SWIFT: prospective 48-week study to evaluate efficacy and safety of switching to emtricitabine/tenofovir from lamivudine/abacavir in virologically suppressed HIV-1 infected patients on a boosted protease inhibitor containing antiretroviral regimen

BACKGROUND

In the United States, emtricitabine/tenofovir disoproxil fumarate (FTC/TDF) is a preferred nucleoside reverse transcriptase inhibitor (NRTI) backbone with lamivudine/abacavir (3TC/ABC) as a commonly used alternative. For patients infected with human immunodeficiency virus (HIV-1) virologically suppressed on a boosted protease inhibitor (PI) + 3TC/ABC regimen, the merits of switching to FTC/TDF as the NRTI backbone are unknown.

METHODS

SWIFT was a prospective, randomized, open-label 48-week study to evaluate efficacy and safety of switching to FTC/TDF. Subjects receiving 3TC/ABC + PI + ritonavir (RTV) with HIV-1 RNA < 200 c/mL ≥3 months were randomized to continue 3TC/ABC or switch to FTC/TDF. The primary endpoint was time to loss of virologic response (TLOVR) with noninferiority measured by delta of 12%. Virologic failure (VF) was defined as confirmed rebound or the last HIV-1 RNA measurement on study drug ≥200 c/mL.

RESULTS

In total, 311 subjects were treated in this study (155 to PI + RTV + FTC/TDF, 156 to PI + RTV + 3TC/ABC). Baseline characteristics were similar between the arms: 85% male, 28% black, median age, 46 years; and median CD4 532 cells/mm(3). By TLOVR through week 48, switching to FTC/TDF was noninferior compared to continued 3TC/ABC (86.4% vs 83.3%, treatment difference 3.0% (95% confidence interval, -5.1% to 11.2%). Fewer subjects on FTC/TDF experienced VF (3 vs 11; P = .034). FTC/TDF showed greater declines in fasting low-density lipoproteins (LDL), total cholesterol (TC), and triglycerides (TG) with significant declines in LDL and TC beginning at week 12 with no TC/HDL ratio change. Switching to FTC/TDF showed improved NCEP thresholds for TC and TG and improved 10-year Framingham TC calculated scores. Decreased estimated glomerular filtration rate [corrected] (eGFR) was observed in both arms with a larger decrease in the FTC/TDF arm.

CONCLUSIONS

Switching to FTC/TDF from 3TC/ABC maintained virologic suppression, had fewer VFs, improved lipid parameters and Framingham scores but decreased eGFR. CLINICALTRIALS.GOV IDENTIFIER: NCT00724711.

How willing are parents to improve pedestrian safety in their community?

STUDY OBJECTIVE

To determine how likely parents would be to contribute to strategies to reduce pedestrian injury risks and how much they valued such interventions.

DESIGN

A single referendum willingness to pay survey. Each parent was randomised to respond to one of five requested contributions towards each of the following activities: constructing speed bumps, volunteering as a crossing guard, attending a neighbourhood meeting, or attending a safety workshop.

SETTING

Community survey.

PARTICIPANTS

A sample of 723 Baltimore parents from four neighbourhoods stratified by income and child pedestrian injury risk. Eligible parents had a child enrolled in one of four elementary schools in Baltimore City in May 2001.

MAIN RESULTS

The more parents were asked to contribute, the less likely they were to do so. Parents were more likely to contribute in neighbourhoods with higher ratings of solidarity. The median willingness to pay money for speed bumps was conservatively estimated at $6.43. The median willingness to contribute time was 2.5 hours for attending workshops, 2.8 hours in community discussion groups, and 30 hours as a volunteer crossing guard.

CONCLUSIONS

Parents place a high value on physical and social interventions to improve child pedestrian safety.

Annual summary of vital statistics: 2000

The birth rate in 2000 (preliminary data) was 14.8 births per 1000 population, an increase of 2% from 1999 (14.5). The fertility rate, births per 1000 women aged 15 to 44 years, increased 3% to 67.6 in 2000, compared with 65.9 in 1999. The 2000 increases in births and the fertility rate were the third consecutive yearly increases, the largest in many years, halting the steady decline in the number of births and fertility rates in the 1990s. Fertility rates for total white, non-Hispanic white, black, and Native American women each increased about 2% in 2000. The fertility rate for black women, which declined 19% from 1990 to 1996, has changed little since 1996. The rate for Hispanic women rose 4% in 2000 to reach the highest level since 1993. Birth rates for women 30 years or older continued to increase. The proportion of births to unmarried women remained about the same at one third, but the number of births rose 3%. The birth rate for teen mothers declined again for the ninth consecutive year. The use of timely prenatal care (83.2%) remained unchanged in 2000, and was essentially unchanged for non-Hispanic white (88.5%), black (74.2%), and Hispanic (74.4%) mothers. The number and rate of multiple births continued their dramatic rise, but all of the increase was confined to twins; for the first time in more than a decade, the number of triplet and higher-order multiple births declined (4%) between 1998 and 1999 (multiple birth information is not available in preliminary 2000 data). The overall increases in multiple births account, in part, for the lack of improvement in the percentage of low birth weight (LBW) births. LBW remained at 7.6% in 2000. The infant mortality rate (IMR) dropped to 6.9 per 1000 live births (preliminary data) in 2000 (the rate was 7.1 in 1999). The ratio of the IMR among black infants to that for white infants was 2.5 in 2000, the same as in 1999. Racial differences in infant mortality remain a major public health concern. The role of low birth weight in infant mortality remains a major issue. Among all of the states, Utah and Maine had the lowest IMRs. State-by-state differences in IMR reflect racial composition, the percentage LBW, and birth weight-specific neonatal mortality rates for each state. The United States continues to rank poorly in international comparisons of infant mortality. Expectation of life at birth reached a record high of 76.9 years for all gender and race groups combined. Death rates in the United States continue to decline. The age-adjusted death rate for suicide declined 4% between 1999 and 2000; homicide declined 7%. Death rates for children 19 years of age or less declined for 3 of the 5 leading causes in 2000; cancer and suicide levels did not change for children as a group. A large proportion of childhood deaths, however, continue to occur as a result of preventable injuries.

Botulinum toxin type A and other botulinum toxin serotypes: a comparative review of biochemical and pharmacological actions

Botulinum toxin type A is an important therapeutic agent for the treatment of movement and other disorders. As the clinical uses of botulinum toxin type A expand, it is increasingly important to understand the biochemical and pharmacological actions of this toxin, as well as those of other botulinum toxin serotypes (B-G). Botulinum neurotoxin serotypes exhibit differences in neurotoxin complex protein size, percentage of neurotoxin in the activated or nicked form, intracellular protein target, and potency. These properties differ even between preparations that contain the same botulinum toxin serotype due to variations in product formulations. As demonstrated in preclinical and clinical studies, these differences result in a unique combination of efficacy, duration of action, safety, and antigenic potential for each botulinum neurotoxin preparation.

"The Embarrassment of Riches;" an historical theme for a children's health agenda in 21st century America

How can the United States use its immense wealth to create an agenda for children in the 21st century? The field of maternal and child health must strengthen and broaden the social strategies needed to overcome the changing demography and diminished political place of children in society, globally. Four approaches are proposed: First, adopting a life-course orientation emphasizes the continuities of the early part of life with the conditions, developmental tasks, and health problems of the rest of the life cycle; it makes maternal and child health relevant to health and well being across the entire life span. Second, shifting to a focus on the multiple determinants of population health will overcome the limitations of a medical model that is narrowly concerned with etiological risk factors for disease and medical interventions; in particular, poverty among children must be addressed on a global scale. Third, promoting social justice for children demands an open political discussion of the moral and ethical foundations of child health. Finally, preventing health problems across the life span requires a new set of population level, univeral intervention strategies. These fundamental principles are proposed to stimulate a discussion of how to make our field more influential in the 21st century.

