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HICNet Medical News Digest      Sun, 27 Aug 1995        Volume 08 : 
Issue 29

Today's Topics:

  [MMWR] Injuries Associated with Self-Unloading Forage Wagons
  [MMWR] Update: HIV-2 Infection Among Blood and Plasma Donors
  [MMWR] Monthly Immunization Table
  [MMWR Aug-11-95] Heat-Related Mortality --- Chicago, July 1995
  CancerNet Update for August 1995
  Gov't Hotline for Environmental Health Questions Available
  [MMWR 25-Aug-95] Disabilities among children aged < 17
  [MMWR] State and National Vaccination Coverage levels...

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To: hicnews

Injuries Associated with Self-Unloading Forage Wagons -- New York,1991-
1994

     In New York, an estimated 3600 injuries occur each year to
farmers operating farm machines (1). In October 1993, the
Occupational Health Nurses in Agricultural Communities (OHNAC)*
program in the New York State Department of Health received a
report of a man who sustained severe injuries when he became
entangled in the power take-off (PTO) driveline to a self-unloading
forage wagon**. Subsequent investigation by OHNAC identified four
additional similar incidents in New York that occurred during
September 1991-October 1994, including one fatality and one injury
to a 9-year-old girl working on a family farm. This report
summarizes the results of the investigation of these forage-wagon-
related
injuries and presents recommendations to reduce the risk
for such injuries.
     On October 1, 1993, a 66-year-old farmer was using a
self-unloading forage wagon to unload chopped corn into a blower
for transfer into a silo. To unload the corn, he used a tractor to
pull the loaded forage wagon next to the blower (which was attached
to a second tractor). To reach the speed-control lever, he stepped
over the rotating PTO driveline that connected his tractor to the
wagon and supplied its power. As he stepped, his pants became
entangled around the unprotected rotating driveline. A nearby
worker witnessed the incident and turned off the driveline. The
farmer's injuries included amputation of the genitalia and deep
tissue damage to the buttocks, requiring extensive grafting. He was
hospitalized for 2 weeks and unable to work for 1 month.
     On investigation by OHNAC, with assistance from the
Cooperative Extension Service, four other incidents were identified
since 1991 involving forage wagons with unprotected drivelines. In
September 1991, a 33-year-old farmer sustained multiple fractures
of the right leg with amputation of the right foot when his shirt
blew into a rotating driveline of a forage wagon while he was
working between two drivelines on a windy day. In October 1992, a
41-year-old farm operator sustained avulsion of the entire scrotal
area when his pants became entangled while he was stepping over the
unprotected PTO driveline. In November 1992, a 9-year-old girl
sustained bilateral above-the-knee amputations when her jacket
became entangled while she was reaching over the unprotected
rotating driveline to operate the speed control of the forage wagon
she was unloading. Finally, in an unwitnessed incident in October
1994, a 19-year-old male farmer sustained fatal internal injuries
after apparently stepping too close to the driveline of a forage
wagon while unloading chopped corn.
Reported by: S Roerig, J Melius, MD, J Pollock, MSP, M London, MS,
G Casey, New York State Dept of Health. Div of Surveillance, Hazard
Evaluations, and Field Studies, National Institute for Occupational
Safety and Health, CDC.
Editorial Note: In the United States, farm machinery is a leading
source of traumatic injuries to farmers, accounting for an
estimated 34,000 lost-time work injuries to farmers nationally in
1993 (2). Mechanical devices are associated with approximately 30%
of the work-related injuries on farms (2). Forage wagons are used
most often on farms that raise large animals and grow their own
feed grain. The fatal and severe nonfatal injuries described in
this report were caused by a combination of factors. To unload feed
grain, the forage wagon and silo blower must be in close proximity,
which requires that the two tractors that power these machines also
be in close proximity (Figure 1). The speed-control lever for the
wagon is often located on the discharge side near the silo blower
(i.e., between the two pieces of equipment). Many older tractors
are small enough that, when the forage wagon and blower are thus
positioned for proper operation, sufficient space remains between
the adjacent rear tires of the two tractors to allow the operator
to dismount from either tractor seat and walk between the two
tractors directly to the forage wagon speed control without
crossing over a revolving PTO driveline. However, as both silos and
self-unloading forage wagons have increased in capacity, both the
size and horsepower of the associated tractors have increased
concomitantly. When these larger tractors are used, their rear
wheels abut, blocking access between the tractors and requiring the
operator to cross over a revolving driveline to operate the forage
wagon.
     Since the 1930s, PTO drivelines have been manufactured with
shields. However, shields are often damaged or removed during
operation or maintenance of the farm equipment. Of the estimated
29,000 self-unloading wagons in use on New York farms, 3000-5000
are believed to lack shields to protect workers adequately from a
revolving PTO driveline (J. Pollock, Cornell University, personal
communication, 1995). Entanglement in PTO drivelines, including
entanglement in those equipped with intact U-shaped shields that
leave one side (generally the underside) unguarded, previously has
been recognized as a hazard in the agricultural industry (3-6).
     Drivelines should be equipped with proper functioning guards
in any work situation,*** especially when the worker must work
between two operating PTO drivelines. Furthermore, workers must be
trained in safe work practices, which include shutting off PTO
drivelines whenever possible before dismounting tractors,
maintaining warning decals, not wearing loose or bulky clothing
around and avoiding close proximity to rotating PTO drivelines, and
keeping bystanders--especially children--away from PTO-driven
equipment (7). To assist in preventing injuries to children,
farmers should recognize that farm equipment is designed for
operation by adults; be aware of the physical, emotional, and
mental characteristics and abilities of children; and select
age-appropriate tasks for children (8). Because of the need for
immediate response to serious injuries, workers should not work
alone when using hazardous equipment; however, if persons do work
alone, they should be monitored frequently to ensure immediate
response in the event of injuries (7).
     The National Institute for Farm Safety is reviewing approaches
to reduce the risk for forage-wagon-related injuries. In addition
to proper shielding of the drivelines, placement of the
speed-control devices to enable operation of such devices from the
tractor driver's seat or from another location on the wagon would
eliminate the need for the operator to step over the driveline.
Leading manufacturers of forage wagons have designed conveyor
extensions that allow for an increase in the space between the two
tractors; the extension can be supplied with new equipment or used
to retrofit some older equipment. An informal survey of forage
wagon equipment indicated that conveyor extensions are available
for all seven wagons selected in a nonrandom sample; costs for the
retrofits ranged from $35 to $600 each. Although these extensions
are marketed to promote productivity, not safety, manufacturers and
dealers should be made aware that these extensions can contribute
to safer operation of the equipment, and farmers should be
encouraged to use them to enhance safety as well as increase
productivity.
     In New York, OHNAC, in collaboration with farm groups, have
alerted farmers about the hazards associated with PTO drivelines--
especially
on forage wagons--through educational presentations and
articles in regional agricultural publications.
References
1. Pollock J. Perspectives of New York farm safety: workplace
injuries and worker opinions [Thesis]. Ithaca, New York: Cornell
University, 1990. 68 p.
2. NIOSH. Traumatic injury surveillance of farmers: annual
statistical abstract, 1993. Morgantown, West Virginia: US
Department of Health and Human Services, Public Health Service,
CDC, NIOSH, 1995 (in press).
3. Cogbill TH, Steenlage ES, Landercasper J, Strutt PJ. Death and
disability from agricultural injuries in Wisconsin: a 12-year
experience with 739 patients. J Trauma 1991;31:1632-7.
4. Heeg M, ten Duis HJ, Klasen HJ. Power take-off injuries. British
Journal of Accident Surgery 1986;17:28-30.
5. Roerig S. Scalping accidents with shielded PTO units: four case
reports. American Association of Occupational Health Nursing
Journal 1993;41:437-9.
6. CDC. Scalping incidents involving hay balers--New York. MMWR
1992;41:489-91.
7. Demmin D, Hallman E. Cornell Cooperative Extension rural health
and safety fact sheet: power take-off (PTO) safety. Ithaca, New
York: Cornell University, 1995; publication no. 123FSF56.
8. Bean TL, Wojtowicz J. Farm safety for children: what job is
right for my child? Columbus, Ohio: Ohio State University, 1992;
publication no. AEX-991.1.
* OHNAC is a national surveillance program conducted by CDC's
National Institute for Occupational Safety and Health that has
placed public health nurses in rural communities and hospitals in
10 states (California, Georgia, Iowa, Kentucky, Maine, Minnesota,
New York, North Carolina, North Dakota, and Ohio) to conduct
surveillance for agriculture-related illnesses and injuries that
occur among farmers and their family members. These surveillance
data are used to assist in reducing the risk for occupational
illness and injury in agricultural populations.
** A forage wagon is used to transport and unload feed into a
storage (e.g., silo) or feed area.
*** 29 CFR section 1928.57. Occupational Safety and Health
Administration (OSHA) Standard for Safety for Agricultural
Equipment. Family-run farms with no other employees are exempt from
compliance with federal OSHA standards, and those with less than or
equal to 10 employees are generally not subject to OSHA inspection.


