Vital Signs: Fruit and Vegetable Intake Among Children — United States, 2003–2010

Background

Eating more fruits and vegetables adds underconsumed nutrients to diets, reduces the risks for leading causes of illness and death, and helps manage body weight. This report describes trends in the contributions of fruits and vegetables to the diets of children aged 2–18 years.

Methods

CDC analyzed 1 day of 24-hour dietary recalls from the National Health and Nutrition Examination Surveys from 2003 to 2010 to estimate trends in children’s fruit and vegetable intake in cup-equivalents per 1,000 calories (CEPC) and trends by sex, age, race/ethnicity, family income to poverty ratio, and obesity status. Total fruit includes whole fruit (all fruit excluding juice) and fruit juice (from 100% juice, foods, and other beverages). Total vegetables include those encouraged in the Dietary Guidelines for Americans, 2010 (i.e., dark green, orange, and red vegetables and legumes), white potatoes, and all other vegetables.

Results

Total fruit intake among children increased from 0.55 CEPC in 2003–2004 to 0.62 in 2009–2010 because of significant increases in whole fruit intake (0.24 to 0.40 CEPC). Over this period, fruit juice intake significantly decreased (0.31 to 0.22 CEPC). Total vegetable intake did not change (0.54 to 0.53 CEPC). No socio-demographic group met the Healthy People 2020 target of 1.1 CEPC vegetables, and only children aged 2–5 years met the target of 0.9 CEPC fruits.

Conclusions

Children’s total fruit intake increased because of increases in whole fruit consumption, but total vegetable intake remained unchanged.

Implications for Public Health Practice

Increased attention to the policies and food environments in multiple settings, including schools, early care and education, and homes might help continue the progress in fruit intake and improve vegetable intake.     

Vital Signs: Repeat Births Among Teens — United States, 2007–2010

Background

Teen childbearing has potential negative health, economic, and social consequences for mother and child. Repeat teen childbearing further constrains the mother’s education and employment possibilities. Rates of preterm and low birth weight are higher in teens with a repeat birth, compared with first births.

Methods

To assess patterns of repeat childbearing and postpartum contraceptive use among teens, CDC analyzed natality data from the National Vital Statistics System (NVSS) and the Pregnancy Risk Assessment Monitoring System (PRAMS) from 2007–2010.

Results

Based on 2010 NVSS data from all 50 states and the District of Columbia, of more than 367,000 births to teens aged 15–19 years, 18.3% were repeat births. The percentage of teen births that represented repeat births decreased by 6.2% between 2007 and 2010. Disparities in repeat teen births exist by race/ethnicity, with the highest percentages found among American Indian/Alaska Natives (21.6%), Hispanics (20.9%), and non-Hispanic blacks (20.4%) and lowest among non-Hispanic whites (14.8%). Wide geographic disparities in the percentage of teen births that were repeat births also exist, ranging from 22% in Texas to 10% in New Hampshire. PRAMS data from 16 reporting areas (15 states and New York City) indicate that 91.2% of teen mothers used a contraceptive method 2–6 months after giving birth, but only 22.4% of teen mothers used the most effective methods. Teens with a previous live birth were significantly more likely to use the most effective methods postpartum compared with those with no prior live birth (29.6% versus 20.9%, respectively). Non-Hispanic white and Hispanic teens were significantly more likely to use the most effective methods than non-Hispanic black teens (24.6% and 27.9% versus 14.3%, respectively). The percentage of teens reporting postpartum use of the most effective methods varied greatly geographically across the PRAMS reporting areas, ranging from 50.3% in Colorado to 7.2% in New York State.

Conclusions

Although the prevalence of repeat teen birth has declined in recent years, nearly one in five teen births is a repeat birth. Large disparities exist in repeat teen births and use of the most effective contraceptive methods postpartum, which was reported by fewer than one out of four teen mothers.

Implications for Public Health Practice

Evidence-based approaches are needed to reduce repeat teen childbearing. These include linking pregnant and parenting teens to home visiting and similar programs that address a broad range of needs, and offering postpartum contraception to teens, including long-acting methods of reversible contraception.     

