Mediation effect of pregnancy-induced hypertension on the association between assisted reproductive technology and adverse neonatal outcomes: a population-based study.

BACKGROUND: Assisted reproductive technology (ART) has been widely used in the treatment of infertility, and is associated with adverse maternal and neonatal outcomes. However, the potential pathways by which ART affects adverse neonatal outcomes are unclear. We aimed to investigate the role of pregnancy-induced hypertension (PIH) in the association between ART and adverse neonatal outcomes. METHODS: Adult women (aged ≥ 18 years) with a singleton pregnancy in the National Vital Statistics System (NVSS) 2020 were enrolled in this retrospective cohort study. Study outcomes were adverse neonatal outcomes, including premature birth, low birth weight, and admission to the neonatal intensive care unit (NICU). Logistic regression models were utilized to investigate the association between ART, PIH, and adverse neonatal outcomes, expressed as odds ratio (OR) and 95% confidence interval (CI). The distribution-of-the-product method was used to explore whether there was a mediating effect of PIH between ART and adverse neonatal outcomes, and the 95% CI of the distribution-of-the-product did not contain 0 indicating a mediating effect. RESULTS: This study included 2,824,418 women, of whom 35,020 (1.24%) women used ART, 239,588 (8.48%) women had PIH, and 424,741 (15.04%) neonates had any adverse neonatal outcomes. The use of ART was associated with higher odds of PIH (OR = 1.42; 95%CI: 1.37-1.46) and any adverse neonatal outcomes (OR = 1.47; 95%CI: 1.43-1.51). The distribution-of-the-product was 0.31 (95%CI: 0.28-0.34), and 8.51% of the association between ART and adverse neonatal outcomes was mediated through PIH. Among different adverse neonatal outcomes, PIH mediated 29.17% of the association between ART and low birth weight, 9.37% of the association between ART and premature birth, and 12.20% of the association between ART and NICU admission. The mediating effect of PIH was found in women of different ages (< 35 years and ≥ 35 years) and parities (primipara and multipara). CONCLUSION: This study supports a mediating role for PIH in the association between ART and adverse neonatal outcomes. Further studies are needed to determine the mechanisms by which AR affects PIH so that interventions to reduce PIH can be developed to reduce adverse neonatal outcomes associated with ART.

Rural-Urban Differences in Maternal Mortality Trends in the United States, 1999-2017: Accounting for the Impact of the Pregnancy Status Checkbox.

It has been difficult to measure rural-urban differences in maternal mortality ratios (MMRs) in the United States in recent years because of the incremental adoption of a pregnancy status checkbox on the standard US death certificate. Using 1999-2017 mortality and birth data, we examined the impact of the pregnancy checkbox on MMRs according to urbanicity of residence (large urban area, medium/small urban area, or rural area), using log-binomial regression models to predict trends that would have been observed if all states had adopted the checkbox as of 1999. Implementation of the checkbox resulted in an average estimated increase of 7.5 maternal deaths per 100,000 live births (95% confidence interval (CI): 6.3, 8.8) in large urban areas (a 76% increase), 11.6 (95% CI: 9.6, 13.6) in medium/small urban areas (a 113% increase), and 16.6 (95% CI: 12.9, 20.3) in rural areas (a 107% increase), compared with MMRs prior to the checkbox. Assuming that all states had the checkbox as of 1999, demographic-factor-adjusted predicted MMRs increased in rural areas, declined in large urban areas, and did not change in medium/small urban areas. However, trends and urban-rural differences were substantially attenuated when analyses were limited to direct/specific causes of maternal death, which are probably subject to less misclassification. Accurate ascertainment of maternal deaths, particularly in rural areas, is important for reducing disparities in maternal mortality.

Trends in mortality in hepatitis C infection and alcoholic liver disease based on drug overdose in the United States.