------------------------------

To: hicnews

Update: HIV-2 Infection Among Blood and Plasma Donors -- United
States, June 1992-June 1995

Human immunodeficiency virus type 1 (HIV-1) and type 2 (HIV-2) both
cause acquired immunodeficiency syndrome (AIDS). Following the
licensure of combination HIV-1/HIV-2 screening enzyme immunoassays
(EIA), the Food and Drug Administration (FDA) recommended that
beginning in June 1992 all donated whole blood, blood components,
and source plasma be screened for antibody to HIV-2 because not all
persons infected with HIV-2 can be detected by HIV-1 testing (1,2).
This report describes the first two cases of HIV-2 infection
detected among potential blood donors since the implementation of
recommended HIV-2 screening and summarizes national data about
persons known to be infected with HIV-2 during December 1987-June
1995.*
Donor 1
     In June 1994, a blood donation was discarded after it tested
positive by combination HIV-1/HIV-2 EIA and indeterminate by HIV-1
Western blot assay (WB). The donor was notified about the test
results and consented to an interview and repeat testing. Testing
at CDC indicated the specimen was positive by HIV-1 EIA, HIV-1 WB,
HIV-2 EIA, and HIV-2 WB for research use only (RUO). Results of RUO
synthetic peptide tests indicated cross-reactivity to HIV-1 and
were interpreted as HIV-2 infection.
     The donor was born and resided in the United States. She
previously had not donated blood or plasma. She reported no
symptoms related to HIV infection and denied injecting-drug use,
receipt of transfusions, and travel outside the United States.
Since 1982, she had had four male sex partners; all were born in
the United States. The HIV status of her partners is unknown, and
she was unaware of any HIV-infection risks among them. She has no
children. She received HIV counseling--including instructions to
refrain from donating blood, blood components, and tissues or
organs--and referral to a health-care provider.
Donor 2
     In November 1994, a plasma donation was destroyed after the
serum tested positive by combination HIV-1/HIV-2 EIA and RUO HIV-2
WB. Attempts by the plasma center to notify the donor were
unsuccessful. However, the donor independently sought HIV testing
2 weeks later at a counseling and testing site (CTS). The CTS
laboratory results were HIV-1 EIA positive with an atypical HIV-1
WB indeterminate band pattern suggestive of HIV-2 infection.
Subsequent testing at CDC indicated the specimen was HIV-1 EIA
positive, HIV-1 WB indeterminate, HIV-2 EIA positive, and HIV-2 WB
positive. RUO synthetic peptide EIA and dot blots were also
positive for HIV-2. These results were interpreted as confirmed
HIV-2 infection.
     During the follow-up interview, the male donor reported no
symptoms of HIV infection. He had not previously donated blood or
plasma. He was born in France and had lived in several countries in
western Africa during 1979-1985 before moving to the United States.
While in western Africa, he was vaccinated on two occasions with
needles that were wiped with cotton and reused between patients. He
also received several tattoos in Africa. Of his estimated 35
lifetime sex partners, most were African. The donor denied having
had sex with men, injecting-drug use, and receipt of transfusions.
He received HIV counseling--including instructions to refrain from
donating blood, blood components, and tissues or organs--and
referral to a health-care provider.
U.S. Reports of HIV-2 Infection
     As of June 30, 1995, a total of 62 persons in the United
States were reported with HIV-2 infection (Figure 1). Of 58 persons
for whom sex data were available, 38 (66%) were male. At least 11
of the 62 persons had an AIDS-defining condition at the time of
report, and five are known to have died. Of these 62 persons, 42
(68%) were born in western Africa and two in Europe; for nine, the
region of origin was unknown although four had malaria antibody
profiles consistent with previous residence in western Africa. Of
the nine persons with HIV-2 infection born in the United States,
six were adults of whom four had either traveled to or had a sex
partner from western Africa, and three were infants born to mothers
of unknown national origin.
Reported by: MD Herr, HIV/AIDS Epidemiology; AL Hathcock, PhD,
State Epidemiologist, Delaware Div of Public Health. DW Hamaker, JM
Schulte, DO, D Hoehns, BE Mitchell, MPH, Bur of HIV and STD
Prevention; DM Simpson, MD, State Epidemiologist, Texas Dept of
Health. Local and state health depts. Office of Blood Research and
Review; Div of Transfusion Transmitted Diseases, Center for
Biologics Evaluation and Research, Food and Drug Administration.
Div of HIV/AIDS, National Center for Infectious Diseases; Div of
HIV/AIDS Prevention, National Center for Prevention Svcs, CDC.
Editorial Note: In the United States, HIV-2 infection among blood
donors is extremely rare. Since the implementation of combination
HIV-1/HIV-2 EIA screening of blood and plasma donations, an
estimated 74 million donations have been tested for HIV. Including
the two cases described in this report, three cases of HIV-2
infection have been detected among blood and plasma donors in the
United States; the first case was detected by HIV-1 screening in
1986 (3). These findings are consistent with previous surveys of

