The following are pre-publication drafts of articles from the Morbidity and Mortality Weekly Report dated September 29, 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 -------------------------------------------------------------- Histoplasmosis -- Kentucky, 1995 Histoplasmosis is an infection resulting from inhalation of spores from the dimorphic fungus Histoplasma capsulatum; the condition primarily affects the lungs. During August 1995, the Department for Health Services, Kentucky Cabinet for Human Resources (KDHS), and local public health officials investigated two unrelated outbreaks of acute histoplasmosis in eastern Kentucky. This report summarizes preliminary findings of the investigations of these outbreaks. Outbreak 1 On June 27, 1995, a crew of five workers began partial demolition of an abandoned city hall building in a community in Kentucky. At the time of demolition, a colony of bats had been observed in the vicinity of the building, and an approximately 2-foot-deep pile of debris covered with bat guano had accumulated in the building. During the demolition, none of the workers wore personal protective equipment (PPE) (i.e., respirators, eye protection, gloves, or protective clothing). Within 3 weeks, all five workers required treatment for acute respiratory illnesses, and three had been hospitalized. Lung biopsies were obtained from the three hospitalized patients; Giemsa stained tissue from the lung biopsy of one of the patients suggested the presence of H. capsulatum. From the demolition crew, local physicians, medical records, personnel from local hospitals and clinics, and community members, KDHS investigators gathered information about persons who possibly had been exposed to H. capsulatum during the demolition. A total of 55 persons (including the demolition crew) were identified who had worked in or near the building or lived in the area during the demolition. Each was questioned about a history of symptoms (including fever greater than or equal to 101 F [greater than or equal to 38.3 C], chills, night sweats, cough, headache, fatigue, and myalgia) during July 1-August 3. Immunodiffusion and complement fixation tests to detect antibodies to H. capsulatum were performed by CDC on serum from these 55 persons. A case of acute Histoplasma infection was defined as a positive serologic test (the presence of M or H band on immunodiffusion or 1:32 or higher titer by complement fixation), or the presence of at least three of the clinical features during July 1-August 3 in a person working in or near or living near the building. Overall, 19 of the 55 persons had a serologic test or clinical features that met the case definition. Of these, 12 persons had participated in the demolition: five had worked as the crew, one truck driver had hauled the debris to the dump site, four workers from the city workshop had helped the truck driver haul and dump the debris, and two had washed the building. Three persons had visited the building during the demolition, and four others had lived or worked within 500 yards of the building. Outbreak 2 KDHS is investigating a second outbreak of histoplasmosis in a different community located 80 miles north of the first city. During March 17-April 5, 1995, the attic of a building was repaired; bird and bat guano had accumulated in the attic. Within 3 weeks after completion of the repairs, 13 employees who worked in the building required treatment for acute respiratory illnesses; of these, two had been hospitalized. On June 26, a lung biopsy was obtained from one of the two hospitalized patients; Giemsa stained tissue from the lung biopsy suggested the presence of H. capsulatum. Serologic testing was performed for 16 employees; based on preliminary findings, 11 (including 10 of those who had received treatment) had acute Histoplasma infection confirmed serologically. Reported by: L Leslie, MD, C Arnette, MD, Archer Memorial Clinic, A Sikder, MD, Big Sandy Health Care, J Adams, MD, C Holbrook, J Bond, Floyd County Health Dept, Prestonsberg; B King, K Roberts, City Hall, Russell; MS Patrick, Greenup County Health Dept, Greenup; C Palmer, MD, R Finger, MD, State Epidemiologist, Dept for Health Svcs, Kentucky Cabinet for Human Resources. JW Tomford, MD, Cleveland Clinic Foundation, Ohio. T Rushton, MD, Marshall Univ, Huntington, West Virginia. Emerging Bacterial and Mycotic Diseases Br, Div of Bacterial and Mycotic Diseases, National Center for Infectious Diseases; Div of Field Epidemiology, Epidemiology Program Office, CDC. Editorial Note: The outbreaks of acute histoplasmosis in Kentucky most likely were caused