HIV infection and other health problems and to establish or strengthen
existing coalitions of community-based organizations that serve youth. By
providing training, improving agency referral systems, and sharing resources,
these coalitions will help participating agencies increase their capacity to
reach youth so that all adolescents will have better access to an integrated
service-delivery system that may better meet their needs.

References:

1. 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):47-55.

2. Morris L, Warren CW, Aral SO. Measuring adolescent sexual behaviors and
related health outcomes. Public Health Rep 1993;108(suppl):31-6.

3. Shah BV, Barnwell BG, Hunt PN, LaVange LM. SUDAAN user's manual, release
5.50. Research Triangle Park, North Carolina: Research Triangle Institute,
1991.

4. National Education Goals Panel. The national education goals report.
Washington, DC: National Education Goals Panel, 1991.

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.

* Drinking five or more drinks of alcohol on at least one occasion during the
30 days preceding the survey.

** 12-13-year-olds were not asked the sexual behavior questions.




------------------------------

Date: Fri, 18 Mar 94 23:21:42 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR] Physical Violence During the 12 Months Preceding Childbirth
Message-ID: <[e-mail]>

        Physical Violence During the 12 Months Preceding Childbirth --
             Alaska, Maine, Oklahoma, and West Virginia, 1990-1991

     In addition to clearly defined health risks that develop during pregnancy
(e.g., toxemia and diabetes), pregnant women are at risk for physical violence
inflicted by intimate partners (1). Although estimates in public and private
health-care settings indicate that 4%-17% of women experience violence during
pregnancy (2-5), population-based prevalence estimates of this problem have
not been available. This report uses 1990 and 1991 data from the Pregnancy
Risk Assessment Monitoring System (PRAMS) in Alaska, Maine, Oklahoma, and West
Virginia to assess the prevalence of physical violence against women during
the 12 months preceding childbirth* and its relation to maternal
characteristics.
     PRAMS is a population-based surveillance system used in 13 states** and
the District of Columbia to supplement data from birth certificates with self-
reported behavioral information obtained from mothers (6). A stratified
systematic sample of 100-200 new mothers in each state is selected monthly
from birth certificates. Sampled women are mailed a 14-page questionnaire 3-6
months after delivery. This report includes an analysis of responses from
women in the four states*** that have both data available for 1990 and 1991
and questionnaire response rates of at least 70% (range: 71%-84%). Data were
weighted to account for survey design and nonresponse. Standard errors (SEs)
were estimated using SUDAAN (7). Weighted percentages and Ses represent
accurate state-based population estimates.
     Respondents were asked if their "husband or partner physically hurt
[them]" during the 12 months preceding childbirth. In addition, the PRAMS
questionnaire elicited information about household crowding****; participation
in the Special Supplemental Food Program for Women, Infants, and Children
(WIC) during pregnancy; initiation of prenatal care; and planning status
(i.e., intended or unintended*****) of the pregnancy. Data on maternal
education, race, age, and marital status were obtained from birth
certificates.
     In each state, most respondents had completed at least 12 years of
education, were white, were aged greater than or equal to 25 years, were
married, were not living in crowded conditions, had not participated in WIC
during pregnancy, had initiated prenatal care during the first trimester, and
had an intended pregnancy (Table 1). The percentage of women who reported
having been physically hurt by their husband or partner during the 12 months
preceding childbirth varied among the four states, from 3.8% in Maine to 6.9%
in Oklahoma (Table 2). In general, in each state, rates of physical violence
were higher for women who had completed fewer than 12 years of education, were
of races other than white, were aged less than or equal to 19 years, were
unmarried, were living in crowded conditions, had participated in WIC during
pregnancy, had delayed or no prenatal care, and had an unintended pregnancy.

Reported by: M VandeCastle, Alaska Dept of Health and Social Svcs. J Danna,
MPH, Maine Dept of Human Svcs. E DeCoster, Oklahoma State Dept of Health. T
Thomas, MPA, West Virginia Dept of Health and Human Resources. Div of
Reproductive Health, National Center for Chronic Disease Prevention and Health
Promotion; Div of Violence Prevention, National Center for Injury Prevention
and Control, CDC.

