CDC Health Disparities and Inequalities Report United States, 2011
Health disparities are differences in health outcomes between groups that reflect social inequalities. Despite progress over the past 20 years in reducing this problem, racial/ethnic, economic and other social disparities in health still exists and need to be addressed. This report is the first in a periodic series examining health disparities in the United States.
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▲ 1. Foreword [1/25]
Supplements
January 14, 2011 / 60(01);1-2
Thomas R. Frieden, MD, MPH
Director, CDC
Corresponding author: Thomas R. Frieden, Director, CDC, 1600 Clifton Road, NE, MS D-14, Atlanta, GA 30333. Telephone: 404-639-7000; E-mail: tfrieden@cdc.gov.
Since 1946, CDC has monitored and responded to challenges in the nation's health, with particular focus on reducing gaps between the least and most vulnerable U.S. residents in illness, injury, risk behaviors, use of preventive health services, exposure to environmental hazards, and premature death. We continue that commitment to socioeconomic justice and shared responsibility with the release of CDC Health Disparities and Inequalities in the United States -- 2011, the first in a periodic series of reports examining disparities in selected social and health indicators.
Health disparities are differences in health outcomes between groups that reflect social inequalities. Since the 1980s, our nation has made substantial progress in improving residents' health and reducing health disparities, but ongoing racial/ethnic, economic, and other social disparities in health are both unacceptable and correctable. Some key findings of this report include:
* Lower income residents report fewer average healthy days. Residents of states with larger inequalities in reported number of healthy days also report fewer healthy days on average. The correlation between poor health and health inequality at the state level holds at all levels of income.
* Air pollution-related disparities associated with fine particulates and ozone are often determined by geographical location. Local sources of air pollution, often in urban counties, can impact the health of people who live or work near these sources. Both the poor and the wealthy in these counties can experience the negative health effects of air pollution; racial/ethnic minority groups, who are more likely to live in urban counties, continue to experience a disparately larger impact.
* Large disparities in infant mortality rates persist. Infants born to black women are 1.5 to 3 times more likely to die than infants born to women of other races/ethnicities.
* Men of all race/ethnicities are two to three times more likely to die in motor vehicle crashes than are women, and death rates are twice as high among American Indians/Alaska Natives.
* Men of all ages and race/ethnicities are approximately four times more likely to die by suicide than females. Though American Indians/Alaska Natives, who have a particularly high rate of suicide in adolescence and early adulthood, account for only about 1% of the total suicides, they share the highest rates with Non-Hispanic whites who in contrast account for nearly 5 of 6 suicides. The suicide rate among AI/ANs and non-Hispanic whites is more than twice that of blacks, Asian Pacific Islanders and Hispanics.
* Rates of drug-induced deaths increased between 2003 and 2007 among men and women of all race/ethnicities, with the exception of Hispanics, and rates are highest among non-Hispanic whites. Prescription drug abuse now kills more persons than illicit drugs, a reversal of the situation 15--20 years ago.
* Men are much more likely to die from coronary heart disease, and black men and women are much more likely to die of heart disease and stroke than their white counterparts. Coronary heart disease and stroke are not only leading causes of death in the United States, but also account for the largest proportion of inequality in life expectancy between whites and blacks, despite the existence of low-cost, highly effective preventive treatment.
* Rates of preventable hospitalizations increase as incomes decrease. Data from the Agency for Healthcare Research and Quality indicate that eliminating these disparities would prevent approximately 1 million hospitalizations and save $6.7 billion in health-care costs each year. There also are large racial/ethnic disparities in preventable hospitalizations, with blacks experiencing a rate more than double that of whites.
* Racial/ethnic minorities, with the exception of Asians/Pacific Islanders, experience disproportionately higher rates of new human immunodeficiency virus diagnoses than whites, as do men who have sex with men (MSM). Disparities continue to widen as rates increase among black and American Indian/Alaska Native males, as well as MSM, even as rates hold steady or are decreasing in other groups.
* Hypertension is by far most prevalent among non-Hispanic blacks (42% vs 28.8% among whites), while levels of control are lowest for Mexican Americans. Although men and women have roughly equivalent hypertension prevalence, women are significantly more likely to have the condition controlled. Uninsured persons are only about half as likely to have hypertension under control than those with insurance, regardless of type.
* Rates of adolescent pregnancy and childbirth have been falling or holding steady for all racial/ethnic minorities in all age groups. However, disparities persist as birth rates for Hispanics and non-Hispanic blacks are 3 and 2.5 times those of whites, respectively.
* More than half of alcohol consumption by adults in the United States is in the form of binge drinking (consuming four or more alcoholic drinks on one or more occasion for women and five or more for men). Younger people and men are more likely to binge drink and consume more alcohol than older people and women. The prevalence of binge drinking is higher in groups with higher incomes and higher educational levels, although people who binge drink and have lower incomes and less educational attainment levels binge drink more frequently and, when they do binge drink, drink more heavily. American Indian/Native Americans report more binge drinking episodes per month and higher alcohol consumption per episode than other groups.
* Tobacco use is the leading cause of preventable illness and death in the United States. Despite overall declines in cigarette smoking, disparities in smoking rates persist among certain racial/ethnic minority groups, particularly among American Indians/Alaska Natives. Smoking rates decline significantly with increasing income and educational attainment.
Differences in health based on race, ethnicity, or economics can be reduced, but will require public awareness and understanding of which groups are most vulnerable, which disparities are most correctable through available interventions, and whether disparities are being resolved over time. These problems must be addressed with intervention strategies related to both health and social programs, and more broadly, access to economic, educational, employment, and housing opportunities. The combined effects of programs universally available to everyone and programs targeted to communities with special needs are essential to reduce disparities. I hope CDC's partners will use this periodic report to better understand and address disparities and help all persons in the United States live longer, healthier, and more productive lives.
Foreword
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► 2. Supplement
Volume 60, Supplement
January 14, 2011
CDC Health Disparities and Inequalities Report United States, 2011
Health disparities are differences in health outcomes between groups that reflect social inequalities. Despite progress over the past 20 years in reducing this problem, racial/ethnic, economic and other social disparities in health still exists and need to be addressed. This report is the first in a periodic series examining health disparities in the United States.
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United States
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Rationale for Regular Reporting on Health Disparities and Inequalities --- United States
▲ Rationale for Regular Reporting on Health Disparities and Inequalities --- United States
Supplements
January 14, 2011 / 60(01);3-10
Benedict I. Truman, MD1
C. Kay Smith, MEd2
Kakoli Roy, PhD1
Zhuo Chen, PhD1
Ramal Moonesinghe, PhD3
Julia Zhu, MS1
Carol Gotway Crawford, PhD1
Stephanie Zaza, MD1
1Epidemiology and Analysis Program Office, CDC
2Scientific Education and Professional Development Program Office, CDC
3Office of Minority Health and Health Disparities, CDC
Corresponding author: Benedict I. Truman, MD, Associate Director for Science, Epidemiology and Analysis Program Office, 1600 Clifton Road, NE, Mailstop E-33, Atlanta, GA 30333. Telephone: 404-498-2347; Fax: 404-498-1177; E-mail: bit1@cdc.gov.
Background
Most U.S. residents want a society in which all persons live long, healthy lives (1); however, that vision is yet to be realized fully. As two of its primary goals, CDC aims to reduce preventable morbidity and mortality and to eliminate disparities in health between segments of the U.S. population. The first of its kind, this 2011 CDC Health Disparities and Inequalities Report (2011 CHDIR) represents a milestone in CDC's long history of working to eliminate disparities (2--6).
Health disparities are differences in health outcomes and their determinants between segments of the population, as defined by social, demographic, environmental, and geographic attributes (7). Health inequalities, which is sometimes used interchangeably with the term health disparities, is more often used in the scientific and economic literature to refer to summary measures of population health associated with individual- or group-specific attributes (e.g., income, education, or race/ethnicity) (8). Health inequities are a subset of health inequalities that are modifiable, associated with social disadvantage, and considered ethically unfair (9). Health disparities, inequalities, and inequities are important indicators of community health and provide information for decision making and intervention implementation to reduce preventable morbidity and mortality. Except in the next section of this report that describes selected health inequalities, this report uses the term health disparities as it is defined in U.S. federal laws (10,11) and commonly used in the U.S. public health literature to refer to gaps in health between segments of the population.
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Rationale for Regular Reporting on Health Disparities and Inequalities --- United States
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United States, 2005 and 2009 [4/25]
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Education and Income --- United States, 2005 and 2009
▲ Education and Income --- United States, 2005 and 2009
Supplements
January 14, 2011 / 60(01);13-17
Gloria L. Beckles, MD1
Benedict I. Truman, MD2
1National Center for Chronic Disease Prevention and Health Promotion, CDC
2Epidemiology and Analysis Program Office, CDC
Corresponding author: Gloria L. Beckles, MD, Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, CDC, 1600 Clifton Road, N.E., MS K-10, Atlanta, GA 30333. Telephone: 770-488-1272; Fax: 770-488-8364; E-mail: glb4@cdc.gov.