_
                                                                 

approximately 20 million U.S. blood donations during 1987-1989 in
which no blood-donor specimens with HIV-2 antibody were detected
(4,5).
     The national blood supply is protected from HIV primarily
through two methods: 1) interviewing donors about risk behaviors
for HIV infection and 2) laboratory screening donations for HIV
(6,7). All donations detected with HIV are excluded from any
clinical use,** and donors are deferred from further donations***.
For both donors described in this report, although no HIV risk
factors were identified during the interview preceding blood
donation, laboratory screening of their blood and plasma donations
detected HIV infection. Subsequent testing revealed HIV-2
cross-reactivity resulting in a positive HIV-1 EIA (which would
have led to exclusion even in the absence of HIV-2 testing) and a
positive or indeterminate HIV-1 WB.
     HIV-1 is distributed worldwide and is prevalent in the United
States; however, HIV-2 is endemic in western Africa with limited
distribution to other regions of the world. Of the 62 persons
reported with HIV-2 infection in the United States, at least 48
(77%) were born in, had traveled to, and/or had a sex partner from
western Africa.
     In addition to detection of HIV-2 cases through blood and
plasma donor screening, epidemiologic data about HIV-2 cases are
collected through the CDC-supported national HIV/AIDS surveillance
system and serosurveys (8,9). Because not all persons who are
infected with HIV-2 donate blood or are otherwise tested for HIV-2,
the number of persons reported with HIV-2 infection probably is
underestimated. Nonetheless, the data from these sources indicate
that HIV-2 is uncommon in the United States.
     Blood centers detecting a repeatedly reactive specimen by
combination HIV-1/HIV-2 EIA should follow the recommended CDC/FDA
testing algorithm (1). Specimens suspected of being HIV-2 positive
may be referred to state health department laboratories or to CDC
for confirmatory HIV-2 testing. Cases of HIV-2 infection should be
reported to state and local health departments as allowed by law
and/or regulation. Periodic updates about the number of persons
known to be infected with HIV-2 in the United States are available
from the CDC National AIDS Clearinghouse.
References
1. CDC. Testing for antibodies to human immunodeficiency virus type
2 in the United States. MMWR 1992;41(no. RR-12).
2. George JR, Rayfield MA, Phillips S, et al. Efficacies of US Food
and Drug Administration-licensed HIV-1-screening enzyme
immunoassays for detecting antibodies to HIV-2. AIDS 1990;4:321-6.
3. O'Brien TR, Polon C, Schable CA, et al. HIV-2 infection in an
American. AIDS 1991;5:85-8.
4. CDC. Surveillance for HIV-2 infection in blood donors--United
States, 1987-1989. MMWR 1990;39:829-31.
5. CDC. AIDS due to HIV-2 infection--New Jersey. MMWR 1988;37:33-5.
6. Food and Drug Administration. Revised recommendations for the
prevention of human immunodeficiency virus (HIV) transmission by
blood and blood products [Memorandum to all registered blood
establishments]. Bethesda, Maryland: US Department of Health and
Human Services, Public Health Service, Food and Drug
Administration, Center for Biologics Evaluation and Research, 1992.
7. Food and Drug Administration. Recommendations for donor
screening with a licensed test for HIV-1 antigen [Memorandum to all
registered blood and plasma establishments]. Rockville, Maryland:
US Department of Health and Human Services, Public Health Service,
Food and Drug Administration, Center for Biologics Evaluation and
Research, 1995.
8. CDC. HIV/AIDS surveillance report. Atlanta, Georgia: US
Department of Health and Human Services, Public Health Service,
1995:36-7. (Vol 6, no. 2).
9. O'Brien TR, George JR, Holmberg SD. Human immunodeficiency virus
type 2 infection in the United States. JAMA 1992;267:2775-9.
* Single copies of this report will be available until August 18,
1996, from the CDC National AIDS Clearinghouse, P.O. Box 6003,
Rockville, MD 20849-6003; telephone (800) 458-5231 or (301)
217-0023.
** 21 CFR section 610.45(c).
*** 21 CFR section 606.160(e).



------------------------------

To: hicnews

Monthly Immunization Table
     To track progress toward achieving the goals of the Childhood
Immunization Initiative (CII), CDC publishes monthly a tabular
summary of the number of cases of all diseases preventable by
routine childhood vaccination reported during the previous month
and year-to-date (provisional data). In addition, the table
compares provisional data with final data for the previous year and
highlights the number of reported cases among children aged less
than 5 years, who are the primary focus of CII. Data in the table
are reported through the National Electronic Telecommunications
System for Surveillance.


