Interpretation

# **INTRODUCTORY MATERIAL**

Information in the annual *State Health Profile* publication series was
obtained from data files or published reports of several governmental
and nongovernmental agencies and organizations. In each case, the
sponsoring agency or organization collected data using its own methods
and procedures. Therefore, the data in this publication varies in terms
of source, method of collection, definitions, and reference period.

Much of the information in this publication is from the ongoing data
collection systems of CDC's National Center for Health Statistics
(NCHS). An overview of these systems can be found in *Vital & Health
Statistics* (1989;23:1--21). Data sometimes differ from those published
by the states because a) the cut-off dates for accepting vital
statistics records into the annual file for producing statistics can be
different and b) the interstate exchange program through which states
receive data on events that involved residents but occurred in other
states might not include all records.

Electronic files of all data on which the graphic presentations in this
publication are based are available on the Internet at the NCHS Data
Warehouse, located at \<http://www.cdc.gov/nchs/ datawh.htm\>.

+---------------------------------+---+--------------------------------+
| ## Health Status Indicators     |   | ures suggested in *Healthy     |
|                                 |   | People 2000*, but to give an   |
| The Public Health Service's     |   | indication of a community's    |
| publication *Healthy People     |   | general health status.         |
| 2000*: *National Health         |   |                                |
| Pro­motion and Disease           |   | ## Bioterrorism                |
| Prevention Objectives*          |   |                                |
| establishes a framework for     |   | In 1999, CDC was designated by |
| developing an explicit national |   | the U.S. Department of Health  |
| prevention program (1991; DHHS  |   | and Human Services (DHHS) to   |
| publication no.                 |   | coordinate and lead overall    |
| \[PHS\]91-50212). As part of    |   | plan­ning to upgrade national   |
| this program, a consensus set   |   | public health capa­bilities at  |
| of 18 health status indicators  |   | the federal, state, and local  |
| was developed to help           |   | levels to respond to           |
| communities assess their        |   | bioterrorism, which is the     |
| general health status and focus |   | de­liberate use of biological   |
| local, state, and national      |   | agents to harm civilians.      |
| efforts on tracking year 2000   |   | CDC's program also addresses   |
| objectives. These indicators    |   | chemical terrorism, including  |
| were chosen, in part, based on  |   | plans to en­hance laboratory    |
| whether relevant data were      |   | capabilities and medical       |
| readily avail­able and commonly  |   | stockpiles. Building an        |
| used in public health.          |   | effective and flexible public  |
|                                 |   | health infrastructure is the   |
| The 18 health status indicators |   | best de­fense against disease   |
| were devel­oped by a committee   |   | outbreaks, whether natural or  |
| through a consensus process     |   | intentional. Tools developed   |
| involving local, state, and     |   | to respond to bioterrorist     |
| federal health officials and    |   | events also can be used to     |
| representatives from aca­demic   |   | improve the recognition and    |
| institutions and professional   |   | control of other emerging      |
| associa­tions (*MMWR*            |   | disease threats.               |
| 1991;40:449--51). These         |   |                                |
| indi­cators are intended to      |   | During fiscal year (FY) 1999   |
| ensure data compara­bility and   |   | and 2000, CDC awarded          |
| facilitate use by public health |   | approximately \$80 million to  |
| agencies at all levels of       |   | 55 state, territorial, and     |
| government. They are not        |   | major metropolitan             |
| intended to supersede specific  |   |                                |
| meas-                           |   |                                |
+---------------------------------+---+--------------------------------+

+---------------------------------+---+--------------------------------+
| health departments to develop   |   | State/local projects include:  |
| and maintain core capacity for  |   |                                |
| five primary components of      |   | • Establishing three Exemplar  |
| bioterrorism preparedness and   |   | Centers for Public Health      |
| response. These components are  |   | Preparedness in Colorado       |
| preparedness planning and       |   | (Denver City and County),      |
| readiness assessment,           |   | Georgia (DeKalb County), and   |
| epidemiology/ surveillance      |   | New York (Monroe County).      |
| capacity, laboratory capacity   |   |                                |
| for biologic agents, laboratory |   | ***Epidemiology/Surveillance   |
| capacity for chemical agents,   |   | Capacity***                    |
| and communications/train­ing.    |   |                                |
| CDC's funding will help states  |   | CDC is working with state and  |
| and cities upgrade their        |   | local partners to ensure that  |
| capabilities in these areas and |   | local epidemiologic and        |
| link their activities with      |   | surveillance capacities are    |
| other local, state, and federal |   | established or enhanced across |
| emergency plans.                |   | the nation. If health-care     |
|                                 |   | providers can detect unusual   |
| ***Preparedness Planning***     |   | events early (e.g., injuries   |
|                                 |   | caused by chemical agents or   |
| ***and Readiness Assessment***  |   | disease outbreaks caused by    |
|                                 |   | pathogens likely to be used by |
| State and local public health   |   | terrorists), potential victims |
| communities will bear much of   |   | can receive appropriate        |
| the responsibility for          |   | medical treatment or be        |
| ad­dressing the health aspects   |   | protected with prophylactic    |
| of a bio-terrorist attack.      |   | medicines or vaccines.         |
| State and local officials will  |   |                                |
| be called upon to quickly       |   | During the past year, CDC has  |
| evaluate a potential threat,    |   | conducted several projects in  |
| identify public health response |   | this area, including:          |
| and preven­tion strategies,      |   |                                |
| advise the public on protec­tive |   | • Creating or updating case    |
| actions, and outline procedures |   | definitions for diseases or    |
| for first responders and        |   | conditions caused by critical  |
| health-care providers.          |   | threat agents.                 |
|                                 |   |                                |
| During the past year, CDC has   |   | • Developing standard          |
| conducted several projects in   |   | bioterrorism curric­ula and     |
| this area, including:           |   | associated training materials. |
|                                 |   |                                |
| • Providing on-site support for |   | State/local projects include:  |
| the World Trade Organization    |   |                                |
| meeting in Seattle, Republican  |   | • Developing a Rapid Syndrome  |
| National Convention in          |   | Report­ing System in New Mexico |
| Philadelphia, Democratic        |   | that allows physicians to      |
| National Con­vention in Los      |   | quickly report symptoms (e.g., |
| Angeles, and a West Nile        |   | flu-like symptoms and fever    |
| encephalitis outbreak in New    |   | with altered mental status)    |
| York City. CDC staff members    |   | using a unique touch screen    |
| helped identify caus­ative       |   | computer that is being         |
| agents, conduct epidemiologic   |   | pilot-tested in selected       |
| in­vestigations, and enhance     |   | emergency departments.         |
| existing sur­veillance systems   |   |                                |
| to detect illness.              |   | • Initiating a web-based       |
|                                 |   | reporting system in New York   |
| • Completing preliminary        |   | that allows real-time          |
| bioterrorism pre­paredness       |   | data-gathering for disease     |
| guidelines for hospitals,       |   | surveillance. The state also   |
| ad­dressing topics such as mass  |   | is exploring using hospital    |
| casualty procedures, triage     |   | claims data to detect          |
| considerations, decon­tamination |   | bioterrorist events early.     |
| issues, and epidemiologic and   |   |                                |
| detection recommendations.      |   | • Developing MERLIN, a         |
|                                 |   | web-based dis­ease reporting    |
| • Developing curricula on       |   | system in Florida that will    |
| clinical mani­festations and     |   | allow the state health         |
| treatments of illnesses caused  |   | department to con­duct          |
| by organisms and toxins on      |   | mortality surveillance for     |
| CDC's critical agents list.     |   | unex­plained and unusual deaths |
|                                 |   | and elec­tronic death           |
| • Completing and evaluating     |   | certificate review.            |
| CDC's role in at least four     |   |                                |
| simulated response exercises.   |   |                                |
+---------------------------------+---+--------------------------------+
| ***Laboratory Capacity for      |   | • Initiating electronic        |
| Biologic***                     |   | laboratory reporting in        |
|                                 |   | California for Level A, B, and |
| ***and Chemical Agents***       |   | C labo­ratories, which will     |
|                                 |   | allow rapid commu­nication of   |
| Rapid identification of a       |   | laboratory results in the      |
| bioterrorist agent will be      |   | event of a suspected           |
| critical to ensuring that       |   | bioterrorist event.            |
| prevention and treatment        |   |                                |
| recommendations are imple­mented |   | • Modifying Iowa's state       |
| quickly. CDC is working with    |   | public health laboratory (the  |
| state and local partners to     |   | University Hygienic            |
| enhance the country's current   |   | Laboratory) so it can serve as |
| public health laboratory        |   | a confir­matory laboratory for  |
| capacity to identify pathogens  |   | suspected bio­terrorism events  |
| likely to be used for           |   | in Iowa and other states       |
| bio­terrorism.                   |   | needing Level B or C           |
|                                 |   | confirmation.                  |
| Major components of this effort |   |                                |
| include a) enhancing local      |   | ###                            |
| ability to identify biologic    |   |                                |
| and chemical agents likely to   |   | ### Communications/Training    |
| be used for bioterrorism; b)    |   |                                |
| creating a rapid response and   |   | CDC is working with state and  |
| advanced technology laboratory  |   | local health departments to    |
| capable of supporting local and |   | establish the Health Alert     |
| state health departments and    |   | Network (HAN) for              |
| bioterrorism response teams 24  |   | communications, in­formation,   |
| hours a day; and c) working     |   | and training related to        |
| with public health part­ners to  |   | bioter­rorism. HAN is a         |
| build on the existing           |   | nationwide, integrated system  |
| laboratory infra­structure to    |   | connecting the nation's state  |
| develop a multilevel network of |   | and local health departments   |
| laboratories with               |   | through the Internet. This     |
| state-of-the-art capabilities   |   | network will serve as the      |
| for detecting a range of        |   | common electronic platform for |
| biological threats.             |   | national disease surveillance, |
|                                 |   | epidemiologic investi­gation,   |
| Laboratories are categorized    |   | electronic laboratory          |
| according to their level of     |   | reporting, and rapid           |
| safety and containment          |   | communications. When fully     |
| stan­dards. Level A laboratories |   | imple­mented with grants to     |
| are public health and hospital  |   | state and local health         |
| laboratories with low-level     |   | departments, HAN will link     |
| bio­safety facilities that use   |   | local, state, and federal      |
| clinical data and standard      |   | public health agencies and     |
| microbiological tests to decide |   | partners and will be used to   |
| which specimens and isolates    |   | protect communities against a  |
| should be for­warded to higher   |   | range of public health         |
| level biocontainment            |   | threats.                       |
| labo­ratories. Level B           |   |                                |
| laboratories are state and      |   | During the past year, CDC has  |
| local public health agency      |   | conducted several projects in  |
| laboratories with core capacity |   | this area, including:          |
| for agent isolation and         |   |                                |
| pre­sumptive-level testing of    |   | • Developing and maintaining   |
| suspect specimens. Level C      |   | CDC's public website for       |
| laboratories can perform        |   | nonsensitive bio­terrorism      |
| advanced and specialized        |   | information, which is          |
| testing, and they can be        |   | available at                   |
| located at state health         |   | \<http://www.bt.cdc.gov\>.     |
| agencies, academic research     |   |                                |
| centers, or federal facilities. |   | • Funding 40 state and local   |
|                                 |   | areas for in­formation systems  |
| During the past year, CDC has   |   | projects related to            |
| conducted several projects in   |   | bioterrorism, targeting three  |
| this area, including:           |   | focus                          |
|                                 |   |                                |
| • Developing curricula on       |   | areas -- Internet              |
| clinical mani­festations and     |   | connectivity,                  |
| treatments of illnesses caused  |   | distance-based--learning       |
| by organisms and toxins on      |   | capacity, and broadcast        |
| CDC's critical agents list.     |   | communications capacity.       |
|                                 |   |                                |
| State/local projects include:   |   | • Teaching eight Level A       |
|                                 |   | laboratory pre­paredness        |
|                                 |   | courses to approximately 700   |
|                                 |   | professionals through joint    |
|                                 |   | training efforts by CDC, the   |
|                                 |   | FBI, and faculty members in    |
|                                 |   | selected states.               |
+---------------------------------+---+--------------------------------+
| State/local projects include:   |   | • Negotiating successfully     |
|                                 |   | with the Vet­eran's             |
| • Conducting information        |   | Administration to establish    |
| systems training and            |   | vendor-managed contracts that  |
| establishing Internet service   |   | will allow NPSP to obtain,     |
| in 27 local health departments  |   | rotate, and rap­idly deploy     |
| in Connecticut.                 |   | appropriate items after a      |
|                                 |   | bioterrorist event.            |
| • Connecting one private and    |   |                                |
| one public hospital to          |   | • Conducting a full field      |
| Delaware's satellite-based      |   | exercise to test readiness and |
| training network. Delaware      |   | distribution capabilities at   |
| plans to connect all hospitals  |   | the state and local level.     |
| in the state by the end of the  |   |                                |
| 3-year project period.          |   | • Designing a delivery and     |
|                                 |   | distribution system for        |
| • Using HAN in Minnesota to     |   | 12-hour push packages, which   |
| report possi­ble exposure of     |   | are caches of medical material |
| persons to asbestos con­taining  |   | (e.g., vaccines, antidotes,    |
| vermiculite, then to provide    |   | respirators, and bandages)     |
| rapid information from the      |   | necessary to treat patients    |
| state health depart­ment to the  |   | exposed to biological or       |
| public, health-care providers,  |   | chemical agents. Push packages |
| and others throughout the       |   | are located strate­gically      |
| state.                          |   | throughout the United States   |
|                                 |   | and can be deployed within 12  |
| • Conducting needs assessments  |   | hours of being requested.      |
| of existing technology capacity |   |                                |
| at 12 local health offices in   |   | For more information, contact  |
| New Hampshire. Also provid­ing   |   | Cyndi Shaffer by telephone at  |
| training on the Internet, the   |   | (404) 639-0131, by FAX at      |
| state's Distance Learning       |   | (404) 639-0382, or by E-mail   |
| Network, and online national    |   | at \<csw3@cdc.gov\>.           |
| and state information related   |   |                                |
| to bioterrorism.                |   | ## CDC Funds for States        |
|                                 |   |                                |
| • Conducting three bioterrorism |   | This section lists financial   |
| awareness training sessions via |   | assistance pro­vided to and     |
| satellite for health and local  |   | within states during FY 2000.  |
| government officials in Rhode   |   | Unobligated balances carried   |
| Island.                         |   | forward from previous years    |
|                                 |   | are not included. Most funds   |
| • Establishing broadcast fax    |   | are provided to state and      |
| capability that allowed health  |   | local health depart­ments and   |
| officials in Vermont to rapidly |   | to special university-based    |
| inform local health departments |   | pro­jects. In some cases, funds |
| about a hantavirus case in      |   | go to other state and          |
| April 2000. Information         |   | nongovernmental agencies       |
| distributed included CDC's      |   | (e.g., state departments of    |
| website and locally generated   |   | education or community-based   |
| response guidance.              |   | organizations for human        |
|                                 |   | immunodefi­ciency virus \[HIV\] |
| ***National Pharmaceutical***   |   | and acquired immuno­deficiency  |
|                                 |   | syndrome \[AIDS\] programs).   |
| ### Stockpile Program           |   |                                |
|                                 |   | ## Local Health Departments    |
| In addition to coordinating the |   |                                |
| overall public health response  |   | ## by Jurisdiction             |
| to bioterrorist events, CDC is  |   |                                |
| mandated to develop and         |   | In most states, local health   |
| maintain the Na­tional           |   | liaison officials provide the  |
| Pharmaceutical Stockpile        |   | information needed to develop  |
| Program (NPSP). This program is |   | state maps of the numbers and  |
| being developed with DHHS's     |   | types of local health          |
| Office of Emergency             |   | departments. In states where   |
| Prepared­ness. In the event of a |   | no such position exists, other |
| bioterrorism emer­gency, the     |   | state officials are asked to   |
| federal government will use     |   | provide or confirm the         |
| NPSP to give states rapid       |   | necessary informa­tion. This    |
| access to necessary vac­cines,   |   | report uses the following      |
| antitoxins, therapeutic drugs,  |   | defini­tion of a local health   |
| and antidotes.                  |   | department: "an ad­ministrative |
|                                 |   | and service unit of local or   |
| During the past year, CDC has   |   | state                          |
| conducted several projects in   |   |                                |
| this area, including:           |   |                                |
+---------------------------------+---+--------------------------------+
| government, concerned with      |   | For more information, contact  |
| health, employ­ing at least one  |   | Ed Vaughn by telephone at      |
| full-time person, and carrying  |   | 770-488-2430 or by FAX at      |
| some responsibility for health  |   | 770-488-8300.                  |
| of a jurisdic­tion smaller than  |   |                                |
| the state" (*Am J Public        |   |                                |
| Health* 1977;67:931--9).        |   |                                |
+---------------------------------+---+--------------------------------+

