Obstetric deaths in Bangladesh, 1996-1997.

OBJECTIVES: The purpose of this study was to measure and to describe obstetric deaths in Bangladesh. METHODS: We reviewed hospital records and interviewed health workers in clinic sites and field workers who cared for pregnant women. RESULTS: We obtained case reports of 28998 deaths of women aged 10-50, of which 8562 (29.5%) were maternal deaths. Most (7086, 82.8%) of these deaths were due to obstetric causes. The most common causes of direct obstetric death were eclampsia (34.3%), hemorrhage (27.9%), and obstructed and/or prolonged labor (11.3%). National direct obstetric death rate was estimated to be 16.9 per 100,000 women. CONCLUSIONS: Efforts to reduce fertility in Bangladesh have led to an estimated 49% reduction in the maternal mortality rate per 1000 women during the past 18 years. Variations in maternal mortality suggest the need to develop local strategies to improve obstetric care.

Undervaccination with hepatitis B vaccine: missed opportunities or choice?

BACKGROUND: An estimated 1 million to 1.25 million people in the United States are chronically infected with hepatitis B virus (HBV) and are at substantially increased risk of developing chronic liver disease, including cirrhosis and primary hepatocellular carcinoma. Immunization with hepatitis B vaccine (HepB) is the most effective means of preventing HBV infection and its consequences. METHODS: To identify and describe children who had not completed the three-dose HepB series, we analyzed data from the 1999 National Immunization Survey (NIS). Among the 2648 children aged 19 to 35 months who did not complete the HepB series, we examined the relationship between the number of doses of HepB received and the number of vaccination visits made, receipt of the birth dose of HepB, age at the time of first vaccination visit (excluding that for the birth dose of HepB), and completion of the 4:3:1:3 series (four doses of diphtheria and tetanus toxoids and pertussis vaccine, three doses of poliovirus vaccine, one dose of measles-containing vaccine, and three doses of Haemophilus influenzae type b vaccine [Hib]). RESULTS: Overall, 11.8% of the children who were included in the 1999 NIS did not complete the HepB series. Among these series-incomplete children, most (79.8%; 95% CI, 77.4%-82.2%) did not receive the birth dose of HepB, and most (80.2%; 95% CI, 77.6%-82.8%) had three or more vaccination visits. Most of the series-incomplete children (87.3%; 95% CI, 85.1%-89.5%) who had three or more vaccination visits received one or two doses of HepB. Among series-incomplete children with at least three vaccination visits, those who did not receive any HepB were more likely to have completed the 4:3:1:3 series (67.1%; 95% CI, 58.8%-75.4%) than those who received at least one dose of HepB (52.7%; 95% CI, 49.0%-56.4%). CONCLUSIONS: Children who did not complete the HepB series fell into three distinct groups: children who made at least three vaccination visits but did not begin the HepB series (n=326); children who made three or more vaccination visits and received one or two doses of HepB (n=1835); and children who made fewer than three vaccination visits (n=487). Different intervention strategies are needed to have an impact on each of these groups, including understanding why parents and providers may not be receptive to HepB, decreasing missed opportunities to administer HepB, and implementing tracking systems such as registries to identify and contact children who are due or overdue for vaccinations.

Association between administration of hepatitis B vaccine at birth and completion of the hepatitis B and 4:3:1:3 vaccine series.

CONTEXT: The association between infant age at initiation of hepatitis B vaccination and completion of the 3-dose hepatitis B vaccination series is unclear. OBJECTIVE: To assess the association between administration of the first dose of hepatitis B vaccine within 7 days of birth and completion of the hepatitis B vaccine series and the 4:3:1:3 vaccine series (4 doses of diphtheria-tetanus-pertussis vaccine, 3 doses of polio vaccine, 1 dose of measles-containing vaccine, and 3 doses of Haemophilus influenzae type b vaccine). DESIGN, SETTING, AND PARTICIPANTS: Analysis of data from the 1998 National Immunization Survey, a random-digit-dialing telephone survey (n = 34,480 completed interviews) of parents of children aged 19 to 35 months from 50 states and 28 selected urban areas in the United States that included a provider record check mail survey. MAIN OUTCOME MEASURES: Percentage of infants who received at least 3 doses of hepatitis B vaccine and percentage who received the 4:3:1:3 vaccine series, by age at receipt of the first dose of hepatitis B vaccine. RESULTS: Overall, 86.9% of children 19 to 35 months of age in 1998 received 3 or more doses of hepatitis B vaccine, and 79.9% completed the 4:3:1:3 vaccine series. Multivariate analysis indicated that, compared with children who received the first hepatitis B vaccine dose within 7 days of birth, odds ratios (ORs) for not completing the 3-dose hepatitis B vaccine series among children who received the first dose at 8 to 41 days, 42 to 91 days, 92 to 182 days, 183 to 273 days, and 274 or more days of age were 2.4 (95% confidence interval [CI], 2.0-3.0), 7.8 (95% CI, 6.5-9.3), 9.6 (95% CI, 7.0-13. 3), 18.3 (95% CI, 12.0-28.0), and 46.6 (95% CI, 33.7-64.5), respectively; ORs for not completing the 4:3:1:3 vaccine series among these same groups were 1.0 (95% CI, 0.8-1.1), 1.0 (95% CI, 0. 8-1.1), 1.7 (95% CI, 1.3-2.3), 3.8 (95% CI, 2.6-5.6), and 4.0 (95% CI, 2.9-5.5), respectively. CONCLUSION: Administration of the first dose of hepatitis B vaccine at birth is associated with increased likelihood of completion of the hepatitis B vaccination series. JAMA. 2000;284:978-983