------------------------------

To: hicnews

            Heat-Related Mortality -- Chicago, July 1995

     During July 12-16, 1995, Chicago experienced unusually high
maximum daily temperatures, ranging from 93 F to 104 F (33.9 C to
40.0 C). On July 13, the heat index* peaked at 119 F (48.3 C)--a
record high for the city. This report describes the heat- related
deaths reported by the Cook County Medical Examiner's Office
(CCMEO) during this heat wave.
     Deaths classified as heat-related by the CCMEO met one of the
following three criteria: 1) core body temperature of the decedent
greater than or equal to 105 F ( greater than or equal to 40.6 C)
at the time of or immediately after death, 2) substantial
environmental or circumstantial evidence of heat as a contributor
to death (e.g., decedent found in a room without air conditioning,
all windows closed, and a high ambient temperature), or 3) decedent
in a decomposed condition without evidence of other cause of death
and with evidence that the decedent was last seen alive during the
heat wave period.
     During July 11-27, a total of 465 deaths were certified as
heat-related by the CCMEO (Figure 1); during July 4-10, no deaths
were certified as heat-related. The highest number of heat-related
deaths previously certified by the CCMEO--associated with a heat
wave in 1988--was 77. The number of heat-related deaths peaked 2
days after the heat index peaked. Deaths increased from 49 (July
14) to a maximum of 162 (July 15) (Figure 1). Of the 465 decedents,
257 (55%) were male. Based on race-specific data, 229 (49%)
decedents were black; 215 (46%), white; and 21 (5%), other
racial/ethnic groups.** Within racial categories, 128 (56%) blacks
were male, and 114 (53%) whites were male. Of the 437 decedents for
whom age could be determined, age ranged from 3 years to 103 years
(median: 75 years, mean: 72 years); 222 (51%) were aged greater
than or equal to 75 years.
     During July 13-21 (when most heat-related deaths were
certified by the CCMEO), a total of 1177 deaths occurred in
Chicago--an 85% increase over the same period in 1994 (637 deaths).
Reported by: ER Donoghue, MD, MB Kalelkar, MD, MA Boehmer, Office
of the Medical Examiner County of Cook, Chicago; J Wilhelm, MD, S
Whitman, PhD, G Good, MS, S Lyne, RSM, Commissioner, City of
Chicago Dept of Health; J Lumpkin, MD, L Landrum, MUPP, BJ Francis,
MD, State Epidemiologist, Illinois Dept of Public Health. Div of
Environmental Hazards and Health Effects, National Center for
Environmental Health, CDC.
Editorial Note: Excess mortality from hyperthermia and
cardiovascular disease during heat waves has been well documented
(2,3). The findings in Chicago by the CCMEO that blacks, males, and
the elderly appear to be particularly susceptible to heat-related
death are similar to previous studies of heat waves. During public
health crises such as heat waves, state-specific mortality data are
often incomplete or unavailable; therefore, data from medical
examiners' (MEs') offices may be used to assess mortality during
such crises. Although ME-based surveillance for heat-related deaths
can prompt timely public health responses during heat waves, use of
ME data is limited because of selection bias. Individual MEs and
other persons who certify deaths (e.g., coroners and attending
physicians) use varying criteria to determine which deaths are
heat-related, largely because no standardized definition exists.
     In the United States, lack of a uniform definition for
heat-related death results in substantial variation in the criteria
used to certify such deaths. The most stringent definition of
heat-related death is a core body temperature of greater than or
equal to 105 F (greater than or equal to 40.6 C) taken at the time
of death, with no other reasonable explanation of death. This
definition precludes certifying any death as heat-related if core
body temperature is not measured before or near the time of death
and may underestimate excess heat-related mortality. A nonspecific
definition of heat-related death (which could include all deaths
that occur during a heat wave) would overestimate this mortality.
The definition used by the CCMEO to classify deaths as heat-related
has remained unchanged since 1978 and is based on a reasonable
approach (i.e., evidence of exposure to high levels of
environmental heat). These two factors (as well as the finding that
the data about heat-related deaths are consistent with preliminary
data about total mortality in Chicago during July 1995) suggest
that the CCMEO data did not overestimate heat-related mortality
during that period.
     The differential impact of a heat wave on specific population
subgroups cannot be determined based on ME data alone because of
incompleteness and potential bias (3,4). For example, based on
CCMEO data, a disproportionately high number of heat-related deaths
occurred among blacks in Chicago on July 15 (Figure 1). Because
CCMEO data do not include all deaths nor equally represent all
socioeconomic status (SES) categories, it is not yet possible to
completely describe mortality, calculate death rates, or determine
whether the race- and sex-specific distribution of the heat-related
deaths is disproportionate to overall mortality in Chicago. A
case-control study is under way in Chicago to examine the
influences of SES and specific environmental factors on
heat-related mortality.
     Despite their limitations, the data in this report confirm
that 1) public health information should be directed toward
susceptible populations (e.g., the elderly), 2) as in other heat
waves (2,3), the time between the beginning of a heat wave and the
resulting heat-related deaths (e.g., 2 days in Chicago) should be
sufficient to disseminate prevention messages to the public, and 3)
a standardized definition of heat-related death is needed.
     Heat-related mortality is preventable. The most effective
measures for preventing heat-related illness and death include
reducing physical activity, drinking additional nonalcoholic
liquids, and increasing the amount of time spent in air-conditioned
environments. In addition, because increased air movement (e.g.,
fans) has been associated with heat stress when the ambient
temperature exceeds approximately 100 F (37.8 C) and because fans
are not protective at temperatures greater than 90 F (greater than
32.3 C) with humidity greater than 35% (the exact temperature
varies with the humidity), fans should not be used for preventing
heat-related illness in areas with high humidity (3,5). To further
define information that can be used to identify persons at greatest
risk during hot weather, CDC is collaborating with Chicago and
Illinois health officials to determine risk factors to better
target persons at increased risk for heat-related illness or death.
A standard definition for heat-related death will be addressed at
the February 1996 meeting of the American Academy of Forensic
Sciences.
References
1. Rothfusz LP. The heat index "equation" (or, more than you ever
wanted to know about heat index). Fort Worth, Texas: National
Oceanic and Atmospheric Administration, National Weather Service,
Office of Meteorology, 1990; publication no. SR 90-23.
2. Wainwright S, Buchanan S, Mainzer H. Cardiovascular mortality:
the hidden peril of heat waves [Abstract]. In: Program and
abstracts of the CDC Epidemic Intelligence Service 43rd annual
conference. Atlanta, Georgia: US Department of Health and Human
Services, Public Health Service, CDC, 1994.
3. Kilbourne EM, Choi K, Jones TS, Thacker SB, and the Field
Investigation Team. Risk factors for heat stroke: a case control
study. JAMA 1982;247:3332-6.
4. Jones TS, Liang AP, Kilbourne EM, et al. Morbidity and mortality
associated with the July 1980 heat wave in St. Louis and Kansas
City, Missouri. JAMA 1982;247:3327-31.
5. Lee DH. Seventy-five years of searching for a heat index.
Environ Res 1980;22:331-56.

