Infant and maternal risk factors related to necrotising enterocolitis-associated infant death in the United States.

AIM: To evaluate necrotising enterocolitis (NEC)-associated infant death and identify risk factors related to NEC infant death in the United States. METHODS: The United States Period Linked Birth/Infant Death data for 2010-2013 were utilised to determine risk factors associated with NEC infant death. Infant mortality rates (IMRs) were calculated and a retrospective matched case-control analysis was performed. An infant case was defined as having the International Classification of Diseases, Tenth Revision code for NEC listed on the death record. Controls were matched on birthweight and randomly selected. Conditional multivariable logistic regression models stratified by birthweight were conducted to determine risk factors for NEC infant death. RESULTS: The average annual NEC IMR was 12.5 deaths per 100 000 live births and was higher among very low birthweight (VLBW) compared to normal birthweight infants and among black compared to white infants. For VLBW infants, the multivariable analysis identified male sex, five-minute Apgar score of less than 7, and white infants born to a mother who is less than or equal to 19 years of age to be related with NEC-associated infant death. CONCLUSION: Paediatricians should be aware of the factors related to NEC-associated infant death to reduce the number of infants at greatest risk for NEC and focus on racial disparities.

Incidence and prevalence of Parkinson's disease among Navajo people living in the Navajo nation.

Parkinson's disease (PD) is largely unstudied among American Indians. Unique populations might harbor clues to elusive causes. We describe the incidence and prevalence of PD among Navajo people residing in the Navajo Nation, home to the largest American Indian tribe in the United States. We analyzed 2001-2011 inpatient and outpatient visit data for Navajo people obtained from the Indian Health Service, which provides health care to American Indian people living on the Navajo Reservation. Cases were defined by at least two inpatient or outpatient visits with the diagnosis of PD. Crude and age-adjusted incidence and prevalence rates were calculated overall as well as by age, sex, region of residence, and time period. Five hundred twenty-four Navajo people with median age-at-onset of 74.0 years were diagnosed with PD during the study period, yielding an average annual crude incidence rate of 22.5/100,000. Age-specific incidence was 232.0 for patients 65 years of age or older and 302.0 for 80 years of age or older. Age-adjusted incidence was 35.9 overall (238.1 for ≥65 years), was higher in men than in women (47.5 vs. 27.7; P<0.001), varied by region (P=0.03), and was similar between time periods (2002-2004 vs. 2009-2011). The age-adjusted point prevalence rate was 261.0. The rate of PD among Navajo People appears to be as high as or higher than rates reported in many other populations. Rates increased to the highest age group, consistent with population-based studies. Further investigation is warranted to examine risk factors for PD in this remote population.

Recurrent Kawasaki disease: USA and Japan.

BACKGROUND: Descriptive epidemiologic studies of recurrent and non-recurrent Kawasaki disease (KD) may identify other potentially important differences between these illnesses. METHODS: Data from the USA and Japan, the Centers for Disease Control and Prevention (CDC) national KD surveillance(1984-2008) and the 17th Japanese nationwide survey (2001-2002), respectively, were analyzed to examine recurrent KD patients <18 years of age meeting the CDC KD case or atypical KD case definition. These patients were compared with non-recurrent KD patients. RESULTS: Of the 5557 US KD patients <18 years of age during 1984-2008, 97 (1.7%) were identified as having had recurrent KD. Among the US Asian/Pacific Islander KD patients, 3.5% had recurrent KD, which was similar to the percentage identified among KD patients (3.5%) in the Japanese survey. Compared with non-recurrent KD patients, KD patients [with recurrent KD] were more likely to be older, fulfill the atypical KD case definition, and have coronary artery abnormalities (CAA) despite i.v. immunoglobulin (IVIG) treatment. CONCLUSIONS: Differences in the age, race, and frequency of CAA exist between recurrent and non-recurrent KD patients. The increased association of CAA with recurrent KD suggests that more aggressive treatment strategies in conjunction with IVIG may be indicated for the second episode of KD.

Leptospirosis-associated hospitalizations, United States, 1998-2009.