Reviews of evidence regarding interventions to improve vaccination coverage in children, adolescents, and adults. The Task Force on Community Preventive Services.

This paper presents the results of systematic reviews of the effectiveness, applicability, other effects, economic impact, and barriers to use of selected population-based interventions intended to improve vaccination coverage. The related systematic reviews are linked by a common conceptual approach. These reviews form the basis for recommendations by the Task Force on Community Preventive Services (the Task Force) regarding the use of these selected interventions. The Task Force recommendations are presented on pp. 92-96 of this issue.

Injury-related deaths among women aged 10-50 years in Bangladesh, 1996-97.

BACKGROUND: Few studies have examined injury-related deaths among women in Bangladesh. We did a case-finding study to identify causes and the impact of intentional and unintentional injury-related deaths among women aged 10-50 years in Bangladesh. METHODS: Between 1996 and 1997, health care and other service providers at 4751 health facilities throughout Bangladesh were interviewed about their knowledge of deaths among women aged 10-50 years. In addition, at all public facilities providing inpatient service, medical records of women who died during the study period were reviewed. The reported circumstances surrounding each death were carefully reviewed to attribute the most likely cause of death. FINDINGS: 28,998 deaths among women aged 10-50 years were identified in our study, and, of these, 6610 (23%) were thought to be caused by intentional or unintentional injuries. About half (3317) of the injury deaths were attributable to suicide, 352 (5%) to homicide, 1100 (17%) to accidental injuries, and the intent was unknown for 1841 (28%) deaths. The unadjusted rate of suicides were higher in the Khulna administrative division (27.0 per 100,000) than the other four administrative divisions of Bangladesh (range 3.5-11.3 per 100,000). Poisoning (n=3971) was the commonest cause of injury-related death--60% of all injury deaths (6610) and 14% of all deaths (28,998). Other common causes of injury deaths in order of frequency were hanging or suffocation, road traffic accidents, burns, drowning, physical assault, firearm or sharp instrument injury, and snake or animal bite. INTERPRETATION: Intentional and unintentional injuries are a major cause of death among women aged 10-50 years in Bangladesh. Strategies to reduce injury-related deaths among women need to be devised.

Progress in coverage with hepatitis B vaccine among US children, 1994-1997.

OBJECTIVES: This study was done to assess progress in hepatitis B vaccination of children from 1994 through 1997. METHODS: We used data from the National Immunization Survey (NIS), a random-digit-dialed telephone survey that includes a mail survey to verify vaccination providers' records. The NIS is conducted in 78 geographic areas (50 states and 28 selected urban areas) in the United States. RESULTS: A total of 32,433 household interviews were completed in the 1997 NIS. An estimated 83.7% of children aged 19 to 35 months received 3 or more doses of hepatitis B vaccine. Coverage with 3 doses was greater (86.7%) among children in states that had day care entry requirements for hepatitis B vaccination than among children in states without such requirements (83.0%) and was greater among children from families with incomes at or above the poverty level (85.0%) than among children below the poverty level (80.6%). Hepatitis B vaccination of children increased from 1994 through 1996, from 41% to 84%, but coverage reached a constant level of 84% to 85% in 1996/97. CONCLUSION: Although substantial progress has been made in fully vaccinating children against hepatitis B, greater efforts are needed to ensure that all infants receive 3 doses of hepatitis B vaccine.

Maternal cigarette smoking and invasive meningococcal disease: a cohort study among young children in metropolitan Atlanta, 1989-1996.