Vital Signs: Obesity Among Low-Income,Preschool-Aged Children — United States, 2008–2011

Background

The prevalence of obesity among U.S. preschoolers has doubled in recent decades. Childhood obesity increases the risk for adult obesity and is associated with negative health consequences. Trends in the state-specific prevalence of obesity among low-income U.S. preschool children have not been examined since 2008. State-specific obesity prevalence surveillance helps determine the need for and impact of state and local obesity prevention strategies.

Methods

Measured weight and height data from approximately 11.6 million low-income children aged 2–4 years from 40 states, the District of Columbia, and two U.S. territories who participated in the Pediatric Nutrition Surveillance System during 2008–2011 were used to estimate state obesity prevalence. Obesity was defined as having an age- and sex-specific body mass index ≥95th percentile, according to the 2000 CDC growth charts. Logistic regression models adjusted for age, sex, and race/ethnicity were used to examine trends in the state-specific obesity prevalence.

Results

During 2008–2011, statistically significant downward trends in obesity prevalence were observed in 18 states and the U.S. Virgin Islands. Florida, Georgia, Missouri, New Jersey, South Dakota, and the U.S. Virgin Islands had the largest absolute decreases in obesity prevalence, each with a decrease of ≥1 percentage point. Twenty states and Puerto Rico experienced no significant change, and obesity prevalence increased significantly in three states.

Conclusions and Implications for Public Health Practice

Small but significant declines in obesity among low-income preschoolers were observed in 19 of 43 states/territories examined. Continued prevention efforts are needed to sustain and expand the implementation and evaluation of population-level interventions to prevent childhood obesity.     

Syphilis Among U.S.-Bound Refugees, 2009–2013

U.S. immigration regulations require clinical and serologic screening for syphilis for all U.S.-bound refugees 15 years of age and older. We reviewed syphilis screening results for all U.S.-bound refugees from January 1, 2009 through December 31, 2013. We calculated age-adjusted prevalence by region and nationality and assessed factors associated with syphilis seropositivity using multivariable log binomial regression models. Among 233,446 refugees, we identified 874 syphilis cases (373 cases per 100,000 refugees). The highest overall age-adjusted prevalence rates of syphilis seropositivity were observed among refugees from Africa (1340 cases per 100,000), followed by East Asia and the Pacific (397 cases per 100,000). In most regions, male sex, increasing age, and living in non-refugee camp settings were associated with syphilis seropositivity. Future analysis of test results, stage of infection, and treatment delivery overseas is warranted in order to determine the extent of transmission risk and benefits of the screening program.     

Vital Signs: Alcohol Poisoning Deaths — United States, 2010–2012

Background

Alcohol poisoning is typically caused by binge drinking at high intensity (i.e., consuming a very large amount of alcohol during an episode of binge drinking). Approximately 38 million U.S. adults report binge drinking an average of four times per month and consuming an average of eight drinks per episode.

Methods

CDC analyzed data for 2010–2012 from the National Vital Statistics System to assess average annual alcohol poisoning deaths and death rates (ICD-10 codes X45 and Y15; underlying cause of death) in the United States among persons aged ≥15 years, by sex, age group, race/ethnicity, and state.

Results

During 2010–2012, an annual average of 2,221 alcohol poisoning deaths (8.8 deaths per 1 million population) occurred among persons aged ≥15 years in the United States. Of those deaths, 1,681 (75.7%) involved adults aged 35–64 years, and 1,696 (76.4%) involved men. Although non-Hispanic whites accounted for the majority of alcohol poisoning deaths (67.5%; 1,500 deaths), the highest age-adjusted death rate was among American Indians/Alaska Natives (49.1 per 1 million). The age-adjusted rate of alcohol poisoning deaths in states ranged from 5.3 per 1 million in Alabama to 46.5 per 1 million in Alaska.

Conclusions

On average, six persons, mostly adult men, die from alcohol poisoning each day in the United States. Alcohol poisoning death rates vary substantially by state.

Implications for Public Health Practice

Evidence-based strategies for preventing excessive drinking (e.g., regulating alcohol outlet density and preventing illegal alcohol sales in retail settings) could reduce alcohol poisoning deaths by reducing the prevalence, frequency, and intensity of binge drinking.     