by inhalation of spores of H. capsulatum dispersed from contaminated bird and bat guano. H. capsulatum grows well in soil enriched with bird or bat guano (1), and histoplasmosis is endemic in states in the Mississippi and Ohio river valleys, including Kentucky, Illinois, Indiana, Missouri, Ohio, and Tennessee (2). In southern Kentucky, middle Tennessee, and surrounding areas, histoplasmin skin testing has been positive in up to 95% of the population (3). Although partial immunity to histoplasmosis can occur following infection with H. capsulatum, susceptibility to the infection remains, especially when the level of exposure to spores is high. The outbreaks in Kentucky are consistent with previous outbreaks of acute histoplasmosis that have been associated with disturbance of bird and bat guano during cleaning, construction, and recreational (e.g., cave exploration) activities (1,4,5). The clinical spectrum of infection with H. capsulatum includes asymptomatic infection (most cases); mild, self-limited influenza-like illness; acute or chronic pulmonary infection; and disseminated disease. Disseminated disease is more likely to occur in the very young, the elderly, and immunocompromised persons (e.g., persons being treated for cancer with chemotherapy or persons with human immunodeficiency virus infection) and can be life-threatening. The incubation period ranges from 5 to 18 days. Acute histoplasmosis usually can be diagnosed by serologic tests (immunodiffusion and complement fixation) and sometimes by positive sputum culture or lung biopsy culture. Chest radiography can be useful in diagnosing histoplasmosis when interstitial infiltrates and/or hilar adenopathy are present; however, histoplasmosis can be difficult to distinguish from other pulmonary mycoses and from mycobacterial infections of the lung. When any material contaminated with bird or bat guano is to be disturbed in an area with endemic histoplasmosis, precautions should be taken to control dust aerosolization and to protect workers and persons in surrounding areas from exposure through inhalation (6). Water should be sprayed at low velocity on contaminated material to reduce the likelihood of aerosolization. During the removal of potentially contaminated material, PPE is necessary to protect workers from exposure to H. capsulatum (6); however, the type and level of PPE will vary based on the risk for exposure. Material that is to be removed and disposable PPE used during removal should be collected and sealed in heavy-duty plastic bags and disposed of in a landfill. Formaldehyde solution (3%-5%) has been reported to be effective in disinfecting soil contaminated with H. capsulatum (7); however, exposure to formaldehyde should be controlled to the lowest feasible limit (8). Additional information about prevention and control of histoplasmosis can be obtained from CDC's Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, Mailstop A-13, 1600 Clifton Rd., N.E., Atlanta, GA 30333; telephone (404) 639-3158. References 1. DiSalvo AF, Johnson WM. Histoplasmosis in South Carolina: support for the microfocus concept. Am J Epidemiol 1979;109:480-92. 2. Rippon JW. Medical mycology: the pathogenic fungi and the pathogenic actinomycetes. 3rd ed. Philadelphia, Pennsylvania: W.B. Saunders Company, 1988. 3. Schulman ST, Phair JP, Sommers HM. The biologic and clinical basis of infectious diseases. 4th ed. Philadelphia, Pennsylvania: W.B. Saunders Company, 1992. 4. Kaufman L. Laboratory methods for the diagnosis and confirmation of systemic mycoses. Clin Infect Dis 1992;14(suppl 1):S23-S29. 5. Schlech WF, Wheat LJ, Ho JL, et al. Recurrent urban histoplasmosis--Indianapolis, Indiana, 1980-81. Am J Epidemiol 1983;118:301-12. 6. Lenhart SW. Case studies: recommendations for protecting workers from Histoplasma capsulatum exposure during bat guano removal from a church's attic. Applied Occupational and Environmental Hygiene 1994;9:230-6. 7. Tosh FE, Weeks RJ, Peiffer FR, Hendrichs SL, Greer DL, Chin TD. The use of formalin to kill Histoplasma capsulatum at an endemic site. Am J Epidemiol 1967;85:259-65. 