The socioeconomic circumstances of persons and the places where they live and work strongly influence their health (1,2). In the United States, as elsewhere, the risk for mortality, morbidity, unhealthy behaviors, reduced access to health care, and poor quality of care increases with decreasing socioeconomic circumstances (2,3). This association is continuous and graded across a population and cumulative over the life course (2,3). Educational attainment and family or household income are two indicators used commonly to assess the influence of socioeconomic circumstances on health (4). Education is a strong determinant of future employment and income. In the majority of persons, educational attainment reflects material and other resources of family of origin and the knowledge and skills attained by young adulthood. Therefore, it captures both the long-term influence of early life circumstances and the influence of adult circumstances on adult health. Income is the indicator that most directly measures material resources. Income can influence health by its direct effect on living standards (e.g., access to better quality food and housing, leisure-time activities, and health-care services).
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Education and Income --- United States, 2005 and 2009
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Inadequate and Unhealthy Housing, 2007 and 2009
▲ Inadequate and Unhealthy Housing, 2007 and 2009
Supplements
January 14, 2011 / 60(01);21-27
Jaime Raymond, MPH
William Wheeler, MPH
Mary Jean Brown, ScD
National Center for Environmental Health, CDC
Corresponding author: Mary Jean Brown, ScD, Division of Emergency and Environmental Health Services, National Center for Environmental Health/Agency for Toxic Substances and Disease Registry, 1600 Clifton Road, NE, MS F-60, Atlanta, GA 30333. Telephone: 770-488-7492; Fax: 770-488-3635; E-mail: mjb5@cdc.gov.
Healthy homes are essential to a healthy community and population (1,2). They contribute to meeting physical needs (e.g., air, water, food, and shelter) and to the occupants' psychological and social health. Housing is typically the greatest single expenditure for a family. Safe housing protects family members from exposure to environmental hazards, such as chemicals and allergens, and helps prevent unintentional injuries. Healthy housing can support occupants throughout their life stages, promote health and safety, and support mental and emotional health. In contrast, inadequate housing contributes to infectious and chronic diseases and injuries and can affect child development adversely (1).
To assess the percentage of persons in the United States living in inadequate or unhealthy homes, CDC analyzed data from the American Housing Survey (AHS) for 2007 and 2009 (3). The U.S. Census Bureau conducts AHS to assess the quality of housing in the United States and to provide up-to-date statistics to the U.S. Department of Housing and Urban Development (HUD). AHS is a national representative survey that collects data on an average of 55,000 U.S. housing units, including apartments, single-family homes, mobile homes, and vacant housing units. The same housing units are visited every 2 years during odd-numbered years, with census bureau interviewers conducting home visits or telephone interviews during April through mid-September of each survey year (4). Information for unoccupied units is obtained from landlords, rental agents, or neighbors.
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Inadequate and Unhealthy Housing, 2007 and 2009
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United States, 2006--2009 [6/25]
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Unhealthy Air Quality --- United States, 2006--2009
▲ Unhealthy Air Quality --- United States, 2006--2009
Fuyuen Y. Yip, PhD1
Jeffrey N. Pearcy, MS2
Paul L. Garbe, DVM1
Benedict I. Truman, MD3
1National Center for Environmental Health, CDC
2National Center for Health Statistics, CDC
3Epidemiology and Analysis Program Office, CDC
Corresponding author: Fuyuen Y. Yip, PhD, Division of Environmental Hazards and Health Effects, 4770 Buford Highway, MS F-58, Atlanta, GA 30341. Telephone: 770-488-3700; Fax: 770-488-1540; E-mail: fay1@cdc.gov.
Particulate matter and ozone are two well-characterized air pollutants that can affect health and are monitored by the U.S. Environmental Protection Agency (EPA). Particulate matter (solid or liquid particles suspended in the air) varies widely in size and chemical composition and can include smoke, fumes, soot, and combustion by-products, as well as natural particles (e.g., windblown dust, pollen, and sea salt) (1,2). Particulate matter therefore represents a complex class of air pollutants that differ from other gaseous air pollutants (e.g., ozone). The transport and effect of particulate matter, both in the atmosphere and in the human respiratory tract, are governed principally by particulate size, shape, and density. Individual particles are characterized by their equivalent aerodynamic diameter: coarse particulate matter (2.5--10 µm); fine particulate matter, or PM2.5 (0.1--2.5 µm); and ultrafine particulate matter (<0.1 µm). Ozone is a gas that occurs naturally in the stratosphere, approximately 10--30 miles above the earth's surface, protecting the earth from the sun's ultraviolet rays. Ozone also exists at ground level and is the primary component of smog. At ground level, ozone is created when specific pollutants react in the presence of sunlight. In urban areas, vehicular and industrial emissions are chief contributors to ozone production. Ground-level ozone adversely affects health and damages the environment. The association between outdoor particulate matter concentrations and acute and chronic adverse health outcomes includes premature death, lung cancer, exacerbation of respiratory and cardiovascular disease, and increased risks for cardiovascular morbidity (e.g., myocardial infarction and arrhythmia) (1--6). Data indicate that fine particulate matter is the size fraction most strongly associated with these observed health effects (1--7). Populations most susceptible to these exposures include older adults and children, as well as persons with heart and lung disease. National Ambient Air Quality Standards (NAAQS) were set forth in the Clean Air Act Amendments of 1970* requiring EPA to set air quality standards for specific pollutants, such as PM2.5 and ozone, to protect the health of the general public, as well as that of sensitive populations. States that do not meet the standards are subject to additional regulatory requirements and must develop a state implementation plan to meet the standards. State implementation plans might include control requirements and limits on emissions. In 2006, on the basis of increasing evidence of the effects of PM2.5 on human health, EPA revised its 24-hour NAAQS from 65 µg/m3 to 35 µg/m3. Throughout the United States, PM2.5 concentrations have been decreasing; more counties were in compliance with national pollution standards as of 2008 compared with previous years (8). During 2001--2008, the average annual and 24-hour PM2.5 concentrations declined by 17% and 19%, respectively (8). full text: Unhealthy Air Quality --- United States, 2006--2009
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United States, 2004 and 2008 [7/25]
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Health Insurance Coverage --- United States, 2004 and 2008
▲ Health Insurance Coverage --- United States, 2004 and 2008
Supplements
January 14, 2011 / 60(01);35-37
Ramal Moonesinghe, PhD1
Julia Zhu, MS2
Benedict I. Truman, MD2
1Office of Minority Health and Health Disparities, Office of the Director, CDC
2Epidemiology and Analysis Program Office, CDC
Corresponding author: Ramal Moonesinghe, PhD, Office of Minority Health and Health Disparities, CDC, 1600 Clifton Road, N.E., MS E-67, Atlanta, GA 30333. Telephone: 404-498-2342; Fax: 404-498-2355; E-mail: zor7@cdc.gov.
During 1987--2006, the estimated number of U.S. residents without health insurance increased from 31 million in 1987 to 47 million in 2006 (1) and is projected to reach 52 million by the end of 2010 (2). The 2010 estimate does not directly take into account the additional effect of job losses, which are likely to add millions more to the number of uninsured persons (2). Chronically ill patients without insurance are more likely than those with coverage 1) not to have visited a health-care professional and 2) either not to have a standard site for care or to identify their standard site of care as an emergency department (3). Lack of health insurance is associated with reduced use of preventive services and medical treatment, particularly among racial/ethnic minorities (4).
To identify disparities in lack of health insurance coverage among adults aged 18--64 years for different demographic and socioeconomically disadvantaged groups over time, CDC analyzed data from the 2004 and 2008 National Health Interview Survey (NHIS). NHIS is a cross-sectional survey of a representative sample of the civilian, noninstitutionalized U.S. household population. Respondents were considered uninsured if they did not have any private health insurance, Medicare, Medicaid, State Children's Health Insurance Program coverage, state-sponsored or other government-sponsored health plan, or a military health-care plan at the time of the interview. Persons also were considered uninsured if they reported having only Indian Health Service coverage or a private plan that paid for only one type of service (e.g., unintentional injuries or dental care).
Using the lowest population group-specific rate of lack of insurance as the reference value, CDC calculated absolute and relative percentage differences between categories for each population domain. The relative percentage difference is the absolute difference between the rates of two population groups being compared as a percentage of the reference value. The 95% confidence intervals for uninsured rates were estimated by using SAS version 9.02 (SAS Institute, Inc., Cary, North Carolina, 2010) (5). Pair-wise differences by sex, age group, race/ethnicity, disability status, educational achievement, and differences between 2004 and 2008 were tested by the z-statistic (one-tailed) at the 0.05 level of significance. A covariance of zero between estimates in conducting these tests was assumed. When testing differences within demographic groups, the Bonferroni method was used to account for multiple comparisons. If κ comparisons existed within a group, the level of significance was set to 0.05/κ. Estimates with relative standard of >20% were considered unreliable.
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Health Insurance Coverage --- United States, 2004 and 2008
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United States, 2000--2010 [8/25]
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Influenza Vaccination Coverage --- United States, 2000--2010
▲ Influenza Vaccination Coverage --- United States, 2000--2010
Supplements
January 14, 2011 / 60(01);38-41
Rosanna W. Setse, MD, PhD
Gary L. Euler, DrPH
Amparo G. Gonzalez-Feliciano, MPH
Leah N. Bryan, MS, MPH
Carolyn Furlow, PhD
Cindy M. Weinbaum, MD
James A. Singleton, MS
National Center for Immunization and Respiratory Diseases, CDC
Corresponding author: Gary L. Euler, DrPH, Immunization Services Division, National Center for Immunization and Respiratory Diseases CDC, 1600 Clifton Road, N.E., Mail Stop E-62, Atlanta, GA 30333. Telephone: 404-639-8742; Fax: 404-639-3266; E-mail: gle0@cdc.gov.
