Operational Definitions for Year 2000 Objectives:

Priority Area 20, Immunization and Infectious

Diseases

Colleen Ryan, Susan Schober, and Kathleen Turczyn

Introduction

Healthy People 2000, with its Midcourse Revisions,

presents 319 objectives to improve the health of Americans

by the year 2000 (1,2). Because these objectives are

national, not solely Federal, the achievement of these

objectives is dependent in part on the ability of health

agencies at all levels of government to assess objective

progress. To permit comparison of local and State health

data with national data and that of other States and localities,

Healthy People 2000 objective 22.3 targets the development,

dissemination, and use of collection methods that improve

comparability among data collected by all levels of

government. The objective states:

Develop and disseminate among Federal, State, and

local agencies procedures for collecting comparable data

for each of the year 2000 national health objectives and

incorporate these into Public Health Service data

collection systems.

Achieving this objective entails determining and

defining the information needed to measure progress toward

each national health objective. The purpose of this Statistical

Note is to provide definitions and data collection

specifications that are used at the national level for

objectives in Priority Area 20: Immunization and Infectious

Diseases, one of 22 priority areas of Healthy People 2000.

In this publication the text (appendix A) and operational

definitions of the objectives are presented, important data

issues are discussed, and references are cited for expanded

discussions of the data systems (appendix B) that provide

data for the national objectives. When appropriate, the text

of questionnaire items used to measure the objectives is also

provided.

Table 1 is a data comparability worktable with objective

definitions, data sources and issues. This table presents the

short text of each objective, the measure, the operational

definition (numerator and denominator where applicable),

national data source, and a brief description of data issues.

The data issues for each objective are discussed in greater

detail below.

Acknowledgments

Publication of this Statistical Note would not have been possible without the contributions of several Centers for Disease Control and Prevention

staff members, to whom we are very grateful. We especially acknowledge the Healthy People 2000 coordinators, Jeanne Walsh and Victoria Sepe,

for their time and commitment, cooperation, and assistance.

Number 11

February 1997

From the CENTERS FOR DISEASE CONTROL AND PREVENTION/National Center for Health Statistics

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

Centers for Disease Control and Prevention

National Center for Health Statistics CENTERS FOR DISEASE CONTROL

AND PREVENTION
Table 1. Objective definitions, data sources, and issues for Healthy People 2000 priority area 20

2

Objective Measure Numerator Denominator data source Data issues

 Operational definition

 Healthy People 2000

20.1 Vaccine preventable Number of cases Disease cases as Not applicable NNDSS, CDC, EPO Data are published

 diseases described in Centers for annually in MMWR 

 - Diphtheria among definitions for public Diseases which may

 people 25 years and health surveillance. include cases that are not

 under MMWR 39(RR-13):39. included in MMWR weekly

 - Tetanus among October 1990. reports due to delays in

 people 25 years and reporting.

 under 

 - Polio (wild type virus) Although this objective

 - Measles specifies indigenous

 - Rubella cases of measles, all

 - Congenital Rubella categories of cases are

 Syndrome included.

 - Mumps

 - Pertussis

Disease Control. Case Summary of Notifiable

20.2 Epidemic-related Number of deaths Deaths from pneumonia Mid-year US Census NCID, CDC A cyclical regression

pneumonia and per 100,000 and influenza that occur population for middle model is used to establish

influenza deaths population above and beyond year of the 3-year NVSS, CDC, NCHS baseline level to define

among people 65 (Three-year moving normal yearly average epidemic-related deaths.

years and over average) fluctuations of mortality.

ICD-9 codes 480-487 this measure, a three-year

Due to high variability in

moving average is used.

Data are calculated by

NCID using data from

NVSS.

20.3 Viral hepatitis cases Number of cases For hepatitis B, a case Mid-year population NNDSS, CDC, EPO NCID corrects for

 - Hepatitis B population case definition and is the July 1 post-censal SCSAVH, CDC analysis by using sentinel

 - Hepatitis A laboratory-confirmed as estimates made by the surveillance system. This

 - Hepatitis C outlined in: Centers for U.S. Bureau of the 20.3 a-c, e, k: system also attributes

 Disease Control. Case Census. SCSAVH cases to high risk groups.

 Hepatitis B special definitions for public

 populations: health surveillance. 20.3 a-c, e, h-j:

 a. Injection drug

 users

 b. Heterosexually

 active people

 c. Homosexual men

 d. Children of Asian

 Pacific Islanders

 e. Occupationally

 exposed workers

 f. Infants 

 g. Alaska Natives

 h. Blacks 20.3 e: VHSP,

 CDC,NCID

 Hepatitis A special population (20.3 h- 15-50 days before onset the July 1 post-censal

 populations: k) of symptoms. estimates made by the

 i. Hispanics reported cases of

 j. American Indians/ hepatitis B infection in

 Alaska Natives children. Pediatr Infect

 Hepatitis C special

 population:

 k. Hispanics

per 100,000 that meets the clinical estimates based on NNDSS, CDC, EPO underreporting in its

Number of cases October 1990. Not applicable When multiple data

(20.3 a-e) For hepatitis A, a case (20.3 a-g) 20.3 d: McMahon BJ, sources are cited for a

Number of new epidemiological link with sequelae in Alaskan are small.

chronic infections a case of laboratory- natives. Lancet

(f,g) confirmed hepatitis A

Number of cases sexual contact with an Mid-year population

per 100,000 infected person in the estimates based on

MMWR 39(RR-13):17. NNDSS, CDC, EPO

that meets the clinical Rhoades ER, Heyward subobjective, NNDSS is

case definition and is WL, et al. A used as the base, data

laboratory-confirmed, or comprehensive from sentinel counties are

a case that meets the programme to reduce used to calculate the

clinical case definition the incidence of proportion at risk, and

and occurs in a person hepatitis B virus VHSP data are used when

who has had an infection and its sentinel counties numbers

(i.e., household or

For hepatitis C, a case U.S. Bureau of the

that meets the clinical Census (20.3 h–k)

case definition and is

laboratory-confirmed as

outlined in MMWR to be

published early 1997.

2:1134-6. 1987.

20.3 f: Margolis HS.

Estimates and

Dis 12: 542-4. 1993.

20.3 g: IHS Alaskan

Carrier Registry
Table 1. Objective definitions, data sources, and issues for Healthy People 2000 priority area 20—Con.