8. NIOSH/Occupational Safety and Health Administration. Current intelligence bulletin no. 34: formaldehyde--evidence of carcinogenicity. Cincinnati, Ohio: US Department of Health and Human Services, Public Health Service, CDC, 1980; DHHS publication no. (NIOSH)81-111. Tuberculosis Among Foreign-Born Persons Who Had Recently Arrived in the United States -- Hawaii, 1992-1993, and Los Angeles County, 1993 During 1986-1994, the number of tuberculosis (TB) cases reported annually among foreign-born persons in the United States increased 55% (from 4925 to 7627), and the proportion of all cases accounted for by persons who were foreign-born increased from 22% to 32%--increases that reflect, in part, effects of recent immigration (1). The largest numbers of foreign-born persons with TB originated from Mexico, Philippines, and Vietnam; persons from these countries currently account for the largest numbers of recent immigrants to the United States (2). This report summarizes a review of foreign-born persons in whom TB was diagnosed in Hawaii during 1992-1993 and in Los Angeles County during 1993 and assesses the impact of screening on the identification of TB among foreign-born persons residing in the United States for less than or equal to 1 year at the time of diagnosis. Immigrants and refugees are the only groups of foreign-born persons required to undergo screening for TB before obtaining a visa to enter the United States. The screening consists of a chest radiograph for persons aged greater than or equal to 15 years. If the radiograph is compatible with active TB, sputum smear examinations are conducted on 3 consecutive days to detect acid-fast bacilli (AFB). Based on these results, applicants with findings compatible with current or past TB infection are classified as class A, TB infectious; class B1, TB clinically active; class B2, TB not clinically active; or class B3, TB old or healed (Table 1). Persons with a class A status are required to undergo anti-TB therapy until they are AFB-smear-negative before being allowed to apply for a waiver to enter the country; no travel restrictions are placed on persons with a class B status. Information about the classification of immigrants and refugees is sent by the Immigration and Naturalization Service (INS) to CDC, which notifies the state or local health departments of the arrival of each person with an A, B1, or B2 status, and informs the immigrants and refugees that they should report promptly to their health department. Since the introduction of new guidelines for the medical examination of immigrants and refugees in 1991 (3), the contribution of the examination process to the identification of TB among recently arrived foreign-born persons has not been evaluated. Hawaii and Los Angeles County were selected for this analysis because most of their reported TB cases are among foreign-born persons. TB registries in Hawaii (1990 population: 1,104,668) and Los Angeles County (1990 population: 8,292,057) were examined to identify all foreign-born persons in whom TB had been diagnosed within 1 year of arrival through comparison of the dates of diagnosis and arrival in the United States. Case records were matched against CDC's Tracking System of Immigrants and Refugees with Suspected TB database to determine both the percentage of foreign-born persons with TB that had been identified as B1 and B2 before arrival in the United States and the percentage of those classified as B1 and B2 in whom active TB was diagnosed after arrival. In Hawaii during 1992-1993, a total of 429 (82%) TB cases were diagnosed in foreign-born persons, of whom 261 (61%) had resided in the United States for less than or equal to 1 year (Table 2). Most of these cases (211 [81%]) were in persons from Philippines, including 101 who were World War II veterans who entered the United States under a temporary provision of the Immigration Act of 1990, which exempted them from medical examination while applying for U.S. citizenship during 1992-1995. Based on inclusion of these veterans, 78 (30%) TB cases in foreign-born persons were classified as B1, and 17 (7%) as B2; the screening process did not identify 166 (64%) cases. Based on the exclusion of these veterans, 78 (49%) of the remaining 160 cases were classified as B1 and 17 (11%) as B2; the screening process did not identify 65 (41%) cases (Table 3). In Los Angeles County during 1993, a total of 1228 (64%) TB cases were diagnosed among foreign-born persons, of whom 261 (21%) had resided in the United States less than or equal to 1 year. Of these, 79 (30%) originated from Mexico, 71 (27%) from Philippines, 36 (14%) from Vietnam, and 48 (18%) from other countries in Asia (Table 2). Sixty-four (25%) persons previously had been classified as B1 and 30 (11%) as B2; the screening process did not identify 167 (64%) cases. Most of the cases from Philippines and Vietnam (65% and 58%, respectively) had been identified through screening before emigration; in comparison, 3% of cases from Mexico and other countries in Central America had been identified by previous screening (Table 3). The number of World War II veterans