Publication of Report on Tobacco Control Investment by States FREE

MMWR. 2001;50:495-6

CDC recently published Investment in Tobacco Control: State Highlights, 2001.¹ The publication presents information for all 50 states and the District of Columbia on the prevalence of tobacco use, the health impact and costs associated with tobacco use, the amount of funding for tobacco control, and excise taxes on tobacco. States can use the information in the report in developing tobacco control programs.

Investment in Tobacco Control is the third state highlights report released by CDC's Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, and is the first to provide a compilation of states' investments in tobacco control. The report presents an analysis of investments in tobacco control, places these investments in the context of health and economic consequences of tobacco use specific to the state, and compares current investments with the funding ranges recommended in CDC's Best Practices for Comprehensive Tobacco Control Programs.²

The report shows that in fiscal year 2001, 45 states are investing $883.2 million in tobacco prevention and control programs, including 36 states investing $654.9 million from state settlements with the tobacco industry; eight states appropriating $218.4 million from tobacco excise tax revenues; and nine states appropriating $9.9 million from their general revenues. Other funding sources include $58.1 million awarded to the states by CDC and $9 million awarded by the American Legacy Foundation.

The report is available at http://www.cdc.gov/tobacco/statehi/pdf_2001/2001statehighlights.pdf, and print copies are available through CDC's Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Mailstop K-50, 4770 Buford Highway, N.E., Atlanta, GA 30341; telephone (770) 488-5705. Up-to-date and historic data on the prevalence of tobacco use, tobacco control laws, the health impact and costs associated with tobacco use, and tobacco agriculture and manufacturing are available for all 50 states and the District of Columbia through CDC's State Tobacco Activities Tracking and Evaluation (STATE) System available at http://www2.cdc.gov/nccdphp/osh/state/.

MMWR. 2001;50:440-444

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Twenty years after the first report on human immunodeficiency virus (HIV) infection in the United States, studies of sexually transmitted diseases (STDs) and sexual behaviors suggest a resurgent HIV epidemic among men who have sex with men (MSM).^1- 2 However, few recent studies have measured HIV incidence in this population.^3- 7 To determine HIV incidence among young MSM, CDC analyzed data from the Young Men's Survey (YMS), a study that found a high prevalence of HIV and associated risks among MSM aged 15-22 years sampled in seven U.S. cities.⁸ This report confirms high HIV incidence among these young men.

YMS Phase I was a cross-sectional, multisite, venue-based sample survey of men aged 15-22 years who attended public venues where young MSM congregate (e.g., urban shopping blocks, dance clubs, bars, and young gay organizations).⁸ During the survey start-up in each city, formative research was conducted to identify all venues frequented by young MSM, and the days and times when young men frequented these venues. A three-stage sampling plan was used to randomly select venues from the sampling frame of venues and then to randomly select times. Sampled venues and times were then scheduled for the third stage of sampling in which young men were sampled at 194 venues in Baltimore, Maryland; Dallas, Texas; Los Angeles, California; Miami, Florida; New York, New York; San Francisco, California; and Seattle, Washington. Eligible men (i.e., local residents aged 15-22 years) were recruited for the survey. Participants were asked about their risk behaviors and demographics, and counseled about and tested for HIV; blood specimens were tested anonymously for HIV. Participants were scheduled to return in 2 weeks for test results, posttest counseling, and service referrals. Duplicate enrollees were removed from the database by various screening methods, including the Miragen Assay, which profiles antibodies. Because no association was found between frequency of venue attendance and HIV prevalence, the data were not weighted according to venue attendance.

An enzyme immunoassay was used to screen blood specimens for HIV antibody. Repeatedly reactive specimens were confirmed by Western blot or indirect immunofluorescence. To estimate HIV incidence, a serologic testing algorithm was used to determine recent HIV seroconversion (STARHS).⁹ HIV-positive specimens were tested with a sensitive HIV-1 whole viral lysate EIA (3A11) (Abbott, Abbott Park, Illinois) that detects infection approximately 30 days after transmission. Specimens that were 3A11-reactive were retested using the 3A11-LS (less-sensitive), which detects HIV infection approximately 140 days after the 3A11 (95% confidence interval [CI] = 125-156 days). A specimen that was 3A11-reactive but 3A11-LS-nonreactive was categorized as a recent infection. Incidence was calculated using the number of persons with recent infections as the numerator and the number of persons with recent infections plus the number of persons who were HIV-negative as the denominator. Incidence estimates were adjusted for HIV-positive specimens that were not tested by STARHS. Incidence was annualized to units of percent per year. All data were analyzed using SAS version 6.12.