We examined trends in mortality from hepatitis C virus (HCV) infection and alcoholic liver disease (ALD) in the setting of drug overdose. Using US Census and national mortality records (2009-2018), we identified deaths with HCV infection, ALD and drug overdose. HCV-related mortality without drug overdose increased up to 2014, followed by a marked decrease. Mortality from HCV and drug overdose increased significantly. Whereas ALD-related mortality without drug overdose continued to rise, no significant trend from ALD with drug overdose was noted. HCV-related mortalities reduced after the introduction of DAA agents, while drug overdose-related mortality in HCV was constantly increased.

Annual report to the nation on the status of cancer, part I: National cancer statistics.

BACKGROUND: The American Cancer Society, the Centers for Disease Control and Prevention, the National Cancer Institute, and the North American Association of Central Cancer Registries collaborate to provide annual updates on cancer occurrence and trends in the United States. METHODS: Data on new cancer diagnoses during 2001 through 2016 were obtained from the Centers for Disease Control and Prevention-funded and National Cancer Institute-funded population-based cancer registry programs and compiled by the North American Association of Central Cancer Registries. Data on cancer deaths during 2001 through 2017 were obtained from the National Center for Health Statistics' National Vital Statistics System. Trends in incidence and death rates for all cancers combined and for the leading cancer types by sex, racial/ethnic group, and age were estimated by joinpoint analysis and characterized by the average annual percent change during the most recent 5 years (2012-2016 for incidence and 2013-2017 for mortality). RESULTS: Overall, cancer incidence rates decreased 0.6% on average per year during 2012 through 2016, but trends differed by sex, racial/ethnic group, and cancer type. Among males, cancer incidence rates were stable overall and among non-Hispanic white males but decreased in other racial/ethnic groups; rates increased for 5 of the 17 most common cancers, were stable for 7 cancers (including prostate), and decreased for 5 cancers (including lung and bronchus [lung] and colorectal). Among females, cancer incidence rates increased during 2012 to 2016 in all racial/ethnic groups, increasing on average 0.2% per year; rates increased for 8 of the 18 most common cancers (including breast), were stable for 6 cancers (including colorectal), and decreased for 4 cancers (including lung). Overall, cancer death rates decreased 1.5% on average per year during 2013 to 2017, decreasing 1.8% per year among males and 1.4% per year among females. During 2013 to 2017, cancer death rates decreased for all cancers combined among both males and females in each racial/ethnic group, for 11 of the 19 most common cancers among males (including lung and colorectal), and for 14 of the 20 most common cancers among females (including lung, colorectal, and breast). The largest declines in death rates were observed for melanoma of the skin (decreasing 6.1% per year among males and 6.3% among females) and lung (decreasing 4.8% per year among males and 3.7% among females). Among children younger than 15 years, cancer incidence rates increased an average of 0.8% per year during 2012 to 2016, and cancer death rates decreased an average of 1.4% per year during 2013 to 2017. Among adolescents and young adults aged 15 to 39 years, cancer incidence rates increased an average of 0.9% per year during 2012 to 2016, and cancer death rates decreased an average of 1.0% per year during 2013 to 2017. CONCLUSIONS: Although overall cancer death rates continue to decline, incidence rates are leveling off among males and are increasing slightly among females. These trends reflect population changes in cancer risk factors, screening test use, diagnostic practices, and treatment advances. Many cancers can be prevented or treated effectively if they are found early. Population-based cancer incidence and mortality data can be used to inform efforts to decrease the cancer burden in the United States and regularly monitor progress toward goals.

Annual Report to the Nation on the Status of Cancer, part I: National cancer statistics.