A small percentage of persons with leptospirosis, a reemerging zoonosis, experience severe complications that require hospitalization. The number of leptospirosis cases in the United States is unknown. Thus, to estimate the hospitalization rate for this disease, we analyzed US hospital discharge records for 1998-2009 for the total US population by using the Nationwide Inpatient Sample. During that time, the average annual rate of leptospirosis-associated hospitalizations was 0.6 hospitalizations/1,000,000 population. Leptospirosis-associated hospitalization rates were higher for persons >20 years of age and for male patients. For leptospirosis-associated hospitalizations, the average age of patients at admission was lower, the average length of stay for patients was longer, and hospital charges were higher than those for nonleptospirosis infectious disease-associated hospitalizations. Educating clinicians on the signs and symptoms of leptospirosis may result in earlier diagnosis and treatment and, thereby, reduced disease severity and hospitalization costs.

Trends in encephalitis-associated deaths in the United States, 1999-2008.

BACKGROUND: While encephalitis may be caused by numerous infectious, immune and toxic processes, the etiology often remains unknown. METHODS: We analyzed multiple cause-of-death mortality data during 1999-2008 for the USA, using the 10th revision of International Classification of Diseases codes for encephalitis, listed anywhere on the death record, including 'specified' and 'unspecified' encephalitis. Annual and average annual age-adjusted and age-specific death rates were calculated. RESULTS: For 1999-2008, 12,526 encephalitis-associated deaths were reported with 68.5% as unspecified encephalitis. The average annual age-adjusted encephalitis-associated death rate was 4.3 per 1 million persons, 1.3 for specified and 2.9 for unspecified encephalitis. Annual encephalitis-associated death rates had a significant downward trend (p < 0.01). The most common specified encephalitis deaths were herpesviral encephalitis (36.7%), Toxoplasma meningoencephalitis (27.8%) and Listeria meningitis/meningoencephaltis (6.8%). HIV was colisted with 15.0% of encephalitis-associated deaths, 58.4% of these with a specified code. CONCLUSION: Encephalitis-associated death rates decreased during 1999-2008, and herpesvirus was the most commonly identified infectious agent associated with encephalitis deaths. The high proportion of unspecified encephalitis deaths highlights the continued challenge of laboratory confirmation for causes of encephalitis and the importance of monitoring trends to assess the impact of new diagnostics and guide potential interventions.

Infectious disease mortality among American Indians and Alaska Natives, 1999-2009.

OBJECTIVES: We described death rates and leading causes of death caused by infectious diseases (IDs) in American Indian/Alaska Native (AI/AN) persons. Methods. We analyzed national mortality data, adjusted for AI/AN race by linkage with Indian Health Service registration records, for all US counties and Contract Health Service Delivery Area (CHSDA) counties. The average annual 1999 to 2009 ID death rates per 100,000 persons for AI/AN persons were compared with corresponding rates for Whites. RESULTS: The ID death rate in AI/AN populations was significantly higher than that of Whites. A reported 8429 ID deaths (rate 86.2) in CHSDA counties occurred among AI/AN persons; the rate was significantly higher than the rate in Whites (44.0; rate ratio [RR] = 1.96; 95% confidence interval [CI] = 1.91, 2.00). The rates for the top 10 ID underlying causes of death were significantly higher for AI/AN persons than those for Whites. Lower respiratory tract infection and septicemia were the top-ranked causes. The greatest relative rate disparity was for tuberculosis (RR = 13.51; 95% CI = 11.36, 15.93). CONCLUSIONS: Health equity might be furthered by expansion of interventions to reduce IDs among AI/AN communities.

American Indian and Alaska Native infant and pediatric mortality, United States, 1999-2009.

OBJECTIVES: We described American Indian/Alaska Native (AI/AN) infant and pediatric death rates and leading causes of death. METHODS: We adjusted National Vital Statistics System mortality data for AI/AN racial misclassification by linkage with Indian Health Service (IHS) registration records. We determined average annual death rates and leading causes of death for 1999 to 2009 for AI/AN versus White infants and children. We limited the analysis to IHS Contract Health Service Delivery Area counties. RESULTS: The AI/AN infant death rate was 914 (rate ratio [RR] = 1.61; 95% confidence interval [CI] = 1.55, 1.67). Sudden infant death syndrome, unintentional injuries, and influenza or pneumonia were more common in AI/AN versus White infants. The overall AI/AN pediatric death rates were 69.6 for ages 1 to 4 years (RR = 2.56; 95% CI = 2.38, 2.75), 28.9 for ages 5 to 9 years (RR = 2.12; 95% CI = 1.92, 2.34), 37.3 for ages 10 to 14 years (RR = 2.22; 95% CI = 2.04, 2.40), and 158.4 for ages 15 to 19 years (RR = 2.71; 95% CI = 2.60, 2.82). Unintentional injuries and suicide occurred at higher rates among AI/AN youths versus White youths. CONCLUSIONS: Death rates for AI/AN infants and children were higher than for Whites, with regional disparities. Several leading causes of death in the AI/AN pediatric population are potentially preventable.

