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This report summarizes the results of that analysis, which indicated that the homicide rate in Brazil more than doubled during this period (Figure 1). Since 2001, Brazilian authorities have implemented several initiatives to reduce the number of homicides, including a law that controls gun ownership and prohibits anyone other than police and members of the armed forces from carrying guns. However, homicides among adolescents and young adults remain a substantial public health problem in Brazil, and additional prevention strategies that target young persons are needed.
Data were obtained from the Mortality Information System operated by Brazil's Ministry of Health. This database includes information from death certificates for all states in Brazil. Additional data for Sao Paulo city were obtained from the Program for Quality Improvement of Mortality Information. Homicide was defined as a death resulting from an injury that was inflicted purposefully by another (including legal intervention) for which the underlying cause listed on the death certificate corresponds to codes E960-E978 and E970-E978 of the International Classification of Diseases, Ninth Revision for 1980-1996, and codes X85-Y09 and Y35 of the Tenth Revision for 1997-2002. Population data for Brazil and Sao Paulo city were obtained from BGSI. Crude, age-, and sex-specific rates were calculated per 100,000 population. To examine the association between socioeconomic status and homicide rates in Sao Paulo city, SHDSP obtained data on the monthly average income of heads of households in all 96 city districts from the 2000 Brazil Population Census. Pearson correlation analysis was used to test this association. Other countries in the Americas have experienced similar increases in homicide rates during this period (3). In 2002, Brazil had one of the world's highest homicide rates, nearly four times higher than that for the United States (4). In 2000, Brazil accounted for an estimated 28% of all the homicides that occurred in the Americas, a region that has the highest homicide rate (4).
Factors that might have contributed to increased violence include increasing urbanization, expansion of illegal drug and firearms trafficking, a lengthy economic crisis, increased unemployment, and widening income inequality (5)(6)(7). The strong negative correlation between monthly average income and homicide rates in Sao Paulo city described in this report is consistent with homicide research in other urban areas worldwide (8). Further research is needed to better understand the association between violence and poverty so appropriate interventions can be developed. This association might be attributed to income inequality and disparities in job and education prospects.
Brazil has adopted measures to reduce the number of homicides. In 2001, the Brazil Ministry of Health issued a national policy to reduce injury-related morbidity and mortality and, in 2002, Brazil issued guidelines for the reporting of child maltreatment by health professionals. In December 2003, the Brazilian Congress passed a law that controls gun ownership and prohibits anyone other than police and members of the armed forces from carrying guns. The law also established tougher penalties for international firearms trafficking. The country also plans to implement an emergency departmentbased registry for injuries. In 2002, the government of Sao Paulo state passed legislation to establish an injury surveillance system. Improved surveillance data can help guide program and policy design and monitor progress toward reducing levels of violence (4).
Several violence-prevention initiatives have been developed in Brazil. In Rio de Janeiro, Viva Rio, a nongovernment organization, directs projects for 1) promoting awareness about the risks of using or carrying firearms, 2) reducing firearm injuries, 3) promoting peace, and 4) providing vocational training for youths who live in impoverished communities. In Sao Paulo state, a coalition of private sector investor groups, state banking organizations, advertising and media companies, and research centers established the Sao Paulo Institute Against Violence to support projects for violence prevention. In addition, the local government of Sao Paulo city implemented the Renda Minima Program, which provides financial support to low-income families, and the Bolsa Trabalho Program, which promotes youth employment; both programs might help reduce the homicide rate. The impact of these efforts should be evaluated to guide development of interventions in other communities.
The findings in this report are subject to at least two limitations. First, data from death certificates might underestimate the proportion of firearm-related homicides. Studies based on medical examiners' records have documented that, in large Brazilian cities like Recife, >90% of homicides involve firearms, whereas death certificates indicate that <70% of deaths were firearm related (9). Second, information is lacking about perpetrator characteristics or circumstances of these deaths (e.g., place of occurrence, relationship between victim and offender, and the use of alcohol and other substances). A homicide surveillance system is being planned for Sao Paulo city that will link information from death certificates with medical examiner and police records to guide public policies.
Homicides among adolescents and young adults constitute a substantial public health problem in Brazil, and additional prevention strategies that target young persons are needed. These strategies should include partnerships among the government, universities, the private sector, nongovernment organizations, and communities.