included in the Los Angeles County cases could not be determined; however, no more than 13 persons with TB could meet the criteria for inclusion in the category based on nationality, age, and year of arrival in the United States. The prevalence of confirmed TB within 1 year after arrival in the United States among persons classified abroad as B1 was 14% in Hawaii and 11% in Los Angeles County, and among those classified as B2, 2% and 3%, respectively. Reported: AC Ignacio, MD, Tuberculosis/Hansen's Disease Br; RL Vogt, MD, State Epidemiologist, Hawaii Dept of Health. LS Knowles, MPH, PT Davidson, MD, Tuberculosis Control, Los Angeles County Dept of Health Svcs, Los Angeles. Div of Quarantine, National Center for Infectious Diseases; Div of Field Epidemiology, Epidemiology Program Office; Div of Tuberculosis Elimination, National Center for Prevention Svcs, CDC. Editorial Note: The findings in this report document two important differences in the epidemiology of TB among recently arrived foreign-born persons in Hawaii and Los Angeles County. First, in Hawaii, 61% of foreign-born persons in whom TB was diagnosed had resided in the United States for less than or equal to 1 year, compared with 21% in Los Angeles County. Second, although the proportion of persons in whom TB was diagnosed shortly after arrival and who had not been detected through screening was similar in both areas, the characteristics of these groups were different. In Hawaii, approximately 60% of the previously undetected cases occurred in World War II veterans from Philippines who were exempted from medical examination (4). In comparison, in Los Angeles County, approximately half of the undetected cases occurred among persons from Mexico and Central America, whose immigration status could not be determined during this investigation. These differences underscore the need for TB-control programs to conduct reviews of the epidemiology of TB among foreign-born persons to enable improved case detection and prevention efforts. The findings in this report also underscore the importance of mandatory screening in the timely diagnosis and treatment of TB among those persons who emigrated to the United States from Philippines and Vietnam. Most persons who had emigrated from these two countries and who had TB diagnosed within 1 year of arrival had been identified previously through the mandatory immigrant and refugee screening system; among persons who were not identified, some may have developed TB after entering the country. In contrast, the system contributed only minimally to the early identification of TB among persons from Mexico and Central America. Potential explanations for the relative ineffectiveness of mandatory screening among these persons include 1) a lower screening sensitivity in these countries to detect active TB, 2) inadequate or incomplete dissemination of information from the ports of entry most commonly used by these populations, and 3) a higher proportion of persons from Mexico and Central America who entered the United States under visa categories not requiring medical examination or who entered illegally. In Hawaii, where it was possible to assess immigration status for new arrivals, less than 10% of the cases diagnosed within the first year were among persons in other visa categories or who were in the United States illegally; similar assessments could not be performed in Los Angeles County. The findings in this report also document the high prevalence of active TB among persons classified as B1 and B2. In addition to confirmed TB, a high proportion of those classified as B1 and B2 have abnormal chest radiographs and positive skin tests and may benefit from preventive chemotherapy (5). These persons should receive prompt and active follow-up after their arrival in the United States. An important strategy for preventing and treating TB among foreign-born persons is ensuring that most persons who intend to become residents of the United States and have active TB are detected before entering the country. The findings in this report suggest the need for some improvements in the screening process abroad and some operational modifications. CDC, in collaboration with state and local health departments, is evaluating the different stages of the screening and tracking process to make recommendations for future strategies. The evaluation includes assessments--similar to those in Hawaii and Los Angeles County--in other areas reporting large proportions of their TB cases among foreign-born persons, a review of data transmission from ports of entry, and a reevaluation of the current screening criteria and supervision at screening sites. References 1. McKenna MT, McCray E, Onorato I. The epidemiology of tuberculosis among foreign-born persons in the United States, 1986 to 1993. N Engl J Med 1995;332:1071-6. 