Objective Measure Numerator Denominator data source Data issues

 Operational definition

 Healthy People 2000

3

20.4 Tuberculosis (TB) Number of new TB cases as described Mid-year population CDC, NCHSTP,

 incidence cases in past 12 in Centers for Disease estimates based on Division of

 - Special Populations: population definitions for public estimates made by the Elimination

 a. Asians/ Pacific health surveillance. U.S. Bureau of the

 Islanders MMWR 39(RR-13):39. Census. Centers for Disease

 b. Blacks October 1990. A Control and

 c. Hispanics revised document will Prevention. Reported

 d. American Indians/ be published in Tuberculosis in the

 Alaska Natives February, 1997. United States, annual.

months per 100,000 Control. Case the July 1 post-censal Tuberculosis

20.5 Surgical wound and Infections per Device-associated Device days in NNISS, CDC, NCID Data are not nationally

 nosocomial 1,000 device-days nosocomial infections intensive care units representative (collected

 infections as defined in: (ICUs) from non-random sample

 - Bloodstream Categories: definitions for volunteered to participate

 infections nosocomial infections. in survey).

 - Urinary tract - Medical/ coronary 

 infections - Surgical/ medical 16(3): 128-40. 1988. Categories of ICU types

 - Pneumonia - Surgical - NNIS Semi-annual are now listed individually.

 

 - Surgical wound Infections per 100 Number of operations

 infection operations

- Pediatric Report, May 1995.

Categories:

- Low-risk patients

- Medium-low risk

 patients

- Medium-high risk

 patients

- High-risk patients

- Garner JS, et al. CDC of hospitals that

Am. J. Inf. Control 1995 for complete

-Horan TC, et al. CDC Calculations and

definitions of interpretation of data are

nosocomial site detailed in the NNIS Semiinfections, 1992: a annual Report, 1995.

modification of CDC

definitions of surgical

wound infections.

Infect. Control Hosp.

Epidemiol. 13:606-608.

1992.

Culver DH, Horan TC,

Gaynes RP, et al.

Surgical wound

infection rates by wound

class, operative

procedure, and patient

risk index. Am J Med

91 (3B): 152S-7S.

1991.

(See NNIS Semiannual Report, May

instructions for

calculating device

days)

20.6 Illness among Number of cases CDC. Case definitions Not applicable TSS, CDC, NCID Data are obtained from

 international for public health NNDSS, CDC, EPO four different surveillance

 travelers surveillance. MMWR VHSP, CDC, NCID systems. Definition of

 - Typhoid fever 1990. differs among systems.

 - Hepatitis A

 - Malaria

39(RR-13). October MSS, CDC, NCID “international traveler”

20.7 Bacterial meningitis Number of cases Wenger JD, et al. Population estimates BMSS, CDC, NCID 1987 baseline was only

 per 100,000 Bacterial meningitis in based on the 4-5 AIL, CDC, NCID data set with all six

 Pathogenic agents: population the United States, 1986: states that participate, classes of bacterial

 - H. Influenzae Report of a multistate with a combined meningitis. There is no

 - S. Pneumoniae

 - N. Meningitis

 - S. Agalactiae

 - L. Monocytogenes

 - Other 

surveillance study. J. population ranging total number of meningitis

Inf. Diseases. 162:

1316-23. 1990.

from 12 to 15 million cases for subsequent

years. 
Table 1. Objective definitions, data sources, and issues for Healthy People 2000 priority area 20—Con.

Objective Measure Numerator Denominator data source Data issues

 Operational definition

 Healthy People 2000

4

20.8 Diarrhea among Percent Number reporting child Number reporting child NHIS, CDC, NCHS Civilian non-

 children in child having diarrhea and receiving child care institutionalized population

 care centers receiving child care outside of the home at only.

outside of the home at any time in the past 12

any time in the past 12 months Plans to incorporate the

months NHIS questions into the

(See table 2 for list of

questions)

NIS are underway.

20.9 Ear infections Number of days per Restricted activity days Number of children in NHIS, CDC, NCHS Civilian non-

 among children 100 children due to ear infections specified age range institutionalized population

 4 years and under only.

From 1987 to 1996, this

measure was extracted

from the core section of

NHIS and was published

annually in Current

Estimates from the

National Health Interview

Survey. 

These data will be

unavailable after 1996.

20.10 Pneumonia-related Number of days per Restricted activity days Number of persons in NHIS, CDC, NCHS Civilian non-

 illness among: 100 people due to pneumonia specified age range institutionalized population

 -People aged 65 and

 over From 1987 to 1996, this

 -Children aged 4 and measure was extracted

 under from the core section of

only.

NHIS and was published

annually in Current

Estimates from the

National Health Interview

Survey.

These data will be

unavailable after 1996.
Table 1. Objective definitions, data sources, and issues for Healthy People 2000 priority area 20—Con.

Objective Measure Numerator Denominator data source Data issues

 Operational definition

 Healthy People 2000

5

20.11 Immunization Percent Number immunized (See text section USIS, CDC, NCHSTP

 Basic Immunization (See table 3 in text

 Series section 20.11 for

 - Children 0-2 years

 - Children 19-35

 months

 - Children in licensed (Presented as a SIS, CDC, NIP

 care facilities range)

 - Children in

 kindergarten-post

 secondary

 education

 institutions

 Pneumococcal and (See tables 4 and 5 in

 influenza text section 20.11 for

 immunizations survey questions) 

 - Institutionalized NNHS,CDC, NCHS 1995 data from the NNHS

 chronically ill or will be available in 1997.

 older people

 - Non-institutionalized NHIS, CDC, NCHS NHIS covers the civilian,

 high-risk non-institutionalized

 populations population only.

 as defined by the 

 Advisory

Committee on

Immunization 

Practices:

 a. Blacks 65+ years

 b. Hispanics 65+

 years

 Hepatitis B

 immunization

 - Infants of antigen- CDC, NCID derived from public sector

 positive mothers data only.

 - Occupationally No data available

 exposed workers

 - IV-drug users in

 drug treatment CDC. MMWR 45(10). Survey is limited to young

 programs March 1996 MSM. Measure is under-

 - Men who have sex Vol. 45 (No.10) estimated because it is

 with men (MSM) based on serological data.

survey questions)

Technical assistance is

available from the

National Immunization

Program, CDC, at (404)

639-8235.

 

20.11 for discussion of NHIS, CDC, NCHS

denominators) NIS, CDC, NIS

Nursing home

residents 

People ages 65 years

and over

SIS, CDC, NIP

PHSGP, CDC, NCID Estimate for infants of

antigen-positive mothers is

20.12 Postexposure Number of Treatments purchased Not applicable RVIGMSD, CDC, Data reflect only the

 rabies treatments treatments NCID amount purchased, not the

(presented as a For detailed explanation amount utilized in

range) of calculations, contact treatments.

