Lyme Disease - Continued

from Missouri, New Jersey, New York, North Carolina, and Texas has been postulated as the possible etiologic agent (3).

Vaccines to protect against LD are in advanced stages of development and evaluation. However, personal protection measures (e.g., applying tick repellants and inspecting for ticks) and environmental modifications (e.g., applying insecticides and using deer fencing) will continue to be important methods for reducing the risk for exposure to tick bites and preventing LD and other tickborne diseases (e.g., ehrlichiosis and babesiosis) (4-6). To enable optimal treatment of patients, clinical and laboratory data must be used to distinguish between these diseases, and the possibility of coinfection with more than one agent should be considered (7,8). Early stages of LD usually are treated with amoxicillin or doxycycline; the treatments of choice for ehrlichiosis and babesiosis are tetracyclines and clindamycin/quinine, respectively (9). Participants in the Second National Conference on the Serologic Diagnosis of Lyme Disease (October 1994) recommended that laboratories use a two-test approach for the serologic diagnosis of LD. Specimens should be tested first by using the more sensitive enzyme-linked immunosorbent assay (ELISA) or indirect immunofluorescence assay (IFA). Specimens that are positive or equivocal then should be tested with the more specific IgG and IgM Western blot (WB). Because sensitivity and specificity of the ELISA and WB vary in relation to the timing of specimen acquisition, clinical and exposure histories must be considered in the interpretation of serologic results (10). References

1. CDC. Case definition for public health surveillance. MMWR 1990;39(no. RR-13):19-21. 2. Campbell GL, Paul WS, Schriefer ME, Craven RB, Robbins KE, Dennis DT. Epidemiologic and diagnostic studies of patients with suspected early Lyme disease, Missouri, 1990-1993. J Infect Dis 1995;172:470-80.

3. Barbour AG, Maupin GO, Teltow GJ, Carter CJ, Piesman J. Identification of an uncultivable Borrelia species in the hard tick Amblyomma americanum. possible agent of a Lyme diseaselike illness. J Infect Dis 1996;173:403-9.

4. Fish D. Environmental risk and prevention of Lyme disease. Am J Med 1995;98:2-9.

5. CDC. Human granulocytic ehrlichiosis-New York, 1995. MMWR 1995;44:593-5.

6. Meldrum SC, Birkhead GS, White DJ, Benach JL, Morse DL. Human babesiosis in New York state: an epidemiological description of 136 cases. Clin Infect Dis 1992;15:1019-23.

7. Krause PJ, Telford SR, Spielman A, et al. Concurrent Lyme disease and babesiosis: evidence for increased severity and duration of illness. JAMA 1996;275:1657-60.

8. Mitchell PD, Reed KD, Hofkes JM. Immunoserologic evidence of coinfection with Borrelia burgdorferi, Babesia microti, and human granulocytic Ehrlichia species in residents of Wisconsin and Minnesota. J Clin Microbiol 1996;34:724-7.

9. Benenson AS. Control of communicable diseases manual. 16th ed. Washington DC: American Public Health Association, 1995;59-61,165-7.

10. CDC. Recommendations for test performance and interpretation from the Second National Conference on Serologic Diagnosis of Lyme Disease. MMWR 1995;44:590-1.

Update: National Breast and Cervical Cancer

Early Detection Program - July 1991-September 1995

During the 1990s, breast or cervical cancer will be diagnosed in an estimated 2 million women in the United States, and 500,000 will die as a result of these diseases (1). Screening mammography followed by timely and appropriate treatment can reduce

Breast and Cervical Cancer — Continued

breast cancer mortality by 30% for women aged 50-69 years, and routine use of the Papanicolaou (Pap) test followed by timely and appropriate treatment can prevent nearly all deaths from cervical cancer (2,3). The Breast and Cervical Cancer Mortality Prevention Act of 1990* established a nationwide, comprehensive public health program for increasing access to breast and cervical cancer screening services for underserved women. This report summarizes the impact of this initiative, CDC's National Breast and Cervical Cancer Early Detection Program (NBCCEDP), during July 1991-September 1995.

During the reporting period, the NBCCEDP was implemented in 35 state health agencies and nine American Indian/Alaskan Native programs that provided screening, referral, and follow-up services; public and professional education; quality assurance; surveillance; and coalition and partnership development. Outreach efforts were initiated to women in high-priority groups, including older women, women with low income, uninsured or underinsured women, or women of racial/ethnic minority groups. During the reporting period, approximately 800,000 screenings for breast and cervical cancer were provided to uninsured or underinsured women.