Vaccines are among the greatest public health achievements of the 20th century (1). The majority of Healthy People 2010 (HP2010) objectives for early childhood vaccination coverage were met by the end of 2010 (2), and progress has been made toward eliminating disparities in vaccination coverage among children (3,4). Remarkable progress also has been made in improving coverage and reducing disparities in coverage for adolescent vaccinations recommended since 2005 (5). Although childhood vaccination programs in the United States have been successful, adolescent programs remain relatively new and adult vaccination programs, although well established, have not achieved acceptable levels of success. Among adults, substantial disparities in vaccination coverage have persisted (6--10). A particular challenge for prevention of influenza is the need for annual vaccination. During 1989--1999, national influenza vaccination coverage among persons aged ≥65 years increased each year for all racial/ethnic groups; however, the rate of increase slowed during 1997--2001, and vaccination coverage among non-Hispanic blacks and Hispanics remained lower compared with non-Hispanic whites throughout the entire period (1989--2001) (11).
To examine racial/ethnic disparities in influenza vaccination coverage among all persons aged ≥6 months for the 2009--10 influenza season as well as trends in racial/ethnic disparities in influenza vaccination coverage for the 2000--01 through 2009--10 influenza seasons among adults aged ≥65 years, CDC analyzed data from the 2002--2010 Behavioral Risk Factor Surveillance System (BRFSS) questionnaire and the National 2009 H1N1 Flu Survey (NHFS). Racial/ethnic disparities were focused on because these disparities in vaccination coverage have been documented (11--13) more extensively compared with other disparity domains (e.g., sex, income, education, and disability status). State-level estimates have been published previously (14,15) and are not included in this report. Additional information is available at http://www.cdc.gov/flu/professionals/vaccination/vaccinecoverage.htm.
BRFSS is a state-based telephone survey collecting information from approximately 400,000 randomly selected persons aged ≥18 years among the noninstitutionalized, U.S. civilian population. NHFS was a national random-digit--dialed telephone survey conducted in all 50 states and the District of Columbia (DC) during October 2009--June 2010 to track both influenza A (H1N1) 2009 monovalent vaccination (H1N1 influenza vaccination) and seasonal influenza vaccination coverage (14,15). In the 2009--10 influenza season, BRFSS respondents were asked if they (or their children, in 43 states and DC) had been vaccinated for the "seasonal flu" in the past 12 months or if they (in 49 states and DC, or their children in 46 states and DC) had been vaccinated for "H1N1 flu" since September 2009, and if so, in which month. NHFS respondents aged ≥18 years were asked whether they (or their children) had received "seasonal flu vaccination" since August 2009 or "H1N1 flu" vaccination since September 2009 and if so, in which month. The Council of American Survey and Research Organizations (CASRO) response rates* for NHFS were 34.0% for landline and 25.5% for cellular telephones; cooperation rates were 45% and 57%, respectively. The median state CASRO response and cooperation rates for BRFSS were 54% and 76%, respectively.
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Influenza Vaccination Coverage --- United States, 2000--2010
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United States, 2002, 2004, 2006, and 2008 [9/25]
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Colorectal Cancer Screening --- United States, 2002, 2004, 2006, and 2008
▲ Colorectal Cancer Screening --- United States, 2002, 2004, 2006, and 2008
Supplements
January 14, 2011 / 60(01);42-46
Sun Hee Rim, MPH
Djenaba A. Joseph, MD
C. Brooke Steele, DO
Trevor D. Thompson
Laura C. Seeff, MD
National Center for Chronic Disease Prevention and Health Promotion, CDC
Corresponding author: Laura C. Seeff, MD, Division of Cancer Prevention and Control, 1600 Clifton Road, NE, MS K-52, Atlanta, GA 30333. Telephone: 770-488-3223; Fax: 770-488-4760; E-mail: lvs3@cdc.gov.
Of the types of cancer that affect both men and women, colorectal cancer is the second leading cause of cancer-related deaths in the United States (1). Screening reduces colorectal cancer incidence and mortality (2). The U.S. Preventive Services Task Force recommended in 2008 that persons aged 50--75 years at average risk for colorectal cancer be screened for the disease by using one or more of the following methods: fecal occult blood testing (FOBT) every year, sigmoidoscopy every 5 years (with high-sensitivity FOBT every 3 years), or colonoscopy every 10 years (1).
To estimate disparities in rates of use of colorectal cancer tests and evaluate changes in test use, CDC compared data from the 2002, 2004, 2006, and 2008 Behavioral Risk Factor Surveillance System (BRFSS) surveys (3). BRFSS is a state-based, random-digit--dialed telephone survey of the noninstitutionalized, U.S. civilian population aged ≥18 years. Survey data were available for all 50 states (except for Hawaii in 2004) and the District of Columbia. The median response rate, based on Council of American Survey and Research Organizations (CASRO) guidelines,* was 58.3% in 2002, 52.7% in 2004, 51.4% in 2006, and 53.3% in 2008 (3). The median cooperation rate, based on CASRO guidelines, was 76.7% in 2002, 74.3% in 2004, 74.5% in 2006, and 75.0% in 2008 (3). Respondents who refused to answer, had a missing answer, or did not know the answer to a question were excluded from analysis of that specific question. Of persons aged ≥50 years who responded, approximately 3% of 108,028 persons were excluded from 2002 results, approximately 3% of 146,794 were excluded from 2004 results, approximately 4.5% of 195,318 were excluded from 2006 results, and approximately 4.1% of 251,623 were excluded from 2008 results.
Survey questions and response options were identical for survey years 2002, 2004, and 2006. Respondents aged ≥50 years were asked if they had ever used a "special kit at home to determine whether the stool contains blood (FOBT)," whether they had ever had "a tube inserted into the rectum to view the colon for signs of cancer or other health problems (sigmoidoscopy or colonoscopy)," and when these tests were last performed. In 2008, respondents also were asked whether their most recent test had been a sigmoidoscopy or a colonoscopy. For this report, as in previous reports (4--6), sigmoidoscopy and colonoscopy rates are measured and reported as a combined measure and described as lower endoscopy. Percentages were estimated for persons aged ≥50 years who reported receiving an FOBT within 1 year preceding the survey or lower endoscopy within 10 years preceding the survey, the recommended interval for colonoscopy for persons at average risk. For this analysis, all persons aged ≥50 years were included based on consideration of the screening recommendations during survey years and other age-related influences on screening (e.g., Medicare benefits for persons aged ≥65 years). States were categorized into poverty quartiles by using data from the 2009 Current Population Survey (available at http://cps.ipums.org/cps/sdaExternal Web Site Icon), and aggregate screening rates per quartile were calculated. Respondents were defined as having a disability if they responded yes when asked whether they were limited in any way in any activities because of physical, mental, or emotional problems. Aggregate percentages and 95% confidence intervals were calculated by selected characteristics. Data were weighted according to the sex, racial/ethnic, and age distribution of the adult population of each state by using intercensal estimates and were age standardized to the 2008 BRFSS population aged ≥50 years. The Wald F test was used to determine the significance of differences among the four surveys.
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Colorectal Cancer Screening --- United States, 2002, 2004, 2006, and 2008
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United States, 2000--2007 [10/25]
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Infant Deaths --- United States, 2000--2007
▲ Infant Deaths --- United States, 2000--2007
Supplements
January 14, 2011 / 60(01);49-51
Marian F. MacDorman, PhD
T. J. Mathews, MS
National Center for Health Statistics, CDC
Corresponding author: Marian F. MacDorman, PhD, Division of Vital Statistics, National Center for Health Statistics, 3311 Toledo Road, Room 7318, Hyattsville, MD 20782. Telephone: 301-458-4356; Fax: 301-458-4033; E-mail: mfm1@cdc.gov.