Vital Signs: Evaluation of Hepatitis C Virus Infection Testing and Reporting — Eight U.S. Sites, 2005–2011

Background

Hepatitis C virus (HCV) infection is a serious public health problem. New infections continue to occur, and morbidity and mortality are increasing among an estimated 2.7–3.9 million persons in the United States living with HCV infection. Most persons are unaware of their infection status. Existing CDC guidelines for laboratory testing and reporting of antibody to HCV do not distinguish between past infection that has resolved and current infection that requires care and evaluation for treatment. To identify current infection, a test for HCV RNA is needed.

Methods

Surveillance data reported to CDC from eight U.S. sites during 2005–2011 were analyzed to determine the proportion of persons newly reported on the basis of a positive test result for HCV infection. Persons reported with a positive result from an HCV antibody test only were compared with persons reported with a positive result for HCV RNA and examined by birth cohort (1945–1965 compared with all other years), surveillance site, and number of reported deaths. Annual rates of persons newly reported with HCV infection in 2011 also were calculated for each site.

Results

Of 217,755 persons newly reported, 107,209 (49.2%) were HCV antibody positive only, and 110,546 (50.8%) were reported with a positive HCV RNA result that confirmed current HCV infection. In both groups, persons were most likely to have been born during 1945–1965 (58.5% of those who were HCV antibody positive only; 67.2% of those who were HCV RNA positive). Among all persons newly reported for whom death data were available, 6,734 (3.4%) were known to have died; deaths were most likely among persons aged 50–59 years. In 2011, across all sites, the annual rate of persons newly reported with HCV infection (positive HCV antibody only and HCV RNA positive) was 84.7 per 100,000 population.

Conclusions

Hepatitis C is a commonly reported disease predominantly affecting persons born during 1945–1965, with deaths more frequent among persons of relatively young age. The lack of an HCV RNA test for approximately one half of persons newly reported suggests that testing and reporting must improve to detect all persons with current infection.

Implications for Public Health

In an era of continued HCV transmission and expanding options for curative antiviral therapies, surveillance that identifies current HCV infection can help assess the need for services and link persons with infection to appropriate care and treatment.     

Water Intake by Outdoor Temperature Among Children Aged 1–10 Years: Implications for Community Water Fluoridation in the U.S.

ObjectiveThe U.S. water fluoridation recommendations, which have been in place since 1962, were based in part on findings from the 1950s that children''s water intake increased with outdoor temperature. We examined whether or not water intake is associated with outdoor temperature.MethodsUsing linked data from the National Health and Nutrition Examination Survey (NHANES) 1999–2004 and the National Oceanic and Atmospheric Administration, we examined reported 24-hour total and plain water intake in milliliters per kilogram of body weight per day of children aged 1–10 years by maximum outdoor temperature on the day of reported water intake, unadjusted and adjusted for age, sex, race/ethnicity, and poverty status. We applied linear regression methods that were used in previously reported analyses of data from NHANES 1988–1994 and from the 1950s.ResultsWe found that total water intake was not associated with temperature. Plain water intake was weakly associated with temperature in unadjusted (coefficient 5 0.2, p=0.015) and adjusted (coefficient 5 0.2, p=0.013) linear regression models. However, these models explained little of the individual variation in plain water intake (unadjusted: R²=0.005; adjusted: R²=0.023).ConclusionOptimal fluoride concentration in drinking water to prevent caries need not be based on outdoor temperature, given the lack of association between total water intake and outdoor temperature, the weak association between plain water intake and outdoor temperature, and the minimal amount of individual variance in plain water intake explained by outdoor temperature. These findings support the change in the U.S. Public Health Service recommendation for fluoride concentration in drinking water for the prevention of dental caries from temperature-related concentrations to a single concentration that is not related to outdoor temperature.In 2015, the U.S. Department of Health and Human Services (HHS) changed the recommended concentration for fluoride in drinking water to prevent dental caries to 0.7 milligrams per liter (mg/L) of drinking water,¹ to replace the recommendations from 1962,² which ranged from 0.7 mg/L for areas with average daily maximum temperatures in degrees Fahrenheit (°F) of 79.3°F–90.5°F through 1.2 mg/L for areas with temperatures of 50.0°F–53.7°F. One reason for the change was that the correlation between temperature and children''s water intake found in the 1950s^3–7 was not evident from studies of data collected in more recent decades.^8–10The 1962 recommendations included a range of fluoride concentrations because studies conducted during the 1950s found that children drank more water on warmer than on colder days.^3–6 Galagan et al.⁶ collected data on water intake among children aged #10 years in two communities in Contra Costa County, California. Each participant contributed data for five consecutive weekdays (Monday–Friday) during the course of a year. The study found positive correlations between temperature and both total and drinking water intake, and negative correlations between temperature and intake of milk, carbonated beverages, and non-water-based beverages. By fitting a regression line to the mean values for water intake and daily maximum temperature (from U.S. Weather Bureau stations) for each of 39 weekly reporting periods, Galagan et al.⁶ found a direct association between water intake and temperature and developed the following estimation equation: ounces of water per pound of body weight = −0.038 + 0.0062 temperature. Galagan and Vermillion⁷ used this estimating equation to develop a table of optimum fluoride concentrations for six ranges of the daily maximum temperature averaged during at least a five-year period; the 1962 recommendations² used this table.More recent studies using nationally representative data did not find consistent associations between water intake and season, month, or monthly average for daily maximum temperature among regions of the United States.^8–11 Two studies attributed their findings'' lack of congruence with those from the 1950s to changes such as wider use of air-conditioning and lower levels of outdoor physical activity.^9,10 Our previous unadjusted analysis of 1999–2004 National Health and Nutrition Examination Survey (NHANES) data did not find an association between total water intake and outdoor temperature among children aged 1–10 years.¹²We used data from NHANES 1999–2004 to reexamine the relationship between water intake and outdoor temperature among children aged 1–10 years and consider the appropriateness of a recommendation for a single fluoride concentration in drinking water across the United States to prevent dental caries.     