NCID (404)639-2762

Measure is an

extrapolation of rates from

previous years for the

lower end of estimate and

biologics for upper end. 

20.13 Immunization laws Number of States States with laws Not applicable SIL, CDC, NIP Laws are counted in terms

of which antigens are

required by the law and in

what facility the law is

upheld.
Table 1. Objective definitions, data sources, and issues for Healthy People 2000 priority area 20—Con.

Objective Measure Numerator Denominator data source Data issues

 Operational definition

 Healthy People 2000

6

20.14 Provision of Percent Clinicians routinely Number of clinicians PCPS, OPHS, Data were collected with

 immunizations by providing service to 81- who report providing ODPHP five separate surveys;

 clinicians 100 percent of patients services there is variability in

 Children:

 - DTP vaccination

 - Oral polio

 vaccination

 - Tetanus-diphtheria

 booster

 - Hib vaccination

 Adults:

 - Tetanus-diphtheria

 booster

 - Influenza

 vaccination

 - Pneumococcal

 vaccination

response rates. 

It is not possible to

combine data on five

clinician categories into

one measure.

20.15 Financial barriers Percent Employer-based Number of employer- HIAAES, Health Each plan type is

 to immunization insurance plans that based insurance plans Insurance Association calculated separately.

 - Conventional immunizations Data do not address all

 insurance plans types of plans.

 - Preferred provider

 organization plans

 - Health maintenance

 organization plans

provide coverage for of America

20.16 Public health Percent Local health Number of responding IGPP, CDC, NCPS Baseline established in

 department departments (LHDs) LHDs NACCHO 1990 by IGPP with follow-

 provision of providing immunizations up data from NACCHO.

 immunizations to adults within prior 12

months

20.17 Local health Percent Local health Number of responding NACCHO This baseline measure

 programs to departments (LHDs) LHDs reflects the number of

 identify persons reporting tuberculosis LHDs that have some

 with clinical services tuberculosis services, and

 tuberculosis or does not specify the

 latent tuberculosis details of their activities. 

 infection

20.18 Preventive therapy Percent Infected persons Number of individuals Program Management The number of reporting

 for tuberculosis completing preventive starting preventive Report Series, DTBE, areas and percent of TB

therapy therapy CDC, NCHSTP cases being reported

varies.

20.19 Laboratory Percent Hospitals/HMOs with Number of hospitals/ SL, CDC, NCID

 capability for laboratories capable of HMOs

 influenza diagnosis diagnosing influenza

 - Tertiary care

 hospitals

 - Secondary care

 hospitals

 - Health

 Maintenance 

 Organizations 

 (HMOs)
Table 1. Objective definitions, data sources, and issues for Healthy People 2000 priority area 20—Con.

7

Data system acronyms:

AIL Arctic Investigations Laboratory

BMSS Bacterial Meningitis Surveillance System

HIAESS Health Insurance Association of American Employer Survey

IGPP Immunization Grant Program Profiles

MSS Malaria Surveillance System

NACCHO National Association of County and City Health Officials

NHIS National Health Interview Survey

NIS National Immunization Survey

NNDSS National Notifiable Disease Surveillance System

NNHS National Nursing Home Survey

NNIS National Nosocomial Infection Surveillance System

NVSS National Vital Statistics Sysytem

PCPS Primary Care Provider Survey

PHSGP Perinatal Hepatitis Screening Grant Program

RVIGMSD Rabies Vaccine and Immune Globulin Manufacturers Sales Data

SCSAVH Sentinel Counties Surveillance for Acute Viral Hepatitis 

SIL Survey of Immunization Laws

SIS State Immunization Survey

SL Survey of Laboratories Using Rapid Viral Diagnosis of Influenza

TMD Tuberculosis Morbidity Data

TPMRD Tuberculosis Program Management Report Data on Completion of Preventive Therapy

TSS Typhoid Surveillance System

USIS United States Immunization Survey

VHSP Viral Hepatitis Surveillance Program

Agency abbreviations:

CDC Centers for Disease Control and Prevention

EPO Epidemiology Program Office

NCHS National Center for Health Statistics

NCHSTP National Center for HIV, STD, and TB Prevention

NCID National Center for Infectious Diseases

NCPS National Center for Preventive Services

NIP National Immunization Program

ODPHP Office of Disease Prevention and Health Promotion

OPHS Office of Public Health and Science
Objective 20.1: Vaccine preventable diseases

Vaccine preventable diseases (see list in Table 1) are

measured by the number of reported cases. Cases are

determined by using criteria established by the Centers for

Disease Control and Prevention (CDC) (3) in collaboration

with the Council of State and Territorial Epidemiologists

(CSTE). Data collected by each State for the different

diseases listed under this objective are aggregated and

published annually by CDC as the Summary of Notifiable

Diseases in the Morbidity and Mortality Weekly Report

(MMWR). The Summary of Notifiable Diseases may include

cases not reported in MMWR weekly reports due to

reporting delays. The data source for this objective is the

CDC’s National Notifiable Disease Surveillance System.

Although objective 20.1 specifies indigenous cases of

measles, all cases are included.

Objective 20.2: Epidemic-related pneumonia

and influenza deaths among people 65 years of

age and over

The estimated number of epidemic-related pneumonia

and influenza deaths among people 65 years and over

involves several steps. The deaths attributable to pneumonia

and influenza are identified using ICD-9 codes 480–487. A

cyclical regression model (4), based on pneumonia- and

influenza-related death rates from previous years, is used to

predict the average expected pneumonia- and

influenza-related deaths for a given year (the baseline).

Periods of increased mortality due to influenza epidemics are

excluded from baseline calculations. Epidemic-related deaths

are the number of influenza deaths that exceed the baseline

by 1.645 standard deviations (4). These deaths are tallied on

a weekly basis and totaled annually, starting July 1st and

ending June 30th, to encompass the peak flu season in the

winter months. Further, the measure used for this objective

is the mean of 3 consecutive years divided by the U.S.

Census mid-season population of the middle year in the

denominator (i.e., the population estimate of January 1, 1995

for people 65 years and over would be used for the 3-year

average of the 1993–1994, 1994–1995, and 1995–1996

seasons). The statistic is reported as a rate (deaths per

100,000 population). The National Center for Infectious

Diseases (NCID), CDC, calculates this statistic based on

data obtained from the National Vital Statistics System

(NVSS) of the National Center for Health Statistics (NCHS),

CDC.

Each year vaccine efficacy rates fluctuate, the strains of

influenza viruses differ, and the virulency of those strains

fluctuates, making trends in this statistic difficult to track,

predict, and compare.