* The heat index (i.e., the apparent temperature) is an estimation
of the influence of temperature and humidity on the evaporative and
radiative transfer of heat between a typical human and the
atmosphere. The values can be derived from a chart available
through the National Weather Service (1).
** The CCMEO categorizes race of decedents as black, white, or
other.


------------------------------

To: hicnews

            +----------------------------------------------+
            |       NATIONAL           INSTITUTE           |
            |               C A N C E R                    |
            |  INTERNATIONAL           INFORMATION         |
            |               C E N T E R                    |
            +----------------------------------------------+
                    |  CancerNet@icicc.nci.nih.gov  |
                    +-------------------------------+




Changes to CancerNet,August 1995



CancerNet was updated on August 1, 1995.

PDQ Statements
--------------

The following PDQ statements were added or updated in CancerNet with the
August update (see the file Monthly PDQ Changes -- cn-405001 for 
detailed
information on the changes in each statement).


New Statements:

One new cancer screening summary, "Screening for Breast Cancer for 
Patients"
(cn-305499), was added.

Changed treatment statements for physicians:
Adult Hodgkin's Disease (cn-100003)
Adult Non-Hodgkin's Lymphoma (cn-100066)
Adult Primary Liver Cancer (cn-101195)
Anal Cancer (cn-100022)
Bladder Cancer (cn-101206)
Breast Cancer  (cn-100013)
Childhood Acute Lymphocytic Leukemia (cn-100026)
Childhood Brain Tumor (cn-100047)
Childhood Hodgkin's Disease (cn-103043)
Childhood medulloblastoma (cn-100048)
Childhood rhabdomyosarcoma (cn-100759)
Childhood soft tissue sarcoma (cn-103085)
Childhood Supratentorial Primitive Neuroectodermal Tumor (cn-104028)
Chronic lymphocytic leukemia (cn-101003)
Colon Cancer (cn-100008)
Cutaneous T-cell Lymphoma (cn-100098)
Esophageal cancer (cn-100089)
Gastrointestinal Carcinoid Tumor (cn-101064)
Hairy cell leukemia (cn-101651)
Melanoma (cutaneous) (cn-101302)
Metastatic Squamous Neck Cancer with Occult Primary (cn-101454)
Neuroblastoma (cn-100530)
Osteosarcoma (cn-100049)
Ovarian epithelial cancer (cn-100950)
Pancreatic cancer (cn-100046)
Plasma Cell Neoplasm (cn-100281)
Prostate cancer (cn-101229)
Rectal Cancer (cn-100076)
Wilms' Tumor (cn-100719)


Changed treatment statements for patients:

Adult Non-Hodgkin's Lymphoma (cn-200066)
Adult Primary Liver Cancer (cn-201195)
Anal Cancer (cn-200022)
Cervical cancer (cn-200103)
Childhood Brain Cancer (cn-200047)
Childhood Hodgkin's Disease (cn-203043)
Childhood Medulloblastoma (cn-200048)
Childhood Rhabdomyosarcoma (cn-200759)
Colon Cancer (cn-200008)
Hairy Cell Leukemia (cn-201651)
Melanoma (cn-201302)
Osteosarcoma (cn-200049)
Pancreatic Cancer (cn-200046)
Prostate Cancer (cn-201229)
Rectal Cancer (cn-200076)

Changed supportive care statements:

Nausea and Vomiting (cn-304466)

Changed cancer screening and prevention statements:
None.

Changed drug information statements:
None.

Changed CancerNet News

The following news bulletin was added:

JAMA Publishes Descriptions of Tobacco Company Activities (cn-400105)

The following news bulletins were changed:

FDA's Mammography Quality Standards Act/Mammography Facility Locator 
Service
(cn-400075)
NCI High Priority Clinical Trials (cn-400007)
Survival Following Breast-Sparing Surgery vs. Mastectomy (cn-400020)
Redistribution of CancerNet and CancerNet Availability (cn-400030)

The following news bulletins were deleted:

Investigator letter: Secondary AML after dose-intensive therapy (cn-
400061)
Mammography Facility Locator Service Opens (cn-400088) - see item cn-
400075


Publications
------------
The following publication information was added:

Cancer Research in Hispanic Populations Monograph (cn-400106)
Sowing Seeds in the Mountains Monograph (cn-400107)

The following publication information was changed:

JNCI Monographs Available (cn-400066)

The following publication information was deleted:

1992 Oncology Overviews (cn-400057)
National Disease Prevention Campaign (cn-400069)

NCI Fact Sheets
---------------
The following fact sheets were added:

PDQ Search Service (cn-600026)
Ten Facts to Know About Cancer (cn-600412)
Q & A: Mammography and Breast Cancer (cn-600521)

The following fact sheets were changed:

NCI's Clinical Trials Cooperative Group Program (cn-600014)
Patients Needed for Breast Cancer Clinical Trials (cn-600713)
NCI's Cancer Centers Program (cn-600012)
Personal Use of Hair Coloring Products and Risk of Cancer (cn-600332)
Oral Contraceptives and Breast Cancer (cn-600336)

No fact sheets were deleted.


CANCERLIT Citations and Abstracts:
----------------------------------

_
                                                                                                              

No new CANCERLIT citations and abstract topics were added.

The CANCERLIT citations and abstracts for August will be available on 
August
9, 1995.


Instructions:

To request the CancerNet Instructions and Contents List, send a
mail message, and in the body of the message,  enter HELP.  Address
the mail message to:

          cancernet@icicc.nci.nih.gov

To request the modified statements, follow the above directions,
and in the body of the mail message, enter the statement code.
When requesting more than one statement, enter each code on a
separate line.

CancerNet statements are also available in Spanish. To request the
Instructions and Contents List in Spanish, enter SPANISH in the
body of the mail message. If you would like to request the statements
in Spanish, substitute the prefix "cs-" in front of the number
(e.g., cs-100022) to receive the statement on anal cancer in Spanish .
All of the physician and patient statements are available in Spanish.
News items that are available in Spanish have a # next to the statement
title. Although both the English and Spanish are updated at the same
time each month, the Spanish statements do not reflect the changes made
in the English statements until the following month to allow time for
translation . If you are interested in requesting CancerNet statements
or news articles in Spanish, it is suggested that you request an updated
Contents List.