## MORTALITY

For data presented by race/ethnicity, persons of Hispanic origin can be
of any race. Conversely, persons listed as white, black, American
Indian/Alaskan Native, or Asian/Pacific Islander can be of Hispanic or
non-Hispanic origin.

Numbers of deaths (numerators for death rates) are provided by the
National Vital Statistics System (NVSS) of CDC's National Center for
Health Statistics (NCHS). Data are derived from information provided by
registrars in all 50 states, New York City, and the District of
Columbia. These data sometimes differ from those published by the states
because a) the cut-off dates for accepting vital statistics records into
the annual file for producing statistics can be different; b) the
interstate exchange program through which states receive data on events
that involved residents but occurred in other states might not include
all records; and c) the international rules for selecting the underlying
cause of death is interpreted and applied differently in some states.

Population data (denominators for average annual death rates for
1996--1998) are 1997 post-censal population estimates from the Bureau of
the Census. Age and race data have been modi­fied to be consistent with
Office of Management and Budget categories and historical categories for
birth data. These modification procedures are described in a report from
the Bureau of the Census (*Age, sex, race, and Hispanic origin
information from the 1990 census: a comparison of census results with
results where age and race have been modified. 1990*. 1991; CPH-L-74).
Race and Hispanic origin data are self-reported or reported by a
household member.

Death rates are age-adjusted by the direct method to the 1940 U.S.
population using the standard million age distribution in 11 age groups
(see Table below). Direct age-adjustment is calcu­lated by weighting the
annual age-specific rates by the population distribution in the standard
population.

For more information, contact Insun Kim, Dr.P.H., by telephone at (301)
458-4313 or by FAX at (301) 458-4036.

+---------------------------------+---+--------------------------------+
| **TABLE. Standard million age   |   | ## Leading Causes of Death     |
| distribution used to age-adjust |   |                                |
| death rates**                   |   | Death rates are presented for  |
|                                 |   | several leading causes of      |
| +-------------+-------------+   |   | death. Data are average annual |
| | All ages    | 1,000,000   |   |   | age-adjusted death rates for   |
| |             |             |   |   | 1996--1998 for men and women   |
| | \<1 year    | 15,343      |   |   | and for persons in the         |
| |             |             |   |   | fol­lowing race/ethnicity       |
| | 1--4 years  | 64,718      |   |   | categories: white, black,      |
| |             |             |   |   | Hispanic, American             |
| | 5--14 years | 170,355     |   |   | Indian/Alaskan Native, and     |
| |             |             |   |   | Asian/Pacific Islander. Race   |
| | 15--24      | 181,677     |   |   | and Hispanic origin are        |
| | years       |             |   |   | recorded on death cer­tificates |
| |             | 162,066     |   |   | by funeral directors on the    |
| | 25--34      |             |   |   | basis of information provided  |
| | years       | 139,237     |   |   | by the next of kin.            |
| |             |             |   |   |                                |
| | 35--44      | 117,811     |   |   | In this section, death rates   |
| | years       |             |   |   | for race/ethnicity are         |
| |             | 80,294      |   |   | presented for states that meet |
| | 45--54      |             |   |   | one of the                     |
| | years       | 48,426      |   |   |                                |
| |             |             |   |   |                                |
| | 55--64      | 17,303      |   |   |                                |
| | years       |             |   |   |                                |
| |             | 2,770       |   |   |                                |
| | 65--74      |             |   |   |                                |
| | years       |             |   |   |                                |
| |             |             |   |   |                                |
| | 75--84      |             |   |   |                                |
| | years       |             |   |   |                                |
| |             |             |   |   |                                |
| | ≥85 years   |             |   |   |                                |
| +-------------+-------------+   |   |                                |
+---------------------------------+---+--------------------------------+
| following criteria: a) at least |   | lost, which is calculated as   |
| 150,000 popu­lation in the       |   | the difference between age 75  |
| designated group in 1997 or b)  |   | years and the midpoint of the  |
| at least 100 deaths from the    |   | age group. For example, the    |
| specified cause of death among  |   | death of a person in the       |
| members of the designated group |   | 15--24 group counts as 55.5    |
| during 1996--1998. Death rates  |   | years of life lost. The total  |
| based on \<20 deaths during     |   | YPLL is all of the years of    |
| 1996--1998 are not shown. Data  |   | life lost over all age groups. |
| for persons of Hispanic origin  |   |                                |
| are limited to the District of  |   | Data in this section are       |
| Columbia and the 49 states that |   | race/ethnicity-specific,       |
| reported Hispanic origin of     |   | age-adjusted YPLL per 100,000  |
| decedent on death certificates  |   | population aged \<75 years for |
| and in which reporting was at   |   | 1996--1998. Numbers of deaths  |
| least 80 percent complete for   |   | (numerators for YPLL rates)    |
| 1996--1998. Data for Oklahoma   |   | are from the NVSS. Population  |
| are not avail­able because that  |   | data (denominators for YPLL    |
| state did not record His­panic   |   | rates) are 1997 postcensal     |
| origin of decedent on death in  |   | population estimates from the  |
| 1996.                           |   | Bureau of the Census. YPLL     |
|                                 |   | rates are age-adjusted by the  |
| Data in this section are for    |   | direct method to the 1940 U.S. |
| the four leading causes of      |   | population using the eight age |
| death in the United States in   |   | groups cited previously. YPLL  |
| 1997 according to the           |   | rates based on \<20 deaths are |
| *International Classification   |   | not shown. Data for Oklahoma   |
| of Diseases, 9th Revision*      |   | are not available because that |
| (hereafter referred to as       |   | state did not record Hispanic  |
| *ICD-9*): heart disease         |   | origin of decedent on death    |
| (*ICD-9* codes 390--398, 402,   |   | certificates in 1996.          |
| 404--429), cancer (*ICD-9*      |   |                                |
| codes 140--208), stroke         |   | Data in this section are for   |
| (*ICD-9* codes 430--438), and   |   | the five leading causes of     |
| chronic obstructive pulmonary   |   | YPLL in the United States in   |
| diseases (*ICD-9* codes         |   | 1998: heart disease (*ICD-9*   |
| 490--496). Leading causes of    |   | codes 390--398, 402,           |
| death are defined as those      |   | 404--429), cancer (*ICD-9*     |
| causing the greatest number of  |   | codes 140-- 208),              |
| deaths in the United States.    |   | unintentional injuries         |
| They are not necessarily the    |   | (*ICD-9* codes E800--E949),    |
| leading causes of death for     |   | suicide (*ICD-9* codes         |
| specific states or specific     |   | E950--E959), and homicide      |
| racial/ethnic or sex groups.    |   | (*ICD-9* codes E960--E969).    |
|                                 |   | They are not necessarily the   |
| ## Years of Potential Life Lost |   | leading causes of YPLL for     |
|                                 |   | specific states.               |
| Years of potential life lost    |   |                                |
| (YPLL) is a meas­ure of          |   | Unintentional injuries include |
| premature mortality, defined as |   | subcategories such as falls,   |
| the number of years between the |   | drownings, fires/burns,        |
| age at death (for those who die |   | poison­ings, and motor vehicle  |
| before age 75 years) and age 75 |   | injuries.                      |
| years. YPLL is calculated from  |   |                                |
| birth to age 75 years using the |   | For more information on how to |
| 1940 U.S. population and the    |   | calculate YPLL, consult the    |
| following eight age groups: \<1 |   | *Journal of Preventive         |
| year, 1--14, 15--24, 25--34,    |   | Medicine* (1988;4:268--73).    |
| 35--44, 45--54, 55--64, and     |   |                                |
| 65--74. The number of deaths    |   |                                |
| for each age group is           |   |                                |
| multiplied by the years of life |   |                                |
+---------------------------------+---+--------------------------------+

## 

## CHILDHOOD HEALTH CONCERNS

For the sections on Prenatal Care and Birth Rates for Females Aged
15--19 Years, data are from the National Vital Statistics System (NVSS)
of CDC's National Center of Health Statistics (NCHS). Data are derived
from information provided by registrars in all 50 states, New York City,
and the District of Columbia. These data sometimes differ from those
published by the states because a) the cut-off dates for accepting vital
statistics records into the annual file for producing statistics can be
different and b) the interstate exchange program through which states
receive data on events that involved residents but occurred in other
states might not include all records. Also, different organizations
sometimes tabulate the race of the mother differently. For example, when
the mother's race is not reported but the father's is, NCHS assigns the
race of the father to the mother. When neither parent's race is
reported, the race of the mother is listed the same as the immediately
preceding record that did have the race of the mother specified. This
listing was necessary for \<1% of births during 1996--1998.