Infant mortality rates are an important indicator of the health of a nation because they are associated with maternal health, quality of and access to medical care, socioeconomic conditions, and public health practices (1,2). The U.S. infant mortality rate (the number of deaths among infants aged <1 year per 1,000 live births) declined from approximately 100 deaths per 1,000 births in 1900 (3) to 6.89 in 2000 (4). However, the rate did not decline substantially from 2000 to 2005. The infant mortality rate declined slightly but significantly from 6.86 in 2005 to 6.68 in 2006. The 2007 rate (6.75) was not significantly different from the 2006 rate (6.68) (4--6). In addition, considerable differences in infant mortality rates among racial/ethnic groups have persisted and even increased, demonstrating that not all racial/ethnic groups have benefited equally from social and medical advances (5,7). To analyze trends and variations in infant mortality in the United States, CDC analyzed data from linked birth--infant death data sets (linked files) for 2000--2006 (8). In these data sets, information from the birth certificate is linked to information from the death certificate for each infant (aged <1 year) who dies in the United States. This allows researchers to use the more accurate race/ethnicity data from the birth certificate for infant mortality analysis (8,9). Linked data are available through 2006. Data by maternal race and Hispanic ethnicity are based on information reported by the mother during the birth registration process. Race and ethnicity are reported separately on birth certificates, and persons of Hispanic origin might be of any race. Data from the main mortality file (i.e., death certificates not linked to birth certificates) are available for 2007 and are used for the overall infant mortality rate but not for race/ethnicity comparisons (6). Infant mortality rates were calculated as the number of infant deaths per 1,000 live births in the specified group. Percentage change over time was calculated by comparing the rates for the beginning and end points in each period. Differences between infant mortality rates were assessed for statistical significance by using the z test (p<0.05). National data on infant mortality according to educational attainment and family income status were not analyzed; these data are not available because they are either not collected or collected inconsistently. During 2007, a total of 29,138 infant deaths occurred in the United States, with a U.S. infant mortality rate of 6.75 deaths per 1,000 live births (6), compared with 6.89 during 2000 (5). The infant mortality rate in the United States was higher than the rate for the majority of other developed countries, in part because of a substantially higher percentage of preterm births, a critical risk factor for infant mortality (10). full text Infant Deaths --- United States, 2000--2007
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United States, 2003--2007 [11/25]
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Motor Vehicle--Related Deaths --- United States, 2003--2007
▲ Motor Vehicle--Related Deaths --- United States, 2003--2007
Supplements
January 14, 2011 / 60(01);52-55
Bethany A. West, MPH
Rebecca B. Naumann, MSPH
National Center for Injury Prevention and Control, CDC
Corresponding author: Bethany A. West, MPH, Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, 4770 Buford Highway, NE, MS F-62, Atlanta, GA 30341. Telephone: 770-488-0602; Fax: 770-488-1317; E-mail: bwest2@cdc.gov.
Motor vehicle crashes are the leading cause of death for persons in the United States aged 5--34 years (1). In 2007, approximately 44,000 persons were killed in motor vehicle crashes, and racial/ethnic minorities were affected disproportionally (1,2). Approximately 7% of all American Indian/Alaska Native (AI/AN) deaths and 5% of all Hispanic deaths are attributed to crashes, whereas crashes are the cause of death for<2% of blacks and whites (2). To assess the extent of disparities in motor vehicle--related crashes among persons of all ages, CDC analyzed data from the National Vital Statistics System (NVSS). This report summarizes the results of that analysis, which examined racial/ethnic death rates from motor vehicle crashes by sex. AI/ANs and males had the highest motor vehicle--related death rates. Overall motor vehicle--related mortality can be reduced through increased adoption of evidence-based strategies, including primary seat belt laws (legislation allowing police to stop a vehicle solely for a safety belt violation), legislation for ignition interlock devices (devices that disable a vehicle's ignition after detection of alcohol in the driver's breath), and multicomponent programs with community mobilization (programs that include numerous components such as sobriety checkpoints, education and awareness-raising efforts, and training in responsible beverage service, as well as, an active community coalition) (3). Tailoring these strategies to the unique cultures of different racial/ethnic groups also can help reduce disparities in motor vehicle--related mortality (4,5). NVSS data were accessed through the CDC Web-based Injury Statistics Query and Reporting System (WISQARS) online database, which provides customized reports of injury-related mortality data from CDC annual mortality data files (1). CDC mortality data are derived from the multiple cause of death data, which are based on death certificate records from vital statistics offices in all 50 states and the District of Columbia. Motor vehicle--related death data were examined for the most recent years available, 2003--2007. Bridged-race postcensal population estimates from the U.S. Census Bureau were used to calculate death rates (6). All reported death rates and corresponding confidence intervals are age adjusted to the 2000 standard U.S. population. Differences between death rates in 2003 and 2007 were compared using the z statistic based on a normal approximation, and p values <0.05 were considered statistically significant. Data were examined for all ages by race/ethnicity and sex. NVSS race categories were coded as white, black, AI/AN, and Asian/Pacific Islander (A/PI). Ethnicity was coded separately as Hispanic or non-Hispanic. Race/ethnicity was divided into five mutually exclusive categories: non-Hispanic whites, non-Hispanic blacks, non-Hispanic AI/ANs, non-Hispanic A/PIs, and Hispanics of all races. All Hispanics were grouped in the Hispanic category; therefore, references to race refer to non-Hispanic members of that race (e.g., blacks are non-Hispanic blacks). NVSS does not collect information on other characteristics such as income level; therefore disparities in motor vehicle-related deaths for other characteristics are not included in this report. In addition, this report does not assess geographical variations in death rates. full text: Motor Vehicle--Related Deaths --- United States, 2003--2007
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United States, 1999--2007 [12/25]
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Suicides --- United States, 1999--2007
▲ Suicides --- United States, 1999--2007
Supplements
January 14, 2011 / 60(01);56-59
Alex E. Crosby, MD
LaVonne Ortega, MD
Mark R. Stevens, MSPH
National Center for Injury Prevention and Control, CDC
Corresponding author: Alex E. Crosby, MD, Division of Violence Prevention, National Center for Injury Prevention and Control, 4770 Buford Highway, NE, MS F-63, Atlanta, GA 30341. Telephone: 770-488-4410; Fax: 770-488-4222; E-mail: aec1@cdc.gov.
Injury from self-directed violence, which includes suicidal behavior and its consequences, is a leading cause of death and disability. In 2007, suicide was the 11th leading cause of death in the United States and the cause of 34,598 deaths (1). In 2000, the estimated cost of self-directed violence (fatal and nonfatal) was $33 billion ($32 billion in productivity losses and $1 billion in medical costs) (2). Suicide rates are influenced by biological, psychological, social, moral, political, and economic factors (3). Self-directed violence in the United States affects all racial/ethnic groups but often is misperceived to be a problem solely affecting non-Hispanic white males (4).
To determine differences in the prevalence of suicide by sex, race/ethnicity, age, and geographic region in the United States, CDC analyzed 1999--2007 data from the Web-based Injury Statistics Query and Reporting System --- Fatal (WISQARS Fatal) (5) and the National Vital Statistics System (NVSS). Mortality data originate from NVSS, which collects death certificate data filed in the 50 states and the District of Columbia (1). Data in this report were based on suicides from any cause and include the 1999--2007 data years. The WISQARS database contains mortality data based on NVSS and population counts for all U.S. counties based on U.S. Census data. Counts and rates of death can be obtained by underlying cause of death, mechanism of injury, state, county, age, race, sex, year, injury cause of death (e.g., firearm, poisoning, or suffocation) and by manner of death (e.g., suicide, homicide, or unintentional injury) (4).
Unadjusted (crude) death rates were based on resident population data from the U.S. Census Bureau (5). Confidence intervals were calculated in two ways: 1) groupings of <100 deaths were calculated by using the gamma method (1), and 2) groupings of ≥100 deaths were calculated by using a normal approximation (1). NVSS codes racial categories as white, black, American Indian/Alaskan Native (AI/AN), and Asian/Pacific Islander (A/PI); ethnicity is coded separately as Hispanic or non-Hispanic (1). All references to a specific race refer to non-Hispanic members (e.g., non-Hispanic white and non-Hispanic black). Differences in rates between two populations were compared using the z statistic based on a normal approximation at a critical value of α = 0.05 (1). Because coding of the mortality data changed to the International Classification of Diseases, Tenth Revision (ICD-10) beginning in 1999, analyses by year and race/ethnicity were conducted for 1999--2007 to examine rate changes during that period. To compare differences in rates across the years 1999--2007, trend analyses to test statistical significance were conducted using a negative binomial rate regression model (6). full text: Suicides --- United States, 1999--2007
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United States, 2003--2007 [13/25]
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Drug-Induced Deaths --- United States, 2003--2007
Drug-Induced Deaths --- United States, 2003--2007
Supplements
January 14, 2011 / 60(01);60-61
Leonard J. Paulozzi, MD
National Center for Injury Prevention and Control, CDC
Corresponding author: Leonard J. Paulozzi, MD, Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, 601 Sunland Park Drive, Suite 200, El Paso, TX 79912. Telephone: 770-365-7616; Fax: 915-834-5973; E-mail: lbp4@cdc.gov.
Drug-induced deaths include all deaths for which drugs are the underlying cause (1), including deaths attributable to acute poisoning by drugs (drug overdoses) and deaths from medical conditions resulting from chronic drug use. A drug includes illicit or street drugs (e.g., heroin or cocaine), as well as legal prescription drugs and over-the-counter drugs; alcohol is not included. The majority of deaths are unintentional drug poisoning deaths, with suicidal drug poisoning and drug poisoning of undetermined intent comprising the majority of the remainder (2). Adverse effects from drugs taken as directed and infections resulting from drug use are not included. In 2007, drug-induced deaths were more common than alcohol-induced or firearm-related deaths in the United States (1).
To examine trends and assess drug-induced deaths during 2003--2007 in the United States, CDC analyzed data from the mortality component of the National Vital Statistics System. Death certificates provide information on the sex, race, and ethnicity of the decedent; they do not provide information on decedent income. Deaths with underlying causes that are defined as drug induced by CDC are included in the category (1). Age-adjusted rates were calculated per 100,000 persons on the basis of U.S Census populations with bridged-race categories. Unadjusted rate ratios were calculated to compare 2007 to 2003 rates and to compare nonwhite with white rates. Rates were not compared by geographic region.