In the seven cities, 3492 young MSM enrolled (range for the seven cities: 357-702 MSM).⁸ The enrollment rate was 62% (range: 51%-75%). The prevalence of HIV infection was 7.2% (range: 2.2%-12.1%), increased with age, and was higher among blacks, Hispanics, and men of mixed race than among whites or Asians/Pacific Islanders. These findings and the high prevalence of unprotected anal sex during the preceding 6 months (41%; range: 33%-49%) suggested that HIV incidence was high among these young men.

Of the 3449 young MSM tested, 249 were HIV-positive. Of the 249 HIV-positive specimens, 224 were tested by STARHS; 29 met the criteria for recent infection. HIV incidence was 2.6% overall, 3.5% among persons aged 20-22 years, 4.0% among blacks, and 5.4% among men of mixed race. Of the 29 persons with recent infections, 14 were from New York City. HIV incidence was similar among homosexual and bisexual men. Recent risk behaviors associated with high HIV incidence were having ≥5 male sex partners during the preceding 6 months, having unprotected anal sex with men, or having injected drugs.

During 1998-2000, YMS Phase II was conducted to sample MSM aged 23-29 years in six of the seven cities (excluding San Francisco). Data are preliminary. Of the 2942 young MSM, 1409 (48%) were white, 651 (22%) were Hispanic, and 497 (17%) were black. Of these, 373 (13%) were HIV-positive; HIV prevalence was 7% among whites, 14% among Hispanics, and 32% among blacks. Of the 373 HIV-positive specimens, 290 were STARHS-tested; 38 were recent infections. Overall incidence was 4.4% (95% CI = 2.9%-6.7%); HIV incidence was 2.5% among whites (95% CI = 1.4%-4.6%), 3.5% among Hispanics (95% CI = 1.4%-8.6%), and 14.7% among blacks (95% CI = 7.9%-27.1%).

W McFarland, MD, MH Katz, MD, San Francisco Dept of Public Health, San Francisco; SR Stoyanoff, MPH, Los Angeles County Dept of Health Svcs, Los Angeles, California. DA Shehan, Univ of Texas Southwestern Medical Center at Dallas, Dallas, Texas. M LaLota, MPH, Florida Dept of Health. DD Celentano, ScD, Johns Hopkins Univ School of Hygiene and Public Health, Baltimore, Maryland. BA Koblin, PhD, New York Blood Center, LV Torian, PhD, New York City Dept of Health, New York, New York. H Thiede, DVM, Public Health-Seattle and King County, Seattle, Washington. Clinical Biochemistry Br, Div of Environmental Health Laboratory Sciences, National Center for Environmental Health; Prevention Svcs Research Br, Statistics and Data Management Br, Office of the Director, Div of HIV/AIDS Prevention-Surveillance and Epidemiology, National Center for HIV, STD, and TB Prevention, CDC.

The findings in this report document a high incidence of HIV among a sample of young MSM, particularly blacks in their 20s. The overall incidence was comparable to that reported in recent studies of adult MSM.^3- 7 In the 20th year of the HIV epidemic, young MSM in these cities continue to be at high risk for HIV infection.

This is the first published report using STARHS to provide incidence estimates in community-recruited sample surveys. In this study, HIV incidence was high among MSM in their 20s and young racial/ethnic minority MSM, especially blacks. Because there were no earlier incidence studies of MSM aged 15-22 years, it is unknown whether HIV transmission among very young MSM is increasing. However, the preliminary high incidence data among MSM aged 23-29 years in YMS Phase II, in conjunction with other recent findings on STDs and sexual behaviors,^1- 2 are of concern and may suggest a resurgent MSM epidemic among young MSM in the late 1990s.

The findings in this report are subject to at least three limitations. First, although enrollment rates were high, sampling was conducted through outreach at venues, and it is not known whether young men with recent high-risk behaviors were more likely to enroll. Second, young men were sampled only at randomly selected venues, and incidence may have been lower if young MSM who did not go to venues or did not live in cities had been sampled. Third, data for YMS Phase II are preliminary, particularly because not all specimens were STARHS-tested and the final results may change slightly.