Editorial Note: Each year, approximately 1.8 million (3.4%) women in the
United States are physically assaulted by their partners (8). Similar
proportions were indicated in the findings in this report for new mothers who
had experienced violence during the 12 months preceding childbirth in Alaska,
Maine, Oklahoma, and West Virginia. Although this analysis indicates that
certain subgroups are at increased risk for physical violence during
pregnancy, health-care providers should be aware of this risk among all
pregnant women. In addition, efforts are needed to determine how health-care
providers can more effectively identify women at risk for physical violence
and to evaluate intervention programs and examine further the patterns of
violence during pregnancy.
     Although this analysis provides state-based population estimates, the
findings are subject to at least five limitations. First, because respondents
were asked to report violent incidents that occurred during the 12 months
preceding childbirth, the precise timing of the incidents could not be
determined; for example, it could not be determined whether reported violence
began during pregnancy in what were previously nonviolent relationships.
Second, respondents may have had different interpretations of what constituted
being physically hurt. Third, many factors that may be associated with
violence during pregnancy were either not available (e.g., characteristics of
the perpetrator of the violence) or not readily ascertainable from this
analysis. For example, women of races other than white were at increased risk
for physical violence during the 12 months preceding childbirth; however, race
is most likely a proxy for other risk factors (e.g., poverty) that increase
the risk for violence during pregnancy among these women. Fourth, PRAMS does
not include women who had spontaneous or induced abortions or fetal deaths;
the effect of including these women on the estimated frequency of violence
during pregnancy is unknown. Finally, violence during the 12 months preceding
childbirth may have been underreported by some women because of the social
stigma associated with violence.
     Because some women receive health care only during pregnancy, interviews
and physical examinations conducted during routine prenatal-care visits may
assist in identifying some women who are experiencing violence (5). In
addition, because other women who are experiencing violence may seek care at
emergency departments, these facilities should establish strategies for
identifying these women. The Joint Commission on Accreditation of Healthcare
Organizations recommends that accredited emergency departments establish
policies, procedures, and education programs to guide staff in the treatment
of battered adults (9). Furthermore, all health-care providers should
establish relations with organizations that can provide battered women with
referral services such as emergency housing, court accompaniment, legal aid,
health care, and support groups (10).

References

1. Newberger EH, Barken SE, Lieberman ES, et al. Abuse of pregnant women and
adverse birth outcome: current knowledge and implications for practice. JAMA
1992;267:2370-2.

2. Hillard PJ. Physical abuse in pregnancy. Obstet Gynecol 1985;66:185-90.

3. Stewart DE, Cecutti A. Physical abuse in pregnancy. Can Med Assoc J
1993;149:1257-63.

4. Helton AS, McFarlane J, Anderson ET. Battered and pregnant: a prevalence
study. Am J Public Health 1987;77:1337-9.

5. McFarlane J, Parker B, Soeken K, Bullock L. Assessing for abuse during
pregnancy: severity and frequency of injuries and associated entry into
prenatal care. JAMA 1992;267:3176-8.

6. Adams MM, Shulman HB, Bruce C, Hogue C, Brogan D, The PRAMS Working Group.
The Pregnancy Risk Assessment Monitoring System: design, questionnaire, data
collection and response rates. Paediatr Perinat Epidemiol 1991;5:333-46.

7. Shah BV, Barnwell BG, Hunt PN, LaVange LM. SUDAAN user's manual, release
5.50. Research Triangle Park, North Carolina: Research Triangle Institute,
1991.

8. Straus MA, Gelles RJ. How violent are American families? In: Straus MA,
Gelles RJ, eds. Physical violence in American families: risk factors and
adaptations to violence in 8,145 families. New Brunswick, New Jersey:
Transaction Publishers, 1990:95-112.

9. Joint Commission on Accreditation of Healthcare Organizations.
Accreditation manual for hospitals. Vol 1--standards. Oakbrook Terrace,
Illinois: Joint Commission on Accreditation of Healthcare Organizations,
1992:21-2.

10. Morey MA, Beleiter ML, Harris DJ. Profile of a battered fetus. Lancet
1981;2:1294-5.

* The 3 months before and 9 months during pregnancy.

** Alabama, Alaska, California, Florida, Georgia, Indiana, Maine, Michigan,
New York, Oklahoma, South Carolina, Washington, and West Virginia.

*** For Alaska, the sample size was 2975; for Maine, 2500; for Oklahoma, 3505;
and for West Virginia, 3632.

**** Determined by dividing the total number of persons living in the
household by the total number of rooms in the house. Women were classified as
living in crowded conditions if the calculation was more than one person per
room.

***** A pregnancy that, at the time of conception, the woman never wanted or
did not want until later in life.




------------------------------

Date: Fri, 18 Mar 94 23:22:28 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR] Clostridium Gastroenteritis Associated with Corned Beef
Message-ID: <[e-mail]>

              Clostridium perfringens Gastroenteritis Associated
             with Corned Beef Served at St. Patrick's Day Meals --
                            Ohio and Virginia, 1993

     Clostridium perfringens is a common infectious cause of outbreaks of
foodborne illness in the United States, especially outbreaks in which cooked
beef is the implicated source (1,2). This report describes two outbreaks of C.
perfringens gastroenteritis following St. Patrick's Day meals in Ohio and
Virginia during 1993.

                                     Ohio

     On March 18, 1993, the Cleveland City Health Department (CCHD) received
telephone calls from 15 persons who became ill after eating corned beef
purchased from one delicatessen. After a local newspaper article publicized
this problem, 156 persons contacted CCHD to report onset of diarrheal illness
within 48 hours of eating food from the delicatessen on March 16 or March 17.
Symptoms included abdominal cramps (88%) and vomiting (13%); no persons were
hospitalized. The median incubation period was 12 hours (range: 2-48 hours).
Of the 156 persons reporting illness, 144 (92%) reported having eaten corned
beef; 20 (13%), pickles; 12 (8%), potato salad; and 11 (7%), roast beef.
     In anticipation of a large demand for corned beef on St. Patrick's Day
(March 17), the delicatessen had purchased 1400 pounds of raw, salt-cured
product. Beginning March 12, portions of the corned beef were boiled for 3
hours at the delicatessen, allowed to cool at room temperature, and
refrigerated. On March 16 and 17, the portions were removed from the
refrigerator, held in a warmer at 120 F (48.8 C), and sliced and served.
Corned beef sandwiches also were made for catering to several groups on March
17; these sandwiches were held at room temperature from 11 a.m. until they
were eaten throughout the afternoon.
     Cultures of two of three samples of leftover corned beef obtained from
the delicatessen yielded greater than or equal to 105 colonies of C.
perfringens per gram.
     Following the outbreak, CCHD recommended to the delicatessen that meat
not served immediately after cooking be divided into small pieces, placed in
shallow pans, and chilled rapidly on ice before refrigerating and that cooked
meat be reheated immediately before serving to an internal temperature of
greater than or equal to 165 F (greater than or equal to 74 C).