+---------------------------------+---+--------------------------------+
| ## Developmental Disabilities   |   | home and auto modifications,   |
|                                 |   | special educa­tion services,    |
| The total lifetime cost of a    |   | and illness and premature      |
| specific develop­mental          |   | mortality.                     |
| disability for a given state    |   |                                |
| (in 1996 U.S. dollars) is       |   | The number of live births in   |
| calculated using the follow­ing  |   | each state for 1998 is         |
| formula: the prevalence rate of |   | reported from NCHS (*Natl      |
| the de­velopmental disability    |   | Vital Stat Rep* 2000;48\[3\]). |
| multiplied by the number of     |   | The average annual preva­lence  |
| 1998 live births in a given     |   | rates of specific              |
| state multiplied by the         |   | developmental dis­abilities     |
| per-person lifetime cost        |   | among 1,000 children aged      |
| estimate associated with the    |   | 5--10 years during 1991--1994  |
| developmental disability, based |   | were mental retar­dation,       |
| on a 3% discount rate.          |   | 11.29; cerebral palsy, 2.97;   |
|                                 |   | hearing impairment, 1.21; and  |
| Sample estimates of the         |   | vision impairment, 1.02. These |
| per-person lifetime costs of    |   | data came from CDC's           |
| specific developmental          |   | Metro­politan Atlanta           |
| disabilities include \$797,592  |   | Developmental Disabilities     |
| for mental retardation,         |   | Surveillance Pro­gram. More     |
| \$706,704 for cerebral palsy,   |   | information regarding birth    |
| \$275,717 for hearing           |   | and developmental disability   |
| impairment, and \$386,074 for   |   | rates is available on the      |
| vision impairment (*The Cost of |   | Internet at                    |
| Developmental Disabilities*.    |   | \                              |
| Research Triangle Park, N.C.:   |   | <http://www.cdc.gov.nchs/data/ |
| Research Triangle Institute,    |   |                                |
| April 2000).                    |   | nvs48_3.pdf\>.                 |
|                                 |   |                                |
| Mental retardation is defined   |   | For more information, contact  |
| as an intelli­gence quotient     |   | Marshalyn Yeargin-Allsopp,     |
| (IQ) of ≤70. Hearing impair­ment |   | M.D., by telephone at (770)    |
| is defined as a measured,       |   | 488-7400.                      |
| bilateral, pure-tone hearing    |   |                                |
| loss at frequencies of 500,     |   | ## Vaccination Coverage        |
| 1,000, and 2,000 hertz          |   |                                |
| averaging ≥40 deci­bels,         |   | Data in this section are from  |
| unaided, in the better ear.     |   | the National Immunization      |
| Vision impairment is defined as |   | Survey (NIS) and include       |
| a measured visual acuity of     |   | immunization coverage rates    |
| ≤20/70, with correction, in the |   | for the follow­ing vaccines: a) |
| better eye. Cerebral palsy is   |   | four doses of diphtheria and   |
| defined as a group of           |   | tetanus toxoids and acellular  |
| nonprogressive but often        |   | pertussis vac­cine (DTaP); b)   |
| changing motor impairment       |   | three doses of poliovirus      |
| syndromes secondary to lesions  |   | vaccine; c) one dose of        |
| or anomalies of the brain       |   | measles-mumps-rubella vaccine  |
| arising at any time during      |   | (MMR); d) three doses of       |
| brain development.              |   | *Haemophilus influenzae* type  |
|                                 |   | b vaccine (Hib); e) three      |
| Per-person lifetime cost        |   | doses of hepatitis B vaccine   |
| estimates are based on a        |   | (HepB); f) one dose of         |
| cost-of-illness approach that   |   | varicella (chicken-pox); and   |
| measures the value of all       |   | g) a 4:3:1:3 combined series   |
| resources used or lost because  |   | that includes four doses of    |
| of a disability (excluding home |   | DTaP, three doses of polio     |
| care costs). Resource           |   | vaccine, one dose of MMR (or   |
| categories analyzed included    |   | other measles-containing       |
| physi­cian office services,      |   | vaccine), and three doses of   |
| prescription medications,       |   | Hib for children aged 19--35   |
| hospital inpatient services,    |   | months.                        |
| therapy and reha­bilitation      |   |                                |
| services, long-term--care       |   |                                |
| services,                       |   |                                |
+---------------------------------+---+--------------------------------+

+---------------------------------+---+--------------------------------+
| The NIS is an ongoing survey    |   | prematurity (*ICD-9* code 765) |
| conducted by CDC's National     |   | combined with respiratory      |
| Immunization Program that       |   | distress syndrome (*ICD-9*     |
| provides estimates of           |   | code 769), and sudden infant   |
| immunization coverage for       |   | death syndrome (SIDS) (*ICD-9* |
| children aged 19--35 months for |   | code 798).                     |
| the United States as a whole,   |   |                                |
| each of the 50 states, and      |   | The rate of SIDS has declined  |
| selected urban areas. CDC       |   | sharply since 1989. Data for   |
| imple­mented the NIS in April    |   | 1995 indicate that the SIDS    |
| 1994 as part of the Childhood   |   | rate declined 18.3% from 1994, |
| Immunization Initiative, a      |   | representing the largest       |
| national strategy to achieve    |   | annual percentage decline      |
| and maintain high immunization  |   | since 1983. This downward      |
| coverage in all 50 states, the  |   | trend could reflect changes in |
| District of Columbia, and 27    |   | the prevalence of known risk   |
| urban areas considered at high  |   | factors or changes in the      |
| risk for undervaccination.      |   | diagnosis of SIDS.             |
|                                 |   |                                |
| ##                              |   | A strong association between   |
|                                 |   | SIDS and a prone sleeping      |
| ## For more i                   |   | position for infants has been  |
| nformation, contact Wayne Steve |   | established, and in 1992, the  |
| ns by telephone at (404) 639-87 |   | American Academy of Pediatrics |
| 30 or by FAX at (404) 639-8613. |   | began recommend­ing that        |
|                                 |   | parents place infants on their |
| ## Infant Mortality             |   | backs or sides to sleep.       |
|                                 |   |                                |
| To provide race/ethnicity data  |   | For more information, contact  |
| on infant mortality, the linked |   | Michele Lynberg by telephone   |
| files of births and infant      |   | at (770) 488-7180.             |
| deaths for 1996--1998 were used |   |                                |
| for racial/ ethnic groups       |   | ## Prenatal Care               |
| relevant to particular states.  |   |                                |
| The national linked files of    |   | Data in this section are the   |
| live births and infant deaths   |   | average annual percentages of  |
| include vital records for       |   | women who did not receive      |
| infants who were born in a      |   | prenatal care during the first |
| given year and died that same   |   | trimester of pregnancy during  |
| year or in the next year before |   | 1996--1998. The data are       |
| their first birthday. Using     |   | reported according to the      |
| linked files avoids             |   | following race/ ethnicity      |
| discrepan­cies in the reporting  |   | categories: white              |
| of race between birth records   |   | non-Hispanic, black            |
| and death certificates.         |   | non-Hispanic, Hispanic,        |
| Although dis­crepancies are      |   | American Indian/Alaskan        |
| relatively rare for white and   |   | Native, and Asian/Pacific      |
| black infants, they can be      |   | Islander. Persons of Hispanic  |
| substantial for other races.    |   | origin can be of any race.     |
|                                 |   | Percentages for racial/ethnic  |
| Data are provided for three     |   | groups are provided for states |
| leading causes of infant death  |   | with ≥200 births among mothers |
| for the three largest           |   | of the designated group during |
| racial/ethnic groups for each   |   | 1996--1998.                    |
| state. For some states, data    |   |                                |
| for fewer than three            |   | For more information, contact  |
| racial/ethnic groups are used   |   | Insun Kim, Dr.P.H., by         |
| because of the limited numbers  |   | telephone at (301) 458-4313 or |
| of deaths. Rates based on \<20  |   | by FAX at (301) 458-4036.      |
| deaths are consid­ered           |   |                                |
| statistically unreliable, and   |   | ## Birth Rates for Females     |
| caution should be used when     |   |                                |
| comparing or interpret­ing such  |   | ## Aged 15--19 Years           |
| rates.                          |   |                                |
|                                 |   | Birth rates for females aged   |
| The underlying cause of death   |   | 15--19 years are the number of |
| is identified by *ICD-9* code   |   | live births per 1,000 women    |
| and ranked according to the     |   | aged 15--19 years in specified |
| three overall leading causes of |   | racial/ethnic groups that      |
| death among infants in the      |   | reside in each state. Data are |
| United States: birth defects    |   |                                |
| (*ICD-9* codes 740--759), low   |   |                                |
| birthweight and                 |   |                                |
+---------------------------------+---+--------------------------------+
| average annual rates during     |   | rates for Hispanic women might |
| 1996--1998 in the following     |   | be under-reported by this      |
| groups: white non-Hispanic,     |   | amount. Persons of Hispanic    |
| black non-Hispanic, Hispanic,   |   | origin can be of any race.     |
| American Indian/ Alaskan        |   |                                |
| Native, and Asian/Pacific       |   | Population data (denominators  |
| Islander. Rates have not been   |   | for birth rates) are 1997      |
| computed within states for      |   | postcensal population          |
| racial/ethnic groups with \<20  |   | estimates from the Bureau of   |
| births to women or with \<1,000 |   | the Census, modified to be     |
| women aged 15--19 years.        |   | consistent with Office of      |
|                                 |   | Management and Budget          |
| Hispanic origin of the mother   |   | categories and historical      |
| is reported separately on birth |   | categories for birth data.     |
| certificates and in the         |   |                                |
| national census. For the 1% of  |   | For more information, contact  |
| records with no origin          |   | Insun Kim, Dr.P.H., by         |
| reported, the mother is assumed |   | telephone at (301) 458-4313 or |
| to be non-Hispanic, which means |   | by FAX at (301) 458-4036.      |
| the reported                    |   |                                |
+---------------------------------+---+--------------------------------+

## 

## DEATHS FROM INJURIES

Data in this section are a) age-adjusted death rates for 1998 for motor
vehicle-related deaths, suicide, and homicide and b)
race/ethnicity-specific, average annual age-adjusted death rates for
1996--1998 for suicide and homicide. They are age-adjusted by the direct
method to the 1940 U.S. population using the standard million age
distribution (see Table, page 62). Direct age-adjustment is calculated
by weighting the annual age-specific rates by the population
distribution in the standard population.

Numbers of deaths (numerators for death rates) are provided by the
National Vital Statistics System (NVSS) of CDC's National Center for
Health Statistics (NCHS). Data are derived from information provided by
registrars in all 50 states, New York City, and the District of Columbia
(except in Alaska, where the number of suicides are state data). These
data sometimes differ from those published by the states because a) the
cut-off dates for accepting vital statistics records into the annual
file for producing statistics can be different; b) the interstate
exchange program through which states receive data on events that
involved residents but occurred in other states might not include all
records; and c) the international rules for selecting the underlying
cause of death is interpreted and applied differently in some states.

## 

Population data (denominators for annual death rates) are from 1998
postcensal population estimates from the Bureau of the Census. Estimates
for 1997 were used for race/ethnicity-specific, average annual
age-adjusted death rates for 1996--1998 for suicide and homicide. Age
and race data have been modified to be consistent with Office of
Management and Budget cate­gories and historical categories for birth
data. These modification procedures are described in a report from the
Bureau of the Census (*Age, sex, race, and Hispanic origin information
from the 1990 census: a comparison of census results with results where
age and race have been modi­fied. 1990*. 1991; CPH-L-74.). Race and
Hispanic origin data are self-reported or reported by a household
member.

Death rates for suicide and homicide are presented by race/ethnicity for
states that meet one of the following criteria: a) at least 150,000
population in the designated group or b) at least 100 suicide- or
homicide-related deaths among members of the designated group.

Data for persons of Hispanic origin are limited to the District of
Columbia and the 49 states that reported Hispanic origin of decedent on
death certificates and in which reporting was at least

80% complete during 1996--1998. Data for Oklahoma are not available
because that state did not record Hispanic origin of decedent on death
certificates in 1996. Persons of Hispanic origin can be of any race,
and, conversely, persons listed as white, black, Asian/Pacific Islander,
or American Indian/Alaskan Native can be Hispanic or non-Hispanic.

The number of deaths and subsequent death rates for 1996--1998 from
suicide and homicide in Alaska are incorrect because NCHS did not
receive changes from amended records for 1995 data and because errors
were made when the cause-of-death data was processed. Differences are
con­centrated among selected causes of death, principally symptoms,
signs, and ill-defined conditions (*ICD-9* codes 780--799) and external
causes. Also, race/ethnicity-specific death rates for suicide and
homicide might not be accurate because race and Hispanic origin are
recorded on death certificates by funeral directors on the basis of
information provided by the next of kin.