During 2007 (the year in which the latest national NVSS mortality data are available), a total of 38,371 drug-induced deaths occurred in the United States (Table). Drug-induced mortality rates increased during 2003--2006 and declined slightly in 2007. During all years, rates for males exceeded those for females. During 2007, rates for non-Hispanic white males (18.7 per 100,000 population) were 64.0% greater than those for non-Hispanic white females (11.4 per 100,000). Drug-induced mortality rate increases were greatest for non-Hispanic whites, whereas rates for Hispanics did not increase with time. The highest rates overall were among non-Hispanic whites for each year examined. Asians/Pacific Islanders had markedly lower rates than all other groups. For females, the highest rates were among American Indians/Alaskan Natives for every year except 2006. For males, the highest rates were among non-Hispanic blacks or non-Hispanic whites each year.
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Drug-Induced Deaths --- United States, 2003--2007
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and Stroke Deaths [14/25]
United States, 2006
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Coronary Heart Disease and Stroke Deaths --- United States, 2006
▲ Coronary Heart Disease and Stroke Deaths --- United States, 2006
Supplements
January 14, 2011 / 60(01);62-66
Nora L. Keenan, PhD
Kate M. Shaw, MS
National Center for Chronic Disease Prevention and Health Promotion, CDC
Corresponding author: Nora L. Keenan PhD, Division for Heart Disease and Stroke Prevention, 2877 Brandywine Road, MS K-47, Atlanta, GA 30341. Telephone: 770-488-6487; Fax: 770-488-8334; E-mail: nlk0@cdc.gov.
Heart disease and stroke are the first and third leading causes of death in the United States* (1) and have maintained this ranking since 1921 and 1938, respectively (2). In 2006, cardiovascular disease was responsible for 31.7% of all deaths: 26.0% from heart disease and 5.7% from stroke (1). Deaths from coronary heart disease (CHD) (425,425 deaths) comprise 67.4% of all deaths from heart disease (631,636 deaths). The Healthy People 2010 objectives of reducing death rates to 162 deaths per 100,000 population for CHD and 50 deaths per 100,000 for stroke (objectives 12-1 and 12-7) were met in 2004 (3). However, despite the overall decrease in CHD and stroke death rates, the target death rates for both diseases were not met for two subpopulations: blacks and men.
Healthy People 2020 has four overarching goals: 1) eliminate preventable disease, disability, injury, and premature death; 2) achieve health equity, eliminate disparities, and improve the health of all groups; 3) create social and physical environments that promote good health for all; and 4) promote healthy development and healthy behaviors across every life stage (4). Examining and monitoring the distribution of death rates provides the requisite information for focusing on the groups most in need of early intervention to eliminate preventable disease, disability, and premature death and to improve the health of all groups.
To examine CHD and stroke death rates among different segments of the U.S. population, CDC analyzed 2006 data from the National Vital Statistics System (NVSS). NVSS is maintained by CDC and compiles data from vital records on all deaths occurring annually in the United States (5). The 2006 CDC Wonder compressed mortality NVSS database (6) was used to obtain the number of deaths for which CHD or stroke was the underlying cause, population estimates for calculation of rates, and mortality rates per 100,000, age-standardized to the 2000 U.S. standard population (7). The underlying cause of death is the disease that initiated the sequence of events leading directly to death. Age-specific rate calculations were restricted to adults aged ≥45 years because 98.1% of CHD deaths and 97.6% of stroke deaths occurred among persons in this age group. CHD and stroke deaths were classified according to codes from the International Classification of Diseases, Tenth Revision (ICD-10) (8). The category of CHD (ICD-10 codes I20--I25) includes acute myocardial infarction, angina pectoris, atherosclerotic cardiovascular disease, and all other forms of acute and chronic ischemic heart disease. Stroke (ICD-10 codes I60--I69) includes ischemic and hemorrhagic strokes, strokes not specified as ischemic or hemorrhagic, and other cerebrovascular diseases (e.g., occlusion and stenosis of cerebral arteries) not resulting in cerebral infarction. Substantial differences in rates were determined by nonoverlapping confidence intervals (CIs), and these differences are discussed in the report; however, nonoverlapping CIs were not used as an indicator of statistical significance.
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Coronary Heart Disease and Stroke Deaths --- United States, 2006
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United States, 1999--2007 [15/25]
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Homicides --- United States, 1999--2007
▲ Homicides --- United States, 1999--2007
Supplements
January 14, 2011 / 60(01);67-70
Joseph E. Logan, PhD
Sharon G. Smith, PhD
Mark R. Stevens, MSPH, MA
National Center for Injury Prevention and Control, CDC
Corresponding author: Joseph E. Logan, PhD, Division of Violence Prevention, National Center for Injury Prevention and Control, 4770 Buford Highway, NE, MS F-63, Atlanta, GA 30341. Telephone: 770-488-1529; Fax: 770-488-1360; E-mail: ffa3@cdc.gov.
During 1991--2007, homicide was ranked as one of the top four leading causes of death each year for persons aged 1--40 years living in the United States (1). Furthermore, vast disparities in homicide rates have been reported between males and females and among different age and racial/ethnic groups (2--6). For example, previous studies have indicated that rates of death from homicide are particularly high among males (4--6), persons aged 15--34 years and <1 year (5), and blacks (2,3,5,6). Homicide rates for males are estimated to be approximately 3--4 times higher than that for females (4,5); among persons aged 20--24 years, the male homicide rate is 6 times higher than that for females (1,5). In addition, minority racial/ethnic children and young adults in the United States are disproportionately affected by homicide. During 1999--2002, among persons aged 10--19 years, the homicide rate for blacks was estimated to be 17.8 per 100,000 population, a rate 10 times that of whites (1.8 per 100,000) and higher than the rates reported for American Indians/Alaska Natives (AI/ANs) (6.0 per 100,000), Asian/Pacific Islanders (A/PIs) (2.9 per 100,000), and Hispanics (8.0 per 100,000) (2). To assess homicide rates in the United States by sex, age, and race/ethnicity for 2007, CDC assessed data from the CDC Web-based Injury Statistics Query and Reporting System --- Fatal (WISQARS Fatal) (1). This report summarizes these rates, identifies specific population groups with the highest rates of death from homicide, and provides homicide rates by race/ethnicity and year throughout a 9-year period (1999--2007). Additional details on homicide rates by these variables for each state and census region can be accessed through the WISQARS Fatal online query system (http://www.cdc.gov/injury/wisqars/index.html). Data on individual and socioeconomic risk factors for homicide were unavailable for analysis. In addition, sufficient data were unavailable to assess disparities by certain racial/ethnic subgroups, family income, educational attainment, disability status, and sexual orientation.
WISQARS Fatal provides injury mortality data by cause (e.g., firearm, poisoning, or suffocation) and manner of death (e.g., suicide, homicide, or unintentional injury) (1). Mortality data originate from the CDC National Vital Statistics System (NVSS). NVSS collects death certificate data filed in the 50 states and the District of Columbia (7). Data in this report were based on homicides caused by any mechanism.
NVSS codes racial categories as white, black, AI/AN, and A/PI, and ethnicity is coded separately as Hispanic or non-Hispanic (7). All references to a specific race refer to non-Hispanic members (e.g., white non-Hispanic and black non-Hispanic).
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Homicides --- United States, 1999--2007
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United States, 1988--2008 [16/25]
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Obesity --- United States, 1988--2008
▲ Obesity --- United States, 1988--2008
Supplements
January 14, 2011 / 60(01);73-77
David S. Freedman, PhD
National Center for Chronic Disease Prevention and Health Promotion, CDC
Corresponding author: David S Freedman, PhD, Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion, 1600 Clifton Road, NE, MS K-26, Atlanta, GA 30333. Telephone: 770-488-6016; Fax: 770-488-6500; E-mail: dxf1@cdc.gov.
The prevalence of obesity in the United States has increased substantially since the 1960s (1). From 1976--1980 to 2007--2008, obesity prevalence increased from 15% to 34% among adults and from 5% to 17% among children and adolescents (2,3). Substantial differences exist in obesity prevalence among racial/ethnic groups, and these differences vary by sex and age group.
To assess differences and trends over time in obesity prevalence and to determine whether these disparities can be attributed to differences in family income, CDC analyzed data from the National Health and Nutrition Examination Survey (NHANES) III (1988--1994) and data collected in NHANES between 1999 and 2008. In 1999, NHANES became a continuous survey, with data releases at 2-year intervals; 2007--2008 is the most recent release for which data were available (4). NHANES samples are selected by using a stratified, multistage cluster design and are representative of the U.S. civilian noninstitutionalized population. CDC examined disparities in obesity prevalence by sex, age, time period, and family income. Disparities were not assessed by education level; disability status; lesbian, gay, bisexual, or transgender status; or geographic region.
Weight and height were measured by using standardized techniques and equipment, and body mass index (BMI) was calculated as kilograms per square meter (kg/m2). Adults aged ≥20 years with BMI ≥ 30.0 kg/m2 obesity were categorized as obese (5). Children aged 2--19 years with BMI-for-age ≥ 95th percentile of the CDC growth charts (6) or BMI ≥ 30.0 kg/m2 were categorized as obese. It is possible for persons aged 18--19 years to have a BMI ≥ 30 kg/m2 (the adult definition of obesity) but to have a BMI-for-age that is less than the CDC 95th percentile. Pregnant women (n = 1,661, approximately 2% of the sample) were excluded from analysis. Data regarding race/ethnicity were self-reported for persons aged ≥16 years or reported by a family member (for persons aged ≤15 years) after being provided a list that included an open-ended response. The analyses described in this report include non-Hispanic whites, non-Hispanic blacks, and Mexican Americans. Because of insufficient numbers, other racial/ethnic groups (including Hispanics who were not Mexican American) were excluded.