Early effects of the healthy steps for young children program

OBJECTIVE

The Healthy Steps for Young Children Program (HS) incorporates early child development specialists and enhanced developmental services into routine pediatric care. An evaluation of HS is being conducted at 6 randomization and 9 quasi-experimental sites. Services received, satisfaction with services, and parent practices were assessed when infants were aged 2 to 4 months.

METHODS

Telephone interviews with mothers were conducted for 2631 intervention (response rate, 89%) and 2265 control (response rate, 87%) families. Analyses were conducted separately for randomization and quasi-experimental sites and adjusted for baseline differences between intervention and control groups. Hierarchical linear models assessed overall adjusted effects, while accounting for within-site correlation of outcomes.

RESULTS

Intervention families were considerably more likely than controls to report receiving 4 or more developmental services and home visits and discussing 5 infant development topics. They also were more likely to be satisfied and less likely to be dissatisfied with care from their pediatric provider and were less likely to place babies in the prone sleep position or feed them water. The program did not affect breastfeeding continuation. Differences in the percentage of parents who showed picture books to their infants, fed them cereal, followed routines, and played with them daily were found only at the quasi-experimental sites and may reflect factors unrelated to HS.

CONCLUSIONS

Intervention families received more developmental services during the first 2 to 4 months of their child's life and were happier with care received than were control families. Future surveys and medical record reviews will address whether these findings persist and translate into improved language development, better utilization of well-child care, and an effect on costs.

Annual summary of vital statistics: trends in the health of Americans during the 20th century

The overall improvement in the health of Americans over the 20th century is best exemplified by dramatic changes in 2 trends: 1) the age-adjusted death rate declined by about 74%, while 2) life expectancy increased 56%. Leading causes of death shifted from infectious to chronic diseases. In 1900, infectious respiratory diseases accounted for nearly a quarter of all deaths. In 1998, the 10 leading causes of death in the United States were, respectively, heart disease and cancer followed by stroke, chronic obstructive pulmonary disease, accidents (unintentional injuries), pneumonia and influenza, diabetes, suicide, kidney diseases, and chronic liver disease and cirrhosis. Together these leading causes accounted for 84% of all deaths. The size and composition of the American population is fundamentally affected by the fertility rate and the number of births. From the beginning of the century there was a steady decline in the fertility rate to a low point in 1936. The postwar baby boom peaked in 1957, when 123 of every 1000 women aged 15 to 44 years gave birth. Thereafter, fertility rates began a steady decline. Trends in the number of births parallel the trends in the fertility rate. Beginning in 1936 and continuing to 1956, there was precipitous decline in maternal mortality from 582 deaths per 100 000 live births in 1935 to 40 in 1956. Since 1950 the maternal mortality ratio dropped by 90% to 7.1 in 1998. The infant mortality rate has shown an exponential decline during the 20th century. In 1915, approximately 100 white infants per 1000 live births died in the first year of life; the rate for black infants was almost twice as high. In 1998, the infant mortality rate was 7.2 overall, 6.0 for white infants, and 14.3 for black infants. For children older than 1 year of age, the overall decline in mortality during the 20th century has been spectacular. In 1900, >3 in 100 children died between their first and 20th birthday; today, <2 in 1000 die. At the beginning of the 20th century, the leading causes of child mortality were infectious diseases, including diarrheal diseases, diphtheria, measles, pneumonia and influenza, scarlet fever, tuberculosis, typhoid and paratyphoid fevers, and whooping cough. Between 1900 and 1998, the percentage of child deaths attributable to infectious diseases declined from 61.6% to 2%. Accidents accounted for 6.3% of child deaths in 1900, but 43.9% in 1998. Between 1900 and 1998, the death rate from accidents, now usually called unintentional injuries, declined two-thirds, from 47. 5 to 15.9 deaths per 100 000. The child dependency ratio far exceeded the elderly dependency ratio during most of the 20th century, particularly during the first 70 years. The elderly ratio has gained incrementally since then and the large increase expected beginning in 2010 indicates that the difference in the 2 ratios will become considerably less by 2030. The challenge for the 21st century is how to balance the needs of children with the growing demands for a large aging population of elderly persons.

Calling the shots: immunization finance policies and practices. Executive summary of the report of the Institute of Medicine

Federal, state, and private-sector investments in vaccine purchases and immunization programs are lagging behind emerging opportunities to reduce the risks of vaccine-preventable disease. Although federal assistance to the states for immunization programs and data collection efforts rapidly expanded in the early part of the 1990s, significant cutbacks have occurred in the last 5 years that have reduced the size of state grant awards by more than 50% from their highest point. During this same period, the vaccine delivery system for children and adults has become more complex and fragmented. This combination of new challenges and reduced resources has led to instability in the public health infrastructure that supports the U. S. immunization system. Many states have reduced the scale of their immunization programs and currently lack adequate strength in areas such as data collection among at-risk populations, strategic planning, program coordination, and assessment of immunization status in communities that are served by multiple health care providers. If unmet immunization needs are not identified and addressed, states will have difficulty in achieving the national goal of 90% coverage by the year 2010 for completion of the childhood immunization series for young children. Furthermore, state and national coverage rates, which reached record levels for vaccines in widespread use (79%, 1998), can be expected to decline and preventable disease outbreaks may occur as a result, particularly among persons who are vulnerable to vaccine-preventable disease because of their underimmunization status. The Institute of Medicine (IOM) Committee on Immunization Finance Policies and Practices has therefore concluded that a renewal and strengthening of the federal and state immunization partnership is necessary. The goal of this renewed partnership is to prevent infectious disease; to monitor, sustain, and improve vaccine coverage rates for child and adult populations within more numerous and increasingly diversified health care settings; and to respond to vaccine-safety concerns. To achieve this renewal, states require a consistent strategy, additional funds, and a multiyear finance plan that can help expedite the delivery of new vaccines; strengthen the immunization assessment, assurance, and policy development functions in each state; and adapt childhood immunization programs to serve the needs of new age groups (especially adults with chronic diseases) in different health care environments. The IOM committee recommends that federal and state governments adopt a national finance strategy that would allocate $1.5 billion in federal and state resources over the first 5 years to strengthen the infrastructure for child and adult immunization-an annual increase of $175 million over current spending levels. These resources would consist of $200 million per year in state infrastructure grants awarded by the Centers for Disease Control and Prevention (the Section 317 program) and an additional $100 million per year in increased state contributions. The committee also recommends that the Congress replace the current discretionary Section 317 grants with a formula approach for state immunization grant awards to improve the targeting and stability of federal immunization grants. The formula should provide a base level of support to all states, as well as additional amounts related to each state's need, capacity, and performance. The committee further recommends that Congress introduce a state match requirement for the receipt of increased federal funds to help strengthen and stabilize the infrastructure that supports long-term public health assessment, assurance, and policy development efforts. (ABSTRACT TRUNCATED)

Assessing the impact of pediatric-based development services on infants, families, and clinicians: challenges to evaluating the Health Steps Program

BACKGROUND

Begun in 1996, the Healthy Steps for Young Children Program (HS) is a new model of pediatric practice that incorporates child development specialists and enhanced developmental services for families of young children. HS is for all families, not just those at high-risk. It is expected to strengthen parents' knowledge, attitudes, and behaviors in ways that promote child health and development, and in turn, to lead to improved child outcomes, such as improved language development, increased utilization of well child care, and decreased problem behaviors, hospitalizations, and injuries. The HS evaluation is designed to assess whether HS is successful in achieving the desired outcomes, measure the program's costs, and determine the relation of the program's costs to its outcomes.