For more information, contact Lee Annest, Ph.D., by telephone at (770)
488-4804 or by FAX at (770) 488-1665, or Barbara Morrison by telephone
at (770) 488-4936 or by FAX at (770)

488-4222.

+--------------------------------+---+---------------------------------+
| #                              |   | Highway Traffic Safety          |
| # Motor Vehicle-Related Deaths |   | Administration, which is part   |
|                                |   | of the U.S. Department of       |
| The *ICD-9* codes for motor    |   | Transportation. This section    |
| vehicle-related deaths are     |   | provides motor vehicle-related  |
| E810--E825. The *Healthy       |   | mortality data per 100,000      |
| People 2000* goals (objective  |   | population and per 100 million  |
| 9.3) for deaths caused by      |   | VMT by state, which             |
| motor vehicle-related crashes  |   | demonstrates the relative       |
| are 14.2/ 100,000 population   |   | mag­nitude of rates among states |
| and 1.5/100 million vehicle    |   | based on quartile               |
| miles traveled (VMT) (*Healthy |   | distributions.                  |
| People 2000: national health   |   |                                 |
| promotion and disease          |   | ## Suicide                      |
| prevention objectives*. 1991;  |   |                                 |
| DHHS publication no.           |   | The *ICD-9* codes for suicide   |
| \[PHS\]91-50212).              |   | are E950--E959.                 |
|                                |   |                                 |
| Population-based data are      |   | ## Homicide                     |
| tracked by the NVSS. Data for  |   |                                 |
| the estimated motor            |   | The *ICD-9* codes for homicide  |
| vehicle-related death rate per |   | are E960--E969.                 |
| 100 million VMT are tracked by |   |                                 |
| the Fatal Accident Reporting   |   |                                 |
| System (FARS) of the National  |   |                                 |
+--------------------------------+---+---------------------------------+

## ENVIRONMENTAL HEALTH CONCERNS

+--------------------------------+---+---------------------------------+
| ## Air Quality Standards       |   | Clean Air Act of 1970 and its   |
|                                |   | 1977 and 1990 amendments. The   |
| This section shows the         |   | National Ambient Air Quality    |
| proportion of persons living   |   | Standards (NAAQS) define        |
| in states with counties that   |   | maximum concentration levels    |
| exceeded U.S. Environmental    |   | (micrograms per cubic meter)    |
| Protection Agency (EPA)        |   | that should not be exceeded     |
| standards for air quality in   |   | during specific time intervals  |
| 1998. The EPA compiles data    |   | for each pollutant.             |
| from each state in the         |   |                                 |
| Aerometric Information         |   | Data are collected at state and |
| Retrieval System (AIRS) on     |   | local air pol­lution monitoring  |
| ambient air levels of lead,    |   | sites. Each site provides data  |
| carbon monoxide, sulphur       |   | for one or more of the six      |
| dioxide, nitrogen diox­ide,     |   | pollutants. In 1998, there were |
| particulate matter smaller     |   | 4,800 sites in the United       |
| than 10 microns, and           |   | States; most are located in     |
| tropospheric ozone. Because    |   | heavily populated urban areas.  |
| these pollutants pose          |   | Air quality for less-populated  |
| significant threats to public  |   |                                 |
| health, they were identified   |   |                                 |
| in the                         |   |                                 |
+--------------------------------+---+---------------------------------+

+--------------------------------+---+---------------------------------+---+
| areas is assessed through a    |   | The loss of productivity        |   |
| combination of data from       |   | because of parents who lose     |   |
| supplemental monitors and air  |   | work days to care for children  |   |
| pollution models.              |   | with asthma is estimated at \$1 |   |
|                                |   | billion. This figure does not   |   |
| This section summarizes 1998   |   | include the cost of lost        |   |
| county-level estimates using   |   | productivity of adults who miss |   |
| the EPA methodology for        |   | work because of their own       |   |
| calculating single-year NAAQS  |   | asthma.                         |   |
| exceed­ances and 1990           |   |                                 |   |
| population data from the       |   | A survey conducted by the       |   |
| Bureau of the Census. These    |   | Council of State and            |   |
| data represent one of the      |   | Territorial Epidemiologists     |   |
| health status indicators       |   | (CSTE) in 1996 showed that 80%  |   |
| developed for national, state, |   | of states want compre­hensive    |   |
| and local monitoring; the      |   | programs to reduce the burden   |   |
| converse of these proportions  |   | of asthma, but do not have the  |   |
| is addressed in *Healthy       |   | resources to do so.             |   |
| People 2000* (objective 11.5)  |   |                                 |   |
| (DHHS publication no.          |   | CDC monitors national trends in |   |
| \[PHS\]91-50212).              |   | asthma mor­bidity and mortality  |   |
|                                |   | and provides technical          |   |
| For more information, contact  |   | assistance on asthma prevention |   |
| Jeff Pearcy by telephone at    |   | to state and local health       |   |
| (301) 458-4425 or by FAX at    |   | agencies. CDC funds             |   |
| (301) 458-4036.                |   | community-based demonstration   |   |
|                                |   | pilot intervention pro­grams and |   |
| ## Asthma                      |   | capacity-building projects in   |   |
|                                |   | several states and urban areas. |   |
| During 1993--1994, asthma      |   | CDC also has developed a        |   |
| affected 13.7 million persons  |   | public/private partnership in   |   |
| of all ages, including 6.8     |   | Atlanta called ZAP Asthma,      |   |
| million children aged \<18     |   | which uses com­munity outreach   |   |
| years. During 1979--1995, the  |   | workers to help families        |   |
| prevalence of asthma in­creased |   | implement environmental control |   |
| 75%, from 30.7 cases/1,000     |   | measures. This model can be     |   |
| popula­tion to 53.8/1,000       |   | replicated in other             |   |
| population. During 1979--1995, |   | com­munities, and CDC has        |   |
| the number of asthma-related   |   | completed a national strategic  |   |
| deaths increased 98%, from     |   | plan for preventing asthma.     |   |
| 2,745 to 5,429, and the        |   | This plan defines the health    |   |
| mortality rate increased 56%,  |   | problem, identifies the         |   |
| from 11.5/ million population  |   | determinants (causes and risk   |   |
| to 17.9/million popula­tion.    |   | factors) and contributing       |   |
| For persons aged \<18 years,   |   | factors, and describes the      |   |
| mortality increased 106%, from |   | process objectives and          |   |
| 1.7/million popula­tion to      |   | activities needed to address    |   |
| 3.5/million population.        |   | each contributing factor.       |   |
| Mortality rates also are       |   |                                 |   |
| consistently higher among      |   | Despite new regulations         |   |
| blacks than whites.            |   | governing pollution, asthma     |   |
|                                |   | continues to increase because   |   |
| During 1993--1995, a total of  |   | most asthma triggers (e.g.,     |   |
| 466,000 hospitalizations       |   | indoor environmental pollutants |   |
| listed asthma as the first     |   | and antigens) are not and       |   |
| discharge diagnosis; children  |   | cannot be regulated             |   |
| aged \<15 years accounted for  |   | effectively. Reductions in such |   |
| 164,000 (35%) of these         |   | asthma triggers as dust mites,  |   |
| hospi­talizations. In 1990, the |   | cockroach antigen,              |   |
| total cost of asthma was       |   | environmental tobacco smoke,    |   |
| estimated at \$6.2 billion;    |   | animal dander, respiratory      |   |
| inpatient hospital services    |   | infections, and air pollutants  |   |
| alone were estimated at \$1.6  |   | -- coupled with improved        |   |
| billion. The cost of           |   | medical management, education,  |   |
| hospitalizations increased by  |   | and sound public health         |   |
| 47% during 1985--1990.         |   | practice -- can substantially   |   |
|                                |   | reduce asthma irritations and   |   |
| Children miss approximately 10 |   | the need for emergency medical  |   |
| million school days each year  |   | intervention.                   |   |
| because of asthma.             |   |                                 |   |
+--------------------------------+---+---------------------------------+---+
| For more information, contact  |   | estimated that approximately    |   |
| Jim Rifenburg by telephone at  |   | 1.7 million children in the     |   |
| (404) 639-2520 or by FAX at    |   | United States had blood lead    |   |
| (404) 639-2560.                |   | levels (BLLs) of ≥10 μg/dL.     |   |
|                                |   | During 1991--1994, NHANES       |   |
| ## Disabilities                |   | III-Phase II reported a decline |   |
|                                |   | in the mean BLLs for the        |   |
| Data presented in this section |   | nation.                         |   |
| are from the Behavioral Risk   |   |                                 |   |
| Factor Surveillance System     |   | Despite this decline, nearly 1  |   |
| (BRFSS). The BRFSS is an       |   | million U.S. children are still |   |
| annual, state-based,           |   | at risk for BLLs of ≥10 μg/dL.  |   |
| random-digit--dialed telephone |   | Public health strategies to     |   |
| survey of health-related       |   | identify children at greatest   |   |
| behavior among civilian,       |   | risk for exposure to lead       |   |
| noninstitutionalized persons   |   | hazards must be intensified and |   |
| aged ≥18 years residing in the |   | appropriate follow-up services  |   |
| United States. In 1998, the    |   | must be provided. CDC provides  |   |
| BRFSS survey included a        |   | financial assistance to state   |   |
| disabil­ity module in 16        |   | and local health agencies for   |   |
| states. This module con­sisted  |   | childhood lead poisoning        |   |
| of 23 questions, including 4   |   | prevention activities and for   |   |
| health status questions, 10    |   | the development of state        |   |
| optional quality-of-life       |   | surveillance systems. In 1999,  |   |
| questions, and 9 new           |   | a total of 54 state and local   |   |
| disability questions.          |   | health agencies were funded for |   |
|                                |   | childhood lead poisoning        |   |
| Disability is determined based |   | prevention activities, and      |   |
| on a) limita­tions in           |   | three states were funded for    |   |
| activities or cognition or b)  |   | surveillance activities.        |   |
| use of compensatory strategies |   |                                 |   |
| (e.g., assistance or adaptive  |   | Prevention activities for state |   |
| devices). Sample population    |   | and local health agencies       |   |
| sizes in the 16 states that    |   | comprise a comprehensive        |   |
| administered the disabil­ity    |   | state­wide plan that a) assesses |   |
| module were increased to       |   | the risk for lead exposure, b)  |   |
| approximately 3,200 to yield   |   | responds appropriately to the   |   |
| an expected 600--800           |   | risks identified, c) oversees   |   |
| respon­dents with disabilities  |   | and evaluates programs and      |   |
| from each reporting            |   | policies consistent with risk   |   |
| jurisdiction. Respondents who  |   | assessment, and d) monitors     |   |
| gave a posi­tive response to    |   | screening, follow-up, and       |   |
| one of the disability          |   | public and professional         |   |
| ques­tions were asked follow-up |   | edu­cational activities.         |   |
| questions related to           |   |                                 |   |
| underlying impairment or       |   | Surveillance activities include |   |
| health prob­lems, duration of   |   | a) collecting, analyzing, and   |   |
| limitation, and need for       |   | disseminating lead-related data |   |
| assistance in activities of    |   | and b) monitoring and           |   |
| daily living and instrumental  |   | evaluating the effectiveness of |   |
| activities of daily living.    |   | screening, follow-up, lead      |   |
|                                |   | hazard control, and primary     |   |
| For more information, contact  |   | prevention activities. CDC also |   |
| Don Lollar by telephone at     |   | provides technical and          |   |
| (770) 488-7094 or by E-mail at |   | management consultation to      |   |
| \<dcl5@cdc.gov\>.              |   | state and local health agencies |   |
|                                |   | to develop and implement lead   |   |
| ## Childhood Lead              |   | poisoning prevention activities |   |
|                                |   | and surveillance systems.       |   |
| ## Poisoning Prevention        |   |                                 |   |
|                                |   | For more information, contact   |   |
| Lead poisoning remains a major |   | Jerry Hershovitz by telephone   |   |
| environ­mental public health    |   | at (404) 639-2500 or by FAX at  |   |
| problem for children despite   |   | (404) 539-2555.                 |   |
| substantial progress in        |   |                                 |   |
| controlling and preventing the |   |                                 |   |
| problem in recent years.       |   |                                 |   |
| During 1988--1994, the         |   |                                 |   |
| National Health and Nutrition  |   |                                 |   |
| Examination Survey (NHANES)    |   |                                 |   |
+--------------------------------+---+---------------------------------+---+