BACKGROUND: The American Cancer Society (ACS), the Centers for Disease Control and Prevention (CDC), the National Cancer Institute (NCI), and the North American Association of Central Cancer Registries (NAACCR) collaborate to provide annual updates on cancer occurrence and trends in the United States. METHODS: Incidence data were obtained from the CDC-funded and NCI-funded population-based cancer registry programs and compiled by NAACCR. Data on cancer deaths were obtained from the National Center for Health Statistics National Vital Statistics System. Trends in age-standardized incidence and death rates for all cancers combined and for the leading cancer types by sex, race, and ethnicity were estimated by joinpoint analysis and expressed as the annual percent change. Stage distribution and 5-year survival by stage at diagnosis were calculated for breast cancer, colon and rectum (colorectal) cancer, lung and bronchus cancer, and melanoma of the skin. RESULTS: Overall cancer incidence rates from 2008 to 2014 decreased by 2.2% per year among men but were stable among women. Overall cancer death rates from 1999 to 2015 decreased by 1.8% per year among men and by 1.4% per year among women. Among men, incidence rates during the most recent 5-year period (2010-2014) decreased for 7 of the 17 most common cancer types, and death rates (2011-2015) decreased for 11 of the 18 most common types. Among women, incidence rates declined for 7 of the 18 most common cancers, and death rates declined for 14 of the 20 most common cancers. Death rates decreased for cancer sites, including lung and bronchus (men and women), colorectal (men and women), female breast, and prostate. Death rates increased for cancers of the liver (men and women); pancreas (men and women); brain and other nervous system (men and women); oral cavity and pharynx (men only); soft tissue, including heart (men only); nonmelanoma skin (men only); and uterus. Incidence and death rates were higher among men than among women for all racial and ethnic groups. For all cancer sites combined, black men and white women had the highest incidence rates compared with other racial groups, and black men and black women had the highest death rates compared with other racial groups. Non-Hispanic men and women had higher incidence and mortality rates than those of Hispanic ethnicity. Five-year survival for cases diagnosed from 2007 through 2013 ranged from 100% (stage I) to 26.5% (stage IV) for female breast cancer, from 88.1% (stage I) to 12.6% (stage IV) for colorectal cancer, from 55.1% (stage I) to 4.2% (stage IV) for lung and bronchus cancer, and from 99.5% (stage I) to 16% (stage IV) for melanoma of the skin. Among children, overall cancer incidence rates increased by 0.8% per year from 2010 to 2014, and overall cancer death rates decreased by 1.5% per year from 2011 to 2015. CONCLUSIONS: For all cancer sites combined, cancer incidence rates decreased among men but were stable among women. Overall, there continue to be significant declines in cancer death rates among both men and women. Differences in rates and trends by race and ethnic group remain. Progress in reducing cancer mortality has not occurred for all sites. Examining stage distribution and 5-year survival by stage highlights the potential benefits associated with early detection and treatment. Cancer 2018;124:2785-2800. © 2018 American Cancer Society.

Estimation of State-Level Prevalence of Hepatitis C Virus Infection, US States and District of Columbia, 2010.

BACKGROUND.: Hepatitis C virus (HCV) infection is the most common chronic blood-borne infection in the United States and a leading cause of morbidity and mortality. Previous analyses of the US National Health and Nutrition Examination Survey (NHANES) indicated approximately 3.6 million noninstitutionalized persons with antibody to HCV (anti-HCV). However, state-level prevalence remains less understood and cannot be estimated reliably from NHANES alone. METHODS.: We used 3 publicly available government data sources to estimate anti-HCV prevalence in each US state among noninstitutionalized persons aged ≥18 years. A small-area estimation model combined indirect standardization of NHANES-based prevalence with logistic regression modeling of mortality data, listing acute or chronic HCV infection as a cause of death, from the National Vital Statistics System during 1999-2012. Model results were combined with US Census population sizes to estimate total number and prevalence of persons with antibody to HCV in 2010. RESULTS.: National anti-HCV prevalence was 1.67% (95% confidence interval [CI], 1.53-1.90), or 3 911 800 (95% CI, 3 589 400- 4 447 500) adults in 2010. State-specific prevalence ranged from 0.71% (Illinois) to 3.34% (Oklahoma). The West census region had the highest region-specific prevalence (2.14% [95% CI, 1.96-2.48]); 10 of 13 states had rates above the national average. The South had the highest number of persons with anti-HCV (n = 1561600 [95% CI, 1 427 700-1 768 900]). The Midwest had the lowest region-specific prevalence (1.14% [95% CI, 1.04%-1.30%]). CONCLUSIONS.: States in the US West and South have been most impacted by hepatitis C. Estimates of HCV infection burden are essential to guide policy and programs to optimally prevent, detect, and cure infection.