2. Immigration and Naturalization Service. Statistical yearbook of the Immigration and Naturalization Service, 1993. Washington, DC: Immigration and Naturalization Service, 1994. 3. CDC. Technical instruction for medical examination of aliens. Atlanta: US Department of Health and Human Services, Public Health Service, 1991. 4. CDC. Tuberculosis in Philippine national World War II veterans immigrating to Hawaii, 1992-1993. MMWR 1993;42:656-7,663. 5. Bass JB Jr, Farer LS, Hopewell PC, et al. Treatment of tuberculosis and tuberculosis infection in adults and children. Am J Respir Crit Care Med 1994;149:1359-74. Assessment of the Incidence of Rape -- North Carolina, 1989-1993 Rape has a substantial impact on the health of victims, including a broad spectrum of physical, psychologic, and social sequelae (1-3). The development of appropriate and effective rape-prevention programs is assisted by consistent collection of information about and by accurate estimation of the incidence of rape. In North Carolina, as in many other states, the only source of statewide and county-specific population-based data on rape incidence is the Uniform Crime Reporting Program (UCR), coordinated by the Federal Bureau of Investigation (FBI); however, these data may underestimate the actual incidence of rape (4,5) because they include only assaults that have been reported to police and that conform to the UCR definition of forcible rape*. To assess the usefulness of rape crisis centers (RCCs) as an additional potential source of data for determining the incidence of rape, in 1994 the Injury Control Section, North Carolina Department of Environment, Health, and Natural Resources (NC-DEHNR), surveyed RCCs in North Carolina, then compared estimates of the annual incidence based on RCC and UCR data for selected counties during 1989-1993. This report summarizes the results of the survey and comparative analysis. A questionnaire developed by NC-DEHNR was mailed to each of the 52 RCCs operating in the state during 1994; each RCC served a single county or a group of adjoining counties. RCCs that did not respond to the initial mailing received an additional mailing and one telephone call. Of the 52 RCCs, 35 (67%) responded: 18 provided information about rape victims served in all 5 years of the study period and 13 for 1-4 years; three did not maintain client records with sufficient information for any of the years; and one did not begin serving clients until 1994 and was excluded. Responding and nonresponding RCCs had similar geographic distributions across the state, and similar proportions of both groups were located in predominantly rural counties. Although the survey requested information about clients whose assaults met the UCR definition of forcible rape, approximately 70% (range: 19 [61%] of 31 RCCs in 1993 to 16 [76%] of 21 RCCs in 1990) of the RCCs were unable to distinguish UCR-defined rapes from other types of assaults. For these RCCs, NC-DEHNR used information provided by the North Carolina Council for Women (NCCW) for 1993 to estimate the proportions of clients whose assaults met the UCR definition of rape. NCCW provides partial funding to all RCCs in North Carolina and collects data from each RCC about the proportion of clients who experienced sexual assault, attempted rape, or marital rape (the combination of these three categories most closely matches the UCR definition of forcible rape). County-specific information about rapes during 1989-1993 was obtained from annual summaries of UCR data prepared by the State Bureau of Investigation. For comparisons of UCR- and RCC-based rape rates, county-specific UCR data were included only for counties served by participating RCCs. Women of any age were included in data from both RCCs and the UCR. By year, UCR-based rates were 8%-14% higher than RCC-based rates for 1989 and 1990, while during 1991-1993, annual RCC-based rates were 15%-48% higher than UCR-based rates (Table 1). Analysis restricted to only the 18 RCCs that provided data for each of the 5 years was consistent with this pattern. Analysis restricted to only those RCCs that provided information about assaults meeting the UCR definition of forcible rape indicated that the corresponding RCC-based rates for 1989-1993 were 23%-136% higher than the corresponding UCR-based rates. Reported by: TB Cole, MD, Injury Control Section; PD Morris, MD, Occupational