OBJECTIVES: This study assessed the association between maternal cigarette smoking during pregnancy and the risk of invasive meningococcal disease during early childhood. METHODS: Using a retrospective cohort study design, cases from an active surveillance project monitoring all invasive meningococcal disease in the metropolitan Atlanta area from 1989 to 1995 were merged with linked birth and death certificate data files. Children who had not died or acquired meningococcal disease were assumed to be alive and free of the illness. The Cox proportional hazards analysis was used to assess the independent association between maternal smoking and meningococcal disease. RESULTS: The crude rate of meningococcal disease was 5 times higher for children whose mothers smoked during pregnancy than for children whose mothers did not smoke (0.05% vs 0.01%). Multivariate analysis revealed that maternal smoking (risk ratio [RR] = 2.9; 95% confidence interval [CI] = 1.5, 5.7) and a mother's having fewer than 12 years of education (RR = 2.1; 95% CI = 1.0, 4.2) were independently associated with invasive meningococcal disease. CONCLUSIONS: Maternal smoking, a likely surrogate for tobacco smoke exposure following delivery, appears to be a modifiable risk factor for sporadic meningococcal disease in young children.

Moderate leisure-time physical activity: who is meeting the public health recommendations? A national cross-sectional study.

We identified the prevalence of adults who met the 1993 Centers for Disease Control and Prevention and the American College of Sports Medicine moderate physical activity recommendation and the 1996 Surgeon General's Report on Physical Activity and Health energy expenditure guideline for leading a moderately active lifestyle. Participants were 16,890 women and 12,272 men at least 18 years old who were asked in the 1990 National Health Interview Survey about their leisure-time physical activities. About one third of US adults met either recommendation for moderate activity; 32% met the Centers for Disease Control and Prevention and the American Association of Sports Medicine recommendation and 38% met the surgeon general's guideline. Women, ethnic minorities, adults with lower educational attainment, and older adults were least active. Public health efforts are needed to address the issues related to physical inactivity and to provide organized programs to increase moderate physical activity levels in US adults.

Impact of multiple risk factor profiles on determining cardiovascular disease risk.

BACKGROUND: We examined the association between clustering of risk factors and the risk for coronary heart disease, stroke, and all-cause mortality. METHODS: Data from the First National Health and Nutrition Examination Survey Epidemiologic Follow-Up Study (N = 12,932) were used to estimate the relative risk for coronary heart disease (N = 2,255), stroke (N = 929), and death from any cause (N = 4,506) by the number of cardiovascular disease risk factors present. Risk factors included current smoking, overweight, hypertension, high blood cholesterol, and diabetes. RESULTS: The proportions of respondents with 0, 1, 2, 3, or > or = 4 risk factors were 25.0, 32.8, 27.8, 12.3, and 2.1%, respectively. Relative risks for coronary heart disease associated with having 1, 2, 3, and > or = 4 risk factors were 1.6 (95% confidence interval [CI] 1.4, 1.9), 2.2 (95% CI 1.9, 2.6), 3.1 (95% CI 2.6, 3.6), and 5.0 (95% CI 3.9, 6.3), respectively. Relative risks for stroke associated with the same risk levels were 1.4 (95% CI 1.1, 1.8), 1.9 (95% CI 1.5, 2.4), 2.3 (95% CI 1.7, 3.0), and 4.3 (95% CI 3.0, 6.3), respectively. Similar results were observed for all-cause mortality. CONCLUSIONS: Risk for cardiovascular disease and all-cause mortality increased substantially with each additional risk factor. This supports the continued need for primary prevention of cardiovascular disease risk factors.

Tuberculosis transmission among five school bus drives and students in two New York countries

OBJECTIVE: Between November 1994 and April 1995, more than 3300 students in 49 schools in two countries in New York were potentially exposed to five school bus drivers with tuberculosis. This investigation was carried out to determine the extent of transmission of Mycobacterium tuberculosis among students. METHODS: Components of the epidemiologic investigation included tuberculin skin-test screening and collection of demographic information for students exposed to a driver with tuberculosis, chest radiography and medical evaluation of individuals with positive skin tests, and DNA fingerprinting of M tuberculosis isolates. A positive skin test was defined as >/=10 mm induration, and a converter was an individual with an increase in reaction size of >/=10 mm in the past 2 years. RESULTS: The rates of positive skin tests were 0.8 percent, 0.3 percent, 9.9 percent, 1.1 percent and 0.7 percent among US-born student exposed to drivers 1 through 5, respectively. The relative risk for a positive tuberculin skin test was significant only for student expose to driver 3 and the only secondary case identified among students was exposed to driver 3. The DNA fingerprinting patterns of isolates from drivers 3 and 4 matched. CONCLUSION: There was no clear evidence of transmission of M tuberculosis to students from driver 1, 2, 4, or 5. However, evidence suggests the driver 3 transmitted M tuberculosis to students and another driver. Routine annual tuberculin skin-test screening of drivers would not have prevented these tuberculosis exposures(AU)

Tuberculosis transmission among five school bus drivers and students in two New York counties.