Incidence and lifetime costs of injuries in the United States.

BACKGROUND: Standardized methodologies for assessing economic burden of injury at the national or international level do not exist. OBJECTIVE: To measure national incidence, medical costs, and productivity losses of medically treated injuries using the most recent data available in the United States, as a case study for similarly developed countries undertaking economic burden analyses. METHOD: The authors combined several data sets to estimate the incidence of fatal and non-fatal injuries in 2000. They computed unit medical and productivity costs and multiplied these costs by corresponding incidence estimates to yield total lifetime costs of injuries occurring in 2000. MAIN OUTCOME MEASURES: Incidence, medical costs, productivity losses, and total costs for injuries stratified by age group, sex, and mechanism. RESULTS: More than 50 million Americans experienced a medically treated injury in 2000, resulting in lifetime costs of $406 billion; $80 billion for medical treatment and $326 billion for lost productivity. Males had a 20% higher rate of injury than females. Injuries resulting from falls or being struck by/against an object accounted for more than 44% of injuries. The rate of medically treated injuries declined by 15% from 1985 to 2000 in the US. For those aged 0-44, the incidence rate of injuries declined by more than 20%; while persons aged 75 and older experienced a 20% increase. CONCLUSIONS: These national burden estimates provide unequivocal evidence of the large health and financial burden of injuries. This study can serve as a template for other countries or be used in intercountry comparisons.

Estimated Number of Injection-Involved Overdose Deaths in US States From 2000 to 2020: Secondary Analysis of Surveillance Data.

BACKGROUND: In the United States, both drug overdose mortality and injection-involved drug overdose mortality have increased nationally over the past 25 years. Despite documented geographic differences in overdose mortality and substances implicated in overdose mortality trends, injection-involved overdose mortality has not been summarized at a subnational level. OBJECTIVE: We aimed to estimate the annual number of injection-involved overdose deaths in each US state from 2000 to 2020. METHODS: We conducted a stratified analysis that used data from drug treatment admissions (Treatment Episodes Data Set-Admissions; TEDS-A) and the National Vital Statistics System (NVSS) to estimate state-specific percentages of reported drug overdose deaths that were injection-involved from 2000 to 2020. TEDS-A collects data on the route of administration and the type of substance used upon treatment admission. We used these data to calculate the percentage of reported injections for each drug type by demographic group (race or ethnicity, sex, and age group), year, and state. Additionally, using NVSS mortality data, the annual number of overdose deaths involving selected drug types was identified by the following specific multiple-cause-of-death codes: heroin or synthetic opioids other than methadone (T40.1, T40.4), natural or semisynthetic opioids and methadone (T40.2, T40.3), cocaine (T40.5), psychostimulants with abuse potential (T43.6), sedatives (T42.3, T42.4), and others (T36-T59.0). We used the probabilities of injection with the annual number of overdose deaths, by year, primary substance, and demographic groups to estimate the number of overdose deaths that were injection-involved. RESULTS: In 2020, there were 91,071 overdose deaths among adults recorded in the United States, and 93.1% (84,753/91,071) occurred in the 46 jurisdictions that reported data to TEDS-A. Slightly less than half (38,253/84,753, 45.1%; 95% CI 41.1%-49.8%) of those overdose deaths were estimated to be injection-involved, translating to 38,253 (95% CI 34,839-42,181) injection-involved overdose deaths in 2020. There was large variation among states in the estimated injection-involved overdose death rate (median 14.72, range 5.45-31.77 per 100,000 people). The national injection-involved overdose death rate increased by 323% (95% CI 255%-391%) from 2010 (3.78, 95% CI 3.33-4.31) to 2020 (15.97, 95% CI 14.55-17.61). States in which the estimated injection-involved overdose death rate increased faster than the national average were disproportionately concentrated in the Northeast region. CONCLUSIONS: Although overdose mortality and injection-involved overdose mortality have increased dramatically across the country, these trends have been more pronounced in some regions. A better understanding of state-level trends in injection-involved mortality can inform the prioritization of public health strategies that aim to reduce overdose mortality and prevent downstream consequences of injection drug use.