During each household interview, respondents were asked to report the total annual income for themselves and for other family members. This information was divided by the poverty threshold for the specific family size to yield the poverty to income ratio (PIR), an indicator of socioeconomic status. The 2009 poverty threshold for a family of four was $22,050 (7); therefore, a PIR of 2.0 indicates that the total income for this family was $44,100. CDC recoded PIR values of > 5 as 5.0.
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Obesity --- United States, 1988--2008
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United States, 2007 [17/25]
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Preterm Births --- United States, 2007
▲ Preterm Births --- United States, 2007
Supplements
January 14, 2011 / 60(01);78-79
Joyce A. Martin, MPH
Division of Vital Statistics, National Center for Health Statistics, CDC
Corresponding author: Joyce A. Martin, MPH, Division of Vital Statistics, National Center for Health Statistics, CDC, 3311 Toledo Road, Room 7415, Hyattsville, MD 20782. Telephone: 301-458-4362; Fax: 301-458-4033; E-mail: jcm9@cdc.gov.
Preterm infants (those born at <37 completed weeks of gestation) are less likely to survive to their first birthday than infants delivered at higher gestational ages, and those who do survive, especially those born at the earlier end of the preterm spectrum, are more likely to suffer long-term disabilities than infants born at term (1,2). During 1981--2006, the U.S. preterm birth rate increased >30%, from 9.4% to 12.8% of all live births (3). Although lower during 2007 and 2008, the U.S. preterm birth rate remains higher than any year during 1981--2002 (3,4).
Substantial differences in preterm birth rates across racial/ethnic groups have long been noted (5). However, trends in preterm birth rates among the larger racial/ethnic groups often have differed, (3,6). During 1981--2006, rates rose steadily among births to non-Hispanic white mothers, increased modestly among births to Hispanics, and declined slightly for non-Hispanic black births (3). Declines were noted in preterm birth rates in 2007 and 2008 for each of these groups (3,4).
To examine differences in the risk for preterm birth by race/ethnicity, CDC analyzed final 2007 birth certificate data from the National Vital Statistics System (NVSS). For 2007, a total 4,316,211 births were reported, of which 546,602 (12.7%) were preterm (3). For the purposes of this study, gestational age was defined as the interval between the date of the last normal menses and the date of birth; the preterm birth rate is the number of preterm births per 100 total births in a given category. Racial/ethnic origin of the mother are self-reported. National gestational age data according to such attributes as educational attainment, income, and disability status are not available or not collected consistently in NVSS and therefore were not analyzed for this report. Comparable gestational age trend data were not available before the 1981 data year.
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Preterm Births --- United States, 2007
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United States, 2004--2007 [18/25]
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Potentially Preventable Hospitalizations --- United States, 2004--2007
▲ Potentially Preventable Hospitalizations --- United States, 2004--2007
Supplements
January 14, 2011 / 60(01);80-83
Ernest Moy, MD1
Marguerite Barrett, MS2
Karen Ho, MHS1
1Agency for Healthcare Research and Quality
2M.L. Barrett, Inc.
Corresponding author: Ernest Moy, MD, Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD 20850. Telephone: 301-427-1329; Fax: 301-427-1341; E-mail: ernest.moy@ahrq.hhs.gov.
When patients seek prompt attention from primary care providers for acute illnesses (e.g., pneumonia) or worsening of chronic conditions (e.g., diabetes), hospitalization often can be avoided. Hospitalizations that better primary care could have prevented are termed "potentially preventable hospitalizations." Although not all such hospitalizations can be avoided, rates of potentially preventable hospitalizations vary; communities with poorer access to coordinated primary care tend to have higher rates of potentially preventable hospitalizations (1).
Because hospitalizations tend to be more costly than outpatient primary care, potentially preventable hospitalizations also are used often as markers of the efficiency of the health-care system. The number and cost of excess potentially preventable hospitalizations can be calculated by comparing rates for a group with an ideal rate. These estimates can help communities identify potential cost savings associated with improving primary care and reducing potentially preventable hospitalizations.
To identify trends in a composite measure of potentially preventable hospitalizations among persons in the United States aged ≥18 years, the Agency for Healthcare Research and Quality (AHRQ) analyzed data for 2004--2007 from AHRQ's Healthcare Cost and Utilization Project (HCUP). Disparities related to race/ethnicity and income were examined. In addition, the impact of reducing preventable hospitalizations to a best rate was estimated in terms of numbers of admissions and associated costs.
HCUP is a family of health-care databases and related software tools and products developed through a federal-state-industry partnership and sponsored by AHRQ. HCUP databases combine the data-collection efforts of state data organizations, hospital associations, private data organizations, and the federal government to create a national information resource of discharge-level health-care data. HCUP includes the largest collection of longitudinal hospital care data in the United States with all-payer, encounter-level information, beginning with 1988. These databases enable research on different health policy topics, including cost and quality of health-care services, medical practice patterns, access to health-care programs, and outcomes of treatments at the national, state, and local levels. AHRQ's Prevention Quality Indicators (PQIs) are a set of measures that can be used with hospital inpatient discharge data to identify quality of care for ambulatory care-sensitive conditions (2). This analysis used version 3.1 of AHRQ's PQIs. The PQI composite includes adult admissions for diabetes (i.e., short-term complications, long-term complications, uncontrolled diabetes, and lower-extremity amputations), hypertension, congestive heart failure, angina without procedure, asthma, dehydration, bacterial pneumonia, and urinary infections. Admissions for chronic obstructive pulmonary disease were excluded because of International Classification of Diseases (Ninth Revision, Clinical Modification) coding changes that cause incompatibility across data years. Rates were adjusted by age group and sex, with the total U.S. population for 2000 used as the standard population.
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Potentially Preventable Hospitalizations --- United States, 2004--2007
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United States, 2006--2008 [19/25]
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Current Asthma Prevalence --- United States, 2006--2008
▲ Current Asthma Prevalence --- United States, 2006--2008
Supplements
January 14, 2011 / 60(01);84-86
Jeanne E. Moorman, MS1
Hatice Zahran, MD1
Benedict I. Truman, MD2
Michael T. Molla, PhD3
1National Center for Environmental Health, CDC
2Epidemiology and Analysis Program Office, CDC
3National Center for Health Statistics, CDC
Corresponding author: Jeanne Moorman, MS, Division of Environmental Hazards and Health Effects, National Center for Environmental Health, CDC, 4770 Buford Highway, MS F-58, Atlanta GA 30341. Telephone: 770-488-3726; Fax: 770-488-1540; E-mail: zva9@cdc.gov.
Asthma is a chronic inflammatory disorder of the airways characterized by episodic and reversible airflow obstruction, airway hyper-responsiveness, and underlying inflammation. Common asthma symptoms include wheezing, coughing, and shortness of breath (1). With correct treatment and avoidance of exposure to environmental allergens and irritants that are known to exacerbate asthma, the majority of persons who have asthma can expect optimal symptom control (2).
Multiple reports provide detailed surveillance information on asthma (1,3--6). A 1987 report that included asthma surveillance data for 1965--1984 identified differences among certain demographic groups by age, sex, and race/ethnicity (3). Subsequent asthma surveillance reports confirmed these differences and documented that the differences have persisted over time (1,4). These reports indicate that population-based asthma prevalence rates, emergency department visit rates, and hospitalization rates were higher among blacks than among whites, higher among females than among males, higher among children than among adults, and higher among males aged 0--17 years than among females in the same age group. In addition, more detailed analysis of ethnicity data demonstrated that different Hispanic groups had differing health outcomes. Among Hispanics, those of Puerto Rican descent (origin or ancestry) had higher asthma prevalence and death rates than other Hispanics (e.g., those of Mexican descent), non-Hispanic blacks, and non-Hispanic whites (5,6).
To examine whether disparities in asthma prevalence exist among certain demographic groups, CDC analyzed data from the National Health Interview Survey (NHIS) for 2006--2008. NHIS is an annual, in-person survey of the civilian, noninstitutionalized U.S. population based on a multistage sampling of households (7). An adult family member is selected to act as a proxy respondent for children. NHIS routinely includes two questions that are used to estimate national asthma prevalence. The question, "Have you ever been told by a doctor or other health professional that you had asthma?" has been used as a lifetime prevalence measure for asthma since 1997. A second question, "Do you still have asthma?" was added in 2001 to assess current asthma prevalence. Consistent with previous CDC publications, respondents were considered to have current asthma if they answered "yes" to both questions (1,4). Race/ethnicity was categorized on the basis of the respondents' self-reported classification. Results for four racial/ethnic groups are reported: non-Hispanic white, non-Hispanic black, multiracial, and Hispanic of Puerto Rican descent. Current asthma prevalence also was estimated by sex (males and females), age group (children aged 0--17 years and adults aged ≥18 years), and federal poverty level. Analyses of disparities in disability status, education, geographic region, and other racial/ethnic populations were not included because of low prevalence or limitations due to data quality or manuscript length. Three years of survey data were combined to provide more stable estimates for relatively small groups. Analysis software accounted for complex sample design, and sample weights were used to produce national estimates. Estimates were age-adjusted by using the year 2000 age distribution, except those for children. Comparative terms used in this report (e.g., "higher" and "similar") indicate the results of statistical testing at p<0.05. full text: Current Asthma Prevalence --- United States, 2006--2008
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United States, 2005 and 2008 [20/25]
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HIV Infection --- United States, 2005 and 2008
▲ HIV Infection --- United States, 2005 and 2008
Supplements
January 14, 2011 / 60(01);87-89
H. Irene Hall, PhD
Denise Hughes
Hazel D. Dean, ScD
Jonathan H. Mermin, MD
Kevin A. Fenton, MD, PhD
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC
Corresponding author: H. Irene Hall, PhD, Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC, 1600 Clifton Road, MS E-47, Atlanta, GA 30333. Telephone: 404-639-2050; Fax: 404-639-2980; E-mail: ixh1@cdc.gov.
