Immunization levels among premature and low-birth-weight infants and risk factors for delayed up-to-date immunization status. Centers for Disease Control and Prevention Vaccine Safety Datalink Group

CONTEXT

Studies have noted that health care professionals may not conform to proper immunization schedules for premature and low-birth-weight infants in the United States. Little is known about the success of current efforts to immunize these high-risk infants.

OBJECTIVE

To describe current immunization practices for premature and low-birth-weight infants and ascertain risk factors for poor immunization status, using large population-based data sources.

DESIGN AND SETTING

Cohort and case-control analyses of immunization data tracked from March 1991 through March 1997 for 3 large health maintenance organizations (HMOs) participating in the Centers for Disease Control and Prevention's Vaccine Safety Datalink project.

PARTICIPANTS

A total of 11580 low-birth-weight and premature infants were enrolled from birth to age 2 months; 6832 of these were continuously enrolled from birth to age 24 months. At age 2 months, there were 173373 full-term, normal-birth-weight infants enrolled as controls; at age 24 months, there were 103 324.

MAIN OUTCOME MEASURES

Age-specific immunization status by prematurity and birth weight (<1500 g, 1500-2500 g, born at <38 weeks' gestation with birth weight of >2500 g, or full-term with normal birth weight) and patient characteristics associated with up-to-date status.

RESULTS

At each age, infants weighing less than 1500 g at birth had lower up-to-date immunization levels than other infants. At age 6 months, 52% to 65% of infants weighing less than 1500 g were up-to-date at each of the 3 HMOs compared with 69% to 73% of those weighing 1500 to 2500 g, 66% to 80% of premature infants weighing more than 2500 g, and 65% to 76% of full-term, normal-birth-weight infants. By age 24 months, 78% to 86% of infants weighing less than 1500 g were up-to-date, significantly less than heavier infants, who had levels of 84% to 89%. Well-child preventive care strongly predicted immunization status, while concomitant pulmonary disease did not.

CONCLUSIONS

Our data suggest that infants born prematurely are vaccinated at levels approaching that of the general population, but levels of vaccination for very low-birth-weight infants lag slightly behind.

Safety of revaccination with pneumococcal polysaccharide vaccine

CONTEXT

Revaccination of healthy adults with pneumococcal polysaccharide vaccine (PPV) within several years of first vaccination has been associated with a higher than expected frequency and severity of local injection site reactions. The risk of adverse events associated with revaccination of elderly and chronically ill persons 5 or more years after first vaccination, as is currently recommended, has not been well defined.

OBJECTIVE

To determine whether revaccination with PPV at least 5 years after first vaccination is associated with more frequent or more serious adverse events than those following first vaccination.

DESIGN

Comparative intervention study conducted between April 1996 and August 1997.

PARTICIPANTS

Persons aged 50 to 74 years either who had never been vaccinated with PPV (n = 901) or who had been vaccinated once at least 5 years prior to enrollment (n = 513).

INTERVENTION

PPV vaccination.

MAIN OUTCOME MEASURES

Postvaccination local injection site reactions and prevaccination concentrations of type-specific antibodies.

RESULTS

Those who were revaccinated were more likely than those who received their first vaccinations to report a local injection site reaction of at least 10.2 cm (4 in) in diameter within 2 days of vaccination: 11% (55/513) vs 3% (29/901) (relative risk [RR], 3.3; 95% confidence interval [CI], 2.1-5.1). These reactions resolved by a median of 3 days following vaccination. The highest rate was among revaccinated patients who were immunocompetent and did not have chronic illness: 15% (33/228) compared with 3% (10/337) among comparable patients receiving their first vaccinations (RR, 4.9; 95% CI, 2.4-9.7). The risk of these local reactions was significantly correlated with prevaccination geometric mean antibody concentrations.

CONCLUSIONS

Physicians and patients should be aware that self-limited local injection site reactions occur more frequently following revaccination compared with first vaccination; however, this risk does not represent a contraindication to revaccination with PPV for recommended groups.