Eclampsia, in vitro fertilization and the risk of preterm birth: a retrospective cohort study based on 2,880,759 samples.

Background: Eclampsia and in vitro fertilization (IVF) are independent risk factors for preterm birth. Understanding the combined effects of multiple risk factors for preterm birth is critical to making accurate and personalized risk predictions. This study aimed to explore the interaction between eclampsia and IVF on the risk of preterm birth. Methods: A total of 2,880,759 eligible participants from Birth Data Files in the National Vital Statistics System (NVSS) database 2019 were enrolled in this retrospective cohort study. Some characteristics were collected, such as maternal age, prepregnancy body mass index (BMI), history of preterm birth, paternal age, race, newborn sex. Preterm birth was defined as <37 weeks gestation. Univariate and multivariate logistic regression models were utilized to assess the associations between eclampsia, IVF and preterm birth. The odds ratio (OR) and 95% confidence interval (CI) were calculated in this study. Relative excess risk due to interaction (RERI), attributable proportion (AP) and synergy index (S) were adopted to evaluate the interaction between eclampsia and IVF on the risk of preterm birth. Results: The age of mothers and fathers, the number of multiple births, the proportion of mothers with a history of preterm birth, pregnancy infections, eclampsia and IVF among the preterm birth group were all higher than those among the non-preterm birth group. The incidence of preterm birth in eclampsia and IVF population was approximately 37.31% and 22.96%, separately. After adjusting some covariates, subjects with both eclampsia and IVF had a higher risk of preterm birth (OR =9.197, 95% CI: 6.795-12.448, P<0.001). Furthermore, the results (RERI =3.426, 95% CI: 0.639-6.213, AP=0.374, 95% CI: 0.182-0.565, S =1.723, 95% CI: 1.222-2.428) suggested that the interaction between eclampsia and IVF on preterm birth was statistically significant, indicating a synergistic interaction. Conclusions: Eclampsia and IVF might interact in a synergistic manner to increase the risk of preterm birth. Awareness of the risk profile associated with preterm birth is crucial for pregnant woman with IVF to implement dietary and lifestyle modifications.

Drugs and Drug Classes Involved in Overdose Deaths Among Females, United States: 1999-2017.

Background: Drug overdose deaths among U.S. women have risen steadily from 1999 to 2017, especially among certain ages. Various studies report involvement of drugs and drug classes in overdose deaths. Less is known, however, regarding the combinations that are most often indicated on death certificates, particularly among females. Analyzing mutually, exclusive drug/drug class combinations listed on death certificates of females are the objective of this study. Materials and Methods: Mortality data for U.S. female residents were obtained from the 1999 to 2017 National Vital Statistics System (n = 260,782). Analyses included deaths with an underlying cause of death based on International Classification of Diseases, 10th Revision (ICD-10) codes for drug overdoses. The drug/drug class involved included individual 4-digit ICD-10 codes in the range T36.0-T50.9, including poisoning deaths due to all drugs, excluding alcohol. Years from 1999 to 2017 were grouped in six 3-year categories with the most recent year (2017) left separate for analysis. All drug overdose deaths were analyzed in mutually exclusive categories. Results: From 1999 to 2017, the top-listed drug/drug class overall and by year grouping was solely "other and unspecified drugs, medicaments and biological substances"; however, that listing dropped from 25.8% from the 1999 to 2001 period to 14.1% in 2017. Overall, the next most frequent single drug/drug class mentions were "natural and semisynthetic opioids" (20,951; 8.0%) and "cocaine" (10,882; 4.2%). Two of the top five drug/drug class combinations included benzodiazepines ("natural and semisynthetic opioids"/"benzodiazepines" and "methadone"/"benzodiazepines"). Conclusions: Analyzing trends in drugs and drug classes involved in female drug overdose deaths is a critical foundation for developing gender-responsive public health interventions. Reducing high-risk drug use by improving prescribing practices, preventing drug use initiation, and addressing use of multiple drugs can help prevent overdose deaths.