Vital Signs: Restraint Use and Motor Vehicle Occupant Death Rates Among Children Aged 0–12 Years — United States, 2002–2011

Background

Motor vehicle crashes are a leading cause of death among children in the United States. Age- and size-appropriate child restraint use is the most effective method for reducing these deaths.

Methods

CDC analyzed 2002–2011 data from the Fatality Analysis Reporting System to determine the number and rate of motor-vehicle occupant deaths, and the proportion of unrestrained child deaths among children aged <1 year, 1–3 years, 4–7 years, 8–12 years, and for all children aged 0–12 years. Age group–specific death rates and proportions of unrestrained child motor vehicle deaths for 2009–2010 were further stratified by race/ethnicity.

Results

Motor vehicle occupant death rates for children declined significantly from 2002 to 2011. However, one third (33%) of children who died in 2011 were unrestrained. Compared with white children for 2009–2010, black children had significantly higher death rates, and black and Hispanic children both had significantly higher proportions of unrestrained child deaths.

Conclusions

Motor vehicle occupant deaths among children in the United States have declined in the past decade, but more deaths could be prevented if restraints were always used.

Implications for Public Health

Effective interventions, including child passenger restraint laws (with child safety seat/booster seat coverage through at least age 8 years) and child safety seat distribution plus education programs, can increase restraint use and reduce child motor vehicle deaths.     

Vital Signs: Current Cigarette Smoking Among Adults Aged ≥18 Years with Mental Illness — United States, 2009–2011

Background

Cigarette smoking remains the leading cause of preventable morbidity and mortality in the United States. Despite overall declines in cigarette smoking, a high prevalence of smoking persists among certain subpopulations, including persons with mental illness.

Methods

Combined data from the 2009–2011 National Survey on Drug Use and Health (NSDUH) were used to calculate national and state estimates of cigarette smoking among adults aged ≥18 years who had any mental illness (AMI), defined as having a mental, behavioral, or emotional disorder, excluding developmental and substance use disorders, in the past 12 months.

Results

During 2009–2011, an annual average of 19.9% of adults aged ≥18 years had AMI; among these persons, 36.1% were current smokers, compared with 21.4 % among adults with no mental illness. Smoking prevalence among those with AMI was highest among men, adults aged <45 years, and those living below the poverty level; smoking prevalence was lowest among college graduates. During 2009–2011, adults with AMI smoked 30.9% of all cigarettes smoked by adults. By U.S. region, smoking prevalence among those with AMI was lowest in the West (31.5%) and Northeast (34.7%) and highest in the Midwest (39.1%) and South (37.8%), with state prevalence ranging from 18.2% (Utah) to 48.7% (West Virginia).

