Structural vulnerabilities and PrEP awareness among Boston heterosexuals and people who inject drugs at risk for HIV: findings from 2018 to 2019 cycles from the Boston, MA site of the NHBS.

Little is known about biopsychosocial factors relating to pre-exposure prophylaxis (PrEP) awareness among people with either heterosexual or injection drug use HIV risk behaviors. Participants engaged in vaginal/anal sex with a person of the opposite sex (N = 515) or were people who injected drugs (PWID; N = 451) in the past 12 months from 2018-2019 in Boston, MA. We examined associations between PrEP awareness and: homelessness; perceived HIV-related stigma; country of birth; bacterial STDs, chlamydia, and/or gonorrhea in the past 12 months, lifetime hepatitis C virus (HCV) infection, sexual orientation, and poverty. More PWID (36.8%) were aware of PrEP than people with heterosexual HIV risk (28%; p = .001). Among people with heterosexual risk, homelessness (aOR = 1.99, p = .003), and among PWID: homelessness (aOR = 2.11, p = .032); bacterial STD (aOR = 2.96, p = .012); chlamydia (aOR = 6.14, p = .008); and HCV (aOR = 2.40, p < .001) were associated with increased likelihood of PrEP awareness. In the combined sample: homelessness (aOR = 2.25, p < .001); HCV (aOR = 2.18, p < .001); identifying as homosexual (aOR = 3.71, p = .036); and bisexual (aOR = 1.55, p = .016) were each associated with PrEP awareness. Although having an STD, HCV, identifying as homosexual or bisexual, and experiencing homelessness were associated with increased PrEP awareness, most participants were unaware of PrEP. Efforts to increase PrEP awareness could engage PWID and heterosexual HIV risk behavior.

Sampling for collection of central line-day denominators in surveillance of healthcare-associated bloodstream infections.

OBJECTIVE: To determine the feasibility of estimating the number of central line-days at a hospital from a sample of months or individual days in a year, for surveillance of healthcare-associated bloodstream infections. DESIGN: We used data reported to the National Nosocomial Infections Surveillance system in the adult and pediatric intensive care unit component for 1995-2003 and data from a sample of hospitals' daily counts of device use for 12 consecutive months. We calculated the percentile error as the central line-associated bloodstream infection percentile based on rates per line-days minus the percentile based on rates per estimated line-days. SETTING AND PARTICIPANTS: A total of 247 hospitals were used for sampling whole months and 12 hospitals were used for sampling individual days. RESULTS: For a 1-month sample of central line-days data, the median percentile error was 3.3 (75th percentile, 7.9; 90th percentile, 15.4). The percentile error decreased with an increase in the number of months sampled. For a 3-month sample, the median percentile error was 1.4 (75th percentile, 4.3; 95th percentile, 8.3). Sampling individual days throughout the year yielded lower percentile errors than sampling an equivalent fraction of whole months. With 1 weekday sampled per week, the median percentile error ranged from 0.65 to 1.40, and the 90th percentile ranged from 2.8 to 5.0. Thus, for 90% of units, collecting data on line-days once a week provides an estimate within +/-5 percentile points of the true line-day rate. CONCLUSION: Sample-based estimates of central line-days can yield results that are acceptable for surveillance of healthcare-associated bloodstream infections.

Tuberculosis in health care workers at a hospital with an outbreak of multidrug-resistant Mycobacterium tuberculosis.