Quality of HMO vaccination databases used to monitor childhood vaccine safety. Vaccine Safety DataLink Team

The availability of large, population-based, automated, medical care databases provides unique opportunities for monitoring the safety of childhood vaccines. The authors assessed the quality of automated vaccination databases by comparing them with vaccinations documented in paper-based medical records at three large US West Coast health maintenance organizations (HMOs) participating in the Vaccine Safety DataLink (VSD) study, a Centers for Disease Control and Prevention collaborative study of childhood vaccine safety. The authors randomly selected 1% or 2% samples of VSD study populations (n = 1,224-2,577) for data quality analyses. Agreement between automated and abstracted vaccinations required identical triads of child identification number, vaccination date, and vaccine type. Separate analyses were conducted for each HMO and for each vaccine type administered between 1991 and 1995. Agreement was measured by three matching proportions: 1) the proportion of automated vaccinations present in the abstracted source, 2) the proportion of abstracted vaccinations present in the automated source, and 3) the proportion of vaccinations from either source present in both sources. Overall, for common childhood vaccines, proportion 1 ranged from 83% to 99%, proportion 2 ranged from 82% to 98%, and proportion 3 ranged from 70% to 97%. Lack of automated data was the most frequent type of discrepancy, followed by date mismatches and vaccine type mismatches. Vaccination exposure classification errors in the range reported here were found by mathematical modeling to only modestly bias measured medical outcome rate ratios toward the null hypothesis. The results of the data quality analyses support the usefulness of vaccination exposure data derived from these automated HMO vaccination databases.

Diabetes mellitus in Egypt: glycaemic control and microvascular and neuropathic complications

We performed a cross-sectional, population-based survey of persons 20 years of age and older living in Cairo and surrounding rural villages. The purpose was to describe glycaemic control and the prevalence of microvascular and neuropathic complications among Egyptians with diagnosed diabetes, previously undiagnosed diabetes, impaired glucose tolerance, and normal glucose tolerance. A total of 6052 households were surveyed. The response rate was 76% for the household survey and 72% for the medical examination. Among people with previously diagnosed diabetes, mean haemoglobin A1c, was 9.0%. Forty-two per cent had retinopathy, 21% albuminuria, and 22% neuropathy. Legal blindness was prevalent (5%) but clinical nephropathy (7%) and foot ulcers (1%) were uncommon in persons with diagnosed diabetes. Among people with diagnosed diabetes, microvascular and neuropathic complications were associated with hyperglycaemia. Retinopathy was also associated with duration of diabetes; albuminuria with hypertension and hypercholesterolaemia; and neuropathy with age, female sex, and hypercholesterolaemia. Albuminuria was as common in people with previously undiagnosed diabetes (22%) as those with diagnosed disease (21%). Mean haemoglobin A1c was lower (7.8%) and retinopathy (16%) and neuropathy (14%) were less prevalent in people with previously undiagnosed disease. Ocular conditions, blindness, and neuropathy were prevalent in the non-diabetic population. The microvascular and neuropathic complications of diabetes are a major clinical and public health problem in Egypt.

Incidence of diagnosed carpal tunnel syndrome in a general population

We sought to determine the incidence rate of carpal tunnel syndrome in the general population. Using three different case definitions, we conducted a prospective study to ascertain by medical record review all cases of incident disease in a defined population during a 2-year period. Newly diagnosed probable or definite carpal tunnel syndrome (N = 309) occurred at a rate of 3.46 cases per 1,000 person-years (95% confidence interval = 3.07-3.84). The incidence rate in our study was 3.5 times higher than the rate 20 years ago in a Minnesota city. The rate difference probably results from a combination of reasons, including a true rise in incidence.

Paroxysmal supraventricular tachycardia in the general population

OBJECTIVES

We sought to determine the epidemiology and clinical significance of paroxysmal supraventricular tachycardia (PSVT) in the general population.

BACKGROUND

Current knowledge of PSVT has been derived primarily from otherwise healthy patients referred to specialized centers.