During July 1991-September 1995, the program provided 327,017 mammograms; 61.2% of the mammograms were provided to women aged ≥50 years, and 46.7% were provided to women of racial and ethnic minorities. Breast cancer was diagnosed in 1674 of the women who received mammograms. Although the rate of abnormalities detected by mammogram was highest for younger women, the rate of breast cancers detected per 100,000 mammograms increased directly with increasing age (Figure 1). A total of 472,188 Pap tests were performed; 59.1% of the Pap tests were provided to women aged ≥40 years, and 46.5% were provided to women in racial/ethnic minorities. Cervical intraepithelial neoplasia, a precursor of cervical cancer that can be successfully treated, was diagnosed in 15,119 women. Invasive cervical cancer was diagnosed in 184 women. The rate of abnormal Pap tests varied inversely with age. Reported by: Program Svcs Br and Office of the Director, Div of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, CDC. Editorial Note: The national health objectives for the year 2000 include increasing to at least 60% the proportion of women in low-income groups and aged ≥50 years who have received a clinical breast examination and mammogram within the preceding 2 years and increasing to at least 80% the proportion of low-income women and women aged ≥18 years (with uterine cervix) who have received a Pap test within the preceding 3 years (objectives 16.11b and 16.12d) (4). The Breast and Cervical Cancer Mortality Prevention Act has enabled state health agencies to build a public health infrastructure to increase access to breast and cervical cancer screening services for women who are medically underserved. During fiscal year 1996, CDC entered the sixth year of the program; the number of women screened for breast and cervical cancer has increased substantially each year.

Although screening mammography and Pap tests are essential strategies for cancer prevention and control, these procedures have been substantially underused. The most important risk factors for breast cancer are female sex and older age (5); however, findings from the 1992 National Health Interview Survey (NHIS) indicated that only 35% of women aged ≥50 years reported having had a screening mammogram during the previous year. In addition, even though cervical cancer death rates are *Public Law 101-354.

Breast and Cervical Cancer - Continued

FIGURE 1. Rate* of breast cancers, by age

United States, National Breast and Cervical Cancer Early Detection Program, July 1991-September 1995

*Per 100,000 mammograms, age-adjusted to the 1970 U.S. population.

higher among older women (6), older women are less likely to receive Pap tests on a regular basis (3). The 1992 NHIS indicated that only 63% of women aged 50-64 years reported having had a Pap test during the previous 3 years (7). Use of mammograms and Pap tests was lower among women of racial/ethnic minorities, women who had less than a high school education, and women who had a low income (7). Reasons for the low proportion of women who use these screening tests include lack of a recommendation for screening from a health-care provider, costs associated with the tests, and lack of an understanding of the value of early detection.

Early detection programs at the state and community levels have resulted in increased staff resources and expertise for cancer control, innovative public and professional education programs for women and health-care providers, collaborative partnerships involving the private and public sectors, state and community coalitions, and improved understanding of the barriers that prevent underserved women from seeking screening services. Improvements in measures for ensuring quality of screening tests and the establishment of public and private partnerships have benefitted all women. For example, when the NBCCEDP was implemented in 1991, provider agencies participating in the program were required to meet technical guidelines for mammography and cytology services, which included having all mammography facilities meet standards established by the American College of Radiology and the Food and Drug Administration and all cytology laboratories meet standards established by the Clinical Laboratory Improvements Act of 1988. To promote the importance of screening services for all women, CDC has developed partnerships with national organizations such as the American Cancer Society, Young Women's Christian Association USA and Susan G. Komen Breast Cancer Foundation.

Breast and Cervical Cancer - Continued

During fiscal year 1996, CDC received Congressional appropriations of $125 million for breast and cervical cancer control. CDC now provides funding to 35 states and nine American Indian/Alaskan Native programs for comprehensive screening programs, and infrastructure grants have been provided to 15 states, the District of Columbia, and three territories. During 1996, CDC will implement a nationwide comprehensive screening program by funding the remaining 15 states, the District of Columbia, and several of the U.S. territories.

References

1. CDC. Implementation of the Breast and Cervical Cancer Mortality Prevention Act: 1992 progress report to Congress. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, 1993.

2. US Preventive Services Task Force. Screening for breast cancer. Am Fam Physician 1989;39: 89-96.

3. Devesa SS, Young JL, Brinton LA, Fraumeni JF. Recent trends in cervix uteri cancer. Cancer 1989;64:2184–90.

4. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives-midcourse review and 1995 revisions. Washington, DC: US Department of Health and Human Services, Public Health Service, 1995.

5. American Cancer Society. Cancer facts and figures, 1996. Atlanta, Georgia: American Cancer Society, 1996; publication no. 5008.96.

6. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute. Incidence data from the Surveillance, Epidemiology, and End Results Program, 1973-1990. Cancer Statistics Review, 1973-1990. Bethesda, Maryland: National Cancer Institute, 1993; publication no. 93-2789.

7. Anderson LM, May DS. Has the use of cervical, breast, and colorectal cancer screening increased in the United States? Am J Public Health 1995;85:840-2.