OBJECTIVE

This article is the first report of the HS evaluation. It describes the evaluation design and characteristics of the HS sites and sample for the evaluation.

METHODS

The evaluation is following a cohort of children from birth to age 3 at 15 evaluation sites across the country. The sites represent a range of organizational practice settings that include group practices, hospital-based clinics, and health maintenance organization pediatric clinics. The evaluation design relies on 2 comparison strategies. At 6 randomization design sites, 400 children were randomized to the intervention or control group. At 9 quasi-experimental design sites, a comparison location with a similar organizational setting and patient profile has been selected and up to 200 children are being followed at each of these sites. At each site, 2 developmental specialists (or their full-time equivalents) work as a team with 4 to 8 pediatricians and pediatric nurse practitioners. The specialist conducts office visits (jointly or sequentially with the pediatric clinician) and home visits, assesses children's developmental progress, provides referrals and follow-up to resources in the community, organizes and conducts parent discussion groups, coordinates early reading activities, and maintains a telephone information line for questions about child development and behavior. The evaluation relies on many data sources including self-administered provider surveys, key informant interviews, forms completed by parents at office visits, telephone interviews with parents, medical record reviews, data from each site on program costs and health services use, and an ongoing log of family contacts maintained by each developmental specialist. Analyses for this article are based on enrollment data for the Healthy Steps sample and national data on 1997 US live births. The chi2 goodness-of-fit test was used to evaluate whether the distribution of selected demographic variables, insurance, and infant's birth weight for the Healthy Steps sample was similar to the distributions for US births in 1997. In addition, comparisons were made between intervention and comparison families at the randomization and quasi-experimental evaluation sites. The chi2 test of independence was used to evaluate differences in variables across groups.

RESULTS

Throughout a 26-month period, 5565 children enrolled in the evaluation, 2963 (53.2%) children in the intervention group and 2602 (46.8%) in the comparison group. More than 10% of mothers in the Healthy Steps sample are teenagers; 18% have 11 years of education or less; 27% have completed college; 18% are black or African-American; slightly >20% are of Hispanic origin; 36% are single; and close to one-third used Medicaid for their prenatal care. Approximately 7% of infants were low birth weight. When compared with national birth data for the United States as a whole, the Healthy Steps sample seems similarly diverse. However, with the exception of maternal age, the distribution of variables was significantly different from the distribution for US births. There are no differences between intervention and comparison families at randomization sites on any of

Annual summary of vital statistics--1998

Most vital statistics indicators of the health of Americans were stable or showed modest improvements between 1997 and 1998. The preliminary birth rate in 1998 was 14.6 births per 1000 population, up slightly from the record low reported for 1997 (14.5). The fertility rate, births per 1000 women aged 15 to 44 years, increased 1% to 65.6 in 1998, compared with 65.0 in 1997. The 1998 increases, although modest, were the first since 1990, halting the steady decline in the number of births and birth and fertility rates in the 1990s. Fertility rates for total white, non-Hispanic white, and Native American women each increased from 1% to 2% in 1998. The fertility rate for black women declined 19% from 1990 to 1996, but has changed little since 1996. The rate for Hispanic women, which dropped 2%, was lower than in any year for which national data have been available. Birth rates for women 30 years or older continued to increase. The proportion of births to unmarried women remained about the same at one third. The birth rate for teen mothers declined again for the seventh consecutive year, and the use of timely prenatal care (82.8%) improved for the ninth consecutive year, especially for black (73.3%) and Hispanic (74.3%) mothers. The number and rate of multiple births continued their dramatic rise; the number of triplet and higher-order multiple births jumped 16% between 1996 and 1997, accounting, in part, for the slight increase in the percentage of low birth weight (LBW) births. LBW continued to increase from 1997 to 1998 to 7.6%. The infant mortality rate (IMR) was unchanged from 1997 to 1998 (7.2 per 1000 live births). The ratio of the IMR among black infants to that for white infants (2.4) remained the same in 1998 as in 1997. Racial differences in infant mortality remain a major public health concern. In 1997, 65% of all infant deaths occurred to the 7.5% of infants born LBW. Among all of the states, Maine, Massachusetts, and New Hampshire had the lowest IMRs. State-by-state differences in IMR reflect racial composition, the percentage LBW, and birth weight-specific neonatal mortality rate for each state. The United States continues to rank poorly in international comparisons of infant mortality. Expectation of life at birth increased slightly to 76.7 years for all gender and race groups combined. Death rates in the United States continue to decline, including a drop in mortality from human immunodeficiency virus. The age-adjusted death rate for suicide declined 6% in 1998; homicide declined 14%. Death rates for children from all major causes declined again in 1998. A large proportion of childhood deaths, however, continue to occur as a result of preventable injuries.

The effect of parental monetary sanctions on the vaccination status of young children: an evaluation of welfare reform in Maryland

OBJECTIVE

To determine whether financial sanctions to Aid to Families With Dependent Children (AFDC) recipients can be used to improve vaccination coverage of young children.

DESIGN

Randomized controlled trial.

SETTING

Six AFDC jurisdictions in Maryland.

INTERVENTION

Recipients of AFDC were randomized to the experimental or control group of the Primary Prevention Initiative. Families in the experimental group were penalized financially for failing to verify that their children received preventive health care, including vaccinations; control families were not.

PARTICIPANTS

Children aged 3 to 24 months from assigned families were randomly selected for the evaluation (911 in the experimental, 864 in the control, and 471 in the baseline groups).

MAIN OUTCOME MEASURES

Up-to-date for age for diphtheria and tetanus toxoids and pertussis (DTP), polio, and measles-mumps-rubella (MMR) vaccines; missed opportunities to vaccinate; and number of visits per year.

ANALYSIS

Comparisons among baseline and postimplementation years 1 and 2.

RESULTS

Vaccination coverage of children was low. Less than 70% of children were up-to-date for age for polio and MMR vaccines; slightly more than 50% were up-to-date for DTP vaccine. Up-to-date rates differed little among baseline, experimental, and control groups. Over time, there was a decrease in missed opportunities, and more children made at least 1 well-child visit; however, neither improvement resulted in a change in vaccination status.

CONCLUSIONS

The Primary Prevention Initiative did not contribute to an increase in vaccination coverage among these children. Minimal economic sanctions alone levied against parents should not be expected substantially to affect vaccination rates.

Innovative methods for monitoring perinatal health outcomes in cities and in smaller geographic areas

OBJECTIVES

Monitoring health in small localities such as cities or local communities is important, because rates of adverse outcomes often vary widely by geographic area. This article explores the utility of CUSUM (cumulative summation), a method developed and refined in industry, for monitoring health outcomes in cities and smaller geographic areas.