OBJECTIVE: Between November 1994 and April 1995, more than 3300 students in 49 schools in two counties in New York were potentially exposed to five school bus drivers with tuberculosis. This investigation was carried out to determine the extent of transmission of Mycobacterium tuberculosis among students. METHODS: Components of the epidemiologic investigation included tuberculin skin-test screening and collection of demographic information for students exposed to a driver with tuberculosis, chest radiography and medical evaluation of individuals with positive skin tests, and DNA fingerprinting of M tuberculosis isolates. A positive skin test was defined as >/=10 mm induration, and a converter was an individual with an increase in reaction size of >/=10 mm in the past 2 years. RESULTS: The rates of positive skin tests were 0.8%, 0.3%, 9.9%, 1.1%, and 0.7% among US-born students exposed to drivers 1 through 5, respectively. The relative risk for a positive tuberculin skin test was significant only for students exposed to driver 3, and the only secondary case identified among students was exposed to driver 3. The DNA fingerprint patterns of isolates from drivers 3 and 4 matched. CONCLUSION: There was no clear evidence of transmission of M tuberculosis to students from drivers 1, 2, 4, or 5. However, evidence suggests that driver 3 transmitted M tuberculosis to students and another driver. Routine annual tuberculin skin-test screening of drivers would not have prevented these tuberculosis exposures.

Leisure-time physical activity among older adults. United States, 1990.

OBJECTIVE: To investigate the prevalence and selected correlates of leisure-time physical activity in a nationally representative sample of persons aged 65 years or older. METHODS: Data from 2783 older male and 5018 older female respondents to the 1990 National Health Interview Survey were used. Regular physical activity was defined as participation in leisure-time physical activities 3 times or more per week for 30 minutes or more during the previous 2 weeks. Odds ratios (ORs) were estimated from multivariate logistic regression analysis. RESULTS: Prevalence of regular physical activity was 37% among older men and 24% among older women. Correlates of regular physical activity included the perception of excellent to good health (men: OR, 1.5; 95% confidence interval [CI], 1.1-1.9; women: OR, 1.6; 95% CI, 1.3-1.9), correct exercise knowledge (men: OR, 2.4; 95% CI, 1.9-3.1; women: OR, 2.7; 95% CI, 2.2-3.4), no activity limitations (men: OR, 1.3; 95% CI, 1.0-1.6; women: OR, 1.7; 95% CI, 1.4-2.0) and not perceiving "a lot" of stress during the previous 2 weeks (men: OR, 1.7; 95% CI, 1.2-2.4; women: OR, 1.3; 95% CI, 1.0-1.6). Among those who had been told at least twice that they had high blood pressure, physician's advice to exercise was associated with regular physical activity (men: OR, 1.6; 95% CI, 1.2-2.3; women: OR, 1.5; 95% CI, 1.2-1.9). The 2 major activities among active older adults were walking (men, 69%; women, 75%) and gardening (men, 45%; women, 35%). CONCLUSIONS: Prevalence of regular physical activity is low among older Americans. Identifying the correlates of physical activity will help to formulate strategies to increase physical activity in this age group.

Hospital-based evaluation of programs to prevent perinatal hepatitis B virus transmission.

OBJECTIVE: To evaluate the frequency of hepatitis B surface antigen (HBsAg) screening of pregnant women in the United States and factors associated with the lack of screening. DESIGN: A random sample of 200 hospitals with 100 or more births per year was surveyed with regard to policy and practices. Each hospital was also asked to provide maternal screening and infant follow-up data for the first 25 infants who were born on or after March 1, 1993. RESULTS: Of 183 participating hospitals, 137 (75%) had maternal HBsAg screening policies, and 102 (56%) had standing orders for HBsAg testing of pregnant women who were admitted without prior screening. Hospitals that were located in states with laws that required maternal HBsAg screening were more likely to have a written screening policy (prevalence ratio [PR], 1.7; 95% confidence interval [CI], 1.2-2.4) and a standing order (PR, 1.7; 95% CI, 1.4-2.2). A lack of screening was related to delivery in hospitals without screening policies (PR, 3.4; 95% CI, 1.3-8.9) or standing orders (PR, 2.8; 95% CI, 1.2-6.2), and to the infant's provider being a family practitioner (PR, 1.7; 95% CI, 1.1-2.7). Among the 3982 infants for whom data were available, 3342 (84%) were born to mothers who had undergone screening for HBsAg. CONCLUSIONS: These findings suggest that hospitals should develop specific policies for HBsAg screening, states should enact laws that require maternal screening, and additional education of health care providers is needed with regard to the screening of all pregnant women for HBsAg.