Factors Associated with Prevalent Self-Reported Arthritis and Other Rheumatic Conditions - United States, 1989-1991

Arthritis and other rheumatic conditions are among the most prevalent diseases in the United States, particularly for women and some racial/ethnic groups (1-3). In 1992, arthritis was the leading cause of disability and was associated with total direct and indirect costs of $64.8 billion (4); projections indicate that by 2020, arthritis will affect 59.4 million (18.2%) persons in the United States (1). Previous reports have documented marked differences in the prevalence rates of arthritis by age, sex, race, ethnicity, education, and body mass index (BMI) (1–3). To examine the relative importance of these factors, CDC used data from the 1989-1991 National Health Interview Survey (NHIS) and a multivariate model to estimate the independent effect of each factor on self-reported arthritis. This report summarizes the results of that analysis, which indicate that a higher risk for arthritis is associated with older age, overweight, or obesity and that a lower risk is associated with being Asian/Pacific Islander or Hispanic or with having a higher education level.

The NHIS is an annual national probability sample of the U.S. civilian, noninstitutionalized population (5). Estimates of the prevalence of arthritis were based on a one-sixth random sample (n=59,289) of respondents who answered questions about the presence of any musculoskeletal condition during the preceding 12 months and provided details about these conditions. Each condition was assigned a code from the

International Classification of Diseases, Ninth Revision (ICD-9). This analysis used the definition of arthritis, which included arthritis and other rheumatic conditions, developed by the National Arthritis Data Workgroup (1)*. The final sample of 41,919 excluded persons aged <18 years (n=16,488), for whom self-reported height and weight were not asked, and persons aged ≥18 years for whom such data were missing (n=882).

Multivariate logistic regression was used to assess the relation between selfreported arthritis and age, race, ethnicity, education, and BMI. Previous studies have documented that each of these variables is associated with arthritis (1-3,6-8). Because stratified analyses suggested that the effect of BMI on arthritis differed by sex, the model was applied separately to men and women. For this analysis, BMI (weight [kg]/height [m]2) was divided into four categories: underweight (BMI<20), normal weight (20≤BMI<25), overweight (25≤BMI <30), and obese (BMI≥30) (9). SUDAAN was used to weight observations and to account for the complex sampling design.

Of the 41,919 persons surveyed, 8706 (21%) reported having arthritis. Older age was the strongest overall predictor for self-reported arthritis (Table 1). Among women, risk for arthritis varied directly with BMI. Among men, the risk was higher among those with greater BMI (odds ratio [OR]=1.3 [95% confidence interval (CI)=1.1–1.4] for overweight, OR=1.7 [95% CI=1.5-2.0] for obese), and those who were underweight (OR=1.4 [95% CI=1.0–1.8]), a finding that persisted despite adjustments for conditions that could cause chronic weight loss (e.g., infections and neoplasms). Risk for arthritis was similar by race for all groups except Asians/Pacific Islanders (OR=0.6 [95% CI=0.4– 0.9]), and by ethnicity, was lower among Hispanics. For men, risk was lower for those who were college graduates (OR=0.8 [95% CI=0.7-1.0]) or who attended graduate school (OR=0.7 [95% CI=0.6–0.9]). Models using different BMI categories and models run without proxy-reported observations yielded similar findings.

Reported by: Dept of Epidemiology, School of Public Health, Univ of North Carolina, Chapel Hill. K Johnston-Davis, Association of Schools of Public Health, Washington, DC. Div of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note: The category of arthritis and other rheumatic conditions comprises several specific diseases associated with a spectrum of etiologies (Table 2). However, the epidemiology of most of these conditions-including incidence and prevalence estimates-has not been well characterized. In the United States, the most common types of arthritis include osteoarthritis and rheumatoid arthritis.

The findings of this analysis indicate that, even when adjusted for other factors, risk for arthritis is higher among persons who are overweight or obese or of older age. In addition, this report documents the low risk for arthritis among Asians/Pacific Islanders and Hispanics and among men with higher education. Although NHIS could not determine whether respondents were overweight or obese before or after the onset of arthritis, previous studies have documented that overweight or obesity are risk factors for osteoarthritis of the knee (6-8). The low risk for arthritis among Asians/Pacific Islanders and Hispanics persisted after adjustment for age, BMI, and education. These race/ethnicity-specific associations may reflect variations in cultural thresholds for reporting arthritis, risk factors (e.g., joint injury, occupations involving knee bending, * International Classification of Diseases, Ninth Revision, Clinical Modification, codes 95.6, 95.7, 98.5, 99.3, 136.1, 274, 277.2, 287.0, 344.6, 353.0, 354.0, 355.5, 357.1, 390, 391, 437.4, 433.0, 446, 447.6, 696.0, 710-716, 719.0, 719.2-719.9, 720-721, 725-727, 728.0-728.3, 728.6-728.9, 729.0729.1, and 729.4.