## OCCUPATIONAL HEALTH CONCERNS

+--------------------------------+---+---------------------------------+
| ## Oc                          |   | lance System. Information from  |
| cupational Lung Disease Deaths |   | death cer­tificates is collected |
|                                |   | from 52 vital statistics        |
| Statistics in this section are |   | reporting units (all 50 states, |
| from the National Surveillance |   | New York City, and the District |
| System for Pneumo­coniosis      |   | of Columbia) according to the   |
| Mortality (NSSPM). This system |   | following criteria: age ≥16     |
| was developed and is           |   | years, an external cause of     |
| maintained by the Division of  |   | death (*ICD-9* codes            |
| Respiratory Disease Studies of |   | E800--E999), and a response     |
| CDC's National Institute for   |   | that the injury occurred at     |
| Occupational Safety and Health |   | work.                           |
| (NIOSH). NSSPM contains death  |   |                                 |
| certificate information for    |   | Because no standard guidelines  |
| 1968--1996 for all U.S.        |   | exist for responding to the     |
| decedents aged ≥15 years       |   | "Injury at work?" portion of a  |
| identified with pneumoconiosis |   | death certificate, the NTOF     |
| listed as an underlying or     |   | Surveillance System's numbers   |
| contributing cause of death.   |   | should be considered the        |
| These data are a subset of     |   | minimum number of work-related  |
| national vital statistics      |   | deaths in the United States     |
| prepared annually by CDC's     |   | during the reporting period. To |
| National Center for Health     |   | address this issue, NIOSH       |
| Statistics (NCHS).             |   | collaborated with NCHS, the     |
|                                |   | National Association for Public |
| Age-adjusted pneumoconiosis    |   | Health Statistics and           |
| mortality rates are presented  |   | Information Systems, and the    |
| for each state during          |   | National Center for             |
| 1987--1996 (*ICD-9* codes      |   | Envi­ronmental Health (NCEH) to  |
| 500--505). Rates by specific   |   | develop guide­lines for          |
| types of pneumoconiosis (i.e., |   | recording work-related          |
| coal workers' pneumoconioses   |   | injuries. These guidelines were |
| \[CWP\], sili­cosis,            |   | implemented by the states in    |
| asbestosis, byssinosis, and    |   | 1993 and should improve future  |
| other/un­specified              |   | surveillance for occupational   |
| pneumoconiosis) are presented  |   | fatalities based on death       |
| for each state and compared    |   | certificates.                   |
| with the U.S. rate. Population |   |                                 |
| data (denominators for rates)  |   | Cause-of-death codes have been  |
| are 1992 postcensal population |   | assigned according to the       |
| estimates from the Bureau of   |   | *ICD-9* supplementary chapter   |
| the Census.                    |   | on the classification of        |
|                                |   | external causes of injury and   |
| Death rates are age-adjusted   |   | poisoning. Occupation           |
| by the direct method to the    |   | narratives are coded into 11    |
| 1940 U.S. population. More     |   | divisions according to the 1980 |
| information on pneumoconiosis  |   | and 1990 Bureau of the Census   |
| mortality patterns during      |   | classification schemes.         |
| 1987--1996 are available in    |   | Denominator data for the        |
| the *Work-Related Lung Disease |   | calculation of rates were       |
| Surveil­lance Report 1996*,     |   | obtained from the Bureau of     |
| which also provides data for   |   | Labor Statistics (BLS) annual   |
| other occupationally relevant  |   | average employment data for     |
| respiratory diseases (e.g.,    |   | 1991--1995. The rates presented |
| occupational asthma,           |   | in this publication are for the |
| hyper­sensitivity pneumonitis,  |   | U.S. civilian labor force.      |
| malignant neoplasm of the      |   |                                 |
| pleura) (1999; DHHS            |   | More information is available   |
| publication no.                |   | from NIOSH (*Fatal injuries to  |
| \[NIOSH\]00-105).              |   | workers in the United States,   |
|                                |   | 1980--1989: a decade of         |
| ## Tra                         |   | surveillance national and state |
| umatic Occupational Fatalities |   | profiles*. 1993; DHHS           |
|                                |   | publication no.                 |
| Occupational fatalities are    |   | \[NIOSH\]93-108S).              |
| identified by NIOSH through    |   |                                 |
| the National Traumatic         |   |                                 |
| Occupational Fatalities (NTOF) |   |                                 |
| Surveil-                       |   |                                 |
+--------------------------------+---+---------------------------------+

+--------------------------------+---+---------------------------------+
| ## Occupational Illnesses      |   | Forty-one states participated   |
|                                |   | in this project.                |
| Data on occupational illness   |   | Nonparticipating states include |
| are from the 1998 Survey of    |   | Colorado, Idaho, Mississippi,   |
| Occupational Injuries and      |   | New Hampshire, North Dakota,    |
| Illnesses, conducted by BLS in |   | Ohio, Pennsylvania, South       |
| cooperation with state         |   | Dakota, and Wyoming. The        |
| agencies (available at         |   | District of Columbia also did   |
| http:/                         |   | not participate.                |
| /stats.bls.gov/oshhome.htm\>). |   |                                 |
| The survey provided state and  |   | Illnesses are reported by       |
| national estimates of the      |   | employers in seven categories.  |
| number and frequency of        |   | Industries are coded into 10    |
| nonfatal occupational injuries |   | cate­gories according to the     |
| and illnesses based on logs    |   | 1987 edition of the *Standard   |
| kept by 169,000 private        |   | Industrial Classification       |
| industry employers. It         |   | Manual*, published by the U.S.  |
| represents the most current    |   | Office of Management and Budget |
| data available. Data that      |   | (1987).                         |
| conform to Occupa­tional Safety |   |                                 |
| and Health Administration      |   | Overall, BLS reported that the  |
| (OSHA) definitions for mining  |   | U.S. rate for occupational      |
| operators in coal, metal, and  |   | injuries and illnesses in       |
| nonmetal mining and for        |   | private industry was 6.7/100    |
| employers in railroad          |   | full-time workers in 1998.      |
| transportation are provided to |   | Approximately 392,000 new cases |
| BLS by the Mine Safety and     |   | of occupational illness were    |
| Health Administration (U.S.    |   | reported in private industry in |
| Department of Labor) and the   |   | 1998. Manufacturing industries  |
| Federal Railroad               |   | accounted for three-fifths of   |
| Administra­tion (U.S.           |   | these cases. Disorders          |
| Department of Transportation). |   | associated with repeated trauma |
|                                |   | (e.g., carpal tunnel syndrome   |
| Independent mining contractors |   | and noise-induced hearing loss) |
| are excluded from data for the |   | represented 65% of the 392,000  |
| mining industry. The survey    |   | cases of illness reported.      |
| also excludes farms with \<11  |   |                                 |
| employees and persons who are  |   |                                 |
| self-employed or employed in   |   |                                 |
| private house­holds.            |   |                                 |
+--------------------------------+---+---------------------------------+

## 

## INFECTIOUS DISEASES

+--------------------------------+---+---------------------------------+
| ## Acquired Immunodeficiency   |   | from 1997 through 1998 and by   |
|                                |   | approxi­mately 27,000 from 1998  |
| ## Syndrome                    |   | through 1999 because of longer  |
|                                |   | survival times after diagnosis. |
| This section provides          |   |                                 |
| estimated rates per 100,000    |   | AIDS-related organizations at   |
| population for adults and      |   | federal, state, and local       |
| adoles­cents (i.e., persons     |   | levels of government, as well   |
| aged ≥13 years) living with    |   | as some businesses and          |
| acquired immunodeficiency      |   | community groups, rely on       |
| syndrome (AIDS) (i.e., AIDS    |   | current AIDS information to     |
| prevalence) at the end of      |   | plan for the future. Because of |
| 1999, by state of residence.   |   | decreases in AIDS inci­dence,    |
| The prevalence of AIDS is a    |   | recent data on the number of    |
| function of the number of      |   | persons living with AIDS allow  |
| inci­dent cases and the length  |   | better planning for future      |
| of time persons survive after  |   | fiscal requirements, along with |
| an AIDS diagnosis. At the end  |   | medi­cal and social service      |
| of 1999, approximately 320,000 |   | needs.                          |
| persons were alive and living  |   |                                 |
| with AIDS in the United        |   | States report AIDS cases to the |
| States. Although the annual    |   | Division of HIV/AIDS Prevention |
| number of new AIDS diagnoses   |   | (DHAP) of CDC's National Center |
| has decreased, largely as a    |   | for HIV, STD, and TB Pre­vention |
| result of recent developments  |   | (NCHSTP). A uniform case        |
| in treatment for human         |   | defini-                         |
| immunodeficiency virus (HIV)   |   |                                 |
| infection, AIDS prevalence     |   |                                 |
| in­creased by approximately     |   |                                 |
| 25,000 persons                 |   |                                 |
+--------------------------------+---+---------------------------------+