METHODS

We used the resources of the Marshfield Epidemiologic Study Area, a region covering practically all medical care received by its 50,000 residents. A review of 1,763 records identified prevalent cases as of July 1, 1991 and all new cases of PSVT diagnosed from that day until June 30, 1993. A mean follow-up period of 2 years was completed in all incident patients. Patients without other cardiovascular disease were labeled as having "lone PSVT."

RESULTS

The prevalence was 2.25/1,000 persons and the incidence was 35/100,000 person-years (95% confidence interval, 23 to 47/100,000). Other cardiovascular disease was present in 90% of males and 48% of females (p = 0.0495). Compared with patients with other cardiovascular disease, those with lone PSVT were younger (mean 37 vs. 69 years, p = 0.0002), had a faster PSVT heart rate (mean 186 vs. 155 beats/min, p = 0.0006) and were more likely to have their condition first documented in the emergency room (69% vs. 30%, p = 0.0377). The onset of symptoms occurred during the childbearing years in 58% of females with lone PSVT versus 9% of females with other cardiovascular disease (p = 0.0272).

CONCLUSIONS

There are approximately 89,000 new cases/year and 570,000 persons with PSVT in the United States. In the general population, there are two distinct subsets of patients with PSVT: those with other cardiovascular disease and those with lone PSVT. Our data suggest etiologic heterogeneity in the pathogenesis of PSVT and the need for more population-based research on this common condition.

Risk factors for carpal tunnel syndrome in a general population

OBJECTIVE

To determine the individual, physical, and psychosocial risk factors for carpal tunnel syndrome in a general population.

METHODS

Population based case-control study in Marshfield epidemiological study area in Wisconsin, USA. Cases were men and women aged 18-69 with newly diagnosed carpal tunnel syndrome (n = 206 (83.1%) of 248 eligible). Controls were a random sample of residents of the study area who had no history of diagnosed carpal tunnel syndrome (n = 211 (81.5%) of 259 eligible). Cases and controls were matched by age. Telephone interviews and reviews of medical records obtained height and weight, medical history, average daily hours of exposure to selected physical and organisational work factors, and self ratings on psychosocial work scales.

RESULTS

In the final logistic regression model, five work and three non-work variables were associated with risk of carpal tunnel syndrome, after adjusting for age. For each one unit of increase in body mass index (kg/m2), risk increased 8% (odds ratio (OR) 1.08; 95% confidence interval (95% CI) 1.03 to 1.14). Having a previous musculoskeletal condition was positively associated with carpal tunnel syndrome (OR 2.54; 95% CI 1.03 to 6.23). People reporting the least influence at work had 2.86 times the risk (95% CI, 1.10 to 7.14) than those with the most influence at work.

CONCLUSIONS

Carpal tunnel syndrome is a work related disease, although some important measures of occupational exposure, including keyboard use, were not risk factors in this general population study. The mechanism whereby a weight gain of about six pounds increases the risk of disease 8% requires explanation.

Long-term symptom outcomes of carpal tunnel syndrome and its treatment

A retrospective follow-up study of a population-based case series was conducted to determine the clinical course and outcomes of carpal tunnel syndrome (CTS). A total of 425 cases first diagnosed between 1979 and 1988 were followed through 1993. Among patients who did not have surgery, median duration of symptoms was between 6 and 9 months, but 22% had symptoms for 8 years or longer. Patients who had surgery were about 6 times more likely to have resolution of their symptoms than were patients who did not have surgery. Patients who had surgery 3 or more years after their initial diagnosis of CTS were less than half as likely to have symptom resolution than were patients who had surgery within 3 years of diagnosis. The results indicate that surgery is a highly effective treatment, but duration of CTS prior to surgery is a key determinant of surgical outcome.