Objective 20.3: Viral hepatitis cases

Viral hepatitis cases are categorized into types A, B, and

C, as described in the case definition of the disease (3). The

measure for each type of hepatitis is the estimated annual

number of cases per 100,000 population, as reported to

CDC. These estimates are adjusted for underreporting by

multiplying reported cases by a factor of 3 for hepatitis A,

5.96 for hepatitis B, and 2.38 for hepatitis C (6). The use of

these correction factors reflect the results of studies

comparing the level of reporting between active and passive

surveillance systems, which have found substantial

underreporting of viral hepatitis (6). Hepatitis B cases among

special high risk populations are reported as number of cases

among injection drug users, heterosexually active people,

homosexual men, children of Asians and/or Pacific Islanders,

and occupationally-exposed workers, and number of new

chronic infections among infants and Alaska Natives.

Hepatitis B cases in black people are measured as a rate

(cases per 100,000 population). Baseline data for hepatitis B

subobjectives have been revised by NCID to take into

account various adjustments, including underreporting and

estimates of the distribution of various risk factors for

hepatitis infection (7). Hepatitis A is tracked as a rate (cases

per 100,000 population) for Hispanics and American

Indian/Alaska Natives. Hepatitis C is tracked as a rate (cases

per 100,000 population) for Hispanics.

Objective 20.4: Tuberculosis incidence

The tuberculosis (TB) incidence rate is calculated by

dividing the number of new cases reported to CDC in a year

by the mid-year U.S. Bureau of the Census population

estimate for that year. The data, published in ‘‘Reported

Tuberculosis in the United States,’’ are reported as the

number of new cases per 100,000 population (8). Between

1992 and 1995, there was a 14.5-percent decline in the

number of TB cases being reported to the tuberculosis

surveillance system. This decline in reported TB cases is

attributed to improvements in TB control and prevention

efforts in the United States.

Objective 20.5: Surgical wound and

nosocomial infections

The measure of nosocomial infections for objective 20.5

is the device-associated nosocomial infection rate, reported

as infections per 1,000 device days in intensive care units

(ICUs). The nosocomial infection rate is reported by the

National Nosocomial Infections Surveillance (NNIS) System

by ICU category: coronary, medical, medical/surgical,

surgical, and pediatric (9). The NNIS Semiannual Report

details the methods used to determine the device-associated

nosocomial infection rates. Case definitions for the infection

types are listed in table 1. The data for this objective are not

nationally representative because the NNIS is based on a

non-random sample of 82 hospitals that volunteered to

participate. Surgical wound infection rates are also measured

by NNIS; they are reported as infections per 100 operations

for four risk categories based on an index established by

Culver, et al.: low risk, medium-low risk, medium-high risk,

and high risk (10). This article details the derivation of the

surgical wound infection rate and explains the patient risk

categories. Methods used to calculate this measure are also

covered in the NNIS manual (9).

8
Objective 20.6: Illness among international

travelers

Illness among international travelers is measured as the

number of reported cases compiled from specific

surveillance systems. Hepatitis A for objective 20.6 is

reported as the number of cases, not cases per 100,000

population as in objective 20.3. The base numbers are

obtained from the National Notifiable Disease Surveillance

System (NNDSS); the proportion attributed to travelers is

obtained from the Viral Hepatitis Surveillance Program

(VHSP); the result is multiplied by 3.0 to adjust for

underreporting. An international traveler is defined by the

VHSP as a person with an identified case who traveled

outside the U.S. or Canada to an area highly endemic for

hepatitis A 2–6 weeks prior to onset of illness. Malaria data

are obtained from the Malaria Surveillance System (MSS),

and typhoid data from the Typhoid Surveillance System

(TSS). Case definitions are listed in table 1.

Objective 20.7: Bacterial meningitis

To measure objective 20.7, the number of cases

involving the isolated pathogenic agents of bacterial

meningitis—H. Influenzae, S. Pneumoniae, N. Meningitis, S.

Agalactiae (Group B streptococcus), L. Monocytogenes, and

‘‘other’’—are compiled from surveillance of 4–5 States

having a combined population of 12–15 million (11). The

measure is the number of cases in those surveillance States

divided by the total population of the States and is reported

as the number of cases per 100,000 population. The rates are

calculated for each pathogenic agent category collected, with

the sum of all six categories constituting the total number of

bacterial meningitis cases per 100,000 population. The

‘‘other’’ category includes pathogens such as Escherichia

Coli, Staphylococcus aureus, Klebsiella-EnterobacterSerratia sp, Streptococcus sp, Staphylococcus epidermidis,

group A streptococcal sp, Pseudomonas sp, Hemophilus sp,

Streptococcus viridans, Salmonella, Arizona sp, and other

infections that were not further identified (12).

Table 2. Diarrhea questions for objective 20.8

` During the past 12 months, how many times has (child) had diarrhea

severe enough the (he/she) had to cut down on more than a half a day

on things that (he/she) usually does?

` During the past twelve months, did (child) ever receive child care in a

place that cares for more than 6 children? This includes day care

centers, pre-school, nursery school, religious school, kindergarten, but

does not include child care that is provided in this home.

` In how many of the past 12 months did (child) receive such child care?

Source: 1991 Healthy People 2000 Supplement (Child Health), National Health Interview

Survey, National Center for Health Statistics, CDC.

Objective 20.8: Diarrhea among children in

child care centers

Objective 20.8 addresses the occurrence of diarrhea

among children 0–3 and 0–5 years of age who have received

child care outside of the home. Data have been collected in

the National Health Interview Survey (NHIS) Healthy

People 2000 Supplement (see table 2 for survey questions)

and are reported as a percent. The measure for this objective

is the population-weighted number of children who were

reported as having experienced a case of diarrhea in the past

year that made the child cut down on the things he/she does

for at least half of a day (numerator) among all those

reported as having received child care outside of the home

in a setting that contained at least six children at any time

during the past year (denominator).

Objective 20.9: Ear infections among children

in child care centers

Objective 20.9 is measured by the number of restricted

activity days per 100 people for children 4 years of age and

under. This measure has been taken directly from the NHIS

core questionnaire. The number of restricted activity days for

children under 5 years old is the total number of bed days

(i.e., the person stays in bed for more than half the day) and

cut-down days (i.e., the person cuts down more than half of

a day on things he/she usually does) attributed to ear

infections and is divided by the total number of children in

that age group. The procedures and technical notes regarding

the calculations of this measure are published annually in

Current Estimates from the National Health Interview Survey

(13). These data will not be available after 1996.