If you are redistributing the PDQ information you retrieve from
CancerNet to others at your location, or are interested in 
redistributing
the information from CancerNet, request the news article, Redistribution
of Cancernet (cn-400030) , to find out about conditions that apply when
redistributing the information.  This article also has information on
other sites providing access to CancerNet information.

Please send comments or questions to:

Cheryl Burg
NCI International Cancer Information Center
Internet: cheryl@icicc.nci.nih.gov




---
Editor, HICNet Medical Newsletter
Internet: david@stat.com                 FAX: +1 (602) 451-6135

------------------------------

To: hicnews

GOVERNMENT HOTLINE PROVIDES ANSWERS TO ENVIRONMENTAL HEALTH QUESTIONS

Durham, North Carolina, August 1, 1995 - ENVIRO-HEALTH, a publicly
accessible clearinghouse on environmental health effects, is a free
information source and referal service sponsored by the National
Institute of Environemental Health Sciences (NIEHS), one of the
National Institutes of Health.  NIEHS created the clearinghouse to
provide environmental health information to the general public.
ENVIRO-HEALTH also responds to requests from public health officials,
environmental justice groups, grassroots environmental organizations,
environmental science writers, educators, and students.

Since opening in October 1994, the ENVIRO-HEALTH hotline has
responded to a broad range of questions regarding the human health
effects of electromagnetic fields, pesticides, indoor air quality,
multiple chemical exposures, radon, industrial emissions, drinking
water, and other health-related topics.

Calls and requests to ENVIRO-HEALTH are received by technical
information specialists who provide information over the telephone,
via fax, and through the mail, or by making referrals to other
government clearinghouses.  The technical information specialists
take calls on weekdays between the hours of 9:00 a.m. and 8:00 p.m.
Eastern Time, but callers can leave messages 24 hours a day.
ENVIRO-HEALTH can be reached through a toll-free telephone number
(1-800-NIEHS-94), by e-mail (envirohealth@niehs.nih.gov) or by
fax (919-361-9408).  General Information about ENVIRO-HEALTH is
located on the NIEHS world wide web home page 
(http://www.niehs.nih.gov).

---
Editor, HICNet Medical Newsletter
Internet: david@stat.com                 FAX: +1 (602) 451-6135

------------------------------

To: hicnews

    Disabilities Among Children Aged less than or equal to 17 Years --
                        United States, 1991-1992

     Disabilities among children result in substantial reductions
in quality of life and are associated with increased dependence on
the health-care and social-service systems. To assess the
prevalence of disabilities and their associated health conditions
among children, CDC reviewed data from the Survey of Income and
Program Participation (SIPP) for 1991-1992, which collected
information about chronic conditions, including the functional
limitations related to those conditions (1,2). This report
summarizes SIPP data for children aged less than or equal to 17
years.
     From October 1991 through January 1992, SIPP collected
information about disabilities during personal household interviews
of a sample (n=97,133 persons in 34,100 households) of the U.S.
civilian, noninstitutionalized population. Measures of disability
were based on definitions from the International Classification of
Impairments, Disabilities, and Handicaps (ICIDH)* (3). The ICIDH
extends the International Classification of Diseases (ICD) to
include the personal and social consequences of diseases. Parents
or legal guardians were asked about disabilities among their
children aged less than or equal to 14 years. Children aged 15-17
years were asked directly about disabilities when they were
available; however, for most children in this age group,
information was obtained from their parents or guardians. For
children reported to have a disability, parents were asked about
the condition(s) that caused the functional limitation. Data were
weighted to calculate national estimates representative of the U.S.
population.
     To ensure that the disability data were comprehensive and
accounted for all developmental stages of children, the SIPP
definitions of disability were varied by age group. For children
aged 0-5 years, disability was defined as 1) limitation in the
usual kind of activities done by most children the same age, or 2)
receipt of therapy or diagnostic services by the child for
developmental needs. For children aged greater than or equal to 6
years, disability was any limitation in the ability to do regular
school work. Additional indicators of disability included, for
children aged 3-14 years, a long-lasting condition that limited the
ability to walk, run, or use stairs, and for children aged 15-17
years, measures of problems in personal care, personal management
(activities of daily living**), and the use of assistive aids
(e.g., wheelchair).
     During 1991-1992, an estimated 48.9 million persons (19.4% of
the total U.S. population of 251.8 million) had a disability; of
these, 3.8 million (7.9%) were aged less than or equal to 17 years
(1). For children aged less than 3 years, the overall estimated
prevalence of disabilities was 2.2%; for those aged 3-5 years,
5.2%; for those aged 6-14 years, 6.3%; and for those aged 15-17
years, 9.3% (Table 1). In all age groups, the prevalence of
disabilities was higher among boys than girls; this sex-specific
difference was greatest in the 6-14-year age group.
     The condition most frequently reported as a cause of
functional limitation among children aged less than or equal to 17
years was learning disability (29.5%), followed by speech problems
(13.1%), mental retardation (6.8%), asthma (6.4%), and mental or
emotional problems or disorders (6.3%) (Table 2).
Reported by: JM McNeil, Bur of the Census, Economics and Statistics
Administration, US Dept of Commerce. Disabilities Prevention
Program; Developmental Disabilities Br, Div of Birth Defects and
Developmental Disabilities, National Center for Environmental
Health; Behavioral Risk Factor Surveillance Br, Office of
Surveillance and Analysis, National Center for Chronic Disease
Prevention and Health Promotion, CDC.
Editorial Note: In the United States, the impact of disabilities is
disproportionately higher among children because disabilities with
onset during childhood account for approximately one third of the
years of disability*** in the U.S. population (4). Improved
characterization of the magnitude and distribution of disabilities
among children is important to identify needed services and to
target appropriate interventions. The findings in this report
further document age and sex variations in the prevalence of
disabilities among children. The increase in the prevalence of
disabilities with advancing age probably reflects the ability to
identify more readily academic or behavioral limitations among
older children and variations in the way educational systems
identify children limited in the ability to do regular school work
(5). Reasons for sex-specific differences are unclear and require
further study.
     The approach used in this report to estimate the prevalence of
disabilities was based on limitations in function resulting from
chronic conditions rather than on the diagnosis of such conditions.
Previous studies may have underestimated the prevalence of
disabilities among children because the definitions were restricted
to certain conditions (6). To improve the precision of estimates of
disability, the SIPP definitions were broadened to include the
functional consequences of chronic conditions. The inclusion of
these functional limitations enables more accurate estimates of the
prevalence of disabilities. However, the SIPP data are subject to
at least two limitations. First, because children living in
institutions or group homes were excluded from the study, the
prevalence of disabilities among children probably is
underestimated. Second, age-group-specific variations in the
definitions of disability limit the basis for comparison across age
groups.
     In SIPP, health conditions associated with disabilities
comprise a combination of diseases (e.g., asthma or diabetes),
impairments (e.g., missing extremities or paralysis), and primary
conditions considered to be disabilities (e.g., mental retardation
or cerebral palsy). Efforts to improve the precision of national
estimates of disabilities among children should distinguish between
those impairments, disabilities, and handicaps that are
consequences of the disabling process. One such effort is the 1999
revision of the ICIDH, which will emphasize measures of disability
and handicap among children (7) and assist in standardizing
collection of information about disabilities among children.
     Improved estimates of the prevalence of disabilities and their
associated health consequences among children are needed to develop
and evaluate prevention strategies. Estimates based on analysis of
data from SIPP can assist public health planners in identifying
primary services for children with disabilities and in projecting
long-range needs of these children. In addition, the linking of
data about primary disabling conditions among children with the
functional consequences of these conditions enables more precise
estimation of costs required to meet the continuing needs of these
children.
References
1. McNeil JM. Americans with disabilities, 1991-1992. Washington,
DC: US Department of Commerce, Economics and Statistics
Administration, Bureau of the Census, 1993. (Current population
reports; series p70, no. 33).
2. CDC. Prevalence of disabilities and associated health
conditions. MMWR 1994;43:730-1,737-9.
3. World Health Organization. International classification of
impairments, disabilities, and handicaps. Geneva: World Health
Organization, 1980.
4. Houk VN, Thacker SB. Program to prevent primary and secondary
disabilities in the United States. Public Health Rep 1989;104:226-31.
5. US Department of Education. 11th Annual report to Congress on
the implementation of the Individuals with Disability Education
Act. Washington, DC: US Department of Education, Office of Special
Education and Rehabilitative Services, Office of Special Education
Programs, 1989.
6. Verbrugge LM. The disability supplement to the 1994-95 National
Health Interview Survey (NHIS-Disability). Hyattsville, Maryland:
US Department of Health and Human Services, Public Health Service,
CDC, NCHS, 1993.
7. Badley EM. An introduction to the concepts and classifications
of the International Classification of Impairments, Disabilities,
and Handicaps. Disabil Rehabil 1993;15:161-78.