+--------------------------------+---+---------------------------------+
| tion and case report form are  |   | Travelers visiting countries    |
| used, and rates are calculated |   | where malaria is endemic can    |
| on an annual basis per 100,000 |   | minimize their risk by taking   |
| population. Population data    |   | an antimalarial drug for        |
| are 1999 postcensal population |   | chemoprophylaxis and using      |
| estimates from the Bureau of   |   | personal protection measures    |
| the Census.                    |   | (e.g., insect repellents,       |
|                                |   | protective clothing, and        |
| Rates per 100,000 population   |   | mosquito nets). Information     |
| also are in­cluded for, at      |   | regarding malaria risk,         |
| most, the four largest         |   | antimalarial drug-resistance    |
| Metro­politan Statistical Areas |   | patterns, and recommended       |
| (MSAs) in states with the      |   | antimalarial prophylaxis is     |
| highest case rates for AIDS.   |   | available in CDC's *Health      |
| For states that do not have    |   | Information for International   |
| MSAs with popula­tions of       |   | Travel, 1999-2000*. Current     |
| ≥500,000, no MSA data are      |   | recommendations are also        |
| pro­vided. MSAs sometimes cross |   | available free on the Internet  |
| state lines. In these          |   | at                              |
| instances, the data are        |   | \<http://www.cdc.gov/travel\>,  |
| assigned to the state with the |   | by calling (888) 232-3228, or   |
| largest proportion of the      |   | by calling (888)                |
| MSA's population. Definitions  |   |                                 |
| and descrip­tions of MSAs are   |   | 232-3299 to request information |
| available on the Bureau of the |   | by fax.                         |
| Census Internet site at the    |   |                                 |
| following address:             |   | Although sustained malaria      |
| \<http://www.census.gov\>.     |   | transmission no longer occurs   |
|                                |   | in this country, anopheline     |
| For more information, contact  |   | mosquitoes capable of           |
| a DHAP Information Specialist  |   | transmitting the in­fection are  |
| by telephone at (404) 639-2072 |   | still found in all 48 of the    |
| or by FAX at (404) 639-2007.   |   | con­tiguous United States. These |
| Information also is available  |   | insects rarely encounter        |
| on the DHAP Internet site at   |   | malaria-infected humans, and    |
| the following address:         |   | they typically do not survive   |
| \<http                         |   | long enough to become           |
| ://www.cdc.gov/hiv/dhap.htm\>. |   | infective, bite another person, |
|                                |   | and transmit the infection.     |
| ## Malaria                     |   | However, when weather           |
|                                |   | conditions are favorable (e.g., |
| The National Malaria           |   | sustained periods of high       |
| Surveillance System is a       |   | temperature and humidity),      |
| passive reporting system       |   | these mosquitoes can survive    |
| operated by the Malaria        |   | longer and become infective     |
| Epidemiology Branch in the     |   | more quickly.                   |
| Divi­sion of Parasitic Diseases |   | Mosquito-transmitted malaria    |
| of CDC's National Center for   |   | occurs in the United States     |
| Infectious Diseases (NCID).    |   | only when certain events        |
| Laboratory-confirmed cases of  |   | coincide (e.g., a person with   |
| malaria are identified by      |   | parasitemia, increased contact  |
| health-care providers or       |   | among humans and the anopheline |
| labo­ratories, reported to      |   | vector, and environmental       |
| local and state health         |   | conditions that favor           |
| departments, then reported to  |   | transmission) (*Emerg Infect    |
| CDC. Ap­proximately 1,500 cases |   | Dis* 1996;2:37-43).             |
| of malaria are re­ported in the |   |                                 |
| United States each year, but   |   | Annual reports from the         |
| many additional cases might go |   | National Malaria Surveillance   |
| unreported because of          |   | System are printed in the *CDC  |
| underreporting. Most           |   | Surveillance Summaries* (*MMWR* |
| infections are acquired        |   | 1999;48\[SS-1\]). These reports |
| outside the United States and  |   | include summary data on         |
| its territories, in parts of   |   | reported cases and their        |
| the world where malaria is     |   | origins and information on      |
| endemic. Typically, \<10 cases |   | locally acquired cases          |
| each year are acquired inside  |   | investigated during the year.   |
| the United States, usually     |   |                                 |
| from transfusion, needlestick, |   | For more information, contact   |
| organ transplantation,         |   | the Malaria Hotline by          |
| congenital transmis­sion, or an |   | telephone at (770) 488-7788 or  |
| infected mosquito.             |   | by FAX at (770) 488-7761.       |
+--------------------------------+---+---------------------------------+
| ## Chlamydia and Gonorrhea     |   | origin of decedent on death     |
|                                |   | certificates in 1996.           |
| **Primary and Secondary        |   |                                 |
| Syphilis**                     |   | Nearly all of the infectious    |
|                                |   | diseases that were among the 10 |
| Data in these sections are     |   | leading causes of death in the  |
| from state and local health    |   | United States at the beginning  |
| departments, which report      |   | of the twenti­eth century are    |
| cases of chlamydia, gonorrhea, |   | now under control (e.g.,        |
| and primary and secondary      |   | tu­berculosis, diphtheria, and   |
| syphilis to the Division of    |   | diarrheal dis­eases). However,   |
| Sexu­ally Transmitted Disease   |   | P&I have continuously been      |
| (STD) Prevention, NCHSTP.      |   | among the top 10 leading causes |
| Crude incidences (new cases/   |   | of death since the beginning of |
| population) are calculated     |   | the 1990s, and they remain a    |
| annually per 100,000           |   | serious health problem. In      |
| population. Rates for 1999 use |   | 1998, P&I ranked sixth among    |
| 1998 population estimates from |   | the 10 leading causes of death. |
| Bureau of the Census           |   |                                 |
| postcensal data. Because no    |   | Minor changes in the            |
| cases of chlamydia were        |   | antigenicity of influ­enza       |
| reported outside New York      |   | viruses, known as antigenic     |
| City, the rate of occurrence   |   | drift, lead to influenza        |
| of chlamydia for the state of  |   | epidemics nearly every winter   |
| New York reflects only the     |   | in the United States. An        |
| occurrence of cases in New     |   | average of approxi­mately 20,000 |
| York City.                     |   | deaths, more than 110,000       |
|                                |   | hospitalizations, millions of   |
| More detailed information on   |   | visits for outpa­tient care, and |
| STDs is avail­able in CDC's     |   | tens of millions of lost work   |
| *Sexually Transmitted Disease  |   | and school days occur each      |
| Surveillance, 1999* (September |   | influenza season.               |
| 2000). Copies can be obtained  |   |                                 |
| from the Office of             |   | Influenza vaccine is the        |
| Communications, NCHSTP; CDC;   |   | primary method for preventing   |
| 1600 Clifton Road, Mailstop    |   | influenza infection and its     |
| E-06; Atlanta, GA 30333. The   |   | more severe complications. This |
| report is also available on    |   | inactivated (i.e.,              |
| the Internet at                |   | killed-virus) vaccine contains  |
| \<http://www.cdc.gov/nchstp/   |   | three strains (two type A and   |
| dstd/S                         |   | one type B), representing the   |
| tats_Trends/1999SurvRpt.htm\>. |   | influenza viruses likely to     |
|                                |   | circulate in the United States  |
| For more information, contact  |   | during the upcoming winter.     |
| Melinda Flock, M.S.P.H., by    |   | Vaccination is strongly         |
| telephone at (404)             |   | recommended for all persons     |
|                                |   | aged ≥6 months who are at       |
| 639-8356 or by FAX at (404)    |   | increased risk for              |
| 639-8611.                      |   | complications because of age or |
|                                |   | an underlying medical condition |
| Information also is available  |   | (*MMWR* 2000;49\[RR-3\]).       |
| on the Division of STD         |   |                                 |
| Prevention website at the      |   | Active global and U.S.          |
| following address:             |   | surveillance for in­fluenza      |
| \<htt                          |   | viruses is critical for         |
| p://www.cdc.gov/nchstp/dstd\>. |   | formulating each year's vaccine |
|                                |   | and detecting new viruses.      |
| ##                             |   | Surveillance for influenza-like |
| Pneumonia and Influenza Deaths |   | ill­ness and mortality caused by |
|                                |   | P&I is an important way to      |
| Data for the total number of   |   | assess the impact of the        |
| deaths and age-adjusted death  |   | circulating strain(s).          |
| rates for pneumonia and        |   |                                 |
| influenza (P&I) (*ICD-9* codes |   | In addition to causing annual   |
| 480--487) are from the         |   | epidemics, new influenza type A |
| *National Vital Statistics     |   | viruses to which most of the    |
| Report* (2000;48\[11\]). P&I   |   | world's population are          |
| death rates are presented by   |   | susceptible can                 |
| race/ethnicity for states that |   |                                 |
| meet one of the following      |   |                                 |
| criteria: a) ≥150,000 persons  |   |                                 |
| in the designated group or b)  |   |                                 |
| ≥20 deaths among members of    |   |                                 |
| the designated group. Data for |   |                                 |
| Oklahoma are not available     |   |                                 |
| because that state did not     |   |                                 |
| record Hispanic                |   |                                 |
+--------------------------------+---+---------------------------------+

+--------------------------------+---+---------------------------------+
| emerge unpredictably and lead  |   | is recommended for all children |
| to pandem­ics. In the twentieth |   | aged \<2 years and for some     |
| century, three pandem­ics       |   | children aged 2--4 years at     |
| (during the 1918-19, 1957-58,  |   | high risk (*MMWR* 2000;49\[No.  |
| and 1968-69 seasons) caused    |   | RR-9\]).                        |
| great increases in illness and |   |                                 |
| more than 650,000 deaths       |   | The Public Health Service       |
| combined. In 1997 and 1999,    |   | publication *Healthy People     |
| human cases of illness and     |   | 2010* (objective 14--29) calls  |
| deaths related to new          |   | for increasing P&I vaccination  |
| influenza viruses were         |   | levels to a) ≥90% among persons |
| discovered but did not result  |   | aged ≥65 years and persons of   |
| in pandemics.                  |   | all ages in long-term--care or  |
|                                |   | nursing homes and b) ≥60% among |
| Pneumococcal infections are    |   | persons aged 18--64 years at    |
| the most com­mon cause of       |   | high risk for complica­tions     |
| bacterial meningitis and of    |   | from pneumococcal disease or    |
| pneumonia leading to           |   | influ­enza infection (*Healthy   |
| hospitalization. Each year,    |   | people 2010.* Con­ference ed, in |
| pneumococcus causes            |   | 2 vols. Washington, DC: US      |
| approximately 60,000 cases of  |   | Department of Health and Human  |
| bacteremic disease, 3,000      |   | Services, 2000). The *Healthy   |
| cases of meningitis, 125,000   |   | People 2000* goal (objective    |
| cases of pneu­monia requiring   |   | 20.11) for P&I vaccination was  |
| hospitalization, and 6 million |   | 60% for noninstitutionalized    |
| ear infections. Approximately  |   | populations at high risk and    |
| 1 in 10 persons with an        |   | 80% for long-term--care and     |
| invasive pneumococcal          |   | nursing home residents (1991;   |
| infection (i.e., infection of  |   | DHHS pub­lication no.            |
| the blood stream or other      |   | \[PHS\]91-50212).               |
| normally sterile body site)    |   |                                 |
| die of the infection (range:   |   | During 1989--1999, pneumonia    |
| from \<1 in 100 children aged  |   | and influenza vaccination       |
| \<5 years to approximately 1   |   | levels in the United States     |
| in 6 adults aged \>65 years)   |   | in­creased. Analysis of data     |
| (CDC. *Active Bacterial Core   |   | from the 1999 Behavioral Risk   |
| Surveillance \[ABCs\] Report,  |   | Factor Surveillance System (The |
| Strepto­coccus pneumoniae,      |   | BRFSS) indicates that 67% of    |
| 1999*. Available on the        |   | nonin­stitutionalized persons    |
| Internet at                    |   | aged ≥65 years re­ported         |
| \<http://www.cdc.gov/ncidod/   |   | receiving influenza vaccination |
| dbmd/abcs\>).                  |   | during the preceding 12 months, |
|                                |   | which exceeds the *Healthy      |
| Multidrug-resistant            |   | People 2000* objective. (BRFSS  |
| pneumococci are be­coming       |   | is an annual, state-based,      |
| increasingly common, making    |   | random-digit--dialed telephone  |
| pneumococcal infections more   |   | survey of health-related        |
| difficult to treat. CDC        |   | behavior. Each participating    |
| surveillance data suggest that |   | state selects a probability     |
| approximately one-quarter of   |   | sample of its                   |
| invasive pneumococcal isolates |   | noninstitutionalized civilian   |
| are no longer sus­ceptible to   |   | adult population aged ≥18 years |
| penicillin and approximately 1 |   | who have telephones. During     |
| in 7 are not susceptible to at |   | 1999, all 50 states, the        |
| least three drug classes (*New |   | District of Columbia, and       |
| Engl J Med*                    |   | Puerto Rico participated in the |
| 2000;343:1917--24). Infants    |   | BRFSS.)                         |
| and young children, persons    |   |                                 |
| aged ≥65 years, persons with   |   | By contrast, influenza          |
| immune system disorders, and   |   | vaccination rates are lower     |
| persons with certain chronic   |   | among adults aged 18--64 years  |
| diseases are at higher risk    |   | who are at high risk for        |
| for pneumococcal infections.   |   | complications. Based on 1997    |
|                                |   | National Health Interview       |
| A 23-valent pneumococcal       |   | Survey (NHIS) data, 1997        |
| polysaccharide vaccine is      |   | influenza vaccination coverage  |
| recommended for persons aged   |   | for persons in this age group   |
| ≥2 years who are at high risk. |   | at high risk was 26% (CDC,      |
| A 7-valent vaccine effective   |   | unpublished data, 1997).        |
| for infants and young children |   |                                 |
| was licensed in February 2000  |   |                                 |
| and                            |   |                                 |
+--------------------------------+---+---------------------------------+
| Although pneumococcal vaccine  |   | sota, New Jersey, New York,     |
| coverage has increased during  |   | Pennsylvania, Rhode Island, and |
| the 1990s, coverage in most    |   | Wisconsin) (*MMWR*              |
| states and the United States   |   | 2000;49\[No.SS-3\]:1--11). The  |
| as a whole remains below       |   | tick vector in these endemic    |
| *Healthy People 2000* goals.   |   | areas is the deer tick or       |
| The 1999 BRFSS report notes    |   | *Ixodes scapularis*.            |
| that only 54% of persons aged  |   |                                 |
| ≥65 years reported ever        |   | A vaccine against Lyme disease  |
| re­ceiving a dose of            |   | was licensed in December 1998   |
| pneumococcal vaccine. In       |   | for persons aged 15--70 years   |
| individual states, coverage    |   | (*MMWR* 1999;48\[No. RR-7\]).   |
| ranged from 40% to 67%, and 8  |   | CDC is funding community-based  |
| states had ≥60% coverage.      |   | programs to pre­vent Lyme        |
| Based on the 1997 NHIS,        |   | disease through health          |
| pneumococcal vaccination       |   | education, appropriate          |
| coverage for persons at high   |   | vaccination, and integrated     |
| risk aged 18--64 years was 13% |   | strategies to reduce vector     |
| (CDC, unpub­lished data, 1997). |   | tick densities.                 |
|                                |   |                                 |
| For more information on        |   | A skin rash that resembles the  |
| pneumococcal infections,       |   | one caused by Lyme disease has  |
| contact Cynthia Whitney, M.D., |   | been associated with bites by   |
| M.P.H., by telephone at (404)  |   | the lone star tick *(Amblyomma  |
| 639-2215 or by FAX at (404)    |   | ameri­canum*), but this rash     |
| 639-3970. For more infor­mation |   | does not appear to be caused by |
| on influenza infections,       |   | *B. burgdorferi* infection (*J  |
| contact Alicia S. Postema,     |   | Infect Dis* 1995;172:470--80    |
| M.P.H., by telephone at (404)  |   | and *Arch Intern Med*           |
| 639-3747 or by FAX at (404)    |   | 1997;157:2635--41). CDC is      |
| 639-3866. For more information |   | conducting studies to determine |
| on vaccine issues, contact     |   | the etiology of this con­dition, |
| James A. Singleton, M.S., by   |   | which occurs primarily in the   |
| telephone at (404) 639-8257 or |   | south-central and southeastern  |
| by FAX at (404) 639-8616.      |   | United States and could be      |
|                                |   | mistakenly reported as Lyme     |
| ## Lyme Disease                |   | disease.                        |
|                                |   |                                 |
| Lyme disease is a multisystem, |   | For more information, contact   |
| multistage disease caused by   |   | CDC's Lyme disease program by   |
| infection with the tick­borne   |   | telephone at (970) 221-6400 or  |
| spirochete, *Borrelia          |   | by FAX at (970) 221-6474.       |
| burgdorferi*, and the most     |   | Infor­mation is also available   |
| commonly reported vectorborne  |   | on the Internet at              |
| disease in the United States.  |   | \<h                             |
| During 1999, a total of 16,273 |   | ttp://www.cdc.gov/ncidod/dvbid/ |
| cases of Lyme disease were     |   | lymeinfo.htm\>.                 |
| reported to CDC (cases are     |   |                                 |
| reported by county of          |   | ## Tuberculosis                 |
| residence, which is not        |   |                                 |
| necessarily the county of      |   | Data in this section are from   |
| exposure).                     |   | health depart­ments in all 50    |
|                                |   | states, New York City, and the  |
| CDC initiated national         |   | District of Columbia, which     |
| surveillance for Lyme disease  |   | report tu­berculosis (TB) cases  |
| in 1982, and 11 states         |   | to the Division of Tuberculosis |
| reported 491 cases. During     |   | Elimination, NCHSTP. Rates were |
| 1992--1998, cases increased    |   | calculated using postcensal     |
| 70%, from 9,986 in 1992 to     |   | estimates from the Bureau of    |
| 16,802 in 1998, with a total   |   | the Census.                     |
| of 88,967 cases reported to    |   |                                 |
| CDC's National Notifiable      |   | In 1999, a total of 17 states   |
| Diseases Surveillance System   |   | had TB case rates of ≤3.5       |
| (NNDSS) during this period     |   | cases/100,000 population. This  |
| (*MMWR*                        |   | rate represents the interim     |
| 2000;49\[No.SS-3\]:1--11).     |   | target for the year 2000        |
| Although cases were reported   |   | established by the Advisory     |
| by all states except Montana,  |   | Council for the Elimination of  |
| 92% were re­ported from only 10 |   | Tuberculosis as part of its     |
| states (Connecticut, Delaware, |   | long-term goal to eliminate TB  |
| Massachusetts, Maryland,       |   | by 2010.                        |
| Minne-                         |   |                                 |
+--------------------------------+---+---------------------------------+
| Fifteen states and the         |   | born persons living in the      |
| District of Columbia had TB    |   | United States increased from    |
| case rates higher than the     |   | 27% in 1992 to 43% in 1999 and  |
| 1999 national rate of 6.4      |   | was ≥50% in 15 states.          |
| cases/100,000 popula­tion.      |   |                                 |
|                                |   | For more information, contact   |
| Eliminating TB in the United   |   | Gloria Kelly by telephone at    |
| States will depend             |   | (404) 639-8117 or by FAX at     |
| increasingly on eliminating TB |   | (404) 639-8959. Information     |
| among persons born in          |   | also is available on the        |
| countries with high TB rates   |   | Division of TB Elimination      |
| (*MMWR* 1998;47\[No. RR-16\]). |   | Internet site at                |
| The proportion of TB cases     |   | \<http://www.cdc.gov/nchstp/    |
| among foreign-                 |   | tb/default.htm\>.               |
+--------------------------------+---+---------------------------------+