Objective 20.10: Pneumonia-related illness

The measure for this objective is given in terms of the

number of restricted activity days due to pneumonia per 100

people. The total number of restricted activity days for

adults 65 years and over is the sum of the number of bed

days (i.e., the person stays in bed for more than half the

day), work-loss days (i.e., the person 18 years and over

misses at least half of a day from a job or business) and

cut-down days (i.e., the person cuts down more than half of

a day on things he/she usually does) attributed to

pneumonia-related illnesses for persons 65 years and over

(13). For children 4 years of age and under, the total number

of bed days and cut-down days attributed to

pneumonia-related illness are aggregated. The denominators

are the total number of persons 65 years and over for the

adult measure and 4 years and under for the child measure.

The procedures and technical notes regarding the

calculations of these measures are published annually in

Current Estimates from the National Health Interview Survey

(13). These data will not be available after 1996.

20.11: Immunization

Immunization is measured in categories based on age,

risk, and specific vaccination regimen. The percent

immunized in children 2 years of age and under is measured

in terms of the proportion who received the complete

schedule of the basic immunization series (four doses of

diphtheria-tetanus-pertussis, three oral live polio, and

9
one measles-mumps-rubella), as well as recommended doses

of specific antigens (Haemophilus Influenzae type b

conjugate, hepatitis B virus, and varicella zoster virus) as

reported on the NHIS.

In 1995 the objective was modified to track children

19–35 months of age. The revised age range allows

comparability with the National Immunization Survey (see

table 3 for survey questions) which collects State-level data

Table 3. Children’s immunization questions for

objective 20.11

Shot record available:

` Looking at the shot record, please tell me how many times (child) has

received (vaccine):

` a DPT or DT shot (sometimes called a DPT shot, diphtheriatetanus-pertussis shot, baby shot, or three-in-one shot)

` a polio vaccine (pink drops) or a polio shot

` a measles or MMR (Measles-Mumps-Rubella) shot

` an H-I-B shot (this is for Meningitis and is called Haemophilus

Influenzae H-I-B vaccine, or H flu vaccine)

` a Hepatitis B shot

Shot record unavailable:

` Has (child) ever received an immunization (that is a shot or drops)?

` Has (child) ever received (vaccine)?

` How many (vaccine) shots did (child) ever receive?

` DPT or DT shots (sometimes called a DPT shot, diphtheria-tetanusperussis shot, baby shot, or three-in-one shot)

` Polio vaccine by mouth, pink drops, or a polio shot

` Measles or MMR (Measeles-Mumps-Rubella) shots

` H-I-B shots (this is for Meningitis and is call Haemophilus

Influenzae H-I-B vaccine, or H flu vaccine)

` Hepatitis B shots

Source: National Immunization Survey, National Immunization Program, CDC; National

Health Interview Survey, National Center for Health Statistics, CDC.

and complements the NHIS. Immunization is also measured

according to involvement of children in specific institutions:

by the proportion immunized in licensed child care facilities

and by the proportion immunized who are enrolled in kindergarten through post-secondary education institutions. The measure is a range of immunization levels for specific antigens. To

obtain a complete explanation of calculations of childhood

immunization levels, contact the National Immunization Program (NIP) technical service at (404) 639–8235.

Other measures being monitored are the pneumococcal

and influenza immunizations in non-institutionalized chronically ill people or people 65 years and over, as well as

high-risk populations. These measures are obtained directly

from NHIS (see table 4 for survey questions).

Table 4. National Health Interview Survey pneumonia and influenza vaccination questions

` Have you EVER had a pneumonia vaccination? This shot is given only

one in a person’s lifetime.

` During the past 12 months, have you had a flu shot? This vaccination is

usually given in the fall and protects against influenza for the flu season.

Source: 1994 National Health Interview Survey, National Center for Health Statistics, CDC.

Between 1986 and 1994 there have been no sources of

data to measure immunization levels among the

institutionalized chronically ill or institutionalized persons 65

years and over. In 1995 NCHS conducted a National

Nursing Home Survey (NNHS) that will be repeated every

other year. This survey includes questions about influenza

and pneumococcal vaccination in nursing home residents

(table 5).

Hepatitis B immunization among infants of

antigen-positive mothers is measured as the percent of

Table 5. National Nursing Home Survey pneumonia

and influenza vaccination questions

` During the past 12 months, has (patient) had a flu shot at this facility or

any other location?

` Has (patient) EVER has a pneumococcal vaccine, that is, pneumonia

vaccination?

Source: National Nursing Home Survey, National Center for Health Statistics, CDC.

infants in this category who receive three doses of the vaccine.

The data are estimated based on public sector data reported

from local health departments, which represent about 50 percent of the cohort. Data for occupationally-exposed workers

are from random sample surveys of approximately 3,000

hospital employee vaccination records. These surveys are

completed every 2–3 years by the Hepatitis Branch, Division

of Viral and Rickettsial Diseases, NCID, CDC, and cover

approximately two-thirds of occupationally-exposed workers.

Hepatitis B immunization baseline data for men who have sex

with men are from an analysis of serologic data from a local

survey in San Francisco (14); there are no national estimates

for this high-risk group. At time of publication, there are no

data sources to monitor hepatitis B immunizations among

injecting drug users.

20.12: Postexposure rabies treatments

Two indirect methods are used to produce a range of

estimated numbers of postexposure prophylaxis treatments

for rabies. The lower end of the range extrapolates annual

numbers of treatments by applying the treatment incidence

rates calculated for participating States during an earlier

study performed by Helmick (15) to annual U.S. Census

population estimates, adjusted to reflect current preponderant

State animal rabies reservoirs. The high end of the range

utilizes sales data for rabies immune globulin furnished by

rabies vaccine manufacturers (Rabies Vaccine and Immune

Globulin Manufacturers Sales Data), which reflect the

amount purchased, not the amount used in treatments.

Because the amount of rabies immune globulin used is based

on body weight, the number of treatments calculated using

this method is based on an assumed average body weight.

The estimates generated by these two methods represent

both an underestimate and an overestimate of the actual

number of treatments. For more information regarding this

measure, contact Jeannie Walsh at NCID, (404) 639–2762.

20.13: Immunization Laws

The measures used to track objective 20.13 are based on

the antigen (diphtheria toxoid, tetanus toxoid, pertussis

10
vaccine, measles vaccine, mumps vaccine, rubella vaccine,

polio vaccine, haemophilus vaccine, and hepatitis B vaccine)

and the type of facility (schools (K-12) and day care

centers). Data are obtained from the Survey on

Immunization Laws (SIL). The 1989 baseline was

established as a single measure, but subsequent measures

have been ranges, based on whether or not the law mandates

immunization at preschool and/or kindergarten level and

above, and based on which antigens are specified in the law.