                                   Virginia

     On March 28, 1993, 115 persons attended a traditional St. Patrick's Day
dinner of corned beef and cabbage, potatoes, vegetables, and ice cream.
Following the dinner, 86 (76%) of 113 persons interviewed reported onset of
illness characterized by diarrhea (98%), abdominal cramps (71%), and vomiting
(5%). The median incubation period was 9.5 hours (range: 2-18.5 hours).
Duration of illness ranged from 1 hour to 4.5 days; one person was
hospitalized.
     Corned beef was the only food item associated with illness; cases
occurred in 85 (78%) of 109 persons who ate corned beef compared with one of
four who did not (relative risk=3.1; 95% confidence interval=0.6-17.1).
Cultures of stool specimens from eight symptomatic persons all yielded greater
than or equal to 106 colonies of C. perfringens per gram. A refrigerated
sample of leftover corned beef yielded greater than or equal to 105 colonies
of C. perfringens per gram.
     The corned beef was a frozen, commercially prepared, brined product.
Thirteen pieces, weighing approximately 10 pounds each, had been cooked in an
oven in four batches during March 27-28. Cooked meat from the first three
batches was stored in a home refrigerator; the last batch was taken directly
to the event. Approximately 90 minutes before serving began, the meat was
sliced and placed under heat lamps.
     Following the outbreak, Virginia health officials issued a general
recommendation that meat not served immediately after cooking be divided into
small quantities and rapidly chilled to less than or equal to 40 F (less than
or equal to 4.4 C), and that precooked foods be reheated immediately before
serving to an internal temperature of greater than or equal to 165 F (greater
than or equal to 74 C).

                            Follow-Up Investigation

     The results of the epidemiologic and laboratory investigations suggest
that the two outbreaks in this report were not related. Traceback of the
corned beef in both of these outbreaks indicated that the meat had been
produced by different companies and sold through different distributors.
Serotyping was performed on C. perfringens isolates recovered from the stool
samples in Virginia and on an isolate from a food sample obtained in Ohio. Six
of the seven Virginia stool isolates were serotype PS86; however, the food
isolate from Ohio could not be serotyped using available antisera.

Reported by: J Zimomra, MPA, T Wenderoth, A Snyder, R Russ, Div of
Environmental Health, Cleveland City Health Dept; ED Peterson, R French, MPA,
TJ Halpin, MD, State Epidemiologist, Div of Preventive Medicine, Ohio Dept of
Health. JE Florance, MD, A Adkins, J Andrew, M Burkgren, K Crisler, T Fagen, L
Fass, JM Galloway, S Haines, RH Hinton, C Jackson, NS Rivera, EL Testor, C
Williams, Prince William Health District; AA DiAllo, PhD, DR Patel, Virginia
Div of Consolidated Laboratory Svcs, Dept of General Svcs; CW Armstrong, MD, D
Woolard, MPH, GB Miller, MD, State Epidemiologist, Virginia Dept of Health.
Div of Field Epidemiology, Epidemiology Program Office; Foodborne and
Diarrheal Diseases Br, Div of Bacterial and Mycotic Diseases, National Center
for Infectious Diseases, CDC.

Editorial Note: C. perfringens is a ubiquitous, anaerobic, gram-positive,
spore-forming bacillus and a frequent contaminant of meat and poultry (3). C.
perfringens food poisoning is characterized by onset of abdominal cramps and
diarrhea 8-16 hours after eating contaminated meat or poultry (4). By
sporulating, this organism can survive high temperatures during initial
cooking; the spores germinate during cooling of the food, and vegetative forms
of the organism multiply if the food is subsequently held at temperatures of
60 F-125 F (16 C-52 C) (3). If served without adequate reheating, live
vegetative forms of C. perfringens may be ingested. The bacteria then
elaborate the enterotoxin that causes the characteristic symptoms of diarrhea
and abdominal cramping (4).
     Laboratory confirmation of C. perfringens foodborne outbreaks requires
quantitative cultures of implicated food or stool from ill persons. Both
outbreaks described in this report were confirmed by the recovery of greater
than or equal to 105 organisms per gram of epidemiologically implicated food
(5). Cultures of stool samples from persons affected in Virginia also met the
alternate criterion of a median of greater than or equal to 106 colonies per
gram (6). Serotyping is not useful for confirming C. perfringens outbreaks
and, in general, is not available (7).
     Corned beef is a popular ethnic dish that is commonly served to celebrate
St. Patrick's Day. The errors in preparation of the corned beef in these
outbreaks were typical of those associated with previously reported foodborne
outbreaks of C. perfringens (8). Improper holding temperatures were a
contributing factor in most (97%) C. perfringens outbreaks reported to CDC
from 1973 through 1987 (2). To avoid illness caused by this organism, food
should be eaten while still hot or reheated to an internal temperature of
greater than or equal to 165 F (greater than or equal to 74 C) before serving
(9).

