The following are pre-publication drafts of articles from the Morbidity and Mortality Weekly Report dated July 21, 1995. Late-breaking articles, and final editorial revisions are not included; therefore, these articles should be considered preliminary, and not to be released to the public. --CDC -------------------------------------------------------------- Trends in Smoking Initiation Among Adolescents and Young Adults -- United States, 1980-1989 The evaluation of efforts to prevent tobacco use among adolescents requires accurate surveillance of both smoking prevalence and smoking initiation rates. Although several surveillance systems provide timely data about adolescent smoking prevalence (1), data characterizing rates of smoking initiation among adolescents have been limited. To improve characterization of trends in smoking initiation among young persons, data from the Tobacco Use Supplement of the 1992 and 1993 Current Population Surveys (CPS) (2) were used to estimate smoking initiation rates for persons who were adolescents (aged 14-17 years) or young adults (aged 18-21 years) during 1980-1989. This report summarizes the results of that analysis. The CPS are monthly surveys of the U.S. civilian, noninstitutionalized population aged greater than or equal to 15 years (2). Approximately 56,000 households are surveyed each month; one household respondent provides information about all household members aged greater than or equal to 15 years. Questions about tobacco use were added to the September 1992, January 1993, and May 1993 monthly surveys. The response rates for the three surveys were 84.7%, 84.9%, and 82.0%, respectively (N=293,543 household members). To minimize biases that could result from discrepancies between self reports and proxy reports of smoking behavior (3), this analysis used data from self-respondents only (82% of total sample). Ever smokers were defined as respondents who answered "yes" to the question, "Have you smoked at least 100 cigarettes in your entire life?" Ever smokers were asked, "How old were you when you started smoking cigarettes fairly regularly?" To restrict the analysis to persons who were adolescents or young adults for some period during 1980-1989, only respondents aged 17-34 years at interview were included. The final sample consisted of 71,321 persons, of whom 27,768 (38.9%) were ever smokers. Using the age of respondents at the time of the interview and the age they reported starting smoking, the age of respondents and their smoking status were calculated for each year during the 1980s. The denominator for the initiation rate for a given year was the number of respondents at risk for initiating smoking during that year (persons already smoking were eliminated from the denominator for that year). The numerator was the number of respondents who reported initiating smoking during that year. Data were weighted by age, sex, and race/ethnicity to provide national estimates. Among adolescents, the smoking initiation rate decreased slightly from 1980 (5.4%) through 1984 (4.7%) and then increased through 1989 (5.5%); the largest annual increase occurred in 1988 (Figure 1). In comparison, among young adults, initiation rates decreased throughout the 1980s (Figure 1). For both age groups, initiation rates and trends were similar for males and females. Reported by: KM Cummings, PhD, D Shah, MS, Roswell Park Cancer Institute, Buffalo, New York. DR Shopland, National Cancer Institute, National Institutes of Health. Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. Editorial Note: The findings in this report indicate an increase in the rate of initiation of cigarette smoking among adolescents from 1985 through 1989, a period during which the rate among young adults declined and overall prevalence of smoking among adults decreased steadily (4). One important consequence of the increased rate of initiation among adolescents will be the increased future burden of tobacco- related disease. In particular, because of the increase in initiation since 1984, an additional 600,000 adolescents began to smoke during 1985-1989.* Of those adolescents who continue to smoke regularly, approximately 50% will die from smoking-attributable disease (5). Potential reasons for an increase in smoking initiation rates among adolescents include a decreased real price of cigarettes, increased levels of disposable income, increased acceptability of smoking, and intensified cigarette marketing (1). However, because the real price of cigarettes increased steadily during 1985-1989 and the real average weekly income among high school seniors remained stable during this period, cigarettes were less affordable to young persons (1,6) (Table 1). In addition, the acceptability of smoking among high school seniors did not increase: during this period there were increases in the percentages of high school seniors who believed cigarettes are harmful, smoking is a "dirty habit," and becoming