Progress on the childhood immunization initiative.

President Clinton submitted the Comprehensive Childhood Immunization Initiative Act to Congress in April 1993. The objective of the legislation is to protect all children in the United States by their second birthday against nine vaccine-preventable infectious diseases. As originally introduced in the Congress the initiative called for (a) Federal purchase and distribution of recommended childhood vaccines for all children, (b) improving the public health capacity to deliver vaccine, (c) establishing a State-based national immunization information and tracking system, and (d) expanding immunization education and mobilization efforts directed to health care providers and parents. The authors review the progress and current status of the initiative, updating a previous progress report. The President's legislative proposal, modified by Congress, was enacted August 10, 1993. Several key provisions of the original legislation, deferred by Congress, may be incorporated in subsequent legislation or implemented through existing authorities. Therefore, the evolving framework for the initiative derives not from a single legislative mandate, but expands current immunization program activities and adds important new and complementary activities. As mentioned in the original title of the legislation, this is a "comprehensive" effort to address the problem of under-immunization in U.S. preschool children.

The president's child immunization initiative--a summary of the problem and the response.

After only 24 days in office, President Bill Clinton announced a comprehensive childhood immunization initiative designed to assure that all children in the United States lead healthier lives by receiving age-appropriate immunizations against preventable diseases such as polio, mumps, measles, whooping cough, and diphtheria. As part of his economic stimulus proposal, the President requested $300 million for Fiscal Year 1993 to reinforce the nation's immunization infrastructure by providing funding for communities to extend clinic hours, provide more staff, and increase information and education efforts and for the planning and implementation of a national immunization tracking system. In its Fiscal 1994 budget request, the Administration asked for a doubling of the Centers for Disease Control and Prevention's immunization program funding to $667 million. In cooperation with key congressional committees, the Administration has also prepared legislation that would provide recommended childhood vaccines to States for free distribution to health care providers who serve children enrolled in Medicaid or who don't have health insurance that covers immunization services. Providers could not charge for the vaccine but could charge a fee for administration. State Medicaid programs would also be required to reimburse providers reasonably for vaccine administration. This measure is designed to improve universal access to immunization services by helping to remove financial barriers that impede children from being immunized at the appropriate age.

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.

Trends in diabetes and diabetic complications, 1980-1987.

OBJECTIVE: Although diabetes is a major source of morbidity and mortality in the United States, only recently has a unified national surveillance system begun to monitor trends in diabetes and diabetic complications. RESEARCH DESIGN AND METHODS: We established a diabetes surveillance system using data for 1980-1987 from vital records, the National Health Interview Survey, the National Hospital Discharge Survey, and the Health Care Financing Administration's records to examine trends in the prevalence and incidence of diabetes, diabetes mortality, hospitalizations, and diabetic complications. RESULTS: From 1980 through 1987, the number of individuals known to have diabetes increased by 1 million--to 6.82 million. Age-standardized prevalence for diabetes increased 9% during this period, from 25.4 to 27.6/1000 U.S. residents (P = 0.03). The incidence of diabetes increased among women (P = 0.003), particularly among those greater than 65 yr old (P = 0.02). Age-standardized mortality rates (for diabetes as either an underlying or contributing cause) per 100,000 individuals with diabetes declined 12%, from 2350 to 2066. Annual mortality rates from stroke (as an underlying cause and diabetes as a contributing cause) and diabetic ketoacidosis declined 29% (P = 0.003) and 22% (P less than 0.001), respectively. During these 8 yr, hospitalization rates for major CVD and stroke (as the primary diagnoses and diabetes as a secondary diagnosis) increased 34% (P = 0.006) and 38% (P = 0.01), respectively. Also during this period, hospitalization rates increased 21% for diabetic ketoacidosis (P = 0.01) and 29% for lower-extremity amputations (P = 0.06). From 1982 through 1986, treatment for end-stage renal disease related to diabetes increased greater than 10% each year (P less than 0.001). The prevalence of diagnosed diabetes was nearly twice as high in blacks as in whites (P = 0.04). Blacks also had increased rates of lower-extremity amputation (P = 0.02), diabetic ketoacidosis (P less than 0.001), and end-stage renal disease (P = 0.01). CONCLUSIONS: Diabetes surveillance data will be useful in planning, targeting, and evaluating public health efforts designed to prevent and control diabetes and its complications.

Epidemiology and prevention of periodontal disease in individuals with diabetes.

OBJECTIVE: This article reviews the epidemiological evidence of the relationship between diabetes and periodontal disease, possible physiological mechanisms for the association, and effects of interventions on the occurrence and severity of periodontal disease among individuals with diabetes. RESEARCH DESIGN AND METHODS: A comprehensive qualitative review of published literature in the area was performed. RESULTS: Much of the research in this area was found to contain methodological problems, such as failing to specify the type of diabetes, small sample sizes, and inadequate control of covariates such as age or duration of diabetes. CONCLUSIONS: Trends indicate that periodontal disease is more prevalent and more severe among individuals with diabetes. This trend may be modified by factors such as oral hygiene, duration of diabetes, age, and degree of metabolic control of diabetes. Generally, poor oral hygiene, a long history of diabetes, greater age, and poor metabolic control are associated with more severe periodontal disease. The association of diabetes and periodontal disease may be due to numerous physiological phenomena found in diabetes, such as impaired resistance, vascular changes, altered oral microflora, and abnormal collagen metabolism. With some modifications, the same prevention and treatment procedures for periodontal disease recommended for the general population are appropriate for those with diabetes. People with diabetes who appear to be particularly susceptible to periodontal disease include those who do not maintain good oral hygiene or good metabolic control of their diabetes, those with diabetes of long duration or with other complications of diabetes, and teenagers and pregnant women.