References

1. Shandera WX, Tacket CO, Blake PA. Food poisoning due to Clostridium
perfringens in the United States. J Infect Dis 1983;147:167-70.

2. Bean NH, Griffin PM. Foodborne disease outbreaks in the United States,
1973-1987: pathogens, vehicles, and trends. Journal of Food Protection
1990;53:804-17.

3. Hall HE, Angelotti R. Clostridium perfringens in meat and meat products.
Appl Microbiol 1965;13:352-7.

4. Hughes JM, Tauxe RV. Food-borne disease. In: Mandell GL, Douglas RG Jr,
Bennett JE, eds. Principles and practice of infectious diseases. 3rd ed. New
York: Churchill Livingstone Inc, 1990;893-905.

5. Hauschild WAH. Criteria and procedures for implicating Clostridium
perfringens in food-borne outbreaks. Can J Public Health 1975;66:388-92.

6. Hauschild WAH, Desmarchelier P, Gilbert RJ, Harmon SM, Vahlefeld R. ICMSF
methods studies: XII. Comparative study for the enumeration of Clostridium
perfringens in feces. Can J Microbiol 1979;25:953-63.

7. Hatheway CL, Whaley DN, Dowell VR Jr. Epidemiological aspects of
Clostridium perfringens foodborne illness. Food Technology 1980;34:77-9.

8. Loewenstein MS. Epidemiology of Clostridium perfringens food poisoning. N
Engl J Med 1972;286:1026-8.

9. Bryan FL. What the sanitarian should know about Clostridium perfringens
foodborne illness. Journal of Milk and Food Technology 1969;32:381-9.




------------------------------

Date: Fri, 18 Mar 94 23:23:09 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR] Progress Elimination Haemophilus influenzae type b
Message-ID: <[e-mail]>

                          Progress Toward Elimination
                   of Haemophilus influenzae type b Disease
            Among Infants and Children -- United States, 1987-1993

     Haemophilus influenzae (Hi) causes disease among persons in all age
groups, and Haemophilus influenzae type b (Hib) was the most common cause of
bacterial meningitis among children in the United States. Since the
introduction of Hib conjugate vaccines in 1988, the incidence of invasive Hib
infections in the United States has declined among infants and children (1).
Hib disease among children aged less than 5 years is now included in the list
of vaccine-preventable diseases targeted for elimination in the United States
by 1996 (2). Because Hi disease rates are generally higher for blacks than for
whites, incidence rates are race-adjusted; race most likely reflects differing
distributions of socioeconomic risk factors for Hi disease (e.g., household
crowding) that may account for the variance in incidence rates. This report
summarizes race-adjusted provisional data about trends in invasive Hi disease
from two separate surveillance systems and emphasizes the need for early
identification, investigation, and reporting of Hi cases.

                             National Surveillance

     State health agencies report weekly provisional notifiable disease data
to the National Notifiable Diseases Surveillance System (NNDSS) through the
National Electronic Telecommunications System for Surveillance (NETSS) managed
by CDC's Epidemiology Program Office (3,4). Although invasive Hi disease did
not become nationally notifiable until 1991, an increasing number of states
voluntarily participated in weekly reporting to NNDSS during 1987-1990.
Because the primary purpose of NNDSS is timely surveillance of nationwide case
information for many diseases, the information transmitted includes only basic
demographic data on persons with invasive Hi disease. The capacity to
electronically transmit supplemental information (e.g., the type of clinical
illness, outcome, serotype causing disease, and Hib vaccination status) for
cases of Hi disease is available through NETSS but is not widely used.
     Among children aged less than 5 years, the race-adjusted incidence of Hi
disease reported to NNDSS declined by 95%, from 41 cases per 100,000 in 1987
(seven states with 2.4 million children aged less than 5 years reported
information) to two cases per 100,000 in 1993 (48 states with 18 million
children aged less than 5 years reported information) (Figure 1). The
incidence of Hi disease among persons aged greater than or equal to 5 years
remained stable during this period (Figure 1).

                         Laboratory-Based Surveillance

     A laboratory-based system coordinated by CDC's National Center for
Infectious Diseases included surveillance projects in four areas of the United
States that participated from 1989 through 1993. The surveillance area
population was 10.4 million in four states (three counties in the San
Francisco Bay area, eight counties in metropolitan Atlanta, four counties in
Tennessee, and the state of Oklahoma). Detailed information is routinely
obtained on all cases of invasive Hi disease and includes serotype, clinical
syndrome, outcome, vaccination status, and demographic information.
     From 1989 through 1993, the race-adjusted incidence of Hib disease among
children aged less than 5 years decreased rapidly when compared with the
decrease in incidence of non-type b Hi disease among children (Figure 2).
During the same period, this surveillance system indicated a rapid decline
(93%) in the race-adjusted rates of all invasive Hi disease (including
serotypes b and non-b) among children (from 41 cases per 100,000 to three
cases per 100,000). Among children aged less than 5 years, the number of Hib
cases declined by 98% (from 281 cases in 1989 to seven cases in 1993); the
number of cases of non-type b Hi declined by 63% (from 52 cases in 1989 to 19
cases in 1993). Of the four Hib cases among children for whom Hib vaccination
status has been determined, one had received the complete primary series. If
projected to the U.S. population, an estimated 150 cases of Hib disease
occurred among children aged less than 5 years in 1993. This system also
indicated a substantial (89%) decrease in the number of cases of Hib disease
among persons aged greater than or equal to 5 years (57 cases in 1989 compared
with six in 1993).