METHODS

CUSUM monitoring methods were applied to rates of late or no prenatal care initiation and very low birthweight for the city of Baltimore as a whole and for a cluster of high-risk areas within the city. The performance of supplementary runs criteria was also assessed. The ability of both methods to flag significant increases or decreases in prenatal care initiation and very low birthweight rates was assessed.

RESULTS

CUSUM and runs criteria detected most significant rate changes. The 2 methods performed better in regard to outcomes with higher prevalence and in larger geographic areas.

CONCLUSIONS

CUSUM methods are convenient and reliable for use in the monitoring of moderately low prevalence outcomes in small geographic areas. Future research should examine their applicability to other health outcomes and further refine these methods, especially for rarer outcomes.

Evaluation of the Community Access to Child Health Program

OBJECTIVE

Increasing attention is being focused on the need for pediatricians to promote child health in their respective communities. The objective of this study was to evaluate, retrospectively, the American Academy of Pediatrics' Community Access to Child Health (CATCH) Program.

STUDY DESIGN

Case studies of 12 Community Pediatric projects in existence from 1989 to 1995 with varying degrees of involvement in the CATCH Program. In-person interviews were conducted with 17 pediatricians, 3 CATCH leaders who were not pediatricians, 27 project advisory committee members, 42 project staff, 47 community partners, 22 public health representatives, and personnel in 13 affiliated institutions.

RESULTS

These projects established or enhanced child health services. Although most pediatricians' interest in community child health preceded CATCH, mentoring, training, and peer support contributed to ongoing involvement. Community factors that facilitated project development included historical collaborative efforts and active public health agencies. However, across sites, significant barriers related to attitude and resource limitations were noted. Attitudinal barriers included both institutional concerns (eg, competition among providers or distrust among community agencies and organizations) and cultural concerns (eg, general negative perceptions of providers about Medicaid beneficiaries or of members of minority population toward medical or government establishments).

CONCLUSIONS

In an era of devolution of responsibility to local communities, there are likely to be more opportunities for pediatricians to work with community members to promote child health. Specific strategies should be refined and expanded to support pediatricians' involvement in community-based activities, particularly because it is recognized that insurance alone will not guarantee children's health.

Community Access to Child Health (CATCH) in the historical context of Community Pediatrics

OBJECTIVES

As part of the evaluation of the American Academy of Pediatrics (AAP) Community Access to Child Health (CATCH), to 1) identify, retrospectively, the actual chronology of activities undertaken through CATCH, and 2) review its antecedents within the AAP, and its predecessor program-Healthy Children.

METHODS

Key informant telephone interviews with 14 national leaders in CATCH were conducted. Relevant program and administrative files and other documents were reviewed. AAP staff assisted the authors in preparing a detailed chronology of Healthy Children and CATCH activities and events from spring 1988 through summer 1996.

RESULTS AND CONCLUSIONS

A decade of change in the AAP, under the acronym CATCH began in the late 1980s. The formation of the AAP's Partnership for Children and the Access to Care for Children Initiative, combined with the decision by the Robert Wood Johnson Foundation to transfer the funding of Healthy Children to the AAP, underpinned the changes. The Foundation's decision provided the resources and stimulus for the expansion and increased recognition of Community Pediatrics at the national AAP office, culminating in the establishment of the Department of Community Pediatrics in mid-1994. A national program of pediatrician-led, community-based programs and supportive services was launched, other resources were attracted, and a philosophical shift in defining the role of the pediatrician was put forward. A responsibility toward all children within the community was included in the role of the pediatrician, as well as caring for the individual child within a community context.

Pediatrician-led community child health initiatives: case summaries from the evaluation of the community access to child health program

OBJECTIVES

Case study investigations of projects identified with the Community Access to Child Health (CATCH) Program were conducted to illustrate the range of achievements of CATCH and to identify those elements related to successful or unsuccessful implementation.

METHODS

We developed a purposive sample of 12 projects, selected based on time of initiation (1989-1995), level of intensity of involvement in CATCH, project locus (statewide or local), nature of program service(s), project setting, and target population(s). Two investigators spent approximately 1.5 days at each site using a preestablished case study guide that included document review and multiple in-person interviews. A total of 171 interviews were conducted with project leadership and staff, community and institutional partners, and public health officials. In seven communities, we also met with individuals receiving project services (consumers).

RESULTS AND CONCLUSIONS

The premise of CATCH that with information, support, and tools, pediatricians can be agents of change in their communities was confirmed. The CATCH pediatricians with whom we met capitalize on their status in the community as physicians, their expertise, and their programmatic and political connections to create opportunities to expand and improve health and social services for children. The specific leadership of these pediatricians is often key in overcoming political and cultural barriers to implement system changes. CATCH was and continues to be an effective program strategy for stimulating and enhancing community-based child health initiatives.

The relation of parent and provider characteristics to vaccination status of children in private practices and managed care organizations in Maryland

OBJECTIVES

This study sought to identify provider practices and policies in private pediatric settings that relate to vaccination status, controlling for the characteristics of the children served.

METHODS

Vaccination data came from the medical records of 709 randomly selected 2-year-old children at 18 private practices and managed care organizations in Maryland, family data from 466 telephone interviews with the children's parents, and provider characteristics from 18 site questionnaires and 42 individual physician and nurse practitioner questionnaires. Logistic regression and generalized estimating equations were used to estimate the relation of provider characteristics to vaccination status. Three age-appropriate (AA) and two up-to-date (UTD) vaccination status variables characterized successful vaccination.

RESULTS

Approximately 70% of the study children were up-to-date by age 2 years for the full vaccination series, excluding hepatitis B vaccine. Family demographic characteristics were the strongest correlates of undervaccination. Neither parents' knowledge and attitudes about immunization nor the children's insurance coverage was statistically related to vaccination status. Site reminder or follow-up systems and provider perceptions about appointment scheduling and receipt of vaccine information from health departments were positively related to vaccination. Concern for liability was associated with a reduced odds of age-appropriate and up-to-date vaccination.

CONCLUSIONS

Family demographics strongly correlate with vaccination status; however, they are generally not modifiable. This study's findings encourage providers to operate a tracking system, to remain current on immunization recommendations, to use all clinical encounters to screen and vaccinate children, and to ensure the availability and convenience of vaccination services.

Annual summary of vital statistics-1997

Many positive trends in the health of Americans continued into 1997. In 1997, the preliminary birth rate declined slightly to 14.6 births per 1000 population, and the fertility rate, births per 1000 women 15 to 44 years of age, was unchanged from the previous year (65.3). These indicators suggest that the downward trend in births observed since the early 1990s may have abated. Fertility rates for white, black, and Native American women were essentially unchanged between 1996 and 1997. Fertility among Hispanic women declined 2% in 1997 to 103.1, the lowest level reported since national data for this group have been available. For the sixth consecutive year, birth rates dropped for teens. Birth rates for women 30 years or older continued to increase. The proportion of births to unmarried women (32.4%) was unchanged in 1997. The trend toward earlier utilization of prenatal care continued for 1997; 82.5% of women began prenatal care in the first trimester. There was no change in the percentage with late (third trimester) or no care in 1997. The cesarean delivery rate rose slightly to 20.8% in 1997, a reversal of the downward trend observed since 1989. The percentage of low birth weight (LBW) infants rose again in 1997 to 7.5%. The percentage of very low birth weight was up only slightly to 1.41%. Among births to white mothers, LBW increased for the fifth consecutive year, to 6.5%, whereas the rate for black mothers remained unchanged at 13%. Much, but not all, of the rise in LBW for white mothers during the 1990s can be attributed to an increase in multiple births. In 1996, the multiple birth rate rose again by 5%, and the higher-order multiple birth rate climbed by 20%. Infant mortality reached an all time low level of 7.1 deaths per 1000 births, based on preliminary 1997 data. Both neonatal and postneonatal mortality rates declined. In 1996, 64% of all infant deaths occurred to the 7.4% of infants born at LBW. Infant mortality rates continue to be more than two times greater for black than for white infants. Among all the states in 1996, Maine, Massachusetts, and New Hampshire had the lowest infant mortality rates. Despite declines in infant mortality, the United States continues to rank poorly in international comparisons of infant mortality. Expectation of life at birth reached a new high in 1997 of 76.5 years for all gender and race groups combined. Age-adjusted death rates declined in 1997 for diseases of the heart, accidents and adverse affects (unintentional injuries), homicide, suicide, malignant neoplasms, cerebrovascular disease, chronic liver disease and cirrhosis, and diabetes. In 1997, mortality due to HIV infection declined by 47%. Death rates for children from all major causes declined again in 1997. Motor vehicle traffic injuries and firearm injuries were the two major causes of traumatic death. A large proportion of childhood deaths continue to occur as a result of preventable injuries.