The measures are reported as the number of States with a

particular attribute of the law.

20.14: Provision of immunization by clinicians

Provision of immunizations is measured by the

proportion of clinicians who routinely provide services to

81–100 percent of their patients in each of the different

clinician categories: pediatricians, nurse practitioners, and

family physicians for services provided to children; nurse

practitioners, obstetricians/gynecologists, internists, and

family physicians for services provided to adults. The data

were collected in the 1992 Primary Care Provider Surveys

(PCPS). Five primary care provider professional associations

participated in the 1992 PCPS by mailing the survey to their

members who were randomly selected to participate. These

associations also compiled and analyzed the data. Data were

collected for children (DTP vaccination, oral polio

vaccination, tetanus-diphtheria booster, and Hib vaccination)

and adults (tetanus-diphtheria booster, influenza vaccination,

and pneumococcal vaccination).

Further discussion on collection procedures,

interpretation of data, lists of survey questions, and

discussion of the results of this survey can be obtained by

contacting the Office of Disease Prevention and Health

Promotion (16). Because the data are derived from five

independently administered surveys, the results of this

survey cannot be combined to create one measure for this

objective. The survey is planned to be re-administered in

1997.

20.15: Financial barriers to immunization

Financial barriers to immunization are measured by the

percent of employer-based insurance plans that provide

coverage for immunizations. The plans that are included are

conventional insurance plans, preferred provider

organizations, and health maintenance organizations. The

data were collected by the Health Insurance Association of

America (HIAA) Employer Survey and each plan was

measured separately. HIAA has no plans to re-administer the

survey at this time.

20.16: Public health department provision of

immunizations

Objective 20.16 is measured in terms of the percent of

public health departments that provide immunizations. The

baseline data for this objective were collected in 1990 by

Immunization Grant Program Profiles (IGPP). Follow-up

data are from the 1992–1993 National Profile of Local

Health Departments, a survey conducted by the National

Association of County and City Health Officials (NACCHO).

The latest measure is a range based on the percent of local

health departments (LHDs) that provide adult immunizations

such as influenza, tetanus, diphtheria, hepatitis B, or

pneumococcal disease within 12 months prior to completing

the survey (17). According to this study, an LHD is defined

as an administrative or service unit of local or state

government concerned with health and carrying some

responsibility for the health of a jurisdiction smaller than the

State. A total of 2,079 LHDs meeting the study definition of

an LHD completed the survey instrument, with an overall

response rate of 72 percent. Because the information

provided in this study came from 1992 data for some LHDs

and 1993 data for others, the study is dated as 1992–93.

However, the data from each LHD reflects a 1-year time

period only. The findings of this study have been published

by NACCHO in their report, 1992–1993 National Profile of

Local Health Departments (17). The next survey to be

administered by NACCHO is in 1996.

20.17: Local health programs to identify

tuberculosis

The measure for monitoring LHDs with ongoing

programs geared to identify TB and latent infections in highrisk populations is the percent of departments with such

programs among all LHDs. This measure was determined in

a survey that assessed the total number of LHDs that

reported tuberculosis services as a service provided directly

or indirectly through contractual arrangement (17). The data

for this objective were obtained from the 1992–93 National

Profile of Local Health Departments (see description in

discussion of objective 20.16). This objective is not likely to

be monitored in this format in the future. Most tuberculosis

screening is done to identify persons with latent infection

who may be candidates for preventive therapy. Much of this

screening is done in settings outside of the health

departments (for example, hospitals or prisons). CDC is

developing systems to assist LHDs assess the outcomes of

screening programs in their communities.

20.18: Preventive therapy for tuberculosis

To monitor successful completion of preventive therapy

for tuberculosis-infected individuals, the percent of persons

who started on such therapy who complete the therapy is

used. This number is a compilation of State and selected

metropolitan area data that are submitted to the Division of

Tuberculosis Elimination, National Center for HIV, STD, and

TB Prevention, CDC, which compiles the data and

summarizes them in the Tuberculosis Program Management

Report Series (18). States submit Tuberculosis Program

Management Report forms which report aggregate data on

the number of persons starting preventive therapy and the

subsequent number of persons completing therapy. The

number of persons starting therapy include those who are

contacts to TB cases, recent tuberculin skin test converters,

11
and others with tuberculous infection. Completion is

determined by the number of people who started therapy and

have completed taking the prescribed medication for the full

six months, or those who, by a physician’s determination,

received an adequate course of therapy in less than six

months. There is variability in the number of States that

participate as well as in the percent of TB cases that are

being reported.

20.19: Laboratory capability for influenza

diagnosis

Objective 20.19 measures the percent of tertiary care

hospitals, secondary care hospitals, and health maintenance

organizations (HMOs) that contain laboratories with the

technologies to perform rapid viral diagnosis of influenza.

Tertiary care facilities are defined by the presence of at least

one sub-specialty intensive care unit (cardiac ICU, neonatal

ICU, pediatric ICU, burn care, or other ICU) (19).

Secondary care facilities possess none of the listed specialty

intensive care units. HMOs are organizations that are

members of the Group Health Association of America and

are listed in the National Directory of Health Maintenance

Organizations (20). The baseline was established in 1993

from the Survey of Laboratories Using Rapid Viral

Diagnosis of Influenza, developed and administered by the

Viral and Rickettsial Disease Division, NCID, CDC.

References

1. U.S. Department of Health and Human Services. Healthy people

2000: National health promotion and disease prevention objectives. Washington: Public Health Service. 1991.

2. U.S. Department of Health and Human Services. Healthy people

2000 midcourse review and 1995 revisions. Washington: Public

Health Service. 1995.

3. Centers for Disease Control and Prevention. Case definitions for

public health surveillance. MMWR Vol. 39 No. RR-13. 1990.

4. Lui, K-J, and Kendal, AP. Impact of influenza epidemics on

mortality in the United States from October 1972 to May 1985.

Am J Public Health 77:712–6. 1987.

5. Schonberger, Larry. Personal communication. March 8, 1996.

6. Coleman, Patrick. Personal communication. July 16, 1996.

7. Center for Disease Control and Prevention, National Center for

Infectious Diseases. Viral Hepatitis Surveillance Report, annual.

8. Centers for Disease Control and Prevention, National Center for

HIV, STD and TB Prevention. Reported tuberculosis in the

United States, 1995. July 1996.

9. Centers for Disease Control and Prevention, National Center for

Infectious Diseases. NNIS Semiannual Report. May 1995.

10. Culver DH, Horan TC, Gaynes RP, et al. Surgical wound

infection rates by wound class, operative procedure, and patient

risk index. Amer J of Med 91(Suppl. 3B):152S-7S. 1991.