* Based on the ICIDH, an impairment is an abnormality of an organ
system, a disability is a person's limitation in function resulting
from an impairment, and a handicap is the social consequence(s) or
disadvantage(s) resulting from impairment and disability that a
person experiences while interacting in the physical and social
environment.
** Ability to 1) "get around inside the home"; 2) "get in and out
of bed or a chair"; 3) "take a bath or shower, dress, and eat;" and
4) "get to and use the toilet."
*** Years of disability are calculated by multiplying the number of
persons with new cases of disabilities by the expected lifespan of
each person with a disability per year. Because years of disability
reflect both prevalence and duration of disability, it is useful in
assessing the impact of preventive interventions.


------------------------------

To: hicnews

   State and National Vaccination Coverage Levels Among Children Aged
          19-35 Months -- United States, April-December 1994

     The National Immunization Survey (NIS) is a single survey
providing state and national estimates of vaccination coverage
levels among children aged 19-35 months. CDC implemented the NIS in
April 1994 as one element of the five-part Childhood Immunization
Initiative (CII) (1), a national strategy to achieve and maintain
high vaccination levels among children during the first 2 years of
life. NIS collects quarterly data from the 50 states, the District
of Columbia, and 27 urban areas considered to have populations at
high risk for undervaccination. This report of initial NIS findings
provides the results of both national and state vaccination
coverage levels for April-December 1994.
     The NIS uses a two-phase sample design. For the first phase,
a quarterly random sample of telephone numbers for each survey area
is called, and a screening questionnaire is administered to locate
households with one or more children aged 19-35 months. Vaccination
information is collected for age-eligible children. All respondents
are requested to refer to written records. During April-December
1994, approximately 1.2 million telephone numbers were called, and
25,247 interviews were completed (an average of 110 interviews per
area per quarter). The overall response rate for eligible
households was 71% (range: 60%-88% among the individual states).
     In the second phase, vaccination information is requested from
health-care providers of children in surveyed households because
parents tend to underestimate the number of doses received for
multiple-dose vaccines and to overestimate coverage for single-dose
vaccines (2,3). Households excluded from phase two include those
that use records indicating their children received all of the
recommended doses for at least four vaccines* because such recorded
histories are highly accurate (CDC, unpublished data, 1995). Based
on these exclusions, 18,479 (73%) households were eligible for
phase two. Of these, vaccination information was obtained from
providers for 7594 (41%) children. The demographic characteristics
and the reported vaccination histories were similar for children in
households with provider information and households with parental
reports only.
     Overall, 57% of the children in the survey had either written
records of having received all of the required doses for at least
four vaccines, or had vaccination information based on provider
records. The data obtained from provider records were used to
improve the accuracy of the vaccination coverage estimates for the
entire sample. Standard two-phase estimation procedures (4) were
used to estimate vaccination coverage for each surveyed area. The
estimates were adjusted using natality data to create a weighted
sample representative of children aged 19-35 months in the United
States; in addition, adjustments were made for nonresponse and for
exclusion of households without a telephone to account for the
finding that children in households without telephones are less
likely to be vaccinated than children in households with a
telephone (CDC, unpublished data, 1995) (5).
     Based on the NIS, among children who were born during May
1991-May 1993 and who were aged 19-35 months (median: 27 months)
when surveyed, estimated vaccination coverage was 75% (confidence
interval [CI]= plus or minus 1.2%) for receipt of at least four
doses of diphtheria and tetanus toxoids and pertussis vaccine
(DTP), three doses of poliovirus vaccine, and one dose of
measles-mumps-rubella vaccine (MMR) (4:3:1 series) (Table 1).
However, except for hepatitis B, coverage levels for each of the
vaccines individually were substantially higher: coverage with
three or more doses of DTP was greater than 90%; coverage for one
dose of MMR, three or more doses of polio, and three or more doses
of Haemophilus influenzae type B vaccine (Hib) ranged from 83% to
89%. The lower overall coverage for the 4:3:1 series was accounted
for primarily by low coverage for the fourth dose of DTP (77%).
     State-specific estimated coverage levels for the 4:3:1 series
ranged from 61% (CI= plus or minus 6.2%) to 88% (CI= plus or minus
4.6%) (Table 2). Coverage levels were less than 65% in three
states, greater than or equal to 85% in three states, and were
higher in the northeastern and southeastern regions (Figure 1).
     To assess the validity of estimates from the NIS, findings
were compared with previously reported data from the National
Health Interview Survey (NHIS) (6,7), a national household survey
of the U.S. civilian, noninstitutionalized population. For January-June 
1994,
NHIS data had been
supplemented with provider
information in the same manner as in the NIS survey. The estimated
coverage level of 75% in the NIS survey was similar to the 72%
estimate obtained from the NHIS, and vaccine coverage levels for
each individual vaccine (except for hepatitis B) were nearly
identical (Table 1). In addition, estimates of vaccination coverage
derived independently by selected states for 1994 were similar to
those reported in the NIS (CDC, unpublished data, 1995).
Reported by: National Center for Health Statistics; Assessment Br,
Data Management Div, National Immunization Program, CDC.
Editorial Note: The NIS data provide the first current,
population-based, state-specific estimates of vaccination coverage
produced by a standard methodology for the United States. These
findings enable valid comparisons of state efforts to deliver
vaccination services. The NIS has obtained the most reliable
estimates of vaccination coverage through the use of health-care
provider records and the use of data from the NHIS to adjust for
households without telephones. The estimate of the coverage for the
4:3:1 series based on NIS (75%) was substantially higher than that
previously reported through the NHIS (67%), probably reflecting
improvements in the accuracy of both NIS and NHIS data with the
inclusion of information from providers rather than a true increase
in coverage. CDC will continue to assess and improve the quality of
national vaccination data.
     The vaccination coverage rates reported in the NIS and in
recent reports from the NHIS are the highest ever recorded in the
United States. In particular, the findings in the NIS indicate that