a smoker reflects poor judgment, and who reported they "mind being around people who are smoking" and would prefer to date nonsmokers (1). The increase in rates of smoking initiation among adolescents during 1985-1989 may reflect increased real expenditures for cigarette advertising and promotion. The increase in rates occurred during a period when real expenditures for total cigarette advertising and promotion** doubled, and expenditures for cigarette promotion more than quadrupled (7) (Figure 2): from 1980 to 1989, total annual advertising and promotional expenditures (in 1993 dollars) increased from $2.1 billion to $4.2 billion, while promotional expenditures alone increased from $771 million (37% of total expenditures) to $3.2 billion (76%) (Figure 2). Promotional efforts have been highly effective among adolescents. For example, among persons aged 12-17 years in 1992, approximately 50% of smokers and 25% of nonsmokers reported having received promotional items from tobacco companies (1). An association between overall cigarette marketing expenditures and initiation rates for smoking among adolescents is plausible for at least four reasons. First, brand loyalty is usually established with the first cigarette smoked (8); therefore, cigarette companies have an economic incentive to encourage first-time smokers to smoke their brands. Second, adolescents are exposed to cigarette advertising and promotions that employ themes and images that appeal to young persons (1). Third, advertising directly influences brand awareness and attitudes toward smoking among adolescents (1). Specifically, adolescents smoke the most heavily advertised brands, and changes in brand preferences among young persons are associated with changes in brand-specific advertising expenditures (9). For example, the Joe Camel campaign introduced nationally in 1988 was associated with an increase in the market share of that specific brand among adolescents (1,9). Finally, consumer research suggests that younger persons (i.e., aged 14-17 years) aspire to be young adults (10); therefore, advertising and promotional efforts targeted toward young adults may have greater appeal to adolescents because of their age aspirations. Although current estimates of smoking initiation rates among adolescents are not available, from 1991 through 1993, the national prevalence of smoking increased among eighth- and 10th-grade students (6). To reverse the trend of increasing smoking initiation rates among adolescents and to achieve the national health objective for the year 2000 of reducing the initiation of cigarette smoking by youth (no more than 15% should become regular smokers by age 20) (objective 3.5) (4), prevention efforts that focus on young persons should be intensified. Such efforts could include making cigarettes less affordable by either increasing their real price (1) or by limiting sales to cartons rather than individual packs, enforcing laws prohibiting the sale and distribution of cigarettes to young persons (4), conducting mass media campaigns to discourage tobacco use (1), and eliminating or severely restricting all forms of tobacco product advertising and promotion to which young persons are likely to be exposed (4). References 1. US Department of Health and Human Services. Preventing tobacco use among young people: a report of the Surgeon General. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1994. 2. Hansen RH. The Current Population Survey: design and methodology (Technical paper no. 40). Washington, DC: US Department of Commerce, Bureau of the Census, 1985. 3. Gilpin EA, Pierce JP, Cavin SW, et al. Estimates of population smoking prevalence: self versus proxy reports of smoking status. Am J Public Health 1994;84:1576-9. 4. NCHS. Health, United States, 1992, and Healthy People 2000 review. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1993; DHHS publication no. (PHS)93-1232. 5. Peto R, Lopez AD, Boreham J, Thun M, Heath C. Mortality from smoking in developing countries, 1950-2000. Indirect estimates from national vital statistics. Oxford, England: Oxford University Press, 1994. 6. Johnston LD, O'Malley PM, Bachman JG. National survey results on drug use from the Monitoring the Future study, 1975-1993. Volume I: secondary school students. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute on Drug Abuse, 1994. 7. Federal Trade Commission. Report to Congress for 1990: pursuant to the Federal Cigarette Labeling and Advertising Act. Washington, DC: U.S. Federal Trade Commission, 1992. 8. DiFranza JR, Eddy JJ, Brown LF, Ryan JL, Bogojavlensky A. Tobacco acquisition and cigarette brand selection among youth. Tobacco Control 1994;3:334-8. 9. CDC. Changes in the cigarette brand preferences of adolescent smokers--United States, 1989-1993. MMWR 1994;43:577-81. 