OBJECTIVE: Investigate reports of tuberculosis in health care workers employed at a hospital with an outbreak of multidrug-resistant Mycobacterium tuberculosis. DESIGN: Case series of tuberculosis in health care workers, January 1, 1989, through May 31, 1992. Antimicrobial susceptibility testing and restriction fragment length polymorphism analysis of M tuberculosis isolates. Longitudinal analysis of cumulative tuberculin skin test surveillance data. Assessment of infection control. The patients consisted of 361 health care workers who had either serial tuberculin skin tests or tuberculosis. RESULTS: Six health care workers, the largest number linked to one multidrug-resistant tuberculosis outbreak, had disease due to M tuberculosis that matched the outbreak strain from hospitalized patients. The two who were seropositive for human immunodeficiency virus died, one of tuberculous meningitis and the other of multiple causes including tuberculosis. The estimated risk of a skin test conversion was positively associated with time and increased by a factor of 8.3 (1979 to 1992). In 1992 the annual risk for workers in the lowest exposure occupational group was 2.4%. In comparison, nurses and housekeepers had relative risks of 8.0 (95% confidence interval, 3.2 to 20.3) and 9.4 (95% confidence interval, 2.7 to 32.3), respectively. Laboratory workers had a relative risk of 4.2 (95% confidence interval, 1.1 to 15.5). Tuberculosis admissions increased, but the hospital had inadequate ventilation to isolate tuberculosis patients effectively. There were lapses in infection control practices. CONCLUSIONS: Health care workers who were exposed during a hospital outbreak of multidrug-resistant tuberculosis had occupationally acquired active disease. The human immunodeficiency virus-infected health care workers with tuberculosis had severe disease and died. The risk of skin test conversion increased during the study period, and higher exposure occupations had elevated risk. Effective infection control is essential to prevent the transmission of tuberculosis to health care workers.

The completeness, validity, and timeliness of AIDS surveillance data.

PURPOSE: To assess the completeness, validity, and timeliness of the AIDS surveillance system after the 1993 change in the surveillance case definition. METHODS: To assess completeness of AIDS case reporting, three study sites conducted a comparison of their AIDS surveillance registries with an independent source of information. To evaluate validity, the same sites conducted record reviews on a sample of reported AIDS cases, we then compared agreement between the original report and the record review for sex, race, and mode of transmission. To evaluate timeliness, we calculated the median delay from time of diagnosis to case report, before and after the change in case definition, in each of the three study sites. RESULTS: After expansion of the case definition, completeness of AIDS case reporting in hospitals (> or = 93%) and outpatient settings (> or = 90%) was high. Agreement between the information provided on the original case report and the medical record was > 98% for sex, > 83% for each race/ethnicity group; and > 67% for each risk group. The median reporting delay after the change was four months, but varied by site from three to six months. CONCLUSIONS: The completeness, validity, and timeliness of the AIDS surveillance system remains high after the 1993 change in the surveillance case definition. These findings might be useful for programs implementing integrated HIV and AIDS surveillance systems.

Characteristics of women with AIDS and invasive cervical cancer.

OBJECTIVE: To characterize women reported with AIDS and invasive cervical cancer in the first year of the expanded AIDS surveillance case definition. METHODS: Using X2 testing and logistic regression, we compared women with invasive cervical cancer with those having other AIDS-defining illnesses. RESULTS: Of the 16,794 women 13 years old or older and reported with AIDS in 1993, 217 (1.3%) had invasive cervical cancer and 9113 (54.3%) had other opportunistic illnesses; the remaining 7464 (44.4%) had no opportunistic illnesses and were reported based on immunologic criteria. Women with invasive cervical cancer were more likely to have had AIDS diagnosed before 1993 (73 and 56%, respectively; P < .01), to be younger (median age 33 and 35 years; P < .001), to be white (31 and 21%; P < .01), and to reside in the south (41 and 34%; P < .05). Among women reported with CD4+ counts, the median value was higher in 149 women with invasive cervical cancer than in the 5993 with other opportunistic illnesses (153 and 50 cells/microL, respectively). Women with invasive cervical cancer were more likely to report injection drug use (57 and 48%; P < .05). In multivariate analysis, Hispanic women were 0.6 times less likely to be reported with invasive cervical cancer than were white women (P < .05). Among women infected through injecting drug use, black women were 0.5 times less likely to be reported with invasive cervical cancer (P < .001). CONCLUSION: Hispanic and black women infected with HIV were less likely to be reported with invasive cervical cancer, a finding that may be associated with inadequate access to health care services. Women with invasive cervical cancer were less severely immunosuppressed than women with other AIDS opportunistic illnesses.

U.S. children living in and near poverty: risk of vaccine-preventable diseases.