Efficacy of tecovirimat (ST-246) in nonhuman primates infected with variola virus (Smallpox).

Naturally occurring smallpox has been eradicated but remains a considerable threat as a biowarfare/bioterrorist weapon (F. Fleck, Bull. World Health Organ. 81:917-918, 2003). While effective, the smallpox vaccine is currently not recommended for routine use in the general public due to safety concerns (http://www.bt.cdc.gov/agent/smallpox/vaccination). Safe and effective countermeasures, particularly those effective after exposure to smallpox, are needed. Currently, SIGA Technologies is developing the small-molecule oral drug, tecovirimat (previously known as ST-246), as a postexposure therapeutic treatment of orthopoxvirus disease, including smallpox. Tecovirimat has been shown to be efficacious in preventing lethal orthopoxviral disease in numerous animal models (G. Yang, D. C. Pevear, M. H. Davies, M. S. Collett, T. Bailey, et al., J. Virol. 79:13139-13149, 2005; D. C. Quenelle, R. M. Buller, S. Parker, K. A. Keith, D. E. Hruby, et al., Antimicrob. Agents Chemother., 51:689-695, 2007; E. Sbrana, R. Jordan, D. E. Hruby, R. I. Mateo, S. Y. Xiao, et al., Am. J. Trop. Med. Hyg. 76:768-773, 2007). Furthermore, in clinical trials thus far, the drug appears to be safe, with a good pharmacokinetic profile. In this study, the efficacy of tecovirimat was evaluated in both a prelesional and postlesional setting in nonhuman primates challenged intravenously with 1 × 10(8) PFU of Variola virus (VARV; the causative agent of smallpox), a model for smallpox disease in humans. Following challenge, 50% of placebo-treated controls succumbed to infection, while all tecovirimat-treated animals survived regardless of whether treatment was started at 2 or 4 days postinfection. In addition, tecovirimat treatment resulted in dramatic reductions in dermal lesion counts, oropharyngeal virus shedding, and viral DNA circulating in the blood. Although clinical disease was evident in tecovirimat-treated animals, it was generally very mild and appeared to resolve earlier than in placebo-treated controls that survived infection. Tecovirimat appears to be an effective smallpox therapeutic in nonhuman primates, suggesting that it is reasonably likely to provide therapeutic benefit in smallpox-infected humans.

Unexplained death due to possible infectious diseases in infants-United States, 2006.

OBJECTIVES: To quantify and examine factors related to unexplained death due to possible infectious causes (UDPIC) in infants and to analyze the associations between these factors in unexplained deaths and infants with fatal and nonfatal outcomes. STUDY DESIGN: Infant deaths meeting the International Classification of Diseases, Tenth Revision code inclusion and exclusion criteria for UDPIC were selected from the 2006 US Linked Birth and Infant Death data set. Two control groups of surviving and nonsurviving infants were selected and compared with the infants with UDPIC using a case-control study design with multivariate logistic regression models stratified by birth weight category. Comparisons with infants with identified infectious causes of death were also made. RESULTS: During 2006, 3570 infant deaths (12.5% of all US infant deaths) were categorized as a UDPIC. The highest rates for these unexplained infants deaths were found in blacks and American Indians/Alaska Natives. Infants of black mothers were more likely to experience UDPIC. Birth weight was a significant effect modifier in these models. CONCLUSIONS: Many factors may contribute to an infant's death being classified as a UDPIC, including race and marital status. Other factors, such as Hispanic ethnicity and maternal age, also may play a role. Infant characteristics, such as birth weight, may be related to factors that influence the decision not to conduct a postmortem examination in infant death cases. Additional research is needed to determine the true extent of infectious disease and its relationship to UDPIC in infants.

Dog bite injuries among American Indian and Alaska Native children.