10. Teenage Research Unlimited, Inc. TRU Teenage Marketing and Lifestyle Study: wave 18, Fall 1991. Northbrook, Illinois: Teenage Research Unlimited, Inc, 1991. * Based on the assumption that the initiation rate during 1985-1989 remained stable at the 1984 rate, and by multiplying the Bureau of the Census population estimates for persons aged 14-17 years for each year from 1985 through 1989 by the difference between the adolescent smoking initiation rate in 1984 and the rate for each year. ** Based on data from the Federal Trade Commission (7), advertising expenditures include costs to advertise outdoors (e.g., billboards), in newspapers or magazines, and on transportation (e.g., buses); promotional expenditures include costs of promotional allowances, distribution of samples or specialty items (e.g., key chains, lighters, T-shirts, caps, and calendars), public entertainment, direct mail, coupons, retail value-added promotions (e.g., specialty items distributed at the point of sale), and point-of-sale promotions (e.g., store displays). Pertussis -- United States, January 1992-June 1995 Pertussis was a major cause of morbidity and mortality among infants and children in the United States during the prevaccine era (i.e., before the mid-1940s). Since pertussis became a nationally reportable disease in 1922, the highest number of pertussis cases (approximately 260,000) was reported in 1934; the highest number of pertussis-related deaths (approximately 9000) occurred in 1923. Following the licensure of whole-cell pertussis vaccine combined with diphtheria and tetanus toxoids (DTP) in 1949 and the widespread use of DTP among infants and children, the incidence of reported pertussis declined to a historical low of 1010 cases in 1976 (Figure 1). However, since the early 1980s, reported pertussis incidence has increased cyclically with peaks occurring in 1983, 1986, 1990, and 1993 (1-3). This report summarizes national surveillance data for pertussis from January 1992 through June 1995 from CDC's National Public Health Surveillance System (NPHSS) and Supplementary Pertussis Surveillance System (SPSS) and assesses the effectiveness of pertussis vaccination in the United States during this period using vaccination coverage data from CDC's National Health Interview Survey (NHIS). National Surveillance for Pertussis and Vaccination Coverage Through NPHSS (formerly the National Notifiable Disease Surveillance System), state health departments report weekly to CDC the number of pertussis cases. Data reported include state and county of residence, age, date of report to CDC, and race/ethnicity. Through SPSS, more detailed information about persons with pertussis is reported to CDC, including demographic variables, vaccination history, selected clinical characteristics, hospital admission, deaths, and results of laboratory tests for Bordetella pertussis. Documented limitations of these pertussis surveillance systems include underreporting, disproportionate representation of classic and severe cases, lack of uniform reporting criteria among the states, and reliance on laboratory diagnosis of pertussis by some states (1). NHIS is an annual cross-sectional household interview survey of the U.S. civilian, noninstitutionalized population (4). In 1992, an immunization supplement was added to the survey to collect data about vaccinations among children aged less than 6 years. Vaccination information was obtained from vaccination records; for children for whom no vaccination records were available (50%-65%), information was based on parental recall. Based on NPHSS data, from 1992 through 1994, a total of 15,286 pertussis cases were reported to CDC (4083 in 1992; 6586 in 1993; and 4617 in 1994), for crude annual incidence rates of 1.6, 2.6, and 1.8 cases per 100,000 population in 1992, 1993, and 1994, respectively. Cases were reported from all 50 states and the District of Columbia. From January 7 through June 30, 1995, a total of 1386 pertussis cases were reported--an 18% decrease from the number reported during the same period in 1994 (1690). Based on the NPHSS, during 1992-1994, of 13,615 persons reported with pertussis for whom age data were available, 5618 (41%) were aged less than 1 year; 2682 (20%), 1-4 years; 1551 (11%), 5-9 years; and 3764 (28%), greater than or equal to 10 years. Of the children aged less than 1 year with pertussis, 4524 (81%) were aged less than 6 months. Of 10,989 patients for whom data about vaccination status were available from SPSS, 6876 (63%) had received fewer than three doses of DTP. Of 3184 patients aged 7 months-4 years for whom vaccination status was known, 725 (23%) had received no doses, 714 (22%) had received one or two doses, and 1745 (55%) had received three or more doses. The proportion of patients who were hospitalized, had complications, or died was highest among infants and decreased with increasing age (Table 1). Of children aged less than 1 year reported with pertussis, 66% were hospitalized, 15% had pneumonia confirmed radiographically, and 2% had seizures. Overall, 32 pertussis- related deaths and 