BACKGROUND: Poverty and factors associated with poverty are strong and persistent barriers to childhood immunization. Substantive differences in coverage with basic vaccinations have been consistently observed over time between children living in poverty and those who are not. METHODS: The National Immunization Survey (NIS) uses a random-digit-dialing sample of telephone numbers in each state and in 28 urban areas. The NIS provides vaccination coverage information representative of all U.S. children aged 19 to 35 months. We categorized children in the NIS using Bureau of Census categories of poverty as follows: "above poverty" for household income > or = 125% of the federal poverty threshold for the household's size and composition; "near poverty," 100% to <125% of the poverty threshold; "intermediate poverty," 50% to <100% of the poverty threshold; and "severe poverty," <50% of the poverty threshold. We described coverage with basic vaccinations from 1996 through 1999 by poverty category and compare coverage between children in poverty and above poverty. RESULTS: From 1996 to 1999, estimated vaccination coverage with the basic vaccine series was consistently higher among children living above the poverty level than all other children. The difference in estimated vaccination coverage between children living in severe poverty and those living above poverty was 13.6 percentage points in 1996, and 10.0 percentage points in 1999. Vaccination coverage with the series 4:3:1:3 among children living in near poverty was similar to that of children living in poverty (74.7% vs 73.3%, p=0.52). Estimated vaccination coverage increased significantly (p<0.05) between 1996 and 1999 for most antigens among children living above poverty and among those living in intermediate and severe poverty. Vaccination coverage among children living in poverty increased significantly (p<0.05) between 1996 and 1999 in 1 of the 28 urban areas in the NIS. CONCLUSIONS: Low vaccination coverage among children living in and near poverty is a persistent problem in the United States. Additional efforts are needed to improve coverage.

Variation in vaccination coverage among children of Hispanic ancestry.

BACKGROUND: Estimated vaccination coverage of Hispanic children is consistently lower than that of white non-Hispanic children. "Hispanic ethnicity" defines a highly heterogeneous group of the U.S. population; however, vaccination coverage by ancestry group has not been studied. This study explores differences in vaccination coverage among Hispanic children by ancestry group. METHODS: The National Immunization Survey (NIS) uses a random-digit-dial sample of telephone numbers in each state and in 28 urban areas. The NIS provides vaccination coverage information representative of all U.S. children aged 19 to 35 months. We pooled NIS data from 1996 through 1999 and selected Hispanic and white non-Hispanic children for analysis. We categorized Hispanic children into the following ancestry groups: Mexican, Central American, Puerto Rican, Cuban, South American, and Dominican. We used t tests to detect differences in coverage between children of Hispanic ancestry, by group, compared to white non-Hispanic children, by vaccine, and the vaccination series 4:3:1:3. RESULTS: Estimated vaccination coverage with 4:3:1:3 was 80.1% (95% CI, 79.6-80.6) among white non-Hispanic children. Estimated coverage was lower among Puerto Rican (75.8%; 95% CI, 72.1-79.5), Cuban (73.1%; 95% CI, 65.1-81.1), Mexican (71.7%; 95% CI, 69.9-73.5), and Central American (68.7%; 95% CI, 62.0-75.4) children, and was higher among South American (82.0%; 95% CI, 75.5-88.5) and Dominican (82.2%; 95% CI, 75.5-88.5) children; however, these differences were only statistically significant for Puerto Rican, Mexican, and Central American children. Among children living in poverty, estimated coverage with 4:3:1:3 was lower among Mexican (68.0%; 95% CI, 65.1-70.9), Central American (69.7%; 95% CI, 59.8-79.6), and South American (69.0%; 95% CI, 50.9-87.1) children than among white non-Hispanic children (73.4%; 95% CI, 71.6-75.2); however, this difference was significant only among Mexican children. Coverage was similar or somewhat higher among Puerto Rican (72.9%; 95% CI, 65.7-80.1) and Dominican (80.2%; 95% CI, 68.5-91.9) children than white non-Hispanic children living below poverty. CONCLUSIONS: Findings from the NIS strongly suggest that estimated vaccination coverage among children of Hispanic ancestry varies by group. Improved monitoring of vaccination coverage among Hispanics by community is necessary, and where undervaccination is identified, interventions should be matched to community needs.