Epidemiologic research in an integrated regional medical care system: the Marshfield Epidemiologic Study Area

To capitalize on Marshfield Clinic's advantages for population-based health research, we developed the Marshfield Epidemiologic Study Area (MESA). Marshfield Clinic is an integrated system consisting of a large multispecialty clinic and 23 affiliated clinics. Clinic physicians provide virtually all of the medical care, both inpatient and outpatient, for residents of the area. MESA consists of 14 ZIP codes in which over 95% of the 50,000 residents and most significant health events are captured in Marshfield Clinic databases, including all deaths, 94% of hospital discharges, and 92% of medical outpatient visits. MESA exemplifies the research potential of integrated medical care systems and the efforts required to realize that potential. Because it is representative of a defined population and provides an unselected sample of patients, MESA is well suited for epidemiologic research and research elucidating the clinical spectrum and natural history of diseases and the effectiveness of treatment.

Diabetes mellitus in Egypt: risk factors and prevalence

Major sociodemographic changes have occurred in Egypt to promote the development of noncommunicable diseases. We have performed a cross-sectional, population-based survey of persons > or = 20 years of age in Cairo and surrounding rural villages to describe the prevalence of diabetes risk factors, diagnosed diabetes, previously undiagnosed diabetes, and impaired glucose tolerance by age, sex, rural and urban residence, and socioeconomic status (SES). In the survey, we identified 6052 eligible households: 76% of household respondents completed a household examination and 72% of selected household respondents subsequently completed a medical examination. Exercise was assessed by questionnaire; adiposity by measurement of height, weight, and girths; and diabetes by history and 2-h 75 g oral glucose tolerance test. In rural areas, 52% of persons > or = 20 years of age were sedentary, 16% were obese, and 4.9% had diabetes. In lower SES urban areas, 73% were sedentary, 37% were obese, and 13.5% had diabetes. In higher SES urban areas, 89% were sedentary, 49% were obese, and 20% had diabetes. The combined prevalence of diagnosed and undiagnosed diabetes in the Egyptian population > or = 20 years of age was estimated to be 9.3%. Approximately half the diabetes was diagnosed and the other half was previously undiagnosed. The prevalence of diabetes in Egypt is high, and the gradient in risk factors and disease from rural to urban areas and in urban areas from lower to higher SES suggest that diabetes is a major, emerging clinical and public health problem in Egypt.

Determinants of serum lipid and lipoprotein concentrations in children

We evaluated determinants of serum lipid and lipoprotein concentrations in 3,106 schoolchildren who participated in a community survey. We administered a brief questionnaire and measured height, weight, and fasting serum lipid concentrations. Family history of hypercholesterolemia and body mass index were strong determinants of lipid and lipoprotein levels. Results for specific foods were not always what would have been expected based on their contents of saturated fatty acids and cholesterol. Our findings point to the need for more detailed studies of the effects of specific foods, especially cheeses, milk, and whole grain bread, on the entire lipoprotein profile of children.

Trends in nonfatal coronary heart disease in the United States, 1980 through 1989

BACKGROUND

Although coronary heart disease mortality has been decreasing, little is known about trends in morbidity from coronary heart disease. We evaluated trends in nonfatal coronary heart disease in the United States during 1980 through 1989.

METHODS

We analyzed data from the National Health Interview Survey, an ongoing survey of representative samples of the civilian, noninstitutionalized population of the United States. Survey respondents were determined to have coronary heart disease if they reported ever having a myocardial infarction or heart attack, angina pectoris, or coronary heart disease. Incidence was defined as initial onset of a coronary heart disease condition during the year preceding the interview date.

RESULTS

About 6 million people were estimated to be living with coronary heart disease. The age-standardized prevalence was relatively constant at about 25 per 1000. Among white men, however, prevalence increased significantly over the 10-year period. Among 75- to 84-year-old men, prevalence increased from 100 per 1000 in 1980 to 179 per 1000 in 1989. Among men and women 45 to 54 years old, prevalence decreased. Overall, the incidence rate of nonfatal coronary heart disease was relatively flat (at about 3 per 1000 per year after 1983). Among white women, the incidence rate increased from 1.4 to 2.8 per 1000, and by the end of the decade it nearly equaled the incidence rate among white men.