Reported by: G Anderson, MPH, Bur of Disease Control, Oakland, California. L
Smithee, MS, Oklahoma State Dept of Health. M Rados, MS, Dept of Preventive
Medicine, Vanderbilt Medical Center, Nashville, Tennessee. W Boughman, MSPH,
Veterans Administration Medical Svcs, Atlanta. National Center for Infectious
Diseases; National Immunization Program; Epidemiology Program Office, CDC.

Editorial Note: This report documents the continued decline in the incidence
of all Hi and Hib disease in children aged less than 5 years in the United
States. National surveillance monitors the occurrence of Hi disease which, in
the past, was primarily caused by Hib organisms; the decline in incidence
monitored by national surveillance most likely reflects a decline in Hib
disease associated with use of Hib conjugate vaccines. In addition, the
laboratory-based surveillance system provided direct evidence of a decline in
Hib disease, which coincided with introduction and use of Hib conjugate
vaccines for children aged 18 months in 1988 and infants aged greater than or
equal to 2 months in 1990.
     Based on findings from the National Health Interview Survey, in 1992, 67%
of children aged 12-23 months had received at least one dose of Hib vaccine,
and 36% had received three or more doses (CDC, unpublished data). Despite this
incomplete level of vaccination coverage, surveillance indicates a decline of
more than 90% in disease incidence, probably reflecting an unexpected
additional benefit of conjugate vaccine use--elimination of carriage (5),
resulting in reduced exposure to the pathogen and decrease in disease
incidence even among unvaccinated persons. The decrease in incidence of Hib
disease among persons aged greater than or equal to 5 years in laboratory-
based surveillance sites also is most likely a result of decreased carriage
and transmission of the organism by infants and children. The availability of
Hib conjugate vaccines, which are efficacious in children (6,7) and reduce
carriage, make feasible the goal of elimination of Hib disease among children
aged less than 5 years by 1996.
     Achievement of the 1996 goal to eliminate Hib disease requires
participation by all levels of the health-care provider system in collection
of surveillance data (i.e., rapid identification, assessment, and prompt
reporting of all cases) and optimal use of this information to prevent
increased disease incidence among poorly vaccinated populations. To optimize
surveillance, case reports should ideally satisfy four criteria. First,
because Hib vaccines protect against serotype b organisms only, serotype
should be determined and reported for all invasive Hi isolates. Second, to
identify persons and groups at risk for Hib disease, vaccination status of all
children with invasive Hib disease should be assessed. Third, to evaluate the
possible role of incomplete or ineffective vaccination in persons with Hib
disease, the date, vaccine manufacturer, and lot number for each Hib
vaccination should be determined. Fourth, important measures of morbidity and
mortality associated with Hi infections should be reported and include
information on the type of clinical syndrome, specimen source (e.g.,
cerebrospinal fluid, blood, or joint fluid), and the outcome from disease. CDC
is working with state health departments to optimize collection, compilation,
and analysis of Hi surveillance data.

References

1. Adams WG, Deaver KA, Cochi SL, et al. Decline of childhood Haemophilus
influenzae type b (Hib) disease in the Hib vaccine era. JAMA 1993;269:221-6.

2. CDC. Reported vaccine-preventable diseases--United States, 1993, and the
Childhood Immunization Initiative. MMWR 1994;43:57-60.

3. CDC. Mandatory reporting of infectious diseases by clinicians. MMWR
1990;39(no. RR-9).

4. CDC. National Electronic Telecommunications System for Surveillance --
United States, 1990-1991. MMWR 1991;40:502-3.

5. Takala AK, Eskola J, Leinonen M, et al. Reduction of oropharyngeal carriage
of Haemophilus influenzae type b (Hib) in children immunized with an Hib
conjugate vaccine. J Infect Dis 1991;164:982-6.

6. Black SB, Shinefield HR, Fireman B, et al. Efficacy in infancy of
oligosaccharide conjugate Haemophilus influenzae type b (HbOC) vaccine in a
United States population of 61,080 children. Pediatr Infect Dis J 1990;10:97-
104.

7. Santosham M, Wolff M, Reid R, et al. The efficacy in Navajo infants of a
conjugate vaccine consisting of Haemophilus influenzae type b polysaccharide
and Neisseria meningitidis outer-membrane protein complex. N Engl J Med
1991;324:1767-72.