Special contribution: transforming a neighborhood health center into a community-oriented primary care practice.

We describe a community-oriented primary care (COPC) preventive medicine residency. Through the residency, medical, nursing, dental, and other health professionals work as fellows to combine clinical and public health skills in primary care practices. We describe the steps that fellows used to begin transforming one community health center into a COPC practice, and we highlight the activities of one specific environmental cleanliness project as an example. COPC activities have laid the foundation for further advances in developing a professional partnership between the center and the community it serves.

Knowledge of partner risk and secondary transmission of HIV.

BACKGROUND: The number and proportion of people living longer with HIV and the proportion of people infected heterosexually have increased. We measured the frequency with which people with heterosexually acquired AIDS knew their partners' risk behaviors, the extent of secondary heterosexual transmission of HIV, and characterized people at risk for secondary heterosexual transmission. METHODS: For each of five sites (Alabama, California, Florida, New Jersey, and Texas) and for New York City, a sample of adults with AIDS was interviewed. Primary heterosexual transmission was contact with a partner who had a known risk factor for HIV infection. Secondary transmission was contact with an HIV-positive partner not known to have a risk for HIV. RESULTS: Among men, 35% knew that a sexual partner was HIV infected, 56% of women knew that a sexual partner was HIV infected. Among women, 12% knew that a partner was bisexual. Overall, 79% (460 of 581) reported a partner with a primary risk for HIV; among men, 236 of 293 (81%), and among women, 224 of 288 (78%) reported a partner with a primary risk. People categorized with secondary transmission were significantly more likely to be black and never married. People categorized with secondary transmission were more frequently women (53%), had less than a high school education (48%), and a history of drug use (52%). Men categorized with secondary transmission of HIV had a mean of 22 heterosexual partners; women had a mean of 16 partners. CONCLUSIONS: We found that many heterosexuals with AIDS did not know their sexual partners' risk for HIV, and that secondary heterosexual transmission probably results in a small proportion of all AIDS cases in the U.S.

Vaccination visits in early childhood: just one more visit to be fully vaccinated.

BACKGROUND: This study characterizes the healthcare visits at which children receive vaccinations, including the number of these visits and the number of vaccinations that are administered. METHODS: The 1999 National Immunization Survey (NIS) is a nationally representative sample of children aged 19 to 35 months, verified by provider records, that is conducted to obtain estimates of vaccination coverage rates. We describe the number of healthcare visits in which one or more vaccinations were given, the number of vaccinations given at these visits, and the number of visits and vaccinations needed for an underimmunized child to complete the recommended vaccination series. RESULTS: Of the children who did not receive all doses of the recommended vaccinations (4:3:1:3:3 vaccination series), three fourths had four or more immunization visits. Vaccination coverage increased as the number of visits increased, and children who had completed the series were more likely to receive multiple vaccinations than those who had not. Most children (70.7%) received a maximum of four vaccinations in any immunization visit. The majority of children (73.5%) who had not completed the 4:3:1:3:3 vaccination series needed only a single visit to complete the series. The majority (61.7%) of children who needed only one visit also needed only one additional vaccination. CONCLUSIONS: While estimated national coverage for all recommended vaccinations is considerably below the Healthy People 2000 and Healthy People 2010 goal of 90%, achieving this goal is in essence just one visit away. If all children who needed one more visit were to receive that final visit, the national coverage among children 19 to 35 months for all recommended vaccinations would be 93%.

Vaccination status of children living in rural areas in the United States: are they protected?