CONCLUSIONS

Overall, the burden of nonfatal coronary heart disease remained fairly constant during the 1980s. The trends, however, were not uniform in all population groups. The apparent increasing incidence among women deserves continued monitoring. An encouraging trend is the decreasing prevalence in the younger age groups.

Surveillance for diabetes mellitus--United States, 1980-1989

PROBLEM/CONDITION

In the United States, diabetes mellitus is the most important cause of lower-extremity amputation and end-stage renal disease; the major cause of blindness among working-age adults; a major cause of disability, premature mortality, congenital malformations, perinatal mortality, and health-care costs; and an important risk factor for the development of many other acute and chronic conditions (e.g., diabetic ketoacidosis, ischemic heart disease, stroke). Surveillance data describing diabetes and its complications are critical to increasing recognition of the public health burden of diabetes, formulating health-care policy, identifying high-risk groups, developing strategies to reduce the burden of this disease, and evaluating progress in disease prevention and control.

REPORTING PERIOD COVERED

In this report, data are summarized from CDC's diabetes surveillance system; trends in diabetes and its complications are evaluated by age, sex, and race for the years 1980-1989.

DESCRIPTION OF SYSTEM

CDC has established an ongoing and evolving surveillance system to analyze and compile periodic, representative data on the disease burden of diabetes and its complications in the United States. Data sources currently include vital statistics, the National Health Interview Survey, the National Hospital Discharge Survey, and Medicare claims data for end-stage renal disease.

RESULTS AND INTERPRETATION

In 1989, approximately 6.7 million persons in the United States reported that they had diabetes mellitus, and a similar number probably had this disabling chronic disease without being aware of it. The disease burden of diabetes and its complications is large and is likely to increase as the population grows older. Effective primary, secondary, and tertiary prevention strategies are needed, and these efforts need to be intensified among groups at highest risk, including blacks. Important gaps exist in periodic and representative data for describing the disease burden.

ACTIONS TAKEN

CDC is assisting diabetes control programs in 26 states and one territory. These programs attempt to reduce the burden of diabetes by preventing blindness, lower-extremity amputations, cardiovascular disease, and adverse outcomes of pregnancy among persons with diabetes. Because of important limitations in measuring the burden of diabetes, CDC is exploring sources of surveillance data for blindness, adverse outcomes of pregnancy, and the public health burden of diabetes among minority groups.

Dental disease and risk of coronary heart disease and mortality

OBJECTIVE

To investigate a reported association between dental disease and risk of coronary heart disease.

SETTING

National sample of American adults who participated in a health examination survey in the early 1970s.

DESIGN

Prospective cohort study in which participants underwent a standard dental examination at baseline and were followed up to 1987. Proportional hazards analysis was used to estimate relative risks adjusted for several covariates.

MAIN OUTCOME MEASURES

Incidence of mortality or admission to hospital because of coronary heart disease; total mortality.

RESULTS

Among all 9760 subjects included in the analysis those with periodontitis had a 25% increased risk of coronary heart disease relative to those with minimal periodontal disease. Poor oral hygiene, determined by the extent of dental debris and calculus, was also associated with an increased incidence of coronary heart disease. In men younger than 50 years at baseline periodontal disease was a stronger risk factor for coronary heart disease; men with periodontitis had a relative risk of 1.72. Both periodontal disease and poor oral hygiene showed stronger associations with total mortality than with coronary heart disease.

CONCLUSION

Dental disease is associated with an increased risk of coronary heart disease, particularly in young men. Whether this is a causal association is unclear. Dental health may be a more general indicator of personal hygiene and possibly health care practices.

Recent trends in the identification and treatment of high blood cholesterol by physicians. Progress and missed opportunities

OBJECTIVE

To investigate recent trends in the percentage and characteristics of patients being treated by a physician for high blood cholesterol (HBC) and to assess missed clinical opportunities to screen for HBC.