Initiating the first DTP vaccination age-appropriately: a model for understanding vaccination coverage

OBJECTIVE

Our earlier research found that the strongest predictor of not being up to date on the full series of immunizations by 24 months is failure to receive the first diphtheria vaccine and tetanus toxoid and pertussis vaccine (DTP1) on time. To learn more about the relationship between successful vaccination during the DTP1 age-appropriate (DTP1-AA) period (between 42 and 92 days of life, inclusive) and an infant's early visit to the physician (before 42 days of life), we quantified children's progression through a sequence of provider visits and outcomes.

DESIGN

This study analyzed data from 426 children living in the 57 poorest census tracts in Baltimore. For each DTP1-AA visit, we calculated the percentage of times a DTP1-AA vaccination, provider missed opportunity, or deferral for a valid contraindication occurred. Relative and attributable risks were computed to assess associations between DTP1-AA vaccination and early visits and missed opportunities.

RESULTS

We found the following: 1) Children who made a visit before 42 days of life were more than twice as likely to receive a DTP1-AA vaccination; 2) the missed opportunity rate for children who did not make an early visit was approximately twice that of the early-visit group; and 3) well visits were more likely to result in DTP1-AA immunization than sick visits. Attributable risk calculations show that DTP1-AA vaccination rates could be increased in this population by one third if all infants had an early visit.

CONCLUSIONS

Early in-office visits seem to make DTP1-AA vaccination more likely. These rates may be amenable to intervention by increasing early visits and reducing DTP1-AA missed opportunities. Introduction of the hepatitis B vaccine to the recommended series may place more emphasis on early visits and result in increased DTP1-AA rates and, ultimately, higher vaccination coverage rates.

Effectiveness of pediatric practice consultation on missed opportunities for immunization

OBJECTIVE

To evaluate the effectiveness of pediatric practice consultation in reducing missed-opportunity rates at eight pediatric sites in Baltimore, Maryland. The overarching goal was to decrease the occurrence of missed opportunities from 33% to 15% for the first, second, and third diphtheria and tetanus toxoids and pertussis vaccines during visits at which children were eligible for the vaccines.

DESIGN

The effect of an in-office educational program alone at four sites is compared with the educational program and a consultation on office vaccination practices at four matched sites. All eight sites received a small grant ($2,000) to fund practice changes. The medical records of children making visits before and after the interventions were audited to determine missed-opportunity rates. The policies and operations and the knowledge, attitudes, and practices of physicians and nurse practitioners at each site were also assessed.

RESULTS

The four education-consultation sites experienced a statistically significant 14% net reduction in the missed-opportunity rate relative to the education-only sites. This positive effect, however, was largely due to an increase in missed opportunities at one education-only site. There was a 10% increase in the missed-opportunity rate among the education-only sites and a 4% decrease among the education-consultation sites; neither change was statistically significant. Two of the three sites that reduced missed opportunities were matched health maintenance organizations (HMOs). Shortly after the interventions, both HMOs implemented tracking and follow-up information systems, which were planned before the interventions.

CONCLUSIONS

There is no evidence that either the educational program alone or the educational program and consultation combination reduced missed opportunities. The findings suggest that improved tracking and follow-up data systems and vaccination of children at sick visits may reduce missed opportunities.

Estimating vaccination coverage using parental recall, vaccination cards, and medical records

OBJECTIVE

To compare estimates based on vaccination cards, parental recall, and medical records of the percentages of children up-to-date on vaccinations for diphtheria, tetanus, and pertussis; polio; and measles, mumps, and rubella.

METHOD

The authors analyzed parent interview and medical records data from the Baltimore Immunization Study for 525 2-year-olds born from August 1988 through March 1989 to mothers living in low-income Census tracts of the city of Baltimore.

RESULTS

Only one-third of children had vaccination cards; based on medical records, these children had higher up-to-date coverage at 24 months of age than did children without cards. For individual vaccines, only two-thirds of parents could provide information to calculate coverage rates; however, almost all provided enough information to estimate coverage for the primary series. For each vaccine and the series, parental recall estimates were at least 17 percentage points higher than estimates from medical records. For children without vaccination cards whose parents could not provide coverage information, up-to-date rates based on medical records were consistently lower than for children with cards or with parents who provided coverage information.

CONCLUSIONS

Population-based vaccine coverage surveys that rely on vaccination cards or parental recall or both may overestimate vaccination coverage.

Deficiencies in current childhood immunization indicators

OBJECTIVE

To investigate "up-to-date" and "age-appropriate" indicators of preschool vaccination status and their implications for vaccination policy.

METHODS

The authors analyzed medical records data from the Baltimore Immunization Study for 525 2-year-olds born from August 1988 through March 1989 to mothers living in low-income Census tracts of the city of Baltimore.

RESULTS

While only 54% of 24-month-old children were up-to-date for the primary series, indicators of up-to-date coverage were consistently higher, by 37 or more percentage points, than corresponding age-appropriate indicators. Almost 80% of children who failed to receive the first dose of DTP or OPV age-appropriately failed to be up-to-date by 24 months of age for the primary series.

CONCLUSIONS

Age-appropriate immunization indicators more accurately reflect adequacy of protection for preschoolers than up-to-date indicators at both the individual and population levels. Age-appropriate receipt of the first dose of DTP should be monitored to identify children likely to be underimmunized. Age-appropriate indicators should also be incorporated as vaccination coverage estimators in population-based surveys and as quality of care indicators for managed care organizations. These changes would require accurate dates for each vaccination and support the need to develop population-based registries.