Assessing state level variation in signature authority and cause of death accuracy, 2005-2017.

This study utilized a convergent mixed-methods design to examine whether variation in death certificate certifier type predicts the accuracy of cause of death reporting in the US. We analyzed the content of state statutes, amendments, and policies concerning cause of death signature authority in 2005-2017 to create the Cause of Death Signature Authority (CoDSA) database. After merging the CoDSA data with 2005-2017 National Vital Statistics System Multiple Cause of Death Mortality files for adults with cerebral palsy (CP) (N = 29,996), we employed logistic regression models to determine the likelihood that different certifier groups made one particular type of death certification error - inaccurately reporting CP as the underlying cause of death (UCOD). The content analysis provided evidence of significant liberalization of cause of death signature authority, with 23 states expanding signature authority to include physician extenders. Logistic regression analysis revealed differences in UCOD accuracy based on certifier type. Compared to medical examiners, the likelihood of CP being reported as the UCOD, was: 41% higher (CI 1.12, 1.78) for coroners; 25% higher (1.05, 1.49) for mixed-system death investigators; 24% higher (1.08, 1.42) for physicians; and 16% higher (1.00, 1.34) for physician extenders. Inaccuracies limit public health efforts aimed at improving the health and longevity for disadvantaged populations, such as people with CP. Poor performance among cause of death certifiers may indicate systemic problems with death certification that should be addressed with more robust training for all professional groups with signature authority.

Trends in Infant Mortality in the United States, 2005-2014.

KEY FINDINGS: Infant mortality is considered a basic measure of public health for countries around the world (1-3). Over the past decade, the overall infant mortality rate in the United States has improved, declining 15% from 6.86 infant deaths per 1,000 live births in 2005-a recent high-to 5.82 in 2014 (4). Over the years, many efforts have been made to understand and lower infant mortality (4,5). This report examines the 2014 linked birth/infant death data from the National Vital Statistics System (NVSS) to describe trends in infant mortality in the United States by race and Hispanic origin, state, and leading causes of infant deaths from 2005 through 2014.

Drug Overdose Deaths in the United States, 1999-2015.

KEY FINDINGS: Key findings Data from the National Vital Statistics System, Mortality ● The age-adjusted rate of drug overdose deaths in the United States in 2015 (16.3 per 100,000) was more than 2.5 times the rate in 1999 (6.1). ● Drug overdose death rates increased for all age groups, with the greatest percentage increase among adults aged 55-64 (from 4.2 per 100,000 in 1999 to 21.8 in 2015). In 2015, adults aged 45-54 had the highest rate (30.0). ● In 2015, the age-adjusted rate of drug overdose deaths among non-Hispanic white persons (21.1 per 100,000) was nearly 3.5 times the rate in 1999 (6.2). ● The four states with the highest age-adjusted drug overdose death rates in 2015 were West Virginia (41.5), New Hampshire (34.3), Kentucky (29.9), and Ohio (29.9). ● In 2015, the percentage of drug overdose deaths involving heroin (25%) was triple the percentage in 2010 (8%). Deaths from drug overdose have been identified as a significant public health burden in the United States in recent years (1-4). This report uses data from the National Vital Statistics System (NVSS) to highlight recent trends in drug overdose deaths, describing demographic and geographic patterns as well as the types of drugs involved.