OBJECTIVE: To estimate the vaccination coverage levels of children living in rural areas and identify statistically significant differences in coverage between children living in rural areas and their suburban and urban counterparts. METHODS: Children aged 19 to 35 months participating in the 1999 National Immunization Survey (NIS) were included in the study. Children were classified as living in a rural, urban, or suburban area based on their telephone exchange (area code plus the first three digits of the telephone number). Statistically significant differences in vaccination coverage levels between the rural population and their urban counterparts were determined for individual vaccines and vaccine series. RESULTS: Overall, 18% of the children included in the 1999 NIS lived in a rural area, 46% lived in a suburban area, and 36% lived in an urban area. The characteristics of the rural population were: 72% were white, non-Hispanic; 24% were below the poverty level; 16% had a mother with <12 years of education; and 30% received vaccinations from a public provider. Eighty percent of rural children, 79% of suburban children, and 77% of urban children completed the 4:3:1:3 series. The rural population had statistically significantly lower (p<0.01) varicella coverage levels than their suburban and urban counterparts. CONCLUSION: Results of this study suggest that children living in rural areas are just as likely to receive the basic 4:3:1:3 vaccination series as their suburban and urban counterparts. Uptake of the varicella vaccine appears to be slower in rural areas than urban areas. Further studies are recommended to identify the risk factors for not receiving the varicella vaccine in rural areas.

Undervaccinated African-American preschoolers: a case of missed opportunities.

OBJECTIVE: To identify factors associated with undervaccination of African-American preschoolers, to describe the number of vaccination visits made by undervaccinated children and the number of visits needed to be series complete, and to describe the children who did not receive the single dose of measles-containing vaccine recommended for preschoolers. METHODS: We used the 1999 National Immunization Survey (NIS) to describe vaccination coverage for the 4:3:1:3 vaccine series (four doses of diphtheria and tetanus toxoids and pertussis vaccine, three doses of poliovirus vaccine, one dose of any measles-containing vaccine, and three doses of Haemophilus influenzae type b vaccine) among non-Hispanic, African-American preschoolers due to concerns that they may be at risk of undervaccination. Children who did not complete this basic vaccine series were classified for further analysis according to the number of doses they lacked (i.e., one dose missed, two or three doses missed, or four or more doses missed). Significant associations between demographic characteristics and vaccination status or degree of undervaccination were determined. RESULTS: Of the 26.2% of African-American preschoolers who did not complete the 4:3:1:3 vaccine series, 40.3% lacked one, 35.3% lacked two or three, and 25.0% lacked four or more doses of vaccine. Children who did not complete the 4:3:1:3 vaccine series were less likely to have married mothers, were less likely to have mothers aged > or = 35 years, or were less likely to be up to date at age 3 months than the children who completed the 4:3:1:3 vaccine series. Among the undervaccinated, 63.7% had a sufficient number of vaccination visits to have completed the basic series. However, most (78.7%) of the severely undervaccinated (children who lacked more than three doses of vaccine) had three or fewer vaccination visits. For 72.6% of the undervaccinated preschoolers, only one additional vaccination visit was needed to complete the 4:3:1:3 vaccine series; among these, 78.3% had an adequate number of vaccination visits to have completed the series. Overall, 9.9% of the African-American children aged 19 to 35 months (i.e., approximately 85,000 African-American children aged 19 to 35 months) were at risk for measles. Among the children who lacked more than three doses of vaccine, 68.1% were at risk. CONCLUSIONS: Our study suggests that the estimated coverage of 73.8% for the 4:3:1:3 vaccine series among African-American children aged 19 to 35 months was not a result of limited access to care. On the contrary, 90.5% of African-American children had enough vaccination visits to complete the series. To raise coverage and prevent potential outbreaks, providers should assess each child's vaccination status at every visit, and administer all needed vaccinations at that time. For the most severely undervaccinated children, this strategy may not be adequate, because they did not have the minimum number of vaccination visits required for series completion. For these children, other strategies are needed for increasing vaccination coverage.

The association between veteran status and cigarette-smoking behaviors.