Young MSM need to be targeted with early and sustained prevention efforts specifically tailored to their needs. In a recent health bulletin sent to HIV prevention providers, CDC encouraged local areas to assess their current situation and services and, if necessary, develop new prevention messages, improve the quality of STD clinical services for MSM, expand prevention and outreach for HIV-positive MSM, and address the factors that may be contributing to high incidence such as the impact of racism and homophobia on risk behavior.¹⁰ The high HIV incidence described in this report calls for a vigorous public health and community response to prevent HIV.

MMWR. 2001;50:491-494

Kernicterus is a preventable life-long neurologic syndrome caused by severe and untreated hyperbilirubinemia during the neonatal period. High levels of bilirubin are toxic to the developing newborn. In full-term infants, hyperbilirubinemia symptoms include severe jaundice, lethargy, and poor feeding. Features of kernicterus may include choreoathetoid cerebral palsy, mental retardation, sensorineural hearing loss, and gaze paresis. Kernicterus is not a reportable condition in the United States, and its prevalence is unknown; however, a pilot registry at a Pennsylvania hospital documented 90 cases in 21 states from 1984 to June 2001 (L. Johnson, Pennsylvania Hospital, Philadelphia, personal communication, 2001). This report summarizes case histories of four full-term, healthy infants who developed kernicterus and underscores that to prevent kernicterus, newborns must be screened and promptly treated for hyperbilirubinemia.¹

In early 2001, a national support group for parents of children with kernicterus conducted a survey on kernicterus. A convenience sample of 15 families was identified by word-of-mouth or through the Internet, and a self-administered questionnaire was mailed. For this report, a case was defined as a child in whom kernicterus (International Classification of Diseases, Ninth Revision, Clinical Modification, codes 773.4, 774.6, and 774.7) was diagnosed since 1994, who was >37 weeks' gestational age, and who weighed at birth >5 lbs, 5 oz (>2500 g). Among the sample families, seven did not complete the questionnaire, four had children who did not meet the case definition, and the remaining four had children who did meet the case definition.

In 1994, an apparently healthy white boy was born at 37 weeks' gestation weighing 6 lbs, 13 oz (3090 g). Delivery was uncomplicated. His 1 minute and 5 minute Apgar scores were eight and nine, respectively (normal range: seven-10). His mother's blood type was O + , and the newborn was A + , Coombs negative. On discharge at 20 hours, he was alert and nursing well; a 2-week follow-up appointment was scheduled at a pediatric clinic. On day 9, the infant was taken to a pediatric clinic with jaundice. The condition was thought to be the result of breastfeeding. That evening, he exhibited lethargy, was not nursing, and had "pumpkin orange" skin coloration. On day 10, the parents notified their physician about the infant's lethargy and poor eating and were given an appointment for the following morning. During a pediatric appointment on day 11, the infant weighed 5 lbs, 10 oz (2552 g), was dehydrated, and jaundiced. A tested serum sample revealed an elevated bilirubin of 41.5 mg/dL (normal range at age >72 hours: <17 mg/dL). Despite treatment with phototherapy and two double-volume exchange transfusions, on day 11, he developed athetosis, oral-motor dysfunction requiring a gastrostomy tube, and dental dysplasia. Kernicterus was diagnosed at age 6 months.

In 1995, an apparently healthy white boy was born at 37 weeks' gestation weighing 6 lbs, 5 oz (2863 g). Apgar scores were eight and nine at 1 and 5 minutes, respectively. At 17, 23, and 33 hours, jaundice was noted. No serum bilirubin level or ABO or Rh status was disclosed. Examination revealed normal neurologic and physical findings, and he was discharged after 36 hours; a follow-up appointment at a pediatric clinic was scheduled at 1 week. On day 4, the patient exhibited lethargy and poor breastfeeding. On day 5, he was admitted to a hospital. Laboratory findings included a bilirubin level of 34.6 mg/dL, and phototherapy was started. Later that day, the patient developed opisthotonus, a high-pitched cry, and poor suckling and later developed athetoid cerebral palsy, hearing loss, and gaze paresis. Kernicterus was diagnosed at age 18 months.