Mortality in the United States, 2015.

KEY FINDINGS: Data from the National Vital Statistics System, Mortality •Life expectancy for the U.S. population in 2015 was 78.8 years, a decrease of 0.1 year from 2014. •The age-adjusted death rate increased 1.2% from 724.6 deaths per 100,000 standard population in 2014 to 733.1 in 2015. •The 10 leading causes of death in 2015 remained the same as in 2014. Age-adjusted death rates increased for eight leading causes and decreased for one. •The infant mortality rate of 589.5 infant deaths per 100,000 live births in 2015 was not significantly different from the 2014 rate. •The 10 leading causes of infant death in 2015 remained the same as in 2014, although two causes exchanged ranks. This report presents 2015 U.S. final mortality data on deaths and death rates by demographic and medical characteristics. These data provide information on mortality patterns among U.S. residents by variables such as sex, race and ethnicity, and cause of death. Life expectancy estimates, age-adjusted death rates by race and ethnicity and sex, 10 leading causes of death, and 10 leading causes of infant death were analyzed by comparing 2015 and 2014 final data (1).

Teen Birth Rates for Urban and Rural Areas in the United States, 2007-2015.

KEY FINDINGS: Data from the National Vital Statistics System •Birth rates for teenagers aged 15-19 declined in urban and rural counties from 2007 through 2015, with the largest declines in large urban counties and the smallest declines in rural counties. •From 2007 through 2015, the teen birth rate was lowest in large urban counties and highest in rural counties. •Declines in teen birth rates in all urban counties between 2007 and 2015 were largest in Arizona, Massachusetts, Connecticut, Minnesota, and Colorado, with 17 states experiencing a decline of 50% or more. •Declines in teen birth rates in all rural counties between 2007 and 2015 were largest (50% or more) in Colorado and Connecticut. •In 2015, teen birth rates were highest in rural counties and lowest in large urban counties for non-Hispanic white, non-Hispanic black, and Hispanic females. Teen birth rates have demonstrated an unprecedented decline in the United States since 2007 (1). Declines occurred in all states and among all major racial and Hispanic-origin groups, yet disparities by both geography and demographic characteristics persist (2,3). Although teen birth rates and related declines have been described by state, patterns by urban-rural location have not yet been examined. This report describes trends in teen birth rates in urban (metropolitan) and rural (nonmetropolitan) areas in the United States overall and by state from 2007 through 2015 and by race and Hispanic origin for 2015.

Cause of Fetal Death: Data From the Fetal Death Report, 2014.

Objectives-This report presents, for the first time, data on cause of fetal death by selected characteristics such as maternal age, Hispanic origin and race, fetal sex, period of gestation, and birthweight. Methods-Descriptive tabulations of data collected on the 2003 U.S. Standard Report of Fetal Death are presented for fetal deaths occurring at 20 weeks of gestation or more in a reporting area of 35 states, New York City, and the District of Columbia. This area represents 66% of fetal deaths in the United States. Causes of death are processed in accordance with the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision. Final data for 2014 are reported. Results-Five selected causes account for about 90% of fetal deaths in the reporting area: Fetal death of unspecified cause; Fetus affected by complications of placenta, cord and membranes; Fetus affected by maternal complications of pregnancy; Congenital malformations, deformations and chromosomal abnormalities; and Fetus affected by maternal conditions that may be unrelated to present pregnancy. Conclusions-Cause-of-fetal-death data reported on vital records are not subject to tightly controlled study protocols, but they provide data for a larger proportion of the country than other studies. While there was limited variation among the selected causes across the maternal and fetal characteristics examined, many variations observed are consistent with associations that have been documented in research literature.