17 cases complicated by encephalopathy were reported. Based on the NHIS, from 1992 through the second quarter of 1994 (the most recent period for which data were available), among children aged 19-35 months (median age: 27 months), vaccination coverage with three or more doses of DTP or diphtheria and tetanus toxoids (DT) was 83% for 1992, 88% for 1993, 87% for the first quarter of 1994, and 90% for the second quarter. Vaccination coverage with four or more doses of DTP or DT was 59% in 1992, 72% for 1993, 67% for the first quarter of 1994, and 70% for the second quarter. Based on vaccine distribution data for 1993, 6.7% of children may have received DT instead of DTP (CDC, unpublished data, 1993). Effectiveness of Pertussis Vaccination The screening method (5) was used to calculate the effectiveness of pertussis vaccine among U.S. children aged 7-47 months during 1992-1994. Estimates of vaccine effectiveness (VE) were derived using the formula VE=1-[PCV/(1-PCV)][(1-PPV)/PPV] (PPV is the proportion of the population vaccinated, and PCV is the proportion of case-patients vaccinated). Persons who were partially vaccinated (i.e., received one to two doses of vaccine) were excluded from both PPV and PCV. Data from the national SPSS were used to determine the PCV. A case of pertussis was defined as either onset of a cough illness of any duration with isolation of B. pertussis from a clinical specimen or onset of an acute cough illness lasting greater than or equal to 14 days plus at least one pertussis-associated symptom (i.e., paroxysms of cough, inspiratory "whoop," or posttussive vomiting) with no other apparent cause. Data from NHIS for 1992, 1993, and the first 2 quarters of 1994 were used to determine PPV for age groups 7-18 months and 19-47 months. Compared with zero doses of pertussis vaccine, during 1992-1994, among children aged 7-18 months, VE for three doses was 85%; among children aged 19-47 months, VE for four or more doses was 94%. When these estimates were corrected by 6.7% to account for use of DT instead of DTP, VE was 64% and 82% for three doses and four or more doses, respectively. Reported by: State and local health depts. Child Vaccine Preventable Disease Br, Epidemiology and Surveillance Div, and Assessment Br, Data Management Div, National Immunization Program, CDC. Editorial Note: Despite the upward trend in the reported incidence of pertussis in the United States since the early 1980s, the annual numbers of cases reported during 1992-1994 represent an approximately 95% decline from those reported during the prevaccine era. Following the peak in reported cases in 1993, the numbers declined during 1994 and the first 2 quarters of 1995--a pattern consistent with the previously observed 3-4-year periodicity in pertussis incidence. Pertussis remains an important cause of morbidity and mortality among infants and preschool-aged children. Rates of complications among infants during 1992-1994 are similar to those reported during 1980-1989 (1) and 1989-1991 (2). The two groups at greatest risk for severe complications are infants aged less than 6 months (the recommended age by which children should have received three doses of DTP) and preschool-aged children who are undervaccinated. The importance of timely vaccination of children is emphasized by the high proportion of undervaccination (approximately 45%) among preschool-aged children with pertussis who were age-eligible for at least three doses of vaccine. The Advisory Committee on Immunization Practices and the American Academy of Pediatrics recommend three doses of DTP to be administered at ages 2, 4, and 6 months. An additional two doses are recommended, one each at ages 12-18 months and at 4-6 years (6). Either DTP or diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) can be administered for the fourth and fifth doses to children aged 15 months-6 years. Since 1992, coverage with three doses of DTP or DT has increased, indicating progress toward the Childhood Immunization Initiative goal of 90% coverage by 1996. As a consequence, the proportion of persons with pertussis who have been vaccinated most likely will increase. Based on the screening method (which accounts for changes in vaccination coverage but may not provide an accurate estimate of vaccine efficacy when vaccination coverage is high) (5), estimated VE during 1992-1994 was consistent with previous reports about the efficacy of whole-cell pertussis vaccine in the United States during the mid-1980s, which documented 64% protection against mild disease and 95% protection against severe disease (7). In the United States, widespread use of whole-cell pertussis vaccines among infants since 1949 has resulted in the successful control of pertussis. National pertussis surveillance data during January 1992-June 1995 indicate the continued effectiveness of the current pertussis vaccination program. However, despite increasing vaccination coverage in recent