# Hypothermia-Related Deaths -United States, 2003
Hypothermia, a preventable lowering of the core body temperature to <95 F (<35 C) (1), causes approximately 600 deaths each year in the United States (2). Exposure to excessive cold (or excessive exposure to cold) slows enzymatic activity throughout the body, leading to potentially fatal rhabdomyolysis, coagulopathy, renal failure, and dysrhythmias (3). Alcohol intake, activity level, and type of clothing are among the modifiable factors associated with hypothermia (4). Understanding the epidemiology and pathophysiology of hypothermia is important to preventing hypothermiarelated mortality. This report describes three cases of fatal hypothermia that occurred during 2003, reviews national statistics on mortality from cold exposure in 2001, and provides recommendations for the diagnosis, treatment, and prevention of hypothermia. Public health strategies tailored to U.S. populations at increased risk for exposure to excessive cold can help reduce mortality and morbidity from hypothermia.

# Case Reports
Case 1. In the fall of 2003, a man aged 44 years was found dead outdoors in Vermont. He wore a T-shirt, long-sleeved shirt, two sweatshirts, underpants, pants, socks, and boots. His clothes were wet, and an empty vodka bottle was nearby. Local investigators reported that he looked as though he "lay down and went to sleep." Overnight, the temperature had dropped to <32 F (<0 C). Autopsy findings were unremarkable except for a fatty liver. A toxicology screen was negative except for an elevated blood alcohol concentration (BAC) of 0.30 g/dL, nearly four times the legal intoxication limit of 0.08 g/dL in Vermont. Cause of death was certified as hypothermia, with alcohol intoxication as a contributing factor. Case 2. In the spring of 2003, a man aged 76 years with Alzheimer's disease was reported missing from his home in Vermont. The next day, a farmer found the man lying in a swampy area where his car had become stuck in the mud. Overnight, the temperature had dropped to <32 F (<0 C). The man was pronounced dead at the scene; cause of death was hypothermia precipitated by a cold, wet environment. Case 3. In the fall of 2003, Alaska state troopers reported that a hiker aged 35 years was found dead alongside a highway. The hiker was not clothed from the waist up and was missing a shoe. The overnight temperature was 44 F (6.7 C), but conditions were wet and windy. The hiker's BAC was 0.28 g/dL, nearly four times the legal intoxication limit of 0.08 g/dL in Alaska; his toxicology screen was positive for cocaine and marijuana. Cause of death was hypothermia, with drug and alcohol intoxication as contributing factors.

# United States
In the United States, certain populations (e.g., alcoholics; drug users; elderly, homeless, and chronically ill persons; and those with preexisting heart disease) are at increased risk for dying from hypothermia. During 2001, a total of 599 persons in the United States (2) died from "exposure to excessive natural cold" (code X31), as categorized in the International Classification of Diseases, Tenth Revision. Of these victims, 67% were male, and 51% were aged >65 years. As persons age, their risk for dying from hypothermia increases (Figure Editorial Note: Hypothermia causes multiple dysfunctions, including cardiac arrhythmias, renal insufficiency, and hemoconcentration. In late stages of hypothermia, brain function deteriorates, predisposing persons to poor judgment and increasing their risk for further exposure to excessive cold.
Improper clothing and comorbidities can interfere with the balance between the body's heat production and cooling. Wet clothing cannot retain body heat; warm clothing keeps the body dry and helps to decrease heat loss, which can save a person's life during excessively cold weather. Advanced age, immobility, and existing medical conditions can increase the risk for hypothermia and death during cold weather. Certain medical conditions (e.g., hypothyroidism, congestive heart failure, and diabetes) can affect a person's ability to recognize warning symptoms of hypothermia, compensate for the cold, or to seek shelter from the cold.
Use of alcohol or other mood-altering drugs often is associated with cases of hypothermia. The vasodilatation caused by alcohol provides a sensation of warmth but also increases heat loss through radiation. In addition, alcohol and other drugs impair hand coordination, mobility, and decision-making abilities.
Treatment of hypothermia focuses on returning the core body temperature to normal while providing supportive care. The method chosen to rewarm a patient depends on the severity of the hypothermia (Box). With rewarming and supportive care, even persons who appear to be dead might survive hypothermia (5).
Prevention of hypothermia requires public health strategies that target persons at greatest risk. Such strategies can include creating community programs for checking on the well-being of elderly persons, opening temporary shelters for the homeless, and urging persons with cardiovascular disease to avoid outdoor exercise during cold weather (6).