Gestational diabetes. Incidence, maternal characteristics, and perinatal outcome.

Accurate estimates of the incidence of abnormal glucose tolerance during pregnancy are virtually nonexistent. Screening select populations of women with risk factors for the condition and the nonrandom, non-population-based nature of most studies have given rise to wide variances in reported incidence. We analyzed data from the states of Mississippi and Washington and from the National Natality and Fetal Mortality Surveys conducted in 1980 in an attempt to provide more accurate population-based estimates of the incidence of gestational diabetes mellitus (GDM). In the national surveys GDM was noted (screening and diagnostic criteria were unavailable) as a complication in 0.38% of all sampled pregnancies; overt (type I and type II) diabetes was noted in 0.78%. Mean maternal age for the GDM group was 28.4 yr; 85% were white (81% controls) and 15% non-white (19% controls). Prepregnancy weights were higher in the GDM group by an average of 20 lb. However, mean weight gain was less in this group than in controls (23 versus 29 lb). Perinatal mortality was noted in approximately 2.8% (1.3% in controls) of the offspring in GDM-complicated pregnancies and congenital malformations in 6.4% (7.9% in controls). Methodologic problems were encountered and included lack of screening and diagnostic criteria, underreporting, and underrecording.

An epidemiologic model for diabetes mellitus: incidence, prevalence, and mortality.

An epidemiologic model is developed to describe the incidence, prevalence, and mortality of diabetes. Available data are reviewed, analyzed, and applied to the model. The model provides a framework for understanding diabetes on a population basis, and is useful in identifying needs and facilitating health care planning.

Parental response to repeat testing of infants with 'false-positive' results in a newborn screening program.

Forty-five percent of the parents of 60 infants being retested in a newborn screening program for metabolic disorders understood that their infant was undergoing retesting because the first test result was abnormal. Fifty-five percent had incorrect or incomplete information, believing that retesting was routine, or that mistakes had been made in the original testing procedure, or they report being told nothing specific about the testing. Parents who were aware that the initial test was abnormal were no more anxious or depressed while waiting for the repeat test results than other parents. At a second interview after learning the normal results of the repeat test, both those parents informed of the initial abnormal result as well as those not informed were less anxious and depressed. However, 36% of the parents of these normal infants reported concern about the health of their infant because of the repeat testing. This concern was not related to a parent's knowledge that the initial test result was abnormal, but was greater in parents reporting that they had not received sufficient information about the screening/testing process and its significance for the health of their infant.

An approach to the prevention of blindness in diabetes.

Diabetic eye disease is the leading cause of new cases of legal blindness in American adults under the age of 65 yr. Diabetic persons are at risk for visual loss due to diabetic retinopathy, glaucoma, and cataracts. Better understanding of the natural histories of these complications and recent advances in treatment have provided a rationale for developing an approach to prevent visual loss. This approach requires that diabetic patients who are at high risk for visual loss, and not under the care of ophthalmologists, be systematically screened, referred, and treated.

Genetic services in the United States.

In fiscal years 1979 and 1980, the Genetic Diseases Service Branch of the Health Services Administration funded 34 state genetic service programs in the United States through monies from the National Genetic Diseases Act (PL 94-278) of 1976. During the two-year period, 131,818 at-risk individuals were provided with genetic counseling. Analyses of amniotic fluid were performed on 42,003 specimens, with 436 abnormal fetuses (1%) detected. Utilization ratios of amniocentesis for advanced maternal age ranged from a low of 5% to a high of 49%. Screening programs for inborn errors of metabolism reported testing 3, 158,521 specimens. The numbers of affected children detected nationally were 195 with phenylketonuria (1:16,000), 536 with hypothyroidism (1:5,900), 25 with galactosemia (1:39,685), eight with maple syrup urine disease (1:86,984), and eight with homocystinuria (1:139,008).

Galactose-1-phosphate uridyl transferase deficiency due to Duarte/galactosemia combined variation: clinical and biochemical studies.

The most common abnormality detected by the screening of newborn infants for galactosemia is a deficiency of galactose-1-phosphate uridyl transferase due to the presence in one individual of allelic genes for the Duarte variant and for galactosemia. Clinical studies of ten untreated individuals with this genetic compound, including three adults, failed to reveal evidence of cataracts, liver disease, or mental subnormality, the major clinical complications associated with galactosemia. Galactose-1-phosphate was not detectable in umbilical cord blood from one infant. Galactose was not detectable in random blood specimens from any of the individuals and was present in only small amounts following ingestion of milk in one infant and a child. It would appear that this common gentic variation is usually, if not always, benign.