DESIGN, SETTING, PARTICIPANTS

Telephone interviews of 154,735 adults in 37 states that participated in the Behavioral Risk Factor Surveillance System during 1988-1990 to assess trends in the percentage of patients treated for HBC by a physician. An opportunity was considered missed if a person did not report being screened for HBC despite seeing a physician for preventive care in the last 2 years.

RESULTS

Between the first quarter of 1988 and the last quarter of 1990, the percentage of persons treated by a physician for HBC increased from 7.6% to 11.7% (P < .001). However, since an estimated 36% of US adults need treatment for HBC, fewer than one third of persons who need treatment are receiving it. Persons with two or more cardiac risk factors were more likely to be treated, while men, blacks, persons in lower socioeconomic groups, and persons between 20 and 34 years of age were less likely to be treated. Among the 126,571 persons who had seen a physician for preventive care within the last 2 years, missed opportunities to screen for HBC were most common among persons aged 20 through 34 years (59%) and among women who had seen obstetricians/gynecologists for preventive care (43%).

CONCLUSIONS

Fewer than one third of persons who need treatment for HBC as estimated by data from the second National Health and Nutrition and Nutrition Examination Survey are receiving treatment. Better use of clinical opportunities to screen for HBC could substantially accelerate the progress in identifying persons, young adults in particular, who are likely to benefit from cholesterol reduction.

Diabetes-associated mortality in Native Americans

OBJECTIVE

To describe diabetes-associated mortality among Native Americans.

RESEARCH DESIGN AND METHODS

In this population-based study, we analyzed diabetes-associated mortality data from the IHS and the NCHS. We also examined diabetes data from the 1986 NMFS.

RESULTS

IHS area-specific diabetes mortality rates for 1984-1986 ranged from 10 to 93/100,000, compared with 15/100,000 for the total U.S. population. NCHS data for the same period listed diabetes as the underlying cause of 708 deaths among Native Americans and the contributory cause of 1252 deaths; 63% of the latter deaths were attributable to circulatory diseases. The 1986 NMFS demonstrated that Native American heritage is underreported by 65% on death certificates. Using deaths identified as Native American by NMFS, the age-adjusted mortality rate for diabetes as the underlying cause for Native Americans (96/100,000) was 4.3 times that for whites and two times that for blacks. Where diabetes was a contributory cause of death, the mortality rate for Native Americans (264/100,000) was 3.7 times that for whites and 2.4 times that for blacks.

CONCLUSIONS

The excessive diabetes-associated mortality among Native Americans is consistent with other indicators of the magnitude of the diabetes problem in this population. Further epidemiological research and expanded diabetes control interventions are needed.

Risk factors for coronary heart disease mortality among persons with diabetes

Although coronary heart disease is a leading cause of morbidity and mortality among persons with diabetes, the risk factors for coronary heart disease have not been well established for this population. The authors performed a case-control analysis by using data from two large population-based surveys. Cases of persons who died of coronary heart disease were identified from the 1986 National Mortality Followback Survey, and controls were taken from behavioral risk factor surveys conducted in 35 states in 1988. Diabetic women younger than 55 years with no other risk factors for coronary heart disease had a 16-fold higher risk of dying from coronary heart disease than did women without diabetes. About one-third of younger women who died of coronary heart disease had diabetes. Diabetic men less than 45 years old with no other risk factors for coronary heart disease had an eightfold higher risk of coronary heart disease mortality. Among older white men and women, diabetes increased the risk of mortality from coronary heart disease about twofold. In younger diabetics, current cigarette smoking was associated with a 50% increase in risk, and high blood pressure increased the risk more than threefold. In the older age group, risk factors for coronary heart disease mortality were similar among those with and those without diabetes: Cigarette smoking and high blood pressure each were associated with about a twofold increase in risk. Diabetes is a particularly strong risk factor for mortality from coronary heart disease in young adults. Smoking and blood pressure control represent major opportunities to reduce the risk of coronary heart disease among persons with diabetes.