Conclusions

The prevalence of cigarette smoking is high among adults with AMI, especially for younger adults, those with low levels of education, and those living below the poverty level; the prevalence varies by U.S. region.

Implications for Public Health Practice

Increased awareness about the high prevalence of cigarette smoking among persons with mental illness is needed to enhance efforts to reduce smoking in this population. Proven population-based prevention strategies should be extended to persons with mental illness, including implementing tobacco-free campus policies in mental health facilities. Primary care and mental health-care providers should routinely screen patients for tobacco use and offer evidence-based cessation treatments. Given that persons with mental illness are at risk for multiple adverse behavioral and health outcomes, tobacco cessation will have substantial benefits, including a reduction in excess morbidity and mortality attributed to tobacco use.     

Vital Signs: Listeria Illnesses,Deaths, and Outbreaks — United States, 2009–2011

Background

Older adults, pregnant women, and persons with immunocompromising conditions are at higher risk than others for invasive Listeria monocytogenes infection (listeriosis), a rare and preventable foodborne illness that can cause bacteremia, meningitis, fetal loss, and death.

Methods

This report summarizes data on 2009–2011 listeriosis cases and outbreaks reported to U.S. surveillance systems. The Listeria Initiative and PulseNet conduct nationwide surveillance to rapidly detect and respond to outbreaks, the Foodborne Diseases Active Surveillance Network (FoodNet) conducts active, sentinel population–based surveillance to track incidence trends, and the Foodborne Disease Outbreak Surveillance System (FDOSS) receives reports of investigated outbreaks to track foods and settings associated with outbreaks.

Results

Nationwide, 1,651 cases of listeriosis occurring during 2009–2011 were reported. The case-fatality rate was 21%. Most cases occurred among adults aged ≥65 years (950 [58%]), and 14% (227) were pregnancy-associated. At least 74% of nonpregnant patients aged <65 years had an immunocompromising condition, most commonly immunosuppressive therapy or malignancy. The average annual incidence was 0.29 cases per 100,000 population. Compared with the overall population, incidence was markedly higher among adults aged ≥65 years (1.3; relative rate [RR]: 4.4) and pregnant women (3.0; RR: 10.1). Twelve reported outbreaks affected 224 patients in 38 states. Five outbreak investigations implicated soft cheeses made from pasteurized milk that were likely contaminated during cheese-making (four implicated Mexican-style cheese, and one implicated two other types of cheese). Two outbreaks were linked to raw produce.

Conclusions

Almost all listeriosis occurs in persons in higher-risk groups. Soft cheeses were prominent vehicles, but other foods also caused recent outbreaks. Prevention targeting higher-risk groups and control of Listeria monocytogenes contamination in foods implicated by outbreak investigations will have the greatest impact on reducing the burden of listeriosis.

Implications for Public Health Practice

Careful attention to food safety is especially important to protect vulnerable populations. Surveillance for foodborne infections like listeriosis identifies food safety gaps that can be addressed by industry, regulatory authorities, food preparers, and consumers.     

Vital Signs: Binge Drinking Among Women and High School Girls — United States, 2011

Background

Excessive alcohol use accounted for an estimated average of 23,000 deaths and 633,000 years of potential life lost (YPLL) among women and girls in the United States each year during 2001–2005. Binge drinking accounted for more than half of those deaths and YPLL. Binge drinking also is a risk factor for many health and social problems among women and girls, including unintended and alcohol-exposed pregnancy, sexually transmitted diseases, and breast cancer.

Methods

To describe the prevalence, frequency, and intensity of binge drinking (four or more drinks on an occasion in the last 30 days) among U.S. women aged ≥18 years, CDC analyzed data from the 2011 Behavioral Risk Factor Surveillance System. Data were also analyzed from the 2011 national Youth Risk Behavior Survey on the prevalence of current alcohol use (one or more drinks during the past 30 days) and binge drinking (five or more drinks in a row during the past 30 days) among U.S. high school girls in grades 9–12.