Annual summary of vital statistics--1996

Several recent trends in the vital statistics of the United States continued in 1996, including an increase in life expectancy and declines in infant mortality, births to teenage mothers, age-adjusted death rates, and death rates for children and adolescents. In 1996, there were an estimated 3 914 953 births in the United States. The preliminary birth rate remained unchanged at 14.8 births per 1000 population, and the fertility rate, births per 1000 women 15 to 44 years of age, was essentially the same at 65.7. Fertility rates rose slightly for most racial and ethnic groups except black women, for whom the rate hit a historic low of 70.8. Overall, fertility remains particularly high for Hispanic women, although there is considerable variation within this heterogenous group. For the fifth consecutive year, birth rates dropped for teenagers. Birth rates for women >/=30 years of age continued to increase. The birth rate for unmarried women declined 1% in 1996 to 44.6 births per 1000 unmarried women, continuing the decline noted in 1995 for the first time in 2 decades. The percentage of women who began prenatal care in the first trimester rose in 1996 to 81.8%, whereas the percentage with late (third trimester) or no care dropped to 4.1%. The rise in timely prenatal care was greatest for black and Hispanic women. The percentage of low birth weight (LBW) infants reached 7.4% in 1996, its highest level since 1975. The very low birth weight rate remained unchanged at 1.4%. The rise in LBW occurred primarily among white women, whereas the LBW rate for black women dropped to 13.0%, the lowest rate reported since 1987. The rise among white women is only partially a result of increases in multiple births, because LBW rates have also risen among white singleton births. The multiple birth ratio rose again in 1996 by 2%, as it has since 1980. The rise was particularly large for higher-order multiple births. Infant mortality reached an all time low level of 7.2 deaths per 1000 births, based on preliminary 1996 data. Neonatal and postneonatal rates declined, as did rates for both black and white infants. National birth weight specific mortality rates are reported here for the first time. In 1995, 63% of infant deaths occurred to the 7.3% of the population that was born LBW. The four leading cause of infant death were congenital anomalies, disorders relating to short gestation and unspecified birth weight, sudden infant death syndrome, and respiratory distress syndrome, accounting for more than half of infant deaths in 1996. Despite the declines in infant mortality, the United States continues to rank poorly in international comparisons of infant mortality. Expectation of life at birth reached a new high in 1996 of 76.1 years for all gender and race groups combined. Age-adjusted mortality rates declined in 1996 for diseases of the heart, malignant neoplasms, cerebrovascular diseases, accidents and adverse effects, chronic liver disease and cirrhosis, and suicide. They rose, as in the past several years, for chronic obstructive pulmonary diseases, diabetes mellitus, and pneumonia and influenza. For the first time since human immunodeficiency virus infection was created as a special cause-of-death category in 1987, death rates for human immunodeficiency virus infection declined from 15.6 in 1995 to 11.6 in 1996. The homicide rate also declined, as it has since 1991. Death rates for children between 1 and 19 years of age declined in 1996, with an estimated 29 183 deaths to children. Unintentional injury mortality has dropped by approximately 50% among children and adolescents since 1979, although it remains the leading cause of death for all age groups of children from 1 to 19 years. Homicide was the fourth leading cause of death for children 1 to 4 and 5 to 9 years of age, the third leading cause for children 10 to 14, and the second leading cause for 15 to 19 year olds.

Are immunizations an incentive for well-child visits?

OBJECTIVE

To assess the beliefs of parents and the visit patterns of their children to determine whether immunizations act as an incentive to use well-child care.

DESIGN AND METHODS

Medical record audits provided data on immunizations and well-child visits. Two questions from a parent interview were used to identify 4 groups of parents: (1) motivated and (2) unmotivated to keep a well-child care appointment regardless of whether immunizations are scheduled, (3) vaccine-motivated and (4) checkup-motivated (parents who were influenced negatively by the prospect of receiving vaccinations). The percentage of children with a visit at each age window for well-child visits and the percentage up-to-date for their immunizations at given ages were compared across the 4 groups. The 4 groups were also compared for other parental attitudes about immunizations and well-child visits, and on sociodemographic and access characteristics.

RESULTS

Most (73.3%) of the 502 parents surveyed were classified as motivated and 5% as unmotivated to keep a well-child care appointment regardless of whether an immunization was scheduled. Only 18.3% were categorized as vaccine-motivated and 3.4% as checkup-motivated. For all 4 groups, there was no discernible difference in attendance between immunization and nonimmunization visits. Attendance in the windows for well-child visits and percentage of children up-to-date on immunizations declined with increasing age.

CONCLUSIONS

In this inner-city population, attendance patterns at visits did not support the incentive hypothesis. This finding should reassure clinicians that providing immunizations outside of regular well-child care visits will not necessarily decrease attendance at visits for well-child care.

Measuring the implementation of injury prevention programs in state health agencies

OBJECTIVE

Injury prevention programs have been implemented with varying degrees of success in the United States. The objective of this study was to identify the variables that influence the successful implementation of injury prevention programs.

METHODS

The key indicators of implementation success and its correlates were identified through consultation with a panel of experts. This consultation informed the content of a mail questionnaire sent to all United States state health departments, followed by telephone interviews. Data were analyzed using factor analysis and regression to identify significant relationships between variables.

RESULTS

Data were obtained from 64 programs, representing 44 states; these included 24 programs in injury control units, 12 in maternal and child health units, 10 in health promotion/education units; and eight in emergency medical services units. Analysis identified four factors that are associated with an index of successful injury prevention program implementation; (1) participation and advocacy by constituent groups; (2) organizational capacity; (3) administrative control; and (4) attributes of relevant policies.

CONCLUSIONS

Findings indicated that constituent participation (the extent and efficacy of constituency support and advocacy) and organizational capacity (a function of program staff and their skill levels) had the greatest influence on successful program implementation. Support from advocacy groups and knowledgeable staff members, whose time is dedicated to the program, are critical for conducting the activities necessary for successful implementation of these programs.

An international study of the exposure of children to traffic

OBJECTIVES

To examine the extent of international differences in children's exposure to traffic as pedestrians or bicyclists.

DESIGN

Children's travel patterns were surveyed using a parent-child administered questionnaire. Children were sampled via primary schools, using a probability cluster sampling design.

SETTING

Six cities in five countries: Melbourne and Perth (Australia), Montreal (Canada), Auckland (New Zealand), Umeå (Sweden), and Baltimore (USA).

SUBJECTS

Children aged 6 and 9 years.

MAIN OUTCOME MEASURES

Modes of travel on the school-home journey, total daily time spent walking, and the average daily number of roads crossed.

MAIN FINDINGS

Responses were obtained from the parents of 13423 children. There are distinct patterns of children's travel in the six cities studied. Children's travel in the three Australasian cities, Melbourne, Perth and Auckland, is characterised by high car use, low levels of bicycling, and a steep decline in walking with increasing car ownership. In these cities, over a third of the children sampled spent less than five minutes walking per day. In Montreal, walking and public transport were the most common modes of travel. In Umeå, walking and bicycling predominated, with very low use of motorised transport. In comparison with children in the Australasian and North American cities, children in Umeå spend more time walking, with 87% of children walking for more than five minutes per day.

CONCLUSIONS

There are large international differences in the extent to which children walk and cycle. These findings would suggest that differences in 'exposure to risk' may be an important contributor to international differences in pedestrian injury rates. There are also substantial differences in pedestrian exposure to risk by levels of car ownership-differences that may explain socioeconomic differentials in pedestrian injury rates.