## 

## CHRONIC DISEASES: CONDITIONS AND RISK FACTORS

This section presents mortality data for total cardiovascular disease,
breast cancer, colon cancer, and lung cancer, as well as related risk
factor data for these and other chronic diseases. In 1999, CDC's
National Center for Chronic Disease Prevention and Health Promotion
(NCCDPHP) pub­lished *Chronic Diseases and Their Risk Factors: The
Nation's Leading Causes of Death* (De­cember 1999). This report provides
state-specific data for the major causes of death, cardiovascu­lar
disease, cancer, and diabetes, as well as for selected risk factors and
the use of preventive ser­vices. A second report, *Unrealized Prevention
Opportunities: Reducing the Health and Economic Burden of Chronic
Disease* (November 2000), lists national priorities for preventing
chronic disease and describes ways to reduce the health-care and
economic burdens of chronic disease. Copies of both documents are
available from NCCDPHP by telephone at (770) 488-5131.

For more information, contact Nora Keenan, Ph.D., by telephone at (770)
488-5414, by FAX at (770) 488-8151, or by E-mail at \<NKeenan@cdc.gov\>.
Information regarding the major chronic diseases and their risk factors
also is available on the NCCDPHP Internet site at
\<http://www.cdc.gov/nccdphp\>.

Data for death rates are annual age-adjusted rates based on the
underlying cause of death for the years indicated. The numbers of deaths
(numerators for death rates) are from the National Vital Statistics
System (NVSS) of CDC's National Center for Health Statistics (NCHS) and
are based on data provided by registrars in all 50 states, New York
City, and the District of Columbia. The numbers of deaths sometimes
differ from those published by the states because a) the cut-off dates
for accepting vital statistics records into the annual file for
producing statistics can be dif­ferent; b) the interstate exchange
program through which states receive data on events that in­volved
residents but occurred in other states might not include all records;
and c) the interna­tional rules for selecting the underlying cause of
death is interpreted and applied differently in some states.

Population data (denominators for death rates) are 1998 postcensal
population estimates from the Bureau of the Census. Death rates are
age-adjusted to the 1940 U.S. population by the direct method. Direct
age-adjustment is calculated by weighting the annual age-specific rates
by the population distribution in the standard population (see the
Mortality section for more information on population data and age
adjustment).

All risk factor data presented in this section, as well as the data on
oral health, clinical breast exam, mammography, and proctoscopy, were
obtained from the Behavioral Risk Factor Surveil­lance System (BRFSS).
The BRFSS is an annual, state-based, random-digit--dialed telephone

survey of health-related behavior. Each participating state selects a
probability sample of its non-institutionalized civilian adult
population (i.e., persons aged ≥18 years) who have telephones. In 1999,
all 50 states, the District of Columbia, and Puerto Rico participated in
the BRFSS.

For more information, contact Eve Powell-Griner, Ph.D., by telephone at
(770) 488-2524 or by FAX at (770) 488-8150. More information about the
BRFSS is available on the NCCDPHP Internet site at
\<http://www.cdc.gov/nccdphp\>.

National objectives for several behavioral risk factors discussed in
this section are from the Public Health Service publication *Healthy
People 2000: National Health Promotion and Disease Prevention
Objectives* (1991; DHHS publication no. \[PHS\]91-50212).

These objectives include the following:

**Objective 1.5** -- Reduce to ≤15% the proportion of persons aged ≥6
years who engage in no leisure-time physical activity.

**Objective 2.3** -- Reduce overweight to a prevalence of ≤20% among
persons aged ≥20 years.

**Objective 2.6** -- Increase to ≥50% the proportion of persons aged ≥2
years who meet the average daily goal of ≥5 servings of vegetables and
fruits. The 50% target was added in the 1995 mid-course revision of
*Healthy People 2000: Midcourse Review and 1995 Revisions*. The average
daily goal of ≥5 servings of vegetables and fruits comes from the
*Dietary Guidelines for Ameri­cans*. *Third Edition* (1990; DHHS
publication no. 1990-273--930).

**Objective 3.4** -- Reduce cigarette smoking to a prevalence of ≤15%
among persons aged ≥20 years.

**Objective 13.4** -- Reduce to ≤20% the proportion of persons aged ≥65
years who have lost all of their natural teeth.

**Objective 13.14** -- Increase to ≥70% the proportion of persons aged
≥35 years using the oral health-care system during each year.

+--------------------------------+---+---------------------------------+
| ## Oral Health                 |   | how many of their permanent     |
|                                |   | teeth were removed because of   |
| Loss of all natural permanent  |   | tooth decay or gum disease.     |
| teeth (edentu-lism) can have a |   |                                 |
| substantial negative effect on |   | Regular dental visits are       |
| quality of life, self-image,   |   | opportunities for prevention,   |
| and daily functioning. Tooth   |   | early diagnosis, treatment, and |
| loss can be prevented through  |   | health education. Adults who do |
| education, regular dental      |   | not receive regular             |
| care, and early diagnosis and  |   | professional care can develop   |
| prompt treatment of diseases   |   | oral diseases that lead to      |
| and conditions that lead to    |   | unnecessary restorative         |
| tooth loss. The *Healthy       |   | treatment and preventable tooth |
| People 2000* goal (objec­tive   |   | loss. Even edentate persons     |
| 13.4) is to reduce to ≤20% the |   | remain at risk for oral soft    |
| propor­tion of persons aged ≥65 |   | tissue lesions and              |
| years who have lost all of     |   | denture-related problems.       |
| their natural teeth.           |   | *Healthy People 2000* objective |
|                                |   | 13.14 is to increase to \>70%   |
| Prevalence estimates for total |   | the proportion of persons aged  |
| tooth loss among persons aged  |   | ≥35 years using the oral        |
| ≥65 years are based on 1999    |   | health-care system each year.   |
| BRFSS data. Participants were  |   |                                 |
| asked                          |   |                                 |
+--------------------------------+---+---------------------------------+