Results

Among adult women, the prevalence of binge drinking was 12.5%, and among those who binge drank, the frequency of binge drinking was 3.2 episodes per month and the intensity was 5.7 drinks on occasion. Binge drinking was most prevalent among women aged 18–24 years (24.2%) and 25–34 years (19.9%), and among those from households with annual incomes of ≥$75,000 (16.0%). Among those who binge drank, women aged 18–24 years had the highest frequency (3.6 episodes) and intensity (6.4 drinks) of binge drinking. Among high school girls, the prevalence of current alcohol use was 37.9%, the prevalence of binge drinking was 19.8%, and the prevalence of binge drinking among girls who reported current alcohol use was 54.6%.

Conclusions

Binge drinking is reported by one in eight U.S. adult women and one in five high school girls. Women who binge drink tend to do so frequently and with high intensity. Most high school girls who reported current alcohol use also reported binge drinking.

Implications for Public Health Practice

More widespread implementation of evidence-based interventions, such as those recommended by the Guide to Community Preventive Services and the U.S. Preventive Services Task Force, would be expected to reduce the frequency and intensity, and ultimately the prevalence of binge drinking among women and girls, and the harms related to it.     

HIV Screening Practices and Hospital Characteristics in the U.S., 2009–2010

Objectives

The Centers for Disease Control and Prevention recommends HIV screening in U.S. health-care settings unless providers document a yield of undiagnosed HIV infections of <1 per 1,000 population. However, implementation of this guidance has not been widespread and little is known of the characteristics of hospitals with screening practices in place. We assessed how screening practices vary with hospital characteristics.

Methods

We used a national hospital survey of HIV testing practices, linked to HIV prevalence for the county, parish, borough, or city where the hospital was located, to assess HIV screening of some or all patients by hospitals. We used multivariate logistic regression analysis to assess the association between screening practices and hospital characteristics that were significantly associated with screening in bivariate analyses.

Results

Of 376 hospitals in areas of prevalence ≥0.1%, only 25 (6.6%) reported screening all patients for HIV and 131 (34.8%) reported screening some or all patients. Among 638 hospitals included, screening some or all patients was significantly (p<0.05) more common at teaching hospitals, hospitals with higher numbers of annual admissions, and hospitals with a high proportion of Medicaid admissions. In multivariable analysis, screening some or all patients was independently associated with admitting more than 15% of Medicaid patients and receiving resources or reimbursement for screening tests.

Conclusion

We found that few hospitals surveyed reported screening some or all patients, and failure to screen is common across all types of hospitals in all regions of the country. Expanded reimbursement for screening may increase compliance with the recommendations.Of the 1.2 million people in the United States who are infected with human immunodeficiency virus (HIV), it is estimated that 20% are unaware of their infection.¹ Early diagnosis of HIV infection allows infected people to obtain treatment that can prolong the quality and duration of their lives and can lead to reductions in high-risk behaviors and HIV transmission.^2–8 More generally, HIV infection satisfies the usual criteria for routine screening for infectious disease: it is a serious health disorder that can be diagnosed before symptoms appear; it can be detected by a reliable, noninvasive test; there are great potential health benefits to early detection; and the benefits of detection are large relative to the cost of screening.⁹ For these reasons, and to reduce the number of undiagnosed people living with HIV, in 2006 the Centers for Disease Control and Prevention (CDC) recommended HIV screening in all health-care settings for all individuals aged 13–64 years, regardless of risk, seen at facilities with an HIV prevalence of undiagnosed infections ≥0.1% among a sample of patients, and annual screening for patients known to be at risk for HIV infection.¹⁰Previous research has shown that the teaching status and size of hospitals, as well as the region and type of metropolitan area in which they are located, are associated with the availability of HIV testing in hospitals.¹¹ However, there are few published data about hospital characteristics that are associated with the adoption of CDC''s revised testing recommendations, and existing studies do not consider the impact of external factors, such as state regulations or third-party reimbursement policies, that might influence whether hospitals adopt the testing guidelines. Also unknown is how the screening practices of hospitals that serve larger proportions of low-income and minority patients compare with the practices of other hospitals.To address these open questions, we assessed the association between characteristics of hospitals and adoption of CDC''s revised recommendations for HIV testing in health-care settings using data from a national hospital survey of HIV testing practices in 2009. The results of that national survey, comparing responses in 2009 with those from 2004, have been previously reported.¹² However, that report did not consider factors that might influence screening practices, such as county HIV prevalence, information on state HIV testing regulations, and information on the percentage of admissions of low-income and minority patients at participating hospitals.