Promotion-resistant JB6 mouse epidermal cells exhibit defects in phosphatidylethanolamine synthesis and phorbol ester-induced phosphatidylcholine hydrolysis

The tumour-promotion-sensitive (P+) and -resistant (P-) variants of mouse JB6 epidermis-derived cells have often been used to study the requirements for the tumour-promoting effect of PMA. As part of an effort to identify the defect(s) in JB6 P- cells that might prevent the promoting effect of PMA, stimulation of phospholipase D (PLD)-mediated hydrolysis of phosphatidylcholine (PtdCho) and phosphatidylethanolamine (PtdEtn) by PMA as well as the rate of phospholipid synthesis were compared in three P+ variants, two P- variants and a transformed variant of the JB6 cell line. PMA (5-100 nM) had significantly less stimulatory effect on PtdCho hydrolysis in P- cells than in P+ or transformed JB6 cells. The effects of PMA on PtdEtn hydrolysis in the P+ and P- cell lines were similar, whereas in transformed cells PMA had slightly less effect. Each JB6 cell line was found to contain similar amounts of PtdCho. In contrast, P- cells contained significantly less PtdEtn and a correspondingly higher level of ethanolamine phosphate compared with P+ and transformed cells. P- cells also secreted ethanolamine phosphate into the medium; this process was greatly enhanced by PMA. In the two P- variants the synthesis of PtdEtn from [14C]ethanolamine was reduced to various extents, whereas the rate of PtdCho synthesis was comparable in each JB6 cell line. The synthesis of PtdCho, but not PtdEtn, was greatly stimulated by PMA in both the P+ and P- clones. The results indicate that decreased synthesis/level of PtdEtn and suboptimal functioning of a PtdCho-specific PLD are common characteristics of the P- JB6 cells examined so far. The observed alterations in phospholipid metabolism may play a role in the resistance of P- cells to the tumour-promoting action of PMA.

MCH functions framework: a guide to the role of government in maternal and child health in the 21st century

OBJECTIVES

At the close of the 20th century, the government's role in maternal and child health is in a state of transition. What is needed is a framework defining roles and responsibilities and guidance on how to operationalize these functions. This article presents the Maternal and Child Health (MCH) Functions Framework and discusses its value as an advocacy, planning, evaluation, and educational tool.

METHODS

The Johns Hopkins Child and Adolescent Health Policy Center developed the Framework in collaboration with leading public health organizations. The process entailed formulating a conceptual approach and facilitating consensus among the relevant organizations.

RESULTS

The Framework consists of three main components: (a) a list of ten essential public health services to promote maternal and child health, (b) an outline detailing program functions specific to MCH that apply to all levels of government and to all MCH populations, and (c) selected examples of local, state, and federal activities for implementing MCH program functions.

CONCLUSIONS

The MCH Functions Framework can be used in advocacy, policy development, program planning, organizational assessment, education, and training. To date, it has been used by several state and local MCH agencies and in MCH education and training programs.

Children's exposure to traffic and risk of pedestrian injury in an urban setting

Pedestrian injuries to children represent a major urban health problem in the United States. Thousands of children each year are struck by moving motor vehicles; such collisions result in numerous hospitalizations and deaths. At particular risk are young school-age children between the ages of 5 and 9 years. Using a survey methodology, we collected data regarding the method by which children in an urban setting travel to and from school, in addition to the number of streets they cross in a typical school day. This information was compared with data from police records on street intersection locations of pedestrian collisions. There is a wide variation in the number of streets children cross in 1 day, calculated as the number of streets crossed in the entire day, not only those crossed to and from school. Children whose parents own a car and home cross an average of 3.7 streets per day, whereas children whose parents do not own both a car and home cross an average of 5.4 streets per day; this difference is highly significant (P < 0.0001). The largest differences in traffic exposure are between families reporting car- and-home ownership (x = 3.70 streets) versus those who do not own both a car and home (x = 5.39 streets) (Mann-Whitney = -5.5, P < 0.0001). There is a significant correlation between the proportion of children driven home from school and the rate of pedestrian injury in different regions of Baltimore. In areas where children are driven home, rates of pedestrian injury are significantly lower, whereas in areas where children walk home, rates of pedestrian injury are high (r = -0.79, P < 0.01). This study underscores the importance of adapting the child's environment to prevent injury. Interventions that alter the nature of the hazard are indicated. Changing the environment may ultimately prove more useful than attempting to change children's behavior.

Parental attitudes do not explain underimmunization

OBJECTIVE

This article describes the results of a community-based study to determine the effect of family knowledge and attitudes on the immunization rates of a random sample of children younger than 2 years in the poorest census tracts of Baltimore.

DESIGN AND METHODS

The two sources of data were (1) parent interviews that provided data on knowledge, attitudes, and beliefs related to immunization and sociodemographic characteristics, and (2) medical record audits from which data on immunization status were obtained. The protection motivation theory, a model of behavioral change, was used to select the variables to assess the relation of parental attitudes with immunization status. A multivariate logistic regression analysis included only variables found to be significantly associated with immunization outcome in the preliminary analysis.

RESULTS

Mothers were well informed and generally had favorable attitudes toward immunizations. Immunization status was more strongly associated with the sociodemographic characteristics of the children than with the protection motivation theory variables. Only two protection motivation theory variables were associated with more than one immunization outcome. The children of mothers who perceived that timing of vaccination did not matter were less likely to be immunized than children of care takers who thought that it did matter and children whose parents believed in the safety of multiple immunizations were less likely to be immunized than children whose parents did not hold this belief.

CONCLUSIONS

In this study, parents' attitudes and beliefs had little effect on their children's immunization levels. Interventions intended to heighten parental awareness about immunization may have little impact. In poor urban neighborhoods, African-American children whose mothers are young, have multiple siblings, and do not use the Women, Infants and Children program may be at highest risk for delayed immunization.

Annual summary of vital statistics--1995

Recent trends in the vital statistics of the United States continued in 1995, including decreases in the number of births, the birth rate, the age-adjusted death rate, and the infant mortality rate; life expectancy at birth increased to a level equal to the record high of 75.8 years in 1992. Marriages and divorces both decreased. An estimated 3,900,089 infants were born during 1995, a decline of 1% from 1994. The preliminary birth rate for 1995 was 14.8 live births per 1000 total population, a 3% decline, and the lowest recorded in nearly two decades. The fertility rate, which relates births to women in the childbearing ages, declined to 65.6 live births per 1000 women 15 to 44 years old, the lowest rate since 1986. According to preliminary data for 1995, fertility rates declined for all racial groups with the gap narrowing between black and white rates. The fertility rate for black women declined 7% to a historic low level (71.7); the preliminary rate for white women (64.5) dropped just 1%. Fertility rates continue to be highest for Hispanic, especially Mexican-American, women. Preliminary data for 1995 suggest a 2% decline in the rate for Hispanic women to 103.7. The birth rate for teenagers has now decreased for four consecutive years, from a high of 62.1 per 1000 women 15 to 19 years old in 1991 to 56.9 in 1995, an overall decline of 8%. The rate of childbearing by unmarried mothers dropped 4% from 1994 to 1995, from 46.9 births per 1000 unmarried women 15 to 44 years old to 44.9, the first decline in the rate in nearly two decades. The proportion of all births occurring to unmarried women dropped as well in 1995, to 32.0% from 32.6% in 1994. Smoking during pregnancy dropped steadily from 1989 (19.5%) to 1994 (14.6%), a decline of about 25%. Prenatal care utilization continued to improve in 1995 with 81.2% of all mothers receiving care in the first trimester compared with 78.9% in 1993. Preliminary data for 1995 suggests continued improvement to 81.2%. The percent of infants delivered by cesarean delivery declined slightly to 20.8% in 1995. The percent of low birth weight (LBW) infants continued to climb in 1994 rising to 7.3%, from 7.2% in 1993. The proportion of LBW improved slightly among black infants, declining from 13.3% to 13.2% between 1993 and 1994. Preliminary figures for 1995 suggest continued decline in LBW for black infants (13.0%). The multiple birth ratio rose to 25.7 per 1000 births for 1994, an increase of 2% over 1993 and 33% since 1980. Age-adjusted death rates in 1995 were lower for heart disease, malignant neoplasms, accidents, and homicide. Although the total number of human immunodeficiency virus (HIV) infection deaths increased slightly from 42,114 in 1994 to an estimated 42,506 in 1995, the age-adjusted death rate for HIV infection did not increase, which may indicate a leveling off of the steep upward trend in mortality from HIV infection since 1987. Nearly 15,000 children between the ages of 1-14 years died in the United States (US) in 1995. The death rate for children 1 to 4 years old in 1995 was 40.4 per 100,000 population aged 1 to 4 years, 6% lower than the rate of 42.9 in 1994. The 1995 death rate for 5- to 14-year-olds was 22.1, 2% lower than the rate of 22.5 in 1994. Since 1979, death rates have declined by 37% for children 1 to 4 years old, and by 30% for children 5 to 14 years old. For children 1 to 4 years old, the leading cause of death was injuries, which accounted for for an estimated 2277 deaths in 1995, 36% of all deaths in this age group. Injuries were the leading cause of death for 5- to 14-year-olds as well, accounting for an ever higher percentage (41%) of all deaths. In 1995, the preliminary infant mortality rate was 7.5 per 1000live births, 6% lower than 1994, and the lowest ever recorded in the US. The decline occurred for neonatal as well as postneonatal mortality rates, and among white and black infants alike.