------------------------------

Date: Fri, 18 Mar 94 23:23:46 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR 11 March 94] Injuries Associated with Soccer Goalposts
Message-ID: <[e-mail]>

                 Injuries Associated with Soccer Goalposts --
                           United States, 1979-1993

     Injuries associated with sports can be related to a variety of factors,
including participant's level of conditioning or training, failure to use
safety equipment, contact, overexertion, difficulty in conducting the task
required, mismatch in skill or size between players, and adverse environmental
conditions. A rare but often fatal event is a blow caused by a falling soccer
goalpost resulting from improper installation or use. From 1979 through 1993,
27 persons were injured or killed from falling soccer goalposts. This report
describes three (two fatal) injuries associated with soccer goalposts and
summarizes an analysis of all fatal and nonfatal soccer goalpost-related
injuries reported in the United States to the Consumer Product Safety
Commission (CPSC) during 1979-1993.

                                    Case 1

     A 16-year-old boy and two friends at a high school soccer field without
adult supervision climbed the mobile soccer goalpost. As one person climbed on
the horizontal header of the 600-pound steel goalpost, the goalpost tipped
forward and struck the head of the 16-year-old, who was hanging from the
header, and rendered him unconscious. Cardiopulmonary resuscitation at the
scene and at the local emergency department was unsuccessful. He was
pronounced dead 1 hour after the incident. An autopsy revealed severe blunt
head trauma with multiple skull fractures and cerebral edema. Analysis of
blood samples was negative for alcohol and drugs. The goalpost, which was
commercially made and had been in service without incident for 6 years, was
not anchored to the ground at the time of the incident.

                                    Case 2

     A 3-year-old boy was playing in front of a metal goalpost after a soccer
game. As his father and brother were lifting one of the goalpost's corners to
remove the net for storage, the goalpost fell, striking the boy's head and
pinning him to the ground; he was rendered unconscious immediately.
Cardiopulmonary resuscitation was unsuccessful, and the boy was pronounced
dead approximately 1 hour later. The goalpost had not been anchored.

                                    Case 3

     A 9-year-old boy was playing goalie during a team practice when a wind
gust blew over the unstaked steel soccer goalpost. The child tried to stop the
fall of the goalpost when it struck his upper leg and fractured his femur. He
was hospitalized for 6 weeks and disabled for 4 months before regaining useful
leg function. The goalpost had been moved before the beginning of practice,
and the seven steel stakes that secured it to the ground had been left behind.

               Analysis of National Morbidity and Mortality Data

     Data about persons injured or killed by falling soccer goalposts in the
United States during 1979-1993 were identified by CPSC from 1) the National
Electronic Injury Surveillance System (1) 2) newspaper clippings, 3) medical
examiner reports, and 4) personal contacts made by soccer coaches or equipment
manufacturers to CPSC. Each case was investigated through site inspections and
interviews with the injured patient, a parent or other family member, a
witness, and/or authorities responsible for purchase or maintenance of the
soccer goalposts.
     During 1979-1993, 27 injuries related to falling soccer goalposts were
investigated by CPSC, of which 18 were fatal. Most (23) injuries occurred
among males; the mean age of injured persons was 10 years. Head trauma was the
principal cause of death in 14 of the fatal injuries and was diagnosed in two
of the nonfatal ones.
     Of the 27 goalposts involved, 26 were made of metal, usually steel or
galvanized pipe; 23 of the goalposts were mobile, one was permanently
installed, and three were of unknown type. Twenty-five injuries occurred when
a goalpost fell forward, with the top crossbar striking the victim. Eighteen
goalposts were not anchored, one was anchored poorly, and three were anchored
properly; for five, the status could not be determined. Fifteen of the
incidents occurred on a school field; 11, at a local or private field; and
one, at an unspecified site. Four events occurred during a soccer game and
four during practice; the remaining events occurred during times not involving
games or practice. All 27 events were witnessed: in six cases, an adult was
directly supervising and in visual contact with the victim; in eight, an adult
supervisor was in the general vicinity, although not in visual contact. Four
injuries were associated with a person climbing; seven, with a person swinging
or doing chin-ups; six, with lifting the soccer goalpost; and four, with wind
gusts. In 12 (nine fatal) incidents, the injured persons caused the goalposts
to fall.

Reported by: J DeMarco, C Reeves, US Consumer Product Safety Commission. Div
of Unintentional Injuries Prevention, National Center for Injury Prevention
and Control, CDC.

Editorial Note: The findings in this report indicate the potential for serious
injuries associated with improperly installed or used soccer goalposts.
Regulation soccer goalposts can be manufactured from steel, aluminum, or metal
pipe; measure approximately 8 feet by 24 feet; and weigh 250-800 pounds.
Because the mouth of the goalpost is completely open to the playing field,
only three sides are available for stabilizing the goalpost from forward
falls. The reports to CPSC indicate that injuries typically result from
climbing on goalposts, swinging or hanging from crossbars, or doing chin-ups
on crossbars.
     In the United States, soccer goalposts are manufactured by seven
companies, and an undetermined number are produced by local machine shops
without strict specifications. In 1990, CPSC issued a voluntary labeling
standard for use of warning labels on the front and back of the crossbar and
the front of the goalposts. Because of concerns about the inability of young
children to read such warnings and the likelihood that older children would
ignore these warnings, voluntary standards were adopted in 1992 by
manufacturers; these standards specify the need to anchor or counterweight the
goalposts using driving stakes, auger stakes, vertical pipe sleeves, or
sandbags. If stakes are used, four are recommended--two on the rear and one on
either side. Goalposts not in use should be chained to a fence or other
permanent structure, placed goal-face down on the ground, or disassembled for
storage. Additional information concerning these or other methods of anchoring
is available from the Coalition to Promote Soccer Goal Safety, telephone (800)
527-7510 or [phone].
     The findings in this report demonstrate the potential benefit of using a
national surveillance system to collect data on rare injury events. Accurately
assessing the extent of such events and targeting prevention efforts requires
calculating an injury rate through improved collection of numerator and
denominator data and collecting exposure risk data (i.e., age and sex of
injured person and level of competition). In addition, schools, park
districts, and soccer associations should report injuries associated with
falling soccer goalposts to the CPSC hotline, telephone [phone]. For
injuries involving goalposts that were properly installed and used, specific
information should be collected about the materials and method used to anchor
these structures and soil and weather conditions on the day of the incident.