11. Walsh, Jeannie. Personal communication. July 19, 1996.

12. Schlech III, WF, Ward, JI, Band, JD, et al. Bacterial meningitis

in the United States, 1978 through 1981: The National Bacterial

Meningitis Surveillance Study. JAMA 253(12):1749–54. 1985.

13. Adams PF, Marano MA. Current estimates from the National

Health Interview Survey, 1994. National Center for Health

Statistics. Vital Health Stat 10(193). 1995.

14. Katz M. Undervaccination for hepatitis B among young men

who have sex with men—San Francisco and Berkeley, California, 1992–1993. MMWR 45(10):215–217. 1996.

15. Helmick CG. The epidemiology of human rabies postexposure

prophylaxis, 1980- 1981. JAMA 250(15):1990–6. 1983.

16. Contact Debbie Maiese, M. A., Office of Disease Prevention and

Health Promotion, for information on the 1992 Primary Care

Providers Surveys, at 202–205-8611.

17. National Association of County and City Health Officials.

1992–1993 National profile of local health departments. Washington, D.C. 1995.

18. For copies of the most recent report, telephone the Centers for

Disease Control and Prevention, National Center for HIV, STD,

and TB Prevention, Division of Tuberculosis Elimination at

404–639-8135.

19. Brammer, Lynette. Personal communication. March 7, 1996.

20. Group Health Association of America. 1995 National directory

of health maintenance organizations. Washington, D.C. 1995.

12
Appendix A: Immunization and Infectious

Diseases Objectives

20.1: Reduce indigenous cases of vaccine-preventable diseases

as follows:

Disease 2000 target

Diphtheria among people aged 25 and younger 0

Tetanus among people aged 25 and younger 0

Polio (wild-type virus) 0

Measles(indigenous) 0

Rubella 0

Congenital Rubella Syndrome 0

Mumps 500

Pertussis 1,000

20.2: Reduce epidemic-related pneumonia and influenza deaths

among people aged 65 and older to no more than 15.9 per

100,000 people.

NOTE: Epidemic-related pneumonia and influenza deaths are

those that occur above and beyond the normal yearly fluctuations of mortality. Because of the extreme variability in

epidemic-related deaths from year to year, the it will be

measured using a 3-year average.

20.3*: Reduce viral hepatitis as follows:

Hepatitis B: 40 per 100,000 people

Hepatitis A: 16.1 per 100,000 people

Hepatitis C: 13.7 cases per 100,000 people

20.3a: Reduce hepatitis B among injecting drug users to

no more than 7,932 cases.

20.3b*: Reduce hepatitis B among heterosexually active

people to no more than 22,663 cases.

Duplicate objective: 19.7

20.3c*: Reduce hepatitis B among homosexual men to

no more than 4,568 cases.

Duplicate objective: 19.7

20.3d: Reduce hepatitis B among children of Asian and

Pacific Islanders to no more than 1,500 cases.

20.3e*: Reduce hepatitis B among occupationally

exposed workers to no more than 623 cases.

Duplicate objective: 10.5

20.3f: Reduce hepatitis B among infants to no more

than 1,111 chronic infections.

20.3g: Reduce hepatitis B among Alaska Natives to no

more than 1 new chronic infection.

20.3h: Reduce hepatitis B among blacks to no more

than 40 cases per 100,000 people.

20.3i: Reduce hepatitis A among Hispanics to no more

than 26.9 cases per 100,000 people.

20.3j: Reduce hepatitis A among American Indians and

Alaska Natives to no more than 128 cases per 100,000

people.

20.3k: Reduce hepatitis C among Hispanics to no more

than 13.7 cases per 100,000 people.

20.4: Reduce tuberculosis to an incidence of no more than 3.5

cases per 100,000 people.

20.4a: Reduce tuberculosis among Asians and Pacific

Islanders to an incidence of no more than 15 cases per

100,000.

20.4b: Reduce tuberculosis among blacks to an

incidence of no more than 10 cases per 100,000.

20.4c: Reduce tuberculosis among Hispanics to an

incidence of no more than 5 cases per 100,000.

20.4d: Reduce tuberculosis among American Indians and

Alaska Natives to an incidence of no more than 5 cases

per 100,000.

20.5: Reduce by at least 10 percent the incidence of surgical

wound infections and nosocomial infections in intensive care

patients.

20.6: Reduce selected illness among international travelers as

follows:

Typhoid fever: 140 cases

Hepatitis A: 1,119 cases

Malaria: 750 cases

20.7: Reduce bacterial meningitis to no more than 4.7 cases

per 100,000 people.

20.7a: Reduce bacterial meningitis among Alaska

Natives to no more than 8 cases per 100,000 people.

20.8: Reduce infectious diarrhea by at least 25 percent among

children in licensed child care centers and children in programs that provide an Individualized Education Program (IEP)

or Individualized Health Plan (IHP).

20.9: Reduce acute middle ear infections among children aged

4 and younger, as measured by days of restricted activity or

school absenteeism, to no more than 105 days per 100

children.

20.10: Reduce pneumonia-related days of restricted activity as

follows:

15.1 days per 100 people aged 65 and older.

24 days per 100 children aged 4 and younger.

20.11: Increase immunization levels as follows:

Basic immunization series among children under age 2: at

least 90 percent.

Basic immunization series among children in licensed child

care facilities and kindergarten through post-secondary education institutions: at least 95 percent.

Hepatitis B immunization among high-risk populations,

including infants of hepatitis B surface antigen-positive mothers

13
to at least 90 percent; occupationally exposed workers to at

least 90 percent; injecting drug users in drug treatment programs to at least 50 percent; and men who have sex with men

to at least 50 percent.

Pneumococcal pneumonia and influenza immunization among

institutionalized chronically ill or older people: at least

80 percent.

Pneumococcal pneumonia and influenza immunization among

noninstitutionalized, high-risk populations, as defined by the

Immunization Practices Advisory Committee: at least

60 percent.

Duplicate objective for occupationally exposed workers: 10.9

20.11a: Increase pneumococcal pneumonia and influenza

immunization among blacks aged 65 years and older to

60 percent.

20.11b: Increase pneumococcal pneumonia and influenza

immunization among Hispanics aged 65 years and older

to 60 percent.

20.12: Reduce postexposure rabies treatments to no more than

9,000 per year.

20.13: Expand immunization laws for schools, preschools, and

day care settings to all States for all antigens.

20.14: Increase to at least 90 percent the proportion of primary

care providers who provide information and counseling about

immunizations and offer immunizations as appropriate for

their patients.