OBJECTIVE: To examine dog bites among American Indian (AI) and Alaska Native (AN) children visiting Indian Health Service and tribal health facilities. STUDY DESIGN: We retrospectively analyzed hospitalizations and outpatient visits with a diagnosis of dog bite between 2001 and 2008 in AI/AN children aged <20 years. Rates of dog bite hospitalizations and outpatient visits were estimated by age group, sex, region, and number and location of open wounds using Indian Health Service data. Analyses of hospitalizations for the general US population aged<20 years used the Nationwide Inpatient Sample. RESULTS: The average annual dog bite hospitalization rate was higher among AI/AN children in Alaska (6.1/100,000 population) and the Southwest region (5.3/100,000) compared with the general US child population (3.1/100,000; 95% CI, 2.9-3.3/100,000). The average annual outpatient visit rate in AI/AN children was highest in the Alaska (596.4/100,000), Southwest (540.0/100,000), and Northern Plains West (537.6/100,000) regions. The hospitalization rate was highest in both AI/AN and US males aged<5 years, and outpatient visit rates were highest in AI/AN males aged 5-9 years. Open wounds diagnoses were most commonly seen on the head, neck, and face in hospitalized children (45.5% of open wounds in AI/AN children, 59.3% in US children; SE, 1.0%) and on the leg in AI/AN outpatients (35.6%). CONCLUSION: Dog bites represent a significant public health threat in AI/AN children in the Alaska, the Southwest, and Northern Plains West regions of the US. Enhanced animal control and education efforts should reduce dog bite injuries and associated problems with pets and stray dogs, such as emerging infectious diseases.

Evaluation of clinical characteristics of Kawasaki syndrome and risk factors for coronary artery abnormalities among children in Denmark.

AIM: To examine clinical characteristics, treatment and outcome of Kawasaki syndrome patients in Denmark. METHODS: A retrospective chart review of hospitalization records for children <15 years of age with a Kawasaki syndrome discharge diagnosis identified through the Danish National Patient Registry during 1994 through June 2008 was conducted. RESULTS: A total of 284 cases <15 years of age were identified as Kawasaki syndrome (n = 279) and atypical Kawasaki syndrome (n = 5); 70.4% were <5 years of age and 64.4% were male. Most patients (91.5%; 258/282) were treated with intravenous immunoglobulin and 74.6% of these patients (191/256) received intravenous immunoglobulin before the 10th day of illness. A total of 37 (13.3%) Kawasaki syndrome patients were diagnosed with coronary artery abnormalities. Not receiving intravenous immunoglobulin treatment before the 10th day of illness, young age and male sex were significantly associated with the development of coronary artery abnormalities. CONCLUSIONS: In Denmark, more than one in 10 children with Kawasaki syndrome develop coronary artery abnormalities. Physicians should increase their index of suspicion for early diagnosis and treatment of Kawasaki syndrome among patients susceptible to increased risk of coronary artery abnormalities, particularly in infants who may have a more atypical presentation of the illness.

Myocardial injury and bacterial pneumonia contribute to the pathogenesis of fatal influenza B virus infection.

BACKGROUND: Influenza B virus infection causes rates of hospitalization and influenza-associated pneumonia similar to seasonal influenza A virus infection and accounts for a substantial percentage of all influenza-related hospitalizations and deaths among those aged <18 years; however, the pathogenesis of fatal influenza B virus infection is poorly described. METHODS: Tissue samples obtained at autopsy from 45 case patients with fatal influenza B virus infection were evaluated by light microscopy and immunohistochemical assays for influenza B virus, various bacterial pathogens, and complement components C4d and C9, to identify the cellular tropism of influenza B virus, characterize concomitant bacterial pneumonia, and describe the spectrum of cardiopulmonary injury. RESULTS: Viral antigens were localized to ciliated respiratory epithelium and cells of submucosal glands and ducts. Concomitant bacterial pneumonia, caused predominantly by Staphylococcus aureus, was identified in 38% of case patients and occurred with significantly greater frequency in those aged >18 years. Pathologic evidence of myocardial injury was identified in 69% of case patients for whom cardiac tissue samples were available for examination, predominantly in case patients aged <18 years. CONCLUSIONS: Our findings suggest that bacterial pneumonia and cardiac injury contribute to fatal outcomes after infection with influenza B virus and that the frequency of these manifestations may be age related.

Determinants for autopsy after unexplained deaths possibly resulting from infectious causes, United States.