Approximately 1.1 million adults and adolescents are living with human immunodeficiency virus (HIV) infection in the United States, with 48,200--64,500 persons newly infected each year (1,2). At the beginning of the HIV epidemic in the United States in the early 1980s, the majority of persons with an HIV diagnosis were white men who have sex with men (MSM) (3,4). MSM continue to comprise a substantial proportion of persons newly infected with HIV, and the proportion of HIV infections among racial/ethnic minorities and women has increased (5). (These categories are not mutually exclusive.) Monitoring the burden of the epidemic among specific population groups provides guidance for targeting prevention and treatment efforts and allows assessment of intervention success.
HIV infection is a notifiable disease in all states and the District of Columbia (DC). Since 1982, all 50 U.S. states and DC have reported stage 3-HIV infection, acquired immunodeficiency syndrome (AIDS), to CDC in a uniform format. In 1994, CDC implemented data management for national surveillance of early-stage HIV infection integrated with AIDS case surveillance, at which time 25 states with confidential, name-based HIV surveillance began submitting de-identified case reports to CDC. Eventually, additional states implemented name-based HIV surveillance, and all states had implemented such surveillance by April 2008. CDC regards data from states with confidential, name-based, HIV surveillance systems as sufficient to monitor trends for HIV infection after 4 continuous years of reporting (5).
To determine the number of persons aged ≥13 years who received a diagnosis of HIV infection during 2005 and 2008, CDC analyzed data from the national HIV surveillance system reported through June 2009. Analysis was limited to the 37 states that had reported HIV cases since at least January 2005 to allow for estimation of diagnoses rates. Rates per 100,000 population were calculated for 2005 and 2008 by sex and race/ethnicity, with population denominators based on postcensal estimates from the U.S. Census Bureau (6). Disparities in HIV diagnosis rates were assessed by using relative percentage difference, a relative measure of disparity recommended by CDC's National Center for Health Statistics to compare variations (7). The relative percentage difference in HIV diagnosis rates was calculated for each racial/ethnic group, using the rates among whites as the referent ([{rate of interest -- rate among whites} / rate among whites] × 100). Rates were compared with whites as the referent group because whites typically have the lowest or second-lowest diagnosis rates, and the numerator provides a stable rate. Percentage difference also was calculated for males compared with females by using females as the referent population (7). For transmission categories, analysis was limited to all men and MSM as a result of the availability of denominator data (8); the category of all men was used as the referent group. MSM denominator was calculated by using data on reports of the proportion of men who engaged in same-sex behavior during the previous 5 years and by using the point estimate (4.0%); however, the denominator might vary (95% confidence interval = 2.8--5.3) (8). Analyses were adjusted for reporting delays (i.e., the time between diagnosis and report) and for missing risk factor information (5). Data were not available for all states, so a state breakdown of disparities is not provided. Because data on income, education, and disability status were not available, these factors were not included in the analysis.
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HIV Infection --- United States, 2005 and 2008
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United States, 2004 and 2008 [21/25]
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Diabetes --- United States, 2004 and 2008
▲ Diabetes --- United States, 2004 and 2008
Supplements
January 14, 2011 / 60(01);90-93
Gloria L. Beckles, MD1
Julia Zhu, MS2
Ramal Moonesinghe, PhD3
1National Center for Chronic Disease Prevention and Health Promotion, CDC
2Epidemiology and Analysis Program Office, CDC
3Office of Minority Health and Health Disparities, CDC
Corresponding author: Gloria L. Beckles, MD, Division of Diabetes Translation, 1600 Clifton Road, NE, MS K-10, Atlanta, GA 30333. Telephone: 770-488-1272; Fax: 770-488-8364; E-mail: glb4@cdc.gov.
Diabetes is a serious, costly, and potentially preventable public health problem in the United States (1--3). Both the prevalence and incidence of diabetes have increased rapidly since the mid-1990s, with minority racial/ethnic groups and socioeconomically disadvantaged groups experiencing the steepest increases and most substantial effects from the disease (1,4--6).
To assess disparities in the prevalence and incidence of medically diagnosed diabetes, CDC used data from the 2004 and 2008 National Health Interview Survey (NHIS), an ongoing, cross-sectional, in-person household interview survey of the civilian, noninstitutionalized U.S. population. A randomly selected adult (aged ≥18 years) in each family was asked whether they had ever been told by a health-care professional that they had diabetes; those who reported having diagnosed diabetes were asked the age at which they received the diagnosis. Respondents who were the same age when interviewed as when they received a diabetes diagnosis were considered to have a case of incident diabetes (Age at interview -- Age at diagnosis = 0 years). In addition, half of the cases among respondents who were aged 1 year older when they were interviewed than when they received the diagnosis were counted as incident cases (Age at interview -- Age at diagnosis = 1 year). Both the values for age at interview and age at diagnosis were rounded to the nearest year; therefore, among respondents with a difference of 1 year (Age at interview -- Age at diagnosis = 1 year), the actual duration with diagnosed diabetes was in the interval (0, 2). Durations were assumed to be spread uniformly over the interval (0, 2), and half were assumed to be within 1 year of diagnosis. Prevalence (cases of diabetes of any duration per 100 population) was calculated for adults aged ≥18 years. Incidence (cases of diabetes ≤1 year's duration per 1,000 population) was calculated for adults aged 18--79 years.
Analyses were performed to assess disparities between groups, defined by age, sex, race/ethnicity, socioeconomic position (measured as educational attainment and poverty to income ratio [PIR]) (7), disability status, and U.S. Census region. Persons with a disability were adults with either a functional limitation from any condition or a health problem that required use of special equipment (8). In each disparity domain (i.e., classifying variable), the group with the lowest stable estimate (i.e., relative standard error <30%) of diabetes prevalence or incidence was chosen as the referent category; for racial/ethnic disparities, white men and white women, the largest groups, were selected as the referent category (9,10). Absolute difference was calculated by subtracting the value in the referent category from each category of the classifying variable. Relative difference (percentage difference) was calculated by dividing the absolute difference by the value in the referent category. For example, with women as the referent category, the relative difference in prevalence between men and women is the absolute difference divided by the value for women with the fraction expressed as a percentage. To assess whether disparities changed with time, the difference between group relative differences that were significant in the 2008 and 2004 data were calculated (9,10). Statistically significant increases and decreases in relative difference from 2004 to 2008 were interpreted as increases and decreases in disparity over time, respectively. In all analyses, data were weighted to provide estimates representative of the U.S. population. Estimates were age adjusted to the U.S. 2000 Census population (11). The z statistic and a two-tailed test with Bonferroni correction were used to test for statistical significance of absolute differences and the change in relative difference between 2004 and 2008. Differences were considered statistically significant at p<0.05. full text: Diabetes --- United States, 2004 and 2008
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United States, 2005--2008 [22/25]
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Prevalence of Hypertension and Controlled Hypertension --- United States, 2005--2008
▲ Prevalence of Hypertension and Controlled Hypertension --- United States, 2005--2008
Supplements
January 14, 2011 / 60(01);94-97
Nora L. Keenan, PhD1
Kimberly A. Rosendorf, MHS2
1National Center for Chronic Disease Prevention and Health Promotion, CDC
2National Center for Health Statistics, CDC
Corresponding author: Nora L. Keenan, PhD, Division for Heart Disease and Stroke Prevention, 2877 Brandywine Road, MS K-47, Atlanta, GA 30341. Telephone: 770-488-6487; Fax: 770-488-8334; E-mail: nlk0@cdc.gov.
Hypertension is a serious public health challenge in the United States, affecting approximately 30% of adults (1,2) and increasing the risk for heart disease and stroke, the first and third leading causes of death in the United States* (3). Racial/ethnic and socioeconomic disparities in hypertension prevalence in the United States have been documented for decades (4). Non-Hispanic blacks have a higher risk for hypertension and hypertension-related complications (e.g., stroke, diabetes, and chronic kidney disease) than non-Hispanic whites and Mexican Americans (2,4). Between 1999--2000 and 2007--2008, the prevalence of hypertension did not change, but control of hypertension increased among those with hypertension (1,5). Despite considerable improvements in increasing awareness, treatment and control of hypertension, in 2007--2008, approximately half of adults with hypertension did not have their blood pressure under control (1). Because of the fundamental role of hypertension in cardiovascular health, Healthy People 2010 includes national objectives to reduce the proportion of adults aged ≥20 years with hypertension to 14% from a baseline of 26% (objective 12-9) and to increase the proportion of adults aged ≥18 years with hypertension whose blood pressure is under control to 68% from a baseline of 25% (objective 12-10) (6,7).