20.15: Improve the financing and delivery of immunizations

for children and adults so that virtually no American has a

financial barrier to receiving recommended immunizations.

20.16: Increase to at least 90 percent the proportion of public

health departments that provide adult immunization for influenza, pneumococcal disease, hepatitis B, tetanus, and diphtheria.

20.17: Increase to at least 90 percent the proportion of local

health departments that have ongoing programs for actively

identifying cases of tuberculosis and latent infection in populations at high risk for tuberculosis.

NOTE: Local health department refers to any local component

of the public health system, defined as an administrative and

service unit of local or State government concerned with

health and carrying some responsibility for the health of a

jurisdiction smaller than a State.

20.18: Increase to at least 85 percent the proportion of people

found to have tuberculosis infection who completed courses of

preventive therapy.

20.19: Increase to at least 85 percent the proportion of tertiary

care hospital laboratories and to at least 50 percent the proportion of secondary care hospital and health maintenance organization laboratories possessing technologies for rapid viral

diagnosis of influenza.

*Duplicate objective.

Appendix B: Bibliography

General:

+ Kovar MG. Data Systems of the National Center for

Health Statistics. Vital Health Stat 1(23). 1989.

+ National Center for Health Statistics. Health, United

States, 1995. Hyattsville, Maryland: Public Health

Service. 1996. Appendix I.

National Health and Nutrition Examination Survey (including

HHANES):

+ McDowell A, et al. Plan and operation of the second

National Health and Nutrition Examination Survey,

1976–80. National Center for Health Statistics. Vital

Health Stat 1(15). 1981

+ Maurer KR. Plan and operation of the Hispanic Health

and Nutrition Examination Survey, 1982–84. Vital Health

Stat 1(19). 1985.

+ Plan and operation of the third National Health and

Nutrition Examination Survey, 1988–94. National Center

for Health Statistics. Vital Health Stat 1(32). 1994.

+ Ezzati TM, et al. Sample design: Third National Health

and Nutrition Examination Survey. National Center for

Health Statistics. Vital Health Stat 2(113). 1992.

National Survey of Family Growth:

+ Waksberg J, Sperry S, Judkins D, Smith V. National

Survey of Family Growth, Cycle IV, evaluation of linked

design. National Center for Health Statistics. Vital Health

Stat 2(117). 1993.

+ Judkins DR, Mosher WD, Botman S. National Survey of

Family Growth: Design, estimation, and inference.

National Center for Health Statistics. Vital Health Stat

2(109). 1991.

+ Waksberg J and Northrup DR. Integration of sample

design for the National Survey of Family Growth, cycle

4, with the National Health Interview Survey. Vital Health

Stat 2(96). 1985.

National Health Interview Survey:

+ Massey JT, Moore TF, Parsons VL, Tadros W. Design and

estimation for the National Health Interview Survey,

1985–94. National Center for Health Statistics. Vital

Health Stat 2(110). 1989.

+ Questionnaires from the National Health Interview

Survey, 1985–89. National Center for Health Statistics.

Vital Health Stat 1(31). 1993.

+ Schoenborn CA and Marano M. Current estimates from

the National Health Interview Survey, 1987. National

Center for Health Statistics. Vital Health Stat 10(166).

1988.

+ Adams PF, Hardy AM. Current estimates from the

National Health Interview Survey, 1988. National Center

for Health Statistics. Vital Health Stat 10(173). 1989.

14
National Health Interview Survey:—Con.

+ Adams PF and Benson V. Current estimates from the

National Health Interview Survey, 1989. National Center

for Health Statistics. Vital Health Stat 10(176). 1990.

+ Adams PF and Benson V. Current estimates from the

National Health Interview Survey, 1990. National Center

for Health Statistics. Vital Health Stat 10(181). 1991.

+ Adams PF and Benson V. Current estimates from the

National Health Interview Survey, 1991. National Center

for Health Statistics. Vital Health Stat 10(184). 1992.

+ Benson V and Marano MA. Current estimates from the

National Health Interview Survey, 1992. National Center

for Health Statistics. Vital Health Stat 10(189). 1994.

+ Benson V and Marano MA. Current estimates from the

National Health Interview Survey, 1993. National Center

for Health Statistics. Vital Health Stat 10(190). 1994.

+ Adams PF and Marano MA. Current estimates from the

National Health Interview Survey, 1994. National Center

for Health Statistics. Vital Health Stat 10(193). 1995.

National Hospital Discharge Survey:

+ Simmons WR and Schnack GA. Development of the

design of the NCHS Hospital Discharge Survey. Vital

Health Stat 2(39). 1970.

+ Haupt BJ and Kozak LJ. Estimates from two survey

designs: National Hospital Discharge Survey. National

Center for Health Statistics. Vital Health Stat 13(111).

1992.

School Health Policies and Programs Study:

+ Errecart MT, Ross JG, Robb W, et al. The School Health

Policies and Programs Study (SHPPS): Methodology. J of

School Health 8(65):295–301. 1995.

Youth Risk Behavior Survey:

+ Kann L, Kolbe LJ, Collins JL (eds.). Measuring the health

behavior of adolescents: The Youth Risk Behavior

Surveillance System and recent reports on high-risk

adolescents. Public Health Reports 108 (Suppl 1):1–67.

1993.

Published issues of Healthy People 2000 Statistical Notes

Number Title

Date of

Issue

1 Health Status Indicators for the Year 2000 Fall 1991

2 Infant Mortality Winter 1991

3 Health Status Indicators: Definitions and National Data Spring 1992

4 Issues Related to Monitoring the Year 2000 Objectives Summer 1993

5 Revisions to Healthy People 2000 Baselines July 1993

6 Direct Standardization (Age-Adjusted Death Rates) March 1995

7 Years of Healthy Life April 1995

8 Evaluating Public Health Data Systems: A Practical Approach June 1995

9 Monitoring Air Quality in Healthy People 2000 September 1995

10 Health Status Indicators: Differentials by Race and Hispanic Origin September 1995

15
DEPARTMENT OF

HEALTH & HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics

6525 Belcrest Road

Hyattsville, Maryland 20782

OFFICIAL BUSINESS

PENALTY FOR PRIVATE USE, $300

To receive this publication regularly, contact

the National Center for Health Statistics by

calling 301-436-8500

E-mail: nchsquery@nch10a.em.cdc.gov

Internet: http://www.cdc.gov/nchswww/nchshome.htm

DHHS Publication No. (PHS) 97-1237

7-0144 (2/97)

FIRST-CLASS MAIL

POSTAGE & FEES PAID

PHS/NCHS

PERMIT NO. G-281