Using Literal Text From the Death Certificate to Enhance Mortality Statistics: Characterizing Drug Involvement in Deaths.

Objectives-This report describes the development and use of a method for analyzing the literal text from death certificates to enhance national mortality statistics on drug-involved deaths. Drug-involved deaths include drug overdose deaths as well as other deaths where, according to death certificate literal text, drugs were associated with or contributed to the death. Methods-The method uses final National Vital Statistics System-Mortality files linked to electronic files containing literal text information from death certificates. Software programs were designed to search the literal text from three fields of the death certificate (the cause of death from Part I, significant conditions contributing to the death from Part II, and a description of how the injury occurred from Box 43) to identify drug mentions as well as contextual information. The list of drug search terms was developed from existing drug classification systems as well as from manual review of the literal text. Literal text surrounding the identified drug search terms was analyzed to ascertain the context. Drugs mentioned in the death certificate literal text were assumed to be involved in the death unless contextual information suggested otherwise (e.g., "METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS INFECTION"). The literal text analysis method was assessed by comparing the results from application of the method with results based on ICD-10 codes, and by conducting a manual review of a sample of records.

Drugs Most Frequently Involved in Drug Overdose Deaths: United States, 2010-2014.

Objectives-This report identifies the specific drugs most frequently involved in drug overdose deaths in the United States from 2010 through 2014. Methods-The 2010-2014 National Vital Statistics System mortality files were linked to electronic files containing literal text information from death certificates. Drug overdose was defined using the International Classification of Diseases, Tenth Revision underlying cause-of-death codes X40-X44 (unintentional), X60-X64 (suicide), X85 (homicide), and Y10-Y14 (undetermined intent). Among deaths with an underlying cause of death of drug overdose, the literal text in three fields of the death certificate (i.e., the cause of death from Part I, significant conditions contributing to death from Part II, and a description of how the injury occurred from Box 43) were searched to identify drug mentions. Search term lists were developed using existing drug classification systems as well as from manual review of the literal text. The search term list was then used to identify the specific drugs involved in overdose deaths. Descriptive statistics were reported for drug overdose deaths involving the 10 most frequently mentioned drugs on death certificates. Tables and figures presenting information on the specific drugs involved in deaths are based on deaths with mention of at least one specific drug on the death certificate. Results-From 2010 through 2014, the number of drug overdose deaths per year increased 23%, from 38,329 in 2010 to 47,055 in 2014. During this time period, the percentage of drug overdose deaths involving at least one specific drug increased, from 67% in 2010 to 78% in 2014. Among drug overdose deaths with at least one drug specified on the death certificate, the 10 drugs most frequently involved in overdose deaths included the following opioids: heroin, oxycodone, methadone, morphine, hydrocodone, and fentanyl; the following benzodiazepines: alprazolam and diazepam; and the following stimulants: cocaine and methamphetamine. During this 5-year period, the age-adjusted rate of drug overdose deaths involving heroin more than tripled, and the rate of drug overdose deaths involving methamphetamine more than doubled. The rate of drug overdose deaths involving fentanyl more than doubled in a single year (from 2013 to 2014). In 2014, of the 36,667 drug overdose deaths involving at least one specific drug, 52% of these deaths specified one drug, 38% specified two or three drugs, and 11% specified four or more drugs. Conclusions-Analysis of the literal text from death certificates can be used to identify patterns in the specific drugs most frequently involved in drug overdose deaths. From 2010 through 2014, the top 10 drugs involved were the same, but the relative ranking and age-adjusted rates for deaths involving these drugs changed. Literal text analysis also revealed that many drug overdose deaths involved multiple drugs. Findings should be interpreted in light of the improvement in the quality of the data that resulted from better reporting of specific drugs on death certificates from 2010 through 2014. Relative increases in the death rates involving specific drugs and the rankings of these drugs may be affected by improvements in reporting, real increases in the numbers of death, or both.