_
                                    

the CII goal for 90% coverage with three doses of DTP was exceeded,
and that the 90% coverage goals for polio, measles, and Hib were
nearly attained (1). Coverage for hepatitis B, the vaccine most
recently added to the pediatric schedule, was the lowest because
many children were born before the recommendations for vaccination
were made.
     Coverage for four doses of DTP is the lowest of the three
vaccines included in the combined series. The Advisory Committee on
Immunization Practices recently reaffirmed its recommendation for
a fourth dose of DTP for all children aged 12-18 months (8).
Efforts to ensure timely administration of the fourth dose of DTP
vaccine must be intensified to further reduce the incidence of
pertussis and should include simultaneous administration with other
vaccines recommended for children aged 12-18 months.
     The substantial variation in state-specific coverage levels
for the 4:3:1 series underscores the need for vaccination efforts
targeted at children aged less than 2 years; in addition, more than
one million children still lack one or more doses of the
recommended vaccines. One of the national health objectives for the
year 2000 is to achieve series-complete coverage for at least 90%
of 2-year-old children for all recommended vaccines** (objective
20.11) (9). Implementation of the five-part CII strategy will be
essential to meet this goal and to build a national system that
maintains high coverage levels.
     Potential limitations of NIS include the possible biases
associated with exclusion of households without telephones,
household nonresponse, and inaccurate reporting from households and
small sample sizes for some states. An adjustment for exclusion of
households without telephones was made to account for findings in
the 1992-1993 NHIS that coverage levels for the 4:3:1 series are
approximately 10 percentage points lower among children in
households without telephones (CDC, unpublished data, 1995).
Although provider information was not available for all children,
those children whose providers were not included in the survey were
similar to children whose provider was included, suggesting that
use of provider data did not introduce a bias. In addition,
estimates based on small sample sizes have a larger variance;
future analyses will include data for four quarters, thereby
reducing the size of the sampling error.
     CDC will use the NIS, with data from the NHIS, to evaluate
progress toward national vaccination goals and, because of the
comparability of the information in the NIS, to identify states
with the highest rates (whose programs may be models for other
states) and states with lower rates (which may need special
attention). These coverage estimates are being used to distribute
$33 million in incentive funds, with the greatest funding per fully
vaccinated child to states that achieve the highest levels of
coverage.
References
1. CDC. Reported vaccine-preventable diseases--United States, 1993,
and the Childhood Immunization Initiative. MMWR 1994;43:57-60.
2. Goldstein KP, Kviz FJ, Daum RS. Accuracy of immunization
histories provided by adults accompanying preschool children to a
pediatric emergency department. JAMA 1993;270:2190-4.
3. Valadez JJ, Weld LH. Maternal recall error of child vaccination
status in a developing nation. Am J Public Health 1992:82:120-2.
4. Cochran WG. Double sampling. In: Cochran WG. Sampling
techniques. 3rd ed. New York: John Wiley & Sons, Inc, 1977:327-58.
5. Massey JT, Botman SL. Weighting adjustments for random digit
dialed surveys. In: Groves RM, Biemer PP, Lyberg LE, Massey JT,
Nicholls WL, Waksberg J. Telephone survey methodology. New York:
John Wiley & Sons, Inc, 1988:143-60.
6. CDC. Vaccination coverage of 2-year-old children--United States,
January-March, 1994. MMWR 1995:44:142-3,149-50.
7. CDC. Vaccination coverage levels among children aged 19-35
months--United States, April-June 1994. MMWR 1995:44:396-8.
8. CDC. Recommended childhood immunization schedule--United States,
1995. MMWR 1995; 44(no. RR-5).
9. Public Health Service. Healthy people 2000: national health
promotion and disease prevention objectives--full report, with
commentary. Washington, DC: US Department of Health and Human
Services, Public Health Service, 1991; DHHS publication no.
(PHS)91-50212.

* Vaccines in this series include four doses of diphtheria and
tetanus toxoids and pertussis vaccine (DTP), three doses of
poliovirus vaccine, one dose of measles-mumps-rubella vaccine
(MMR), and three doses of Haemophilus influenzae type B vaccine
(Hib). Children may or may not have received three doses of
hepatitis B vaccine.
** Series-complete coverage of all currently recommended vaccines
include four doses of DTP, three doses of polio, one dose of MMR,
and three doses each of Hib and hepatitis B vaccine.


------------------------------

End of HICNet Medical News Digest V08 Issue #29
***********************************************


---
Editor, HICNet Medical Newsletter
Internet: david@stat.com                 FAX: +1 (602) 451-6135

                                                                      