Reference

1. US Consumer Product Safety Commission. The NEISS sample: design and
implementation. Washington, DC: US Consumer Product Safety Commission, March
1986.




------------------------------

Date: Fri, 18 Mar 94 23:24:12 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR] Heterosexually Acquired AIDS
Message-ID: <[e-mail]>

              Heterosexually Acquired AIDS -- United States, 1993

     From 1991 through 1992, persons with acquired immunodeficiency syndrome
(AIDS) who were infected with human immunodeficiency virus (HIV) through
heterosexual transmission accounted for the largest proportionate increase in
reported AIDS cases in the United States (1). During 1993, a total of 103,500
persons aged greater than or equal to 13 years with AIDS were reported to CDC.
This report summarizes the characteristics of persons reported with AIDS in
the United States in 1993 attributed to heterosexual contact, compares data
with those for 1992, and presents trends in heterosexual exposure categories.*
     From 1985 through 1993, the proportion of persons with AIDS who reported
heterosexual contact with a partner at risk for or with documented HIV
infection increased from 1.9% to 9.0%, respectively (Figure 1). During the
same period, the proportion of cases attributed to male-to-male sexual contact
decreased from 66.5% to 46.6%, while the proportion attributed to injecting-
drug use among women and heterosexual men increased from 17.4% to 27.7%. In
1993, AIDS cases attributed to heterosexual contact (n=9288) increased 130%
over 1992 (n=4045). Cases in all other exposure categories combined increased
109% in 1993, when the expanded AIDS surveillance case definition resulted in
substantial increases in reported cases in all demographic and exposure
categories (2,3). These reports include present AIDS cases diagnosed in 1993
and in earlier years.
     In 1993, most heterosexually acquired AIDS cases were attributed to
heterosexual contact with an injecting-drug user (IDU) (42.3%) or with a
partner with HIV infection or AIDS whose risk was unreported or unknown
(49.7%) (Figure 2). Men were more likely than women to report contact with a
partner with HIV infection or AIDS whose risk was unreported or unknown (60%
versus 44%); this group may include persons whose sex partners were IDUs or
bisexual men for whom risk was not known or reported and persons whose sex
partners were themselves infected heterosexually. Compared with 1992, during
1993 the number of cases associated with heterosexual contact with an IDU
(n=3916) increased 79%, and the number of cases associated with heterosexual
contact with a partner with HIV infection or AIDS whose risk was unknown or
unreported (n=4617) increased 195%. Increases also occurred in the number of
cases associated with heterosexual contact with a bisexual man (171%), a
person with hemophilia or other coagulation disorder (200%), or a transfusion
or transplant recipient (132%). However, the number of cases in these latter
three categories is small, and they represent a decreasing proportion of all
heterosexual-contact cases (Figure 2).
     In 1993, heterosexual HIV transmission accounted for 6056 AIDS cases
reported among women (median age: 33 years) and 3232 cases among men (median
age: 38 years). In addition, 55% of men and 50% of women were non-Hispanic
black, and 23% of men and 24% of women were Hispanic (Table 1). Rates were
highest for non-Hispanic blacks (20 per 100,000 population) and Hispanics (10
per 100,000) than for non-Hispanic whites (1 per 100,000), Asians/Pacific
Islanders (1 per 100,000), and American Indians/Alaskan Natives (2 per
100,000). During 1992 and 1993, persons aged 13-29 years accounted for 25% and
27%, respectively, of heterosexual-contact cases, while representing 18% of
total adolescent and adult AIDS cases each year.
     The highest proportions of cases associated with heterosexual contact
during 1993 were in the South** (42%) and Northeast*** (31%); these areas also
accounted for 24% and 53%, respectively, of cases reported among heterosexual
IDUs (n=28,687). States reporting the largest number of heterosexually
acquired AIDS cases in 1993 were Florida (1772 cases), New York (1336), and
New Jersey (855).
     As of December 31, 1993, of 34,952 persons with AIDS ever reported
without a behavioral risk factor, 14,787 (42%) had been reclassified; of
these, 10% of men and 63% of women were reclassified as having acquired AIDS
through heterosexual transmission of HIV (Figure 3). By comparison, in 1993,
4% of men and 37% of women with AIDS were reported as having HIV infection
associated with heterosexual transmission.

Reported by: Local, state, and territorial health depts. Div of HIV/AIDS,
National Center for Infectious Diseases, CDC.