We analyzed US multiple cause-of-death data for 2003-2006 for demographic and clinical determinants for autopsy in unexplained deaths possibly resulting from infectious causes. For 96,242 deaths, the definition for unexplained death was met and autopsy status was recorded. Most decedents were male, 40-49 years of age, and white. To identify factors associated with unexplained death, we used data from Arizona records. Multivariate analysis of Arizona records suggested that decedents of races other than white and black and decedents who had clinicopathologic syndromes in the cardiovascular, sepsis/shock, and multisyndrome categories recorded on the death certificate were least likely to have undergone autopsy; children with unexplained death were the most likely to have undergone autopsy. Improved understanding of unexplained deaths can provide opportunities for further studies, strengthen collaboration between investigators of unexplained deaths, and improve knowledge and awareness of infectious diseases of public health concern.

Community survey after rabies outbreaks, Flagstaff, Arizona, USA.

Flagstaff, Arizona, USA, experienced notable outbreaks of rabies caused by a bat rabies virus variant in carnivore species in 2001, 2004, 2005, 2008, and 2009. The most recent epizootic involved transmission among skunk and fox populations and human exposures. Multiple, wide-ranging control efforts and health communications outreach were instituted in 2009, including a household survey given to community members. Although the Flagstaff community is knowledgeable about rabies and the ongoing outbreaks in general, gaps in knowledge about routes of exposure and potential hosts remain. Future educational efforts should include messages on the dangers of animal translocation and a focus on veterinarians and physicians as valuable sources for outreach. These results will be useful to communities experiencing rabies outbreaks as well as those at current risk.

Trends in lower respiratory tract infection hospitalizations among American Indian/Alaska Native children and the general US child population.

OBJECTIVE: To describe trends in the rate of hospitalization for lower respiratory tract infection (LRTI) among American Indian/Alaska Native (AI/AN) children and the general US population of children aged <5 years. STUDY DESIGN: This was a retrospective analysis of trends and hospitalization rates for LRTI-associated hospitalizations in 1998-2008 among AI/AN children aged <5 years using the Indian Health Service direct/contract inpatient data, and also among the general population of US children aged <5 years using the Nationwide Inpatient Sample. RESULTS: The 2006-2008 LRTI-associated hospitalization rate for AI/AN children aged <5 years (21.8 per 1000/year) was 32% lower than the 1998-1999 rate, and 1.6-fold higher than the general US children rate (13.8 per 1000/year; 95% CI, 12.8-14.8). Higher rates were seen in AI/AN children aged <5 years in the Alaska and the Southwest regions of the United States (41.2 and 28.0 per 1000/year, respectively). In infants, these rates were 136.4 and 82.4 per 1000/year, respectively, exceeding the rate in the general US infant population (37.1 per 1000/year; 95% CI, 34.3-40.0). The greatest disparity in the LRTI-associated hospitalization rate between AI/AN infants and the general US infant population was seen for pneumonia, with a 3-fold higher rate in AI/AN infants (36.2 per 1000/year vs 12.7 per 1000/year; 95% CI, 11.8-13.6). CONCLUSION: The LRTI-associated hospitalization rate is higher in AI/AN children, particularly infants from Alaska and the American Southwest, compared with the general US child population. Closing this gap will require addressing housing and sanitation inequities and ensuring high immunization rates and access to care.

Parkinson's disease among American Indians and Alaska natives: a nationwide prevalence study.

BACKGROUND: The objective of this study was to determine the prevalence of Parkinson's disease (PD) among American Indian and Alaska Native (AI/AN) people. METHODS: We analyzed records for AI/AN people between 2002 and 2009 using inpatient and outpatient visit data from the Indian Health Service. Crude and age-adjusted prevalence, using the 2000 projected US population as the standard, was determined overall and by age group, sex, period, and region. RESULTS: An estimated 2613 AI/AN people carried the diagnosis of PD (crude prevalence, 143.8/100,000). Prevalence increased with age through 84 years. The age-adjusted rate was 355.7 and was higher among men than women (P < .0001). Rates differed by region (P < .0001). CONCLUSIONS: Parkinson's disease is prevalent among AI/AN people. The prevalence increases with age, varies by geographic region, and is higher among men than women. Community-based studies are needed to define incidence, examine risk factors, and determine reasons for sex and regional differences in PD among AI/AN people.

Changing trends in viral hepatitis-associated hospitalizations in the American Indian/Alaska Native population, 1995-2007.