Although the prevalence of smoking has decreased since 1980 among active duty military personnel, it remains higher than among the adult civilian population; among military veterans, the prevalence of smoking has not been well described. The objectives of this study were to describe patterns of cigarette smoking behaviors among United States veterans and nonveterans and to examine the association between military veteran status and cigarette smoking. We analyzed data from a cross-sectional survey from a national probability sample of the civilian, noninstitutionalized adult population (National Health Interview Survey supplements). We estimated the prevalence of ever, current, and former smoking, as well as crude and adjusted odds ratios (AORs) of each outcome measure among veterans and nonveterans, by gender. The prevalence of ever smoking was 74.2% (+/- 0.7%) among veterans and 48.4% (+/- 0.5%) among nonveterans; current smoking prevalence was 33.9% (+/- 1.0%) among veterans and 27.7% (+/- 0.5%) among nonveterans. Among those who had not initiated smoking before the age of 18 years, veterans were more likely than nonveterans to report ever smoking (AOR = 1.8 for men and 1.9 for women) and current smoking (AOR = 1.9 for both men and women). After statistical adjustment, no difference was seen in cessation behavior. We concluded that the prevalence of ever and current smoking was higher among U.S. military veterans. The association was the strongest among veterans who had not initiated smoking before the age of 18 years. These findings are consistent with the hypothesis that military service is a risk factor for cigarette smoking, and they support the military's current prevention and cessation efforts.

Assessing the generalizability of smoking studies.

We used data from the 1986 Adult Use of Tobacco Survey, 10 studies of self-quitters and seven studies of treatment seekers, to illustrate how subpopulations of smokers might differ; e.g. treatment seekers vs. self-quitters and research volunteers vs. smokers in the general population. Smoking researchers may wish to use our results to determine whether their sample is similar to the population of interest.

Cigarette smoking: an independent risk factor for impotence?

The authors sought to determine whether current cigarette smoking was associated with impotence among middle-aged men. This is a secondary analysis of a cross-sectional survey of 4,462 US Army Vietnam-era veterans aged 31-49 years who took part in the Vietnam Experience Study in 1985-1986. The main outcome measurement was the odds ratio for reported impotence, which was calculated by comparing current smokers with nonsmokers while controlling for multiple confounders. The study sample consisted of 1,162 never smokers, 1,292 former smokers, and 2,008 current smokers. The prevalence of impotence was 2.2% among never smokers, 2.0% among former smokers, and 3.7% among current smokers (p = 0.005). The unadjusted odds ratio (OR) of the association between smoking and reported impotence was 1.8 (95% confidence interval (CI) 1.2-2.6). The association held even after adjustments were made for confounders, including vascular disease, psychiatric disease, hormonal factors, substance abuse, marital status, race, and age (OR = 1.5, 95% CI 1.0-2.2). Neither years smoked nor cigarettes smoked daily were significant predictors of impotence in current smokers. The authors concluded that, among the men in this study, a higher percentage of cigarette smokers reported impotence than did nonsmokers. This observation could not be totally explained by comorbidity factors related to smoking.

Vaccination coverage among children enrolled in Head Start programs or day care facilities or entering school.