years, pertussis outbreaks (e.g., in Cincinnati and Chicago in 1993 [3]) continue to occur. Preliminary results of the protective efficacy of new acellular pertussis vaccines (when used for the first three doses among infants) suggest that these vaccines are either equally or more efficacious than whole-cell vaccines. Further scientific review of these results is in progress, but until such vaccines are licensed and available for use among infants, timely age-appropriate vaccination of infants with whole-cell pertussis vaccines should continue. Previous delays in administering pertussis vaccine to infants have resulted in widespread outbreaks (e.g., in the United Kingdom and Japan during the 1970s and Sweden during the 1980s) (8). References 1. Farizo KM, Cochi SL, Zell ER, Patriarca PA, Wassilak SGF, Brink E. Epidemiologic features of pertussis in the United States, 1980-1989. Clin Infect Dis 1992;14:708-19. 2. Davis SF, Strebel PM, Cochi SL, Zell ER, Hadler SC. Pertussis surveillance--United States, 1989-1991. In: CDC surveillance summaries (December). MMWR 1992;41(no. SS-8):11-9. 3. CDC. Resurgence of pertussis--United States, 1993. MMWR 1993;42:952-3,959-60. 4. Massey JT, Moore TF, Parsons VL, Tadros W. Design and estimation for the National Health Interview Survey, 1985-1994. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1989. (Vital and health statistics; series 2, no. 110). 5. Farrington CP. Estimation of vaccine effectiveness using the screening method. Int J Epidemiol 1993;22:742-6. 6. CDC. Recommended childhood immunization schedule--United States, 1995. MMWR 1995; 44(no. RR-5). 7. Onorato IM, Wassilak SG, Mead B. Efficacy of whole-cell pertussis vaccine in preschool children in the United States. JAMA 1992;267:2745-9. 8. Mortimer EA. Pertussis vaccine. In: Plotkin SA, Mortimer EA, eds. Vaccines. 2nd ed. Philadelphia, Pennsylvania: W.B. Saunders Co, 1994:91-135. Pneumonia and Influenza Death Rates -- United States, 1979-1994 The combined cause-of-death category pneumonia and influenza (P&I) (International Classification of Diseases, Ninth Revision, codes 480-487) ranks as the sixth leading cause of death in the United States following heart disease, cancer, stroke, unintentional injuries, and chronic obstructive pulmonary disease (1). Changes in the epidemiology of Streptococcus pneumoniae and other recognized respiratory pathogens, the increasing occurrence of drug-resistant microorganisms, and the detection of new respiratory pathogens have heightened awareness of the public health importance of severe respiratory infections (2-5). To characterize the epidemiology of P&I deaths in the United States, CDC further analyzed underlying and multiple cause-of-death mortality files for 1979-1994. This report summarizes the results of this analysis. From 1979 to 1994, the overall crude death rates for P&I (based on underlying cause of death) increased 59%, from 20.0 to 31.8 deaths per 100,000 population (Figure 1). From 1979 to 1992 (the most recent year for which age-adjusted data are available), the P&I death rate, age-adjusted to a 1980 standard population, increased 22%, from 20.4 to 24.8. In 1992, persons aged greater than or equal to 65 years accounted for 89% of all P&I deaths. From 1979 to 1992, P&I death rates for persons aged greater than or equal to 65 years increased 44%, from 145.6 deaths per 100,000 population to 209.1. During this period, rates also increased for persons aged 20-44 years; however, the small number of deaths among persons in this age group (2148 in 1992) limited the contribution to the overall trend. To control for the highly variable seasonal contribution of influenza-associated deaths, the trend for mean weekly number of P&I deaths for noninfluenza months (May-October) was analyzed. From 1979 through 1992, age-adjusted P&I death rates during these months increased steadily from 3.1 to 5.0 per 1 million population. Analysis of P&I deaths listed in any position on the death certificate (multiple cause-of-death data) indicated a similar increase. During 1979-1992, the diagnostic code for pneumonia of unspecified etiology (ICD-9 code 486) accounted for most of the overall increase: age-adjusted death rates in this diagnostic category increased 74%. In addition, in 1992, 84% of all P&I deaths were assigned this code, compared with 59% in 1979. Reported by: Childhood and Respiratory Diseases Br, Div of Bacterial and Mycotic Diseases, and Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases; Mortality Statistics Br, Div of Vital Statistics, National Center for Health Statistics, CDC. Editorial Note: The findings in this report document the recent increase in mortality attributed to P&I in the United States. This increase reflects both growth in the proportion of persons in older age groups (from 1970 to 1990, the proportion of persons in the United States population aged greater than or equal to 65 years increased from 9.8% to 12.5%) and higher P&I