# Epidemiology

# Alcohol Use Among Adolescents and Adults -New Hampshire, 1991-2003
Alcohol abuse is the third leading preventable cause of death in the United States (1). Because binge and heavy drinking increase the risk for cirrhosis, cancer, heart disease, stroke, injury, and depression (2,3), public health efforts have focused on reducing these patterns of alcohol use. The Council of State and Territorial Epidemiologists, the Association of State and Territorial Chronic Disease Program Directors, and CDC developed Indicators for Chronic Disease Surveillance (4), which provides a standard set of measures for alcohol surveillance. The New Hampshire Department of Health and Human Services used these measures to facilitate statewide trend analysis of alcohol use among adolescents and adults. This report summarizes the results of that analysis, which indicated that, in 2003, a total of 30.6% of adolescents reported binge drinking. In 2001, a total of 15.8% of adults reported binge drinking, and 6.3% reported heavy drinking. Interventions are needed to prevent adolescent drinking and to reduce excessive alcohol use among adults.
Three data sources were used to examine trends in alcohol use: New Hampshire (NH) Youth Risk Behavior Survey (NHYRBS), NH Behavioral Risk Factor Surveillance System (NHBRFSS), and NH Vital Records (NHVR). NHYRBS is a biennial, self-administered, school-based survey of students in grades 9-12; NHYRBS was conducted in odd-numbered years during 1995-2003. Because the statewide response rate was 18 years. Alcohol-related questions were asked annually during 1991-1993 and in odd-numbered years during 1995-2001 (response rate: 42.5%-70.9%). NHVR maintains and analyzes death-related data that are reported according to state law. The cause of death reported is the underlying cause of death or the specific disease, condition, or injury that leads to death.
For this analysis, seven public health indicators of alcoholrelated impact were assessed: binge drinking among adults, women of child-bearing age (i.e., aged 18-44 years), and adolescents (indicators 1-3); heavy drinking among adult men and women (indicators 4-5); alcohol use among adolescents (indicator 6); and mortality from chronic liver disease (indicator 7). Binge drinking was defined as having five or more drinks on one or more occasions during the 30 days preceding the survey. Heavy drinking was defined as an average daily consumption of greater than two drinks for men and one drink for women. Alcohol use among adolescents was defined as having one or more drinks during the 30 days preceding the survey. Mortality from chronic liver disease was determined by using the underlying primary cause of death from International Classification of Diseases, Tenth Revision codes K70 or K73-K74 or, for years before 1999, Ninth Revision code 571. Age-standardized prevalence estimates were calculated by using the 2000 U.S. standard population for all indicators except those that were age specific.
In the 2003 NHYRBS, 47.1% of high school students reported alcohol use, and 30.6% reported binge drinking; in comparison with 1995 results, changes were not statistically significant (Table 1). Both alcohol use and binge drinking among students increased significantly in grades 9 and 12 in 1995 and 2003.
In the 2001 NHBRFSS, 15.8% of adults reported binge drinking. During 1991-2001, men were two to three times more likely than women to report binge drinking (Table 2). In 2001, women of child-bearing age were six times more likely to report binge drinking than women aged >45 years (14.2%  versus 2.3% ). In 2001, a total of 6.3% of adults reported heavy drinking (Table 3). No statistically significant differences were observed in heavy drinking between men and women during 1991-2001.
According to the 2001 NHVR, 9.7 deaths per 100,000 New Hampshire residents were attributable to chronic liver disease.  (6). The findings in this report are subject to at least four limitations. First, because approximately half of all adults and high school students reported no alcohol use, the prevalence of binge drinking among current drinkers was underestimated. Second, a trend analysis of alcohol use among high school students could not be performed because weighted data from NHYRBS during 1997-2001 were unavailable. Third, analysis of annual data at the substate level was not possible because of sample size limitations. Finally, the full burden of alcohol-related disease and death, including injuries, violence, and other health impacts, could not be determined because analysis of alcohol-related health effects was limited to deaths caused by chronic liver disease.
New Hampshire was one of 12 states that included a module on binge drinking in its 2003 BRFSS survey, which will provide more recent and comprehensive information on adult binge drinking, including the type and quantity of alcohol consumed, the location of consumption, and alcohol-impaired driving that might have resulted from binge drinking. Alcohol surveillance information in New Hampshire was published for the first time in 2003 (6); the report will be updated annually to help policymakers and public health authorities implement programs to prevent adolescent drinking and excessive alcohol use among adults.