Assuring quality of care for children with special needs in managed care organizations: roles for pediatricians

Increasing numbers of children with special health care needs are enrolling in managed care programs. Although managed care may improve service coordination and use of primary care, it may also threaten health outcomes for these children by potentially decreasing access to the range of needed services, eroding progress in developing community-based service systems, and failing to assure quality of care. To date, few frameworks have been proposed to assess quality of care for this population of children in managed care organizations. In this article, we adapt the Institute of Medicine's definition of quality and identify six key components: content of service delivery systems, the nature of desired health outcomes, risks associated with service delivery, constraints of care, interpersonal dimensions, and attention to developmental issues. These components can be assessed at three levels: the individual, the health plan, and the community. Pediatricians and other child health professionals have critical roles to play in assuring that policies and practices within managed care organizations promote a high quality of care for this vulnerable population of children.

The contribution of missed opportunities to childhood underimmunization in Baltimore

OBJECTIVE

To determine the community-wide incidence of missed opportunities to vaccinate, to describe the clinical settings in which they occur, and to estimate the impact of missed opportunities on immunization coverage.

DESIGN AND METHODS

We abstracted outpatient medical records from a random, community-based sample of 2-year-old children whose residence was inner-city Baltimore. The date of each vaccine and the date, diagnoses, and temperature at each visit were collected for 502 children at 98 different provider sites.

MAIN OUTCOME MEASURES

Missed opportunities to vaccinate and up-to-date vaccination status.

RESULTS

By 24 months of age, 75% of the children had at least one missed opportunity and only 55% were up-to-date for the 4:3:1 series. Missed opportunities occurred at more than one third of eligible visits for each vaccine, including > 20% of preventative care visits. Diagnoses commonly associated with missed opportunities were "well child," otitis media, upper respiratory infection, gastroenteritis, skin infection, and resolving illness. If no missed opportunities had occurred, 73% of the children would have been up-to-date by 24 months.

CONCLUSIONS

Missed opportunities occurred commonly at providers serving inner-city children in Baltimore and represent a major factor in underimmunization. Reduction of missed opportunities by accurate screening at all visits and adherence to the contraindication guidelines is a provider-based, low-cost method to increase immunization coverage.

Burn-related physical impairments and disabilities in Ghanaian children: prevalence and risk factors

The prevalence, and risk factors for childhood burn-related physical impairments and disabilities in Ghana were determined with data from mothers of burned children. Of 650 identified burns 113 (174%) resulted in physical impairments, 5 (1%) resulted in physical disabilities. After multivariate adjustment, the odds of developing burn-related physical impairments were increased by burns with protracted healing (odds ratio [OR] = 5.80), burns to the head/neck (OR = 344), burns involving skin removal (OR = 3.04), and wound infection (OR = 2.03) and decreased by first aid (OR = 0.51) and maternal education (OR = 0.54). Education on the proper care of burns may prevent burn-related physical impairments. The results also underscore the link between maternal education and child morbidity.

Annual summary of vital statistics-1994

Recent trends in the vital statistics of the United States continued in 1994, including decreases in the number of births, the birth rate, the age-adjusted death rate, and the infant mortality rate. Life expectancy increased slightly to 75.7 years. Only marriages reversed the recent trend with a slight increase in 1994. An estimated 3,979,000 infants were born during 1994, a decline of < 1% from 1993. The birth rate was 15.3 live births per 1000 population, a 1% decline. These decreasing rates reflect a decline in the fertility rate to 67.1 live births per 1000 women aged 15 to 44 years. Final figures for 1993 indicate that fertility rates declined for all racial groups, by 1% for white women (to 65.4) and 3% for black women (to 80.5). The fertility rate for Hispanic women (106.9) was 84% higher than that for non-Hispanic white women and 31% higher than for non-Hispanic black women. Between 1991 and 1993, birth rates for teenage mothers remained virtually unchanged, and abortion rates have steadily declined, suggesting that teenage pregnancy rates are levelling off. The number and proportion of births to women over age 30, however, continued to rise. The rate of births to all unmarried women (45.3 per 1000 in 1993) has been stable for 3 years. Prenatal care utilization improved in 1993; 79% of women initiated care in the first trimester and < 5% had delayed care or no care. Improvements occurred among nearly all racial and ethnic groups. Reported smoking during pregnancy declined to 15.8% in 1993 from 16.9% in 1992. The proportion of babies delivered by cesarean section was 21.8% in 1993, a 2% decrease from 1992. Between 1992 and 1993, the rate of low birth weight (LBW) rose slightly to 7.2%, while very low birth weight (VLBW) remained stable at 1.3%. Most of the increase in LBW occurred among white infants and reflected, primarily, an increase in the proportion of multiple births. The black/white ratio in LBW continued to increase to more than two-fold with the largest difference recorded among term and postterm infants. Age-adjusted death rates in 1994 were lower for heart disease, malignant neoplasm, pulmonary diseases, other accidents, and homicides. The age-adjusted death rate for human immunodeficiency virus disease continued to rise to 15.1 in 1994. The infant mortality rate declined 4% in 1994, to 7.9 per 1000, the lowest rate ever recorded in the United States. The decline was primarily in neonatal mortality.(ABSTRACT TRUNCATED AT 400 WORDS)

Prevalence and age-specific incidence of burns in Ghanaian children

The incidence of burns in developing countries is not precisely known due to unavailability or incompleteness of death registration and disease reporting. In this study, we determined prevalence and age-specific incidence of burns in children 0-5 years in the Ashanti region of Ghana using burn scars as proxy. We used a community-based, multi-site survey to identify children who had scars as evidence of previous burns. A scar prevalence of 6 per cent was found. No sex differences were found. However, significant differences were found among age groups, with children aged 18-23 months having the highest incidence (57.4 per 1000 person-years). There was evidence of focal occurrence of childhood burns in certain districts, and a higher prevalence in rural areas. We conclude that childhood burns are a significant health problem in Ghana, especially among rural residents and the very young, and recommend that interventions be developed to control them.