+--------------------------------+---+---------------------------------+
| In states that administered    |   | aged ≥6 years who engage in no  |
| the BRFSS oral health module,  |   | leisure-time physical activity  |
| participants were asked how    |   | and reducing the prevalence of  |
| long it had been since they    |   | overweight to ≤20% among        |
| last visited a dentist or      |   | persons aged ≥20 years are      |
| dental clinic. Estimates of    |   | *Healthy People 2000* goals     |
| the pro­portion of persons aged |   | (objectives 1.5 and 2.3,        |
| ≥35 years who re­ported that    |   | respectively). The average      |
| they saw a dentist during the  |   | 3-year prevalence of physical   |
| pre­ ceding 12 months are       |   | inac­tivity and overweight are   |
| presented for 48 states that   |   | presented for each state and    |
| administered the oral health   |   | the District of Columbia, in    |
| module during at least 1 year  |   | relation to *Healthy People     |
| during 1995--1999. To increase |   | 2000* objectives.               |
| the precision of prevalence    |   |                                 |
| esti­mates, data from multiple  |   | Leisure-time physical           |
| years were aggre­gated for      |   | inactivity is defined as not    |
| states that administered the   |   | participating in any            |
| BRFSS oral health module       |   | leisure-time physical           |
| during more than 1 year.       |   | activities or exercises (e.g.,  |
|                                |   | running, calis­thenics, golfing, |
| Estimates of the proportion of |   | gardening, or walking) dur­ing   |
| persons aged ≥35 years who     |   | the previous month. Overweight  |
| reported visiting a dentist    |   | is de­fined as body mass index   |
| during the preceding 12 months |   | ≥27.8 kg/m^2^ for men and ≥27.3 |
| are based on 1999 BRFSS data.  |   | kg/m^2^ for women.              |
| Participants were asked how    |   |                                 |
| long it had been since they    |   | Estimates of leisure-time       |
| last visited a dentist or      |   | physical inactivity and         |
| dental clinic.                 |   | overweight are calculated by    |
|                                |   | taking the average prevalence   |
| For more information, contact  |   | for 1994, 1996, and 1998. These |
| William Konn, D.D.S., by       |   | years were chosen because       |
| telephone at (770) 488-6071,   |   | physical activity data are not  |
| by FAX at (770) 488-6080, or   |   | available for 1995, 1997, and   |
| by E-mail at \<wak4@cdc.gov\>. |   | 1999.                           |
|                                |   |                                 |
| ## Pr                          |   | For more information, contact   |
| evalence of Diagnosed Diabetes |   | Anita Blankenship by telephone  |
|                                |   | at (770) 488-5680, by FAX at    |
| This section presents          |   | (770) 488-5473, or by E-mail at |
| age-specific and total         |   | \<aob4@cdc.gov\>.               |
| prevalence of diagnosed        |   |                                 |
| diabetes for the state and for |   | ## Total Cardiovascular Disease |
| the BRFSS median value (50th   |   |                                 |
| percentile) for all states.    |   | The age-adjusted death rates    |
| The percentage of the          |   | for total cardio­vascular        |
| population with diagnosed      |   | disease per 100,000 population  |
| diabetes is a 3-year average   |   | for 1998 are provided for all   |
| of BRFSS data for 1997--1999.  |   | 50 states and the District of   |
| Persons with diagnosed         |   | Columbia. The *ICD-9* codes for |
| diabetes are defined as those  |   | cardiovascular disease as the   |
| who report that a physician    |   | underlying cause of death are   |
| told them they have diabetes.  |   | 390--459. These cardio­vascular  |
|                                |   | diseases include rheumatic      |
| For more information, contact  |   | fever/ rheumatic heart disease  |
| Linda Geiss, M.A., by          |   | (*ICD-9* codes 390--398);       |
| telephone at (770) 488-1056,   |   | hypertensive heart disease      |
| by FAX at (770) 488-1148, or   |   | (*ICD-9* code 402);             |
| by E-mail at \<lsg2@cdc.gov\>. |   | hypertensive heart and renal    |
|                                |   | disease (*ICD-9* code 404);     |
| ## Pre                         |   | ischemic heart disease (*ICD-9* |
| valence of Physical Inactivity |   | codes 410--414); diseases of    |
|                                |   | pulmo­nary circulation,          |
| ## and Overweight              |   | including acute pulmonary heart |
|                                |   | disease, chronic pulmonary      |
| Physical inactivity and        |   | heart dis­ease, and other        |
| overweight are con­sidered      |   | conditions (*ICD-9* codes       |
| important risk factors for     |   | 415--417); other forms of heart |
| coronary heart disease and     |   | disease, including heart        |
| other chronic diseases.        |   | failure (*ICD-9* codes          |
| Reducing to ≤15% the           |   | 420--429), stroke (*ICD-9*      |
| proportion of persons          |   | codes 430--438), diseases of    |
|                                |   | the                             |
+--------------------------------+---+---------------------------------+
| arteries, arterioles, and      |   | The section on clinical breast  |
| capillaries (*ICD-9* codes     |   | exam and mammography presents   |
| 440--448), and diseases of the |   | BRFSS data for 1994--1999 for   |
| veins and lymphatics; and      |   | each state and the BRFSS median |
| other diseases of the          |   | value (50th percentile) for all |
| circulatory system (*ICD-9*    |   | states. The BRFSS data for this |
| codes 451--459).               |   | section are based on women aged |
|                                |   | ≥50 years who reported having   |
| The state-based, self-reported |   | had a clinical breast           |
| prevalence estimates for four  |   | examination and a mam­mogram     |
| behavioral risk factors for    |   | within the preceding 2 years    |
| cardiovascular disease are     |   | either as part of a routine     |
| based on the 1999 BRFSS. For   |   | check up or because of a breast |
| each risk factor, the state    |   | condition (e.g., cancer or a    |
| value is compared with the     |   | lump in the breast). The        |
| BRFSS median value (50th       |   | denominator excludes            |
| percentile) for all states and |   | respon­dents who refused to      |
| the nu­merical value from the   |   | answer the questions on         |
| corresponding *Healthy People  |   | clinical breast exam or         |
| 2000* objective. These risk    |   | mammography and those who       |
| factors and their objectives   |   | answered that they did not know |
| are current smoking (objective |   | or were not sure of the answer  |
| 3.4), overweight (objec­tive    |   | to these questions.             |
| 2.3), eating \<5 servings of   |   |                                 |
| fruits and vegetables a day    |   | For more information, contact   |
| (objective 2.6), and physi­cal  |   | Steve L. Reynolds, M.P.H., by   |
| inactivity (objective 1.5).    |   | telephone at (770) 488-3075, by |
|                                |   | FAX at (770) 488-4760, or by    |
| For this section, current      |   | E-mail at \<slr6@cdc.gov\>.     |
| smokers are defined as persons |   |                                 |
| who report smoking ≥100        |   | ## Co                           |
| ciga­rettes during their        |   | lorectal Cancer and Proctoscopy |
| lifetime and who report        |   |                                 |
| smoking every day or some      |   | The annual age-adjusted death   |
| days. Over­weight is calculated |   | rates for colorectal cancer as  |
| based on self-reported weight  |   | the underlying cause of death   |
| and height and is defined as   |   | are presented for 1988--1998    |
| body mass index ≥27.8 kg/m^2^  |   | for the states by sex and by    |
| for men and ≥27.3 kg/m^2^ for  |   | total deaths in relation to the |
| women. Persons classified as   |   | *Healthy People 2000* target of |
| phy­sically inactive reported   |   | ≤13.2 deaths/100,000 persons    |
| not participating in any       |   | (objective 16.5). The *ICD-9*   |
| leisure-time physical          |   | codes for colorectal cancer are |
| activities or exer­cises (e.g., |   | 153.0--154.3, 154.8, and 159.0. |
| running, calisthenics,         |   |                                 |
| golfing, gardening, or         |   | The section on proctoscopy      |
| walking) during the previous   |   | presents BRFSS data for 1995    |
| month.                         |   | and 1997 for the states and the |
|                                |   | BRFSS median value (50th        |
| For more information, contact  |   | percentile) for all states. The |
| Carma Ayala, Ph.D., by         |   | BRFSS data for this section are |
| telephone at (770) 488-8072,   |   | based on survey respondents     |
| by FAX at (770) 488-8151, or   |   | aged ≥50 years who reported     |
| by E-mail at \<cia1@cdc.gov\>. |   | ever having had a proctoscopic  |
|                                |   | exam for signs of cancer or     |
| ##                             |   | other health problems.          |
|  Breast Cancer and Mammography |   |                                 |
|                                |   | For more information, contact   |
| This section presents annual   |   | Steven L. Reynolds, M.P.H., by  |
| age-adjusted death rates for   |   | telephone at (770) 488-3075, by |
| breast cancer as the           |   | FAX at (770) 488-4760, or by    |
| underly­ing cause of death for  |   | E-mail at \<slr6@cdc.gov\>.     |
| women during 1988--1998 for    |   |                                 |
| each state and the United      |   |                                 |
| States as a whole in relation  |   |                                 |
| to the *Healthy People 2000*   |   |                                 |
| target of ≤20.6 deaths/100,000 |   |                                 |
| women (objective 16.3). The    |   |                                 |
| *ICD-9* code for breast cancer |   |                                 |
| is 174.                        |   |                                 |
+--------------------------------+---+---------------------------------+
| ## L                           |   | Alaskan Native, and             |
| ung Cancer and Current Smoking |   | Asian/Pacific Islander racial   |
|                                |   | groups is not reported for      |
| The annual age-adjusted death  |   | states with \<50 respondents in |
| rates for lung cancer as the   |   | their BRFSS sample for those    |
| underlying cause of death are  |   | racial/ethnic groups in 1999.   |
| presented for 1988--1998 for   |   | Thus, the BRFSS median for      |
| the states by sex and by total |   | smoking prevalence for          |
| deaths in relation to the      |   | racial/ethnic groups is         |
| *Healthy People 2000* target   |   | calculated based on data from   |
| of ≤42 deaths/ 100,000 persons |   | states with ≥50 respondents     |
| (objective 16.2). The *ICD-9*  |   | from a particular group.        |
| codes for lung cancer are      |   |                                 |
| 162.2--162.9.                  |   | Survey respondents who declined |
|                                |   | to answer questions regarding   |
| The section on current         |   | smoking are excluded from the   |
| cigarette smoking among        |   | denominator of this analysis,   |
| persons aged ≥18 years is      |   | which might explain slight      |
| based on BRFSS data for        |   | differences between these and   |
| 1993--1997. Current smok­ers    |   | other estimates.                |
| are defined as persons who     |   |                                 |
| report smok­ing ≥100 cigarettes |   | For more information, contact   |
| during their lifetime and who  |   | Pascale Wortley, M.D., M.P.H.,  |
| report smoking every day or    |   | by FAX at                       |
| some days. Results are         |   |                                 |
| presented by sex and total     |   | \(770\) 488-5848, or by E-mail  |
| population in relation to the  |   | at \<Pwortley@cdc.gov\>.        |
| *Healthy People 2000* target   |   |                                 |
| of reducing cigarette smoking  |   | **Prevalence of Not Having**    |
| to ≤15% among this population  |   |                                 |
| (objective 3.4).               |   | **Health-Care Coverage**        |
|                                |   |                                 |
| For more information, contact  |   | This section presents 1999      |
| Pascale Wortley, M.D., M.P.H., |   | BRFSS data on persons aged      |
| by FAX at                      |   | 18--64 years who do not have    |
|                                |   | health-care coverage, by race   |
| \(770\) 488-5848, or by E-mail |   | and Hispanic ethnicity.         |
| at \<PWortley@cdc.gov\>.       |   | Participants were asked, "Do    |
|                                |   | you have any kind of health     |
| ## Prevalence of Smoking       |   | care coverage, in­ cluding       |
|                                |   | health insurance, prepaid plans |
| This section presents 1999     |   | such as HMOs, or government     |
| BRFSS data on current          |   | plans such as Medicare?"        |
| cigarette smoking by           |   |                                 |
| demographic groups in relation |   | The prevalence of not having    |
| to the *Healthy People 2000*   |   | health-care coverage for        |
| target of reducing cigarette   |   | persons of Hispanic ethnicity   |
| smoking to ≤15% among current  |   | and for black, American         |
| smokers (objective 3.4).       |   | Indian/Alaskan Native, and      |
| Reported prevalences are BRFSS |   | Asian/Pacific Islander racial   |
| estimates for persons aged ≥18 |   | groups is not reported for      |
| years.                         |   | states with \<50 respondents in |
|                                |   | their BRFSS sample for those    |
| Current smokers are defined as |   | racial/ethnic groups in 1999.   |
| persons who report smoking     |   | Thus, the BRFSS median for      |
| ≥100 cigarettes during their   |   | health-care coverage for        |
| lifetime and who report        |   | racial/ethnic groups is         |
| smoking every day or some      |   | calculated based on data from   |
| days. Demographic groups are   |   | states with ≥50 respondents     |
| based on self-reporting of     |   | from a particular group.        |
| age, sex, educa­tional          |   |                                 |
| attainment, race, and Hispanic |   | For more information, contact   |
| ethnic­ity. Women aged 18--44   |   | Nora Keenan, Ph.D., by          |
| years represent women of       |   | telephone at (770) 488-5414, by |
| reproductive age. The lower    |   | FAX at (770) 481-5081, or by    |
| age limit was used because the |   | E-mail at \<Nkeenan@cdc.gov\>.  |
| BRFSS does not survey persons  |   |                                 |
| aged \<18 years.               |   |                                 |
|                                |   |                                 |
| Smoking prevalence for persons |   |                                 |
| of Hispanic ethnicity and for  |   |                                 |
| black, American Indian/        |   |                                 |
+--------------------------------+---+---------------------------------+

####  

#### HEALTH PROMOTION STRATEGIES

+--------------------------------+---+--------------------------------+
| ## Training Networks           |   | having a vaccination for       |
|                                |   | influenza during the preceding |
| The Public Health Training     |   | year or ever having a          |
| Network (PHTN) information for |   | vaccina­tion for pneumococcal   |
| this section is from a         |   | disease. Data are from the     |
| database of registrants in     |   | 1999 Behavioral Risk Factor    |
| distance-based learning        |   | Sur­veillance System (BRFSS),   |
| courses who later received     |   | which is an annual,            |
| continu­ing education credits.  |   | state-based,                   |
| For more information, contact  |   | random-digit--dialed telephone |
| Dennis McDowell by telephone   |   | survey of health-related       |
| at (404) 639-3707 or by FAX at |   | behavior. Each participating   |
| (404) 639-3982. Information is |   | state selects a probability    |
| also available on the PHTN     |   | sample of its                  |
| Internet site at the following |   | noninstitutionalized civilian  |
| address:                       |   | adult population (aged ≥18     |
| \<http://www.cdc.gov/phtn/\>.  |   | years) who have telephones. In |
|                                |   | 1999, all 50 states, the       |
| The National Laboratory        |   | District of Columbia, and      |
| Training Network (NLTN)        |   | Puerto Rico participated in    |
| information for this section   |   | the BRFSS.                     |
| is from a database of          |   |                                |
| registrants in training        |   | For more information on        |
| activities sponsored by NLTN.  |   | pneumonia and influenza        |
| For more information, contact  |   | mortality, *Healthy People     |
| Judy Delany, M.S., by          |   | 2000*                          |
| telephone at (770) 488-8063,   |   |                                |
| by FAX at (770) 488-8278, or   |   | objectives, and other          |
| by E-mail at                   |   | vaccination coverage data, see |
| \<jdelany@cdc.gov\>.           |   | pages 72--74.                  |
| Infor­mation also is available  |   |                                |
| on the Internet at             |   | For more information on        |
| \<http:/                       |   | influenza and pneumococcal     |
| /www.phppo.cdc.gov/dls/nltn\>. |   | vaccination levels, contact    |
|                                |   | James A. Singleton by          |
| ## Adult Vaccination Coverage  |   | telephone at (404) 639-8689,   |
|                                |   | by FAX at (404) 639-8616, or   |
| Data in this section indicate  |   | by E-mail at                   |
| the percentage of persons aged |   | \<JSingleton@cdc.gov\>.        |
| ≥65 years who reported         |   |                                |
+--------------------------------+---+--------------------------------+