To estimate age-adjusted hypertension prevalence and control among persons aged ≥18 years, CDC analyzed combined National Health and Nutrition Examination Survey (NHANES) data from two survey periods: 2005--2006 and 2007--2008.† NHANES is a nationally representative survey of the noninstitutionalized U.S. civilian population. Data are collected annually but released in 2-year cycles. NHANES includes a home interview and a physical examination at a mobile examination center where blood pressure is measured. Participants were selected through a complex, multistage sampling probability design. During 2005--2008, the response rate among persons in the sample was 76.4%.§ Data were analyzed for 10,488 participants for whom adequate interview and examination data were collected to determine hypertension status.
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Prevalence of Hypertension and Controlled Hypertension --- United States, 2005--2008
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United States, 2009 [23/25]
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Binge Drinking --- United States, 2009
▲ Binge Drinking --- United States, 2009
Supplements
January 14, 2011 / 60(01);101-104
Dafna Kanny, PhD
Yong Liu, MS
Robert D. Brewer, MD
National Center for Chronic Disease Prevention and Health Promotion, CDC
Corresponding author: Dafna Kanny, PhD, Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, CDC, 4770 Buford Highway, NE, MS K-67, Atlanta, GA 30341. Telephone: 770-488-5411; Fax: 770-488-5965; E-mail: dkk3@cdc.gov.
Excessive alcohol use is the third leading preventable cause of death in the United States (1) and was responsible for approximately 79,000 deaths and 2.3 million years of potential life lost (YPLL) in the United States each year during 2001--2005.* Binge drinking, defined as consuming four or more alcoholic drinks on one or more occasion for women and five or more drinks on one or more occasion for men, was responsible for more than half of these deaths and for two thirds of YPLL (2). More than half of alcohol consumed by adults in the United States is in the form of binge drinks (3). Healthy People 2010 (HP2010) (objective no. 26-11c) called for reducing the prevalence of binge drinking among adults (4). An overarching national health goal is to eliminate health disparities among different segments of the population.
To assess binge drinking by sex, age group, race/ethnicity, education level, income level, and disability status at the individual level, as well as geographic disparities in binge drinking at the state level, CDC analyzed data from the 2009 Behavioral Risk Factor Surveillance System (BRFSS) on binge drinking prevalence, frequency (i.e., the average number of binge drinking episodes), and intensity (i.e., the average largest number of drinks consumed by binge drinkers).
BRFSS is a state-based, random-digit--dialed telephone survey of the noninstitutionalized U.S. civilian population aged ≥18 years that is conducted monthly in all states and selected territories. BRFSS includes data regarding leading health conditions and health risk behaviors, including binge drinking. For this report, responses to questions regarding the prevalence, frequency, and largest number of drinks consumed by binge drinkers (a measure of the intensity of binge drinking) were analyzed, beginning with the question, "Considering all types of alcoholic beverages, how many times during the past 30 days did you have X [X = 5 for men; X = 4 for women] or more drinks on an occasion?" Respondents then were asked, "During the past 30 days, what is the largest number of drinks you had on any occasion?" Responses to this question were assessed for binge drinkers only. After exclusion of persons who reported "don't know/not sure" or "refused" and those with missing information and respondents from the U.S territories, data from 408,845 respondents in the 50 states and the District of Columbia (DC) were used for analysis. Response rates for each state were calculated by using the Council of American Survey and Research Organizations (CASRO) guidelines. Response rates ranged from 37.9% (Oregon) to 66.9% (Nebraska) (median: 52.5%), and cooperation rates ranged from 55.5% (California) to 88.0% (Kentucky) (median: 75.0%).†
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Binge Drinking --- United States, 2009
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United States, 1991--2008 [24/25]
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Adolescent Pregnancy and Childbirth --- United States, 1991--2008
▲ Adolescent Pregnancy and Childbirth --- United States, 1991--2008
Supplements
January 14, 2011 / 60(01);105-108
Stephanie J. Ventura, MA
TJ Mathews, MS
Brady E. Hamilton, PhD
Paul D. Sutton, PhD
Joyce C. Abma, PhD
National Center for Health Statistics, CDC
Corresponding author: Stephanie J. Ventura, MA, Division of Vital Statistics, National Center for Health Statistics, CDC, 3311 Toledo Road, Room 7418, Hyattsville, MD 20782. Telephone: 301-458-4547; Fax: 301-458-4033; E-mail: sjv1@cdc.gov.
Giving birth to a child during the adolescent years frequently is associated with long-term adverse consequences for the mother and her child (1--3) that often are attributable in part to fragile family structure and limited social support and financial resources. Compared with infants born to adult women, infants born to adolescent females are at elevated risk for preterm birth, low birth weight, or death during infancy (4--6). An estimated 82% of pregnancies in 2001 among adolescents were unintended (7,8).
To analyze trends and variations in adolescent pregnancy and birth rates, CDC analyzed birth data from the National Vital Statistics System (NVSS) for 1991--2008. Data for 1991--2007 are final; data for 2008 are preliminary (4,6). Data by maternal race/ethnicity are based on information reported by the mother during the birth registration process. Race and ethnicity are reported separately on birth certificates. Birth rates were calculated by using population estimates prepared by the U.S. Census Bureau. Percentage change over time was calculated by comparing the rates for the beginning and end points in each time period. In analyzing differences over time and among groups, only statistically significant differences are noted. Significance testing is based on the z-test at the 95% confidence level (4,6). Additional information is available elsewhere (4,6). Data regarding adolescent pregnancy are not as current or complete as NVSS data regarding adolescent births. Birth data are based on NVSS and are shared with CDC through the Vital Statistics Cooperative Program (VSCP). National data on adolescent pregnancy and childbirth according to such attributes as educational attainment and disability status are not available because this information is not collected consistently and completely in NVSS and the National Abortion Surveillance System. Abortion estimates are from abortion surveillance information collected from the majority of states by CDC; these estimates are adjusted to national totals by the Guttmacher Institute (9). Information on fetal losses is derived from the pregnancy history data collected from multiple cycles of the National Survey of Family Growth (NSFG), conducted by CDC's National Center for Health Statistics (9). The most recent pregnancy estimates that include data on live births, induced abortions, and fetal losses are for 2005 (9).
In 2005, on the basis of available data, approximately 57% of the estimated 740,000 adolescent pregnancies ended in a live birth, 27% ended in an induced abortion, and 16% ended in a fetal loss. Substantial differences exist by race/ethnicity in how adolescent pregnancies are resolved. Pregnancies among non-Hispanic white and Hispanic adolescents are more likely to end in live births and less likely to end in induced abortions than are pregnancies among non-Hispanic black adolescents.
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Adolescent Pregnancy and Childbirth --- United States, 1991--2008
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United States, 1965--2008 [25/25]
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Cigarette Smoking --- United States, 1965--2008
▲ Cigarette Smoking --- United States, 1965--2008
Supplements
January 14, 2011 / 60(01);109-113
Bridgette E. Garrett, PhD
Shanta R. Dube, PhD
Angela Trosclair, MS
Ralph S. Caraballo, PhD
Terry F. Pechacek, PhD
National Center for Chronic Disease Prevention and Health Promotion, CDC
Corresponding author: Bridgette E. Garrett, PhD, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC, 4770 Buford Highway, MS K-50, Atlanta, GA 30341. Telephone: 770-488-5715; Fax: 770-488-5767; E-mail: beg8@cdc.gov.
Cigarette smoking remains the leading cause of preventable morbidity and mortality in the United States, resulting in an estimated 443,000 premature deaths and $193 billion in direct health-care expenditures and productivity losses each year (1). The prevalence of cigarette smoking among youth and adult smokers has declined, but that decline has stalled during the past 5 years among adults (2,3). Despite overall declines in cigarette smoking, disparities in smoking and other tobacco use still persist among certain racial/ethnic minority groups, particularly among American Indians/Alaska Natives (AI/ANs) (4). In addition to racial/ethnic disparities in cigarette smoking, other groups have higher prevalence of cigarette smoking, with higher use reported among persons with low socioeconomic status; persons with histories of mental health and substance abuse conditions; the lesbian, gay, bisexual, and transgender community; and persons living in the South and Midwest regions of the United States (5--7).
Each day in the United States, approximately 3,900 persons aged 12--17 years smoke their first cigarette, and an estimated 1,000 adolescents become daily cigarette smokers (8). The vast majority of persons who begin smoking during adolescence are addicted to nicotine by age 20 (9). Among youth, factors associated with smoking include low socioeconomic status, low academic achievement (e.g., poor grades and absenteeism), high-risk sexual behavior, and use of alcohol and other drugs (9,10). As with adult smoking, racial/ethnic differences in cigarette smoking exist among youth smokers, with AI/ANs having the highest prevalence of cigarette smoking, particularly among females. In comparison, youth smoking among black females has consistently been lower and has declined during past years. These declines have contributed to the overall lower prevalence of cigarette smoking among black youth smokers (2).
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Cigarette Smoking --- United States, 1965--2008
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