and Environmental Epidemiology Section, Div of Epidemiology, North Carolina Dept of Environment, Health, and Natural Resources. Family and Intimate Violence Prevention Team, Div of Violence Prevention, National Center for Injury Prevention and Control; Div of Field Epidemiology, Epidemiology Program Office, CDC. Editorial Note: The findings in this report indicate the inconsistency of rape estimates in North Carolina between sources and over time. Similar discrepancies exist among various sources of national estimates of rape incidence, including the FBI's nationwide UCR (6) used in this report, the National Women's Study (7), and the National Crime Victimization Survey (8). Each of these sources employs different methods for defining rape and collecting information and yields different estimates of the magnitude of the problem (Table 2). The lack of a standard definition and the different methods for estimating the incidence of rape have constrained both the public health surveillance of this problem and comparisons across data sets. In particular, the determination of age-specific and sex-specific counts and rates would enable more valid comparisons over time and between population groups. To consider issues related to the improvement of surveillance for rape, CDC recently convened separate meetings of experts about rape (state health department representatives, researchers, and rape-victim advocates) and state sexual assault prevention coordinators. These groups recommended o developing consistent definitions of rape--varying interpretations and use of terms such as rape, completed rape, attempted rape, sexual assault, and child sexual abuse impede understanding and prevention of the problem. o determining the best sources for surveillance data for rape--although potentially useful sources include records from hospitals, emergency departments, RCCs, other health and human service providers, the justice system, police departments, and population surveys, linkage of such sources would enable more precise estimation of the incidence of rape; confidentiality must be an essential component of any such surveillance system. o modifying and developing surveillance systems to capture at least the type of incident (e.g., rape or sexual assault), relationship between victim and perpetrator, sex of victim, and age of victim both at the time of the report and at the time of the incident (many victims report only after prolonged periods). The findings of this analysis in North Carolina and of the comparison of national data sources document the effects of different data sources on estimates of the incidence of reported rape and suggest approaches for improving surveillance. In conjunction with advocates for rape victims and other groups, CDC is assisting in the development of standard public health definitions of rape and sexual assault that, when adopted, will enable comparability across data sources. Surveillance as an initial process in the public health approach will enable more accurate documentation of the magnitude of the problem and assist efforts to further identify the long-term physical and mental health consequences associated with rape. References 1. Council on Scientific Affairs, American Medical Association. Violence against women: relevance for medical practitioners. JAMA 1992;267:3184-9. 2. Resick PA. The psychological impact of rape. Journal of Interpersonal Violence 1993;8:223-55. 3. Schwartz IL. Sexual violence against women: prevalence, consequences, societal factors, and prevention. Am J Prev Med 1991;7:363-73. 4. Von JM, Kilpatrick DG, Burgess AW, Hartman CR. Rape and sexual assault. In: Rosenberg ML, Fenley MA, eds. Violence in America: a public health approach. New York: Oxford University Press, 1991:95-122. 5. Koss MP, Gidycz CA, Wisniewski N. The scope of rape: incidence and prevalence of sexual aggression and victimization in a national sample of higher education students. J Consult Clin Psychol 1987;55:162-70. 6. Federal Bureau of Investigation. Uniform crime reports, 1990: crime in the United States. Washington, DC: US Department of Justice, Federal Bureau of Investigation, 1991. 7. Kilpatrick DG, Edmunds CN, Seymour AK. Rape in America: a report to the nation. Arlington, Virginia: National Victim Center, 1992. 8. Bureau of Justice Statistics. Criminal victimization in the United States, 1990: a national crime victimization survey report--February 1992, NCJ-134126. Washington, DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, 1992. 