PROBLEM/CONDITION: Undervaccinated children enrolled in day care centers and schools are vulnerable to outbreaks of vaccine-preventable diseases. A Healthy People 2000 objective is to increase to > or = 95% vaccination coverage among children attending licensed day care facilities and kindergarten through postsecondary school (objective 20.11). REPORTING PERIOD COVERED: September 1997-June 1998. DESCRIPTION OF SYSTEM: CDC's National Immunization Program administers grants to support 64 vaccination programs. These programs are in all 50 states, eight territories or jurisdictions (American Samoa, Republic of Marshall Islands, Federated States of Micronesia, Guam, Commonwealth of Northern Mariana Islands, Puerto Rico, Republic of Palau, and the U.S. Virgin Islands), five cities (Chicago, Houston, San Antonio, New York City, and Philadelphia), and the District of Columbia. Grant guidelines require annual school vaccination surveys and biennial surveys of Head Start programs and licensed day care facilities. This system constitutes the only source of nationally representative vaccination coverage estimates for these populations. RESULTS: Head Start Programs: Of the 64 reporting areas, 33 (51.6%) submitted coverage levels for children enrolled in Head Start programs. Of these, all 33 programs reported coverage levels for diphtheria and tetanus toxoids and pertussis vaccine (DTP), diphtheria and tetanus toxoids (DT), or tetanus toxoids (Td), poliovirus vaccine, and measles vaccine; and 32 reported coverage levels for mumps and rubella vaccines. Four programs reported coverage levels for the combined measles, mumps, and rubella vaccine (MMR). The mean vaccination coverage levels for the 1997-98 school year among the reporting vaccination programs were 97.8% for poliovirus vaccine (range: 80.0%-100.0%), 97.0% for DTP/DT/Td (range: 87.7%-100.0%), 93.3% for measles vaccine (range: 91.4%-100.0%), and 93.2% for mumps and rubella vaccines (range: 91.4%-100.0%). Licensed Day Care Facilities: Of the 63 reporting areas with licensed day care facilities, 38 (60.3%) submitted coverage levels for enrolled children. Of these, all 38 programs reported coverage levels for poliovirus vaccine and DTP/DT/Td, 37 reported coverage levels for measles vaccine, and 36 reported coverage levels for mumps and rubella vaccines. Four programs reported coverage levels for the combined MMR. The mean vaccination coverage levels among the reporting areas were 95.8% for poliovirus vaccine (range: 85.1%-99.8%), 95.7% for DTP/DT/Td (range: 77.6%-99.9%), 89.1% for measles vaccine (range: 78.0%-99.9%), and 89.1% for mumps and rubella vaccines (range: 78.0%-99.9%). Kindergarten/First Grade: Of the 64 reporting areas, 43 (67.2%) submitted coverage levels for children enrolled in kindergarten and first grade. Of these 43 programs, 42 reported coverage levels for poliovirus vaccine and DTP/DT/Td, and 43 reported coverage levels for measles, mumps, and rubella vaccines. Four of the 43 programs reported coverage levels for the combined MMR. The mean vaccination coverage levels among the reporting areas were 96.7% for poliovirus vaccine (range: 82.8%-99.9%), 96.7% for DTP/DT/Td (range: 82.8%-99.8%), 96.0% for measles vaccine (range: 82.8%-99.9%), and 96.5% for mumps and rubella vaccines (range: 82.8%-99.9%). INTERPRETATION: High levels of vaccination coverage among children entering school most likely result from the successful implementation of state-specific school vaccination laws, which have applied to children entering school in all states and the District of Columbia since at least 1990. All states, territories, and the District of Columbia have additional laws that require vaccination of children in licensed day care facilities. However, because a high proportion of states and territories did not submit vaccination coverage reports to CDC, these estimated means may not reflect levels for all children in the United States.

Impact of laboratory-initiated reporting of CD4+ T lymphocytes on U.S. AIDS surveillance.

This study was conducted to measure the impact of laboratory-initiated reporting of CD4+ results on reporting of AIDS in the United States. States were categorized by whether CD4+ reporting was required; we compared the number and percentage of AIDS cases reported based on immunologic criteria, controlling for whether states also required HIV infection reporting. We observed cases reported in 1994 with CD4+ values and the delay between diagnosis and report by CD4+ and HIV-reporting status. From 1992 to 1994, states with CD4+ reporting had a greater proportionate increase in reported AIDS cases (98%) than states without CD4+ reporting (55%; p < 0.0001). From 1993 to 1994, the eight states with both CD4+ and HIV reporting had a higher increase in cases meeting immunologic criteria (7%) than the 13 states with only HIV reporting (< 1%), the three states with only CD4+ reporting (< 1%), and the 16 states with neither form of laboratory reporting (4%). Of 1987 definition cases reported in 1994, the percentage reported with CD4+ values was lower in states without either CD4+ or HIV reporting (79%) than in states with both CD4+ and HIV reporting (83%), only HIV reporting (84%), or only CD4+ reporting (88%). The percentage of AIDS cases reported within 3 months of diagnosis was lower in states without laboratory reporting (40%) than in states with CD4+ reporting (45%, p = 0.001). CD4+ reporting may enable states to report AIDS cases earlier in the course of HIV disease, permitting early targeting of health care and social services.