In 1997, an apparently healthy white boy was born at 37 weeks' gestation weighing 8 lbs, 2 oz (3686 g). His Apgar scores were nine at 1 and 5 minutes. On discharge at 22 hours, a cephalohematoma and heart murmur were noted. The following day, the infant was taken to a pediatric clinic where examination found jaundice but no heart murmur. Fifteen minutes of sunlight per day was recommended as treatment. During the next 4 days, the infant developed lethargy and poor breastfeeding. On day 6, he was taken to a pediatric clinic where a serum sample was drawn and tested. Results included a bilirubin level of 27 mg/dL; phototherapy was started. By 11 p.m., the patient's bilirubin peaked at 33.4 mg/dL, and he received an exchange transfusion. During the next 4 months, he developed athetoid cerebral palsy, oral-motor dysfunction requiring a gastrostomy tube, and gaze paresis. Kernicterus was diagnosed at age 4 months.

In 1998, an apparently healthy white boy was born at 39 weeks' gestation weighing 9 lbs, 8 oz (4313 g). Pregnancy was unremarkable but delivery required vacuum extraction. His Apgar scores were eight and nine at 1 and 5 minutes, respectively. AO blood incompatibility was noted and Rh status was unknown. At 22 hours, he appeared jaundiced; at 52 hours, he was discharged with the treatment recommendation that he receive sunlight. The infant was alert and nursed well during the next 11 days. However, at his follow-up examination on day 12, he appeared jaundiced. The initial serum bilirubin level was 23.6 mg/dL, which peaked at 29.4 mg/dL. The same day, the infant was admitted to a hospital for phototherapy. During the next 4 months, he developed athetoid cerebral palsy, hearing loss, and enamel hypoplasia, and kernicterus was diagnosed at age 4 months.

K Carter, MD, Emory Univ School of Medicine, Atlanta, Georgia. K Dixon, Parents of Infants and Children with Kernicterus, Birmingham, Alabama. National Center on Birth Defects and Developmental Disabilities; and an EIS Officer, CDC.

These cases illustrate that hyperbilirubinemia in full-term, otherwise healthy infants can lead to kernicterus. Each of these white male infants was nursing normally when discharged but shortly after developed feeding problems. A historic cohort study suggests boys are more susceptible than girls to adverse outcomes from hyperbilirubinemia.² At follow-up, initial serum bilirubin levels in all the infants exceeded maximum levels (mean: 34.7 mg/dL) specified for treatment by the American Academy of Pediatrics practice guideline, which currently is under revision.³

Treating hyperbilirubinemia with phototherapy and exchange transfusions prevents kernicterus if treatment is initiated promptly and is continued until bilirubin levels normalize. By the 1970s, such therapy was implemented effectively, and kernicterus virtually disappeared in full-term infants until the early 1990s,⁴ when physicians began to debate the need to identify and treat hyperbilirubinemia in healthy, full-term infants without risk factors for hemolysis.^5- 7

Increases in breastfeeding and early hospital discharge after delivery coincided with this debate.^8- 9 Although mild jaundice occasionally is associated with breastfeeding, it provides optimum nutrition. In the full-term newborn, serum bilirubin levels peak at 48-72 hours. Healthy, full-term infants often are discharged from hospitals before this peak. Some health-care providers rely on visual assessment to detect pathology; however, this method can be unreliable. Hyperbilirubinemia can be reduced if heath-care providers recognize risk factors and remember the acronym "JAUNDICE" (see box). Another useful tool is the May 2, 2001, Sentinel Event Alert issued by the Joint Commission on Accreditation of Healthcare Organizations.

The findings in this report are subject to at least two limitations. First, a small number of case reports has inherent limitations that include lack of representativeness. No inference can be made about risks for disease or trends. Second, these cases reflect self-reported data and are subject to potential reporting bias.

Early hyperbilirubinemia detection is critical to the prevention of the irreversible effects of kernicterus. Health-care providers, parents, and other caretakers should be aware of risk factors for hyperbilirubinemia, and treatment should begin immediately after hyperbilirubinemia is diagnosed. Verbal and written information received before the infant is discharged may be useful in gaining an understanding of risk factors for and signs and treatment of jaundice and hyperbilirubinemia. Bilirubin levels before discharge may provide quantitative measurement that could aid management.^5,10 Infants discharged <48 hours after birth should be examined by a health-care provider within 2 to 3 days to receive routine follow-up visits and a jaundice assessment. In addition, CDC, along with other agencies, researchers, and partners, plans to initiate surveillance and the systematic evaluation of trends and prevalence rate that will provide the data necessary to target prevention activities.