Editorial Note: This report documents the continued increase in the number and
proportion of AIDS cases attributed to heterosexual HIV transmission. Persons
at highest risk for heterosexually transmitted HIV infection include
adolescents and adults with multiple sex partners, those with sexually
transmitted diseases (STDs), and heterosexually active persons residing in
areas with a high prevalence of HIV infection among IDUs (4). In addition, a
disproportionate number of persons with AIDS who acquired HIV infection
through heterosexual contact are black or Hispanic; monitoring HIV prevalence
and AIDS incidence in different racial/ethnic populations can assist in
developing culturally and linguistically appropriate HIV-prevention messages.
     Among heterosexuals at high risk for HIV infection (e.g., heterosexually
active clients at STD clinics and drug-treatment centers), the seroprevalence
of HIV infection is higher among men than women (5). However, serosurveillance
findings indicate that rates of HIV infection are increasing among women in
some populations and geographic areas. For example, among disadvantaged young
women who enter the Job Corps and among childbearing women in the South,
seroprevalence rates were higher during 1991-1992 than during earlier years
(5). Therefore, to understand the extent of heterosexual transmission and to
develop targeted prevention programs, health officials must account for local
variations in population characteristics and behaviors that may affect the
risk for HIV transmission.
     Although some persons classified as having acquired HIV infection through
heterosexual contact may have other unreported risk factors (6), the
proportions of AIDS cases attributed to heterosexual contact (9% and 6%,
respectively, of persons reported in 1993 and cumulatively) probably are a
conservative estimate of heterosexual contact AIDS cases. The classification
for heterosexual transmission requires a history of heterosexual contact with
a partner who has HIV infection, AIDS, or risk factors for HIV infection
(i.e., male-to-male sexual contact, injecting-drug use, or receipt of HIV-
contaminated blood or blood products). In addition, persons whose origin is a
country where heterosexual transmission was presumed to be the predominant
mode of HIV transmission (i.e., formerly classified by the World Health
Organization as Pattern II countries [7]) and persons who had sex with a
person whose origin is such a country are no longer automatically classified
as having acquired AIDS through heterosexual contact. To promote more
consistent risk ascertainment among persons reported with AIDS, all persons
who have no specific risks for HIV infection are classified as "no risk
reported."
     Other persons with AIDS also may have become infected through
heterosexual contact. For example, of the 86,961 persons cumulatively
classified as IDUs, approximately 12,600 also reported heterosexual contact
with a person at risk. In addition, after follow-up investigations are
completed, some persons currently classified as "risk not reported" will be
found to have risks for heterosexual transmission. To develop more accurate
estimates of the proportion of AIDS cases resulting from heterosexual
transmission, CDC is collaborating with six local and state health departments
to evaluate the validity and accuracy of heterosexual risk information
reported to surveillance programs.
     Compared with persons who acquired HIV infection through other modes of
transmission, the number of persons infected through heterosexual transmission
is increasing rapidly. Increased awareness of these trends and concerns about
STDs and unintended pregnancies among adolescents and young adults should
result in enhanced efforts to promote safer-sex behaviors. These behaviors
include postponing sexual activity among youths, restricting sexual contact to
a mutually monogamous relationship with an uninfected partner, and
consistently and correctly using latex condoms during intercourse (8). Because
promotion of such behavior change is influenced by community norms (9), CDC
has expanded efforts to assist local and state health departments in planning
HIV-prevention programs at the community level.

References

1. CDC. Update: acquired immunodeficiency syndrome--United States, 1992. MMWR
1993; 42:547-51,557.

2. CDC. 1993 Revised classification system for HIV infection and expanded
surveillance case definition for AIDS among adolescents and adults. MMWR
1992;41(no. RR-17).

3. CDC. Update: impact of the expanded AIDS surveillance definition for
adolescents and adults on case reporting--United States, 1993. MMWR
1994;43:160-1,170.

4. CDC. Update: heterosexual transmission of acquired immunodeficiency
syndrome and human immunodeficiency virus infection--United States. MMWR
1989;38:423-4,429-34.

5. CDC. National HIV serosurveillance summary: results through 1992. Vol 3.
Atlanta: US Department of Health and Human Services, Public Health Service,
CDC, 1993:29-30.

6. Nwanyanwu OC, Conti L, Ciesielski CA, et al. Increasing frequency of
heterosexually transmitted AIDS in southern Florida: artifact or reality? Am J
Public Health 1993;83:571-3.

7. Mertens TE, Burton T, Stoneburner R, et al. Global estimates and
epidemiology of HIV infection and AIDS. AIDS: A Year in Review, 1993-1994 (in
press).

8. CDC. Update: barrier protection against HIV infection and other sexually
transmitted diseases. MMWR 1993;42:589-91,597.

9. National Commission on AIDS. Behavioral and social sciences and the
HIV/AIDS epidemic. Washington, DC: National Commission on AIDS, July 1993:44-
9.

* Single copies of this report will be available free until March 11, 1995,
from the CDC National AIDS Clearinghouse, P.O. Box 6003, Rockville, MD 20849-
6003; telephone [phone].

** South Atlantic, East South Central, and West South Central regions.

*** New England and Middle Atlantic regions.




------------------------------

End of HICNet Medical News Digest V07 Issue #08
***********************************************


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