9. Kilpatrick DG, Resnick HS, Saunders B, Best CL. Measuring violent assaults against women: results from the National Women's Study. In: The American Society of Criminology 46th annual meeting: challenges of crime and social control--1994 program and proceedings. Columbus, Ohio: The American Society of Criminology, 1994. 10. Bachman R, Saltzman LE. Violence against women: estimates from the redesigned survey. Washington, DC: US Department of Justice, Office of Justice Programs, 1995. (Bureau of Justice Statistics special report no. NCJ-154348). * Defined as the carnal knowledge of a woman forcibly and against her will. Assaults or attempts to commit rape by force or threat of force are included; statutory rape (without force) and other sex offenses are excluded. Knowledge and Use of Folic Acid by Women of Childbearing Age -- United States, 1995 Each year in the United States approximately 2500 infants are born with spina bifida and anencephaly (1), and an estimated 1500 fetuses affected by these birth defects are aborted. Recent studies indicate that the B vitamin folic acid can reduce the risk for spina bifida and anencephaly by at least 50% when consumed daily before conception and during early pregnancy. In September 1992, the Public Health Service (PHS) recommended that all women of childbearing age who are capable of becoming pregnant consume 0.4 mg of folic acid daily (1). Folic acid can be obtained from multi-vitamins or other supplements containing folic acid and some breakfast cereals. This report summarizes the results of a survey conducted during January-February 1995 regarding knowledge and practices of women of childbearing age in the United States about consumption of folic acid from supplements and breakfast cereals. During January-February 1995, The Gallup Organization conducted for the March of Dimes Birth Defects Foundation a proportionate, stratified random-digit-dialed telephone survey of a national sample of 2010 women aged 18-45 years. The response rate was 50%. Respondents were asked, "Have you ever heard or read anything about folic acid?" Respondents also were asked, "From what you know, is there anything a woman can do to reduce her risk of having a baby with birth defects?" and "To the best of your knowledge, can consuming vitamins during pregnancy reduce the risk of birth defects?" For this analysis, estimates were statistically weighted to reflect the total population of women aged 18-45 years in the continental United States residing in households with telephones. The margin of error for estimates based on the total sample size within 95% confidence intervals is 2%. Overall, 52% of women reported ever hearing of or reading about folic acid. Of these, 9% answered that folic acid helps to prevent birth defects and 6% that folic acid helps reduce the risk for spina bifida; 45% were unable to recall what they had heard or read. Fifteen percent of respondents reported having knowledge of the PHS recommendation regarding the use of folic acid; 4% reported that the recommendation was for prevention of birth defects and 1%, for prevention of spina bifida. A total of 88% of respondents reported that a woman can help reduce the risk for having an infant with birth defects. The most common responses about how to reduce risk were avoiding alcohol and drugs (73%), and not smoking (63%); 1% reported that folic acid could reduce risk. Overall, 56% reported that consumption of vitamins during pregnancy can reduce the risk for having an infant with birth defects, and 78% reported that women should take multivitamins before pregnancy. The most frequently mentioned supplements respondents believed to be especially important to women of childbearing age and to pregnant women were iron (27%), calcium (26%), multivitamins (20%), vitamin C (14%), and folic acid (6%). Overall, 25% of nonpregnant women of childbearing age reported taking a daily vitamin supplement containing folic acid. Of women who had been pregnant during the 2 years preceding the survey, 20% reported taking the vitamins before pregnancy. Among women who did not take vitamin or mineral supplements daily, the most frequently cited reasons for not taking them were "Don't feel I need them," (22%); "Forget to take them," (18%); and "Get balanced nutrition from foods," (12%). Overall, 77% of women surveyed reported eating at least one serving of breakfast cereal each week; 14% reported eating at least seven servings per week. The average number of servings per week was three. Most cereals eaten contained 0.1 mg folic acid per serving, and few (6%) respondents who included cereals in their diets reported eating a cereal that contains 0.4 mg folic acid per serving. Reported by: RB Johnston, Jr, MD, DA Staples, March of Dimes Birth Defects Foundation, White Plains, New York. Birth Defects and Genetic Diseases Br, Div of Birth Defects and Developmental Disabilities, National Center for Environmental Health, CDC. Editorial Note: A convenient method for a woman to achieve the PHS recommendation for the use of folic acid to reduce the risk for spina bifida and anencephaly is to take daily a vitamin supplement that contains 0.4 mg folic acid or eat a breakfast cereal containing 0.4 mg folic acid per serving. The findings in this report indicate that only 25% of nonpregnant women in the United States regularly consumed a vitamin supplement containing 0.4 mg folic acid, and only a small proportion ate a breakfast cereal containing 0.4 mg folic acid per serving. A previous report indicated that among women in South Carolina who had given birth during October 1992-September 1994, only 12% had used folic acid-containing vitamin supplements during the periconceptional period (2). In addition to consumption of folic acid-containing supplements or breakfast cereals, women can increase their consumption of folates by choosing foods consistent with the U.S. Dietary Guidelines for Americans and the U.S. dietary pyramid (e.g., orange juice and green leafy vegetables) (1). An important limitation of this telephone survey was the low response rate (50%). In particular, knowledge and behavior patterns of nonparticipants may have been different from those of participants. Because participating women were more highly educated than the total U.S. population, the prevalence of use of vitamin supplements may have been higher among these women than U.S. women in general because vitamin usage increases with education (3). Additional surveys of a more representative sample of women of childbearing age in the United States will be necessary to obtain more precise estimates of the use of vitamin supplements among such women. Nonetheless, the findings in this report and the South Carolina study (2) suggest the need to increase knowledge of the importance of consuming folic acid among women of childbearing age and to heighten awareness among women about the potential benefits of taking folic acid on a daily basis. Strategies for educating women about folic acid include reporting the issues in the news media, widely distributing informational materials (e.g., in physicians' offices, clinics, schools, and health clubs), and encouraging health-care providers to emphasize consistently the importance of daily consumption of folic acid when speaking to women of childbearing age. The most effective and efficient methods for increasing knowledge of the benefits of increased folic acid consumption and for changing behavior to increase use should be determined by additional research and demonstration projects. In addition, because folic acid consumption also could be increased by the addition of folic acid to staple foods, the Food and Drug Administration has proposed requiring the addition of folic acid to a variety of enriched cereal grain products (4). The March of Dimes Birth Defects Foundation is using data from this survey as an integral part of its new "Think Ahead" public education campaign to promote preparation for pregnancy. Additional information about folic acid consumption patterns among women is available from R.B. Johnston, Jr., M.D., March of Dimes Birth Defects Foundation, 1275 Mamarneck Ave., White Plains, NY 10605. References 1. CDC. Recommendations for the use of folic acid to reduce the number of cases of spina bifida and other neural tube defects. MMWR 1991;41(no. RR-14):1-7. 2. CDC. Prevention program for reducing risk for neural tube defects--South Carolina, 1992-1994. MMWR 1995;44:141-3,149-50. 3. Block G, Cox C, Madans J, et al. Vitamin supplement use by demographic characteristics. Am J Epidemiol 1988;127:297-309. 4. FDA. Proposed rule. Food standards: amendment of the standards of identity for enriched grain products to require addition of folic acid. Federal Register 1993;58:53305-12. AIDS Map The following map provides information about the reported number of acquired immunodeficiency syndrome (AIDS) cases per 100,000 population, by person's state of residence from July 1994 through June 1995. More detailed information on AIDS cases is provided in the HIV/AIDS Surveillance Report, single copies of which are available free from the CDC National AIDS Clearinghouse, P.O. Box 6003, Rockville, MD 20849-6003; telephone (800) 458-5231 or (301) 217-0023. Internet users can obtain an electronic copy of the report by accessing gopher.niaid.nih.gov.