OBJECTIVE: We described the changing epidemiology of viral hepatitis among the American Indian/Alaska Native (AI/AN) population that uses Indian Health Service (IHS) health care. METHODS: We used hospital discharge data from the IHS National Patient Information Reporting System to determine rates of hepatitis A-, B-, and C-associated hospitalization among AI/ANs using IHS health care from 1995-2007 and summary periods 1995-1997 and 2005-2007. RESULTS: Hepatitis A-associated hospitalization rates among AI/AN people decreased from 4.9 per 100,000 population during 1995-1997 to 0.8 per 100,000 population during 2005-2007 (risk ratio [RR] = 0.2, 95% confidence interval [CI] 0.1, 0.2). While there was no significant change in the overall hepatitis B-associated hospitalization rate between time periods, the average annual rate in people aged 45-64 years increased by 109% (RR=2.1, 95% CI 1.4, 3.2). Between the two time periods, the hepatitis C-associated hospitalization rate rose from 13.0 to 55.0 per 100,000 population (RR=4.2, 95% CI 3.8, 4.7), an increase of 323%. The hepatitis C-associated hospitalization rate was highest among people aged 45-64 years, males, and those in the Alaska region. CONCLUSIONS: Hepatitis A has decreased to near-eradication levels among the AI/AN population using IHS health care. Hepatitis C-associated hospitalizations increased significantly; however, there was no significant change in hepatitis B-associated hospitalizations. Emphasis should be placed on continued universal childhood and adolescent hepatitis B vaccination and improved vaccination of high-risk adults. Prevention and education efforts should focus on decreasing hepatitis C risk behaviors and identifying people with hepatitis C infection so they may be referred for treatment.

Disparities in infectious disease hospitalizations for American Indian/ Alaska Native people.

OBJECTIVES: We described disparities in infectious disease (ID) hospitalizations for American Indian/Alaska Native (AI/AN) people. METHODS: We analyzed hospitalizations with an ID listed as the first discharge diagnosis in 1998-2006 for AI/AN people from the Indian Health Service National Patient Information Reporting System and compared them with records for the general U.S. population from the Nationwide Inpatient Survey. RESULTS: The ID hospitalization rate for AI/AN people declined during the study period. The 2004-2006 mean annual age-adjusted ID hospitalization rate for AI/AN people (1,708 per 100,000 populiation) was slightly higher than that for the U.S. population (1,610 per 100,000 population). The rate for AI/AN people was highest in the Southwest (2,314 per 100,000 population), Alaska (2,063 per 100,000 population), and Northern Plains West (1,957 per 100,000 population) regions, and among infants (9,315 per 100,000 population). ID hospitalizations accounted for approximately 22% of all AI/AN hospitalizations. Lower-respiratory-tract infections accounted for the largest proportion of ID hospitalizations among AI/AN people (35%) followed by skin and soft tissue infections (19%), and infections of the kidney, urinary tract, and bladder (11%). CONCLUSIONS: Although the ID hospitalization rate for AI/AN people has declined, it remains higher than that for the U.S. general population, and is highest in the Southwest, Northern Plains West, and Alaska regions. Lower-respiratory-tract infections; skin and soft tissue infections; and kidney, urinary tract, and bladder infections contributed most to these health disparities. Future prevention strategies should focus on high-risk regions and age groups, along with illnesses contributing to health disparities.

Trends in hospitalizations for peptic ulcer disease, United States, 1998-2005.

Infection with Helicobacter pylori increases the risk for peptic ulcer disease (PUD) and its complications. To determine whether hospitalization rates for PUD have declined since antimicrobial drugs to eradicate H. pylori became available, we examined 1998-2005 hospitalization records (using the Nationwide Inpatient Sample) in which the primary discharge diagnosis was PUD. Hospitalizations for which the diagnosis was H. pylori infection were also considered. The age-adjusted hospitalization rate for PUD decreased 21% from 71.1/100,000 population (95% confidence interval [CI] 68.9-73.4) in 1998 to 56.5/100,000 in 2005 (95% CI 54.6-58.3). The hospitalization rate for PUD was highest for adults > or =65 years of age and was higher for men than for women. The age-adjusted rate was lowest for whites and declined for all racial/ethnic groups, except Hispanics. The age-adjusted H. pylori hospitalization rate also decreased. The decrease in PUD hospitalization rates suggests that the incidence of complications caused by H. pylori infection has declined.