death rates in these age groups. A high proportion of these deaths was attributed to pneumonia of unspecified etiology, which probably includes both pneumonias caused by known pathogens not specified on the death certificate and pneumonias caused by new or unrecognized agents. Changes in the epidemiology of recognized respiratory pathogens (e.g., S. pneumoniae), for which precise diagnoses are difficult to make in clinical settings, may have contributed to the increasing death rate in older persons. Although the proportion of the increase in P&I death rates accounted for by all vaccine-preventable respiratory diseases is unknown, the increased rates also underscore the need for more complete use of pneumococcal and influenza vaccines as recommended by the Immunization Practices Advisory Committee (ACIP) (6,7). One of the national health objectives for the year 2000 is to vaccinate 60% of persons at risk for pneumococcal disease and influenza (objective 20.11) (8). Although coverage levels for influenza vaccinations among persons aged greater than or equal to 65 years have increased (in 1993, 52% reported having received influenza vaccine in the previous year), only 28% reported ever having received the pneumococcal vaccine in 1993 (9). In addition to known but undiagnosed causes of respiratory infection, new or previously uncharacterized agents probably account for some of the increase in age-adjusted death rates attributed to pneumonia of unspecified etiology. For example, since the 1970s, several bacterial and viral agents have been identified as causes of lower respiratory infections, including Legionella pneumophila, Chlamydia pneumoniae, and Sin Nombre virus (the etiologic agent of hantavirus pulmonary syndrome). Recent prospective studies of community-acquired pneumonia have suggested that an etiology cannot be identified in 40%-50% of cases (10), probably reflecting both the lack of sensitive diagnostic tests for some known respiratory pathogens and the occurrence of respiratory infections for which the etiologies have not yet been identified. Based on shifts in the age distribution of the total U.S. population, respiratory infectious diseases among the elderly probably will increase the need for health-care services and require the development of more effective prevention strategies. Improvements in understanding the epidemiology of morbidity and mortality associated with unspecified pneumonias will require further examination of diagnostic and reporting practices for certification of causes of death and analyses of additional data sources (e.g., hospital discharge records). In addition, improved characterization of bacterial and viral causes of pneumonia may result from prospective epidemiologic and laboratory studies, development of more sensitive diagnostic tests, and wider use of available tests. References 1. NCHS. Advance report of final mortality statistics, 1992. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1994. (Monthly vital statistics report; vol 43, no. 6, suppl). 2. Duchin JS, Koster FT, Peters CJ, et al. Hantavirus pulmonary syndrome: a clinical description of 17 patients with a newly recognized disease. N Engl J Med 1994;330:949-55. 3. Breiman RF, Spika JS, Navarro VJ, Darden PM, Darby CP. Pneumococcal bacteremia in Charleston County, South Carolina--a decade later. Arch Intern Med 1990;150:1401-5. 4. Hoge CW, Reichler MR, Dominguez EA, et al. An epidemic of pneumococcal disease in an overcrowded, inadequately ventilated jail. N Engl J Med 1994;331:643-8. 5. Breiman RF, Butler JC, Tenover FC, Elliot JA, Facklam RR. Emergence of drug-resistant pneumococcal infections in the United States. JAMA 1994;271:1831-5. 6. CDC. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1995;44(no. RR-3):2. 7. CDC. Update on adult immunization: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1991:40(no. RR-12):33-6,42-4. 8. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives. Washington, DC: U.S. Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50213. 9. CDC. Influenza and pneumococcal vaccination coverage levels among persons aged greater than or equal to 65 years --United States, 1973-1993. MMWR 1995;44:506-15. 10. Marrie TJ. Community-acquired pneumonia. Clin Infect Dis 1994;18:501-15. Notice to Readers Final 1994 Reports of Notifiable Diseases The notifiable diseases table on pages 538-543 summarizes final data for 1994. These data, final as of July 7, 1995, will be published in more detail in the Summary of Notifiable Diseases, 1994 (1). Population estimates for the states are from the July 1, 1994, estimates by the U.S. Bureau of the Census, Population Division, Population Estimates Branch, press release CB94-204. Population estimates for territories are from the 1990 census, U.S. Bureau of the Census, press releases CB91-142, 242, 243, 263, and 276. Reference 1. CDC. Summary of notifiable diseases, United States, 1994. MMWR 1995;44(no. 53) (in press).