Disease Control Bulletin: January 2003
- Chronic Disease in Vermont: Obesity
- VT AIDS/HIV Update
- VT HIV/AIDS Quarterly Report
- Vermont’s Pre-Event Smallpox Vaccination Plan Update
- Childhood Overweight Prevention and WIC
- Selected Reportable Diseases December 28, 2002
- Azithromycin Dosing for Genital Chlamydia Infection Notice
Chronic Disease in Vermont: Obesity
Obesity is a major cause of morbidity and mortality in both men and women in the United States and Vermont. Over the last several decades obesity has been increasing in prevalence according to self-reported data from the Behavioral Risk Factor Surveillance System (BRFSS)1 and the National Health and Nutrition Examination Survey III.2
Data in this report reflect the characteristics and percentages of adult Vermonters in each body mass index (BMI) category and the relationship between selected chronic conditions and BMI. Body mass index, defined as weight in kilograms divided by squared height in meters, encompasses the range of weight categories including under healthy weight (BMI <19 kg/m2), healthy weight (BMI 19–24.9 kg/m2), overweight (BMI 25–29.9 kg/m2), obese (BMI 30–39.9 kg/m2), and class III obesity3 (BMI ³ 40 kg/m2.
Consequences of Obesity
Men and women with BMIs above the healthy weight range have an increased incidence of Type 2 diabetes, hypertension, coronary heart disease and gallbladder disease.4 Post-menopausal breast, endometrial, colon and kidney cancer, osteoarthritis and infertility are also related to excess body fat.4 The lowest rates of all causes of mortality are found among individuals with BMIs between 23.5 and 24.9 in men and 22.0 and 23.4 in women. Rates are highest among individuals with class III or extreme obesity (BMI³ 40).5 Individuals with class III obesity have twice the risk for all causes of mortality compared to obese individuals.6
Vermont data substantiate the relationship between obesity and chronic disease. The percentages of adult Vermont-ers in each BMI category who reported ever being diagnosed with diabetes, cardiovascular disease (including coronary heart disease, stroke or myocardial infarction), or arthritis are shown in Figure 1. Percentages for individuals reporting current asthma or being “at risk for depression” 7 are also shown in Figure 1. In 2000, more Vermonters reported having a disability8 if they were in the overweight (19%), obese (26%) or class III obesity (37%) categories than if they were in the healthy weight category (12%) (p<0.001).
Prevalence of Obesity
Six Healthy Vermonter 2010 goals relate to physical activity, nutrition and obesity. The goals directly related to obesity include 1) reducing the percentage of adults age 20 and older who are obese from 17.6 percent in 2001 to 15 percent by 2010, and 2) reducing the percentage of youth who are obese or overweight from 10 percent of children in grades 8–12 in 2001 to 5 percent by 2010.
Secular trends: From 1990 to 2001, the percentage of Vermonters in the under healthy weight category declined by 33 percent, from 4.3 percent to 2.9 percent, and in the healthy weight category by 19 percent, from 55.1 percent to 44.7 percent. The percentage of overweight adult Vermonters increased 16 percent, from 29.9 percent to 34.7 percent, while the percentage of obese Vermont men and women increased 55 percent, from 10.3 percent to 16.0 percent, during this period. A dramatic rise in the percentage of adult Vermont-ers with class III obesity was also seen with a 600 percent increase, from 0.3 percent in 1990 to 2.1 percent in 2000. The corresponding U.S. prevalence was 0.78 percent in 1990 to 2.2 percent in 2000.4
Characteristics of Vermonters over healthy weight: In grades 8–12, more Vermont boys [14.1%; 95% confidence interval (CI) =11.9–16.2] than girls [5.4%; 95% CI =4.0–6.9] were overweight.9 For adult Vermonters, more men than women were obese, but more women than men reported extreme or class III obesity (See Figure 2).
For the period 1999–2000, the prevalence of obesity (BMI ³ 30) was highest among adult Vermonters with education at the level of “some high school or less” (7.7%), adults age 55–64 (22.5%), and lowest among those with incomes over $75,000 (10.9%).1
Physical Activity: the key to a healthy weight: The National Institutes of Health states, “Physical activity should be an integral part of weight loss and weight maintenance. Initially, moderate levels of physical activity for 30–45 minutes, 3–5 days per week should be encouraged. All adults should set a long-term goal to accumulate at least 30 minutes or more of moderate-intensity physical activity on most, and preferably all, days of the week.” 4 In 2000, the percentage of adult Vermonters reporting 30 minutes of physical activity at least five times per week declined with increasing body mass index (healthy weight = 29% [95%CI =26–31], overweight = 24% [95%CI =22–27], obese = 16% [95%CI=13–19], and class III obesity = 15% [95%CI =7–23]).1
A combination of increased physical activity and reduced caloric intake produces greater weight loss than either alone.5 Individuals who engaged in physical activity expending 1,500–2,000 calories per week maintained 76–85 percent of the weight loss at the end of two years.10 This level of physical activity is equivalent to approximately five hours per week or 45 minutes a day, seven days a week.
Physician’s advice: In 2000, of adult Vermonters advised to lose weight by a physician, 76 percent were trying to lose weight. Twelve percent of overweight Vermonters, 33 percent of obese Vermonters and 52 percent of individuals in the class III obese category reported they were advised by their physicians to lose weight.
According to the 2001 Vermont BRFSS, an estimated 151,490 adult Vermonters were overweight, 45,090 were obese, and 2,502 were in the class III obesity category. Nearly three-quarters of individuals who reported a physician’s recommendation to lose weight were attempting to do so. More emphasis is needed in educating overweight and obese patients about the importance of physical activity and healthy eating in managing their weight long term. For more information on the identification, evaluation, and treatment of overweight and obesity, go to http://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm.
- Behavioral Risk Factor Surveillance System is an annual telephone survey of a random sample of non-institutionalized adult Vermonters (age 18+). For more details, visit: http://www.cdc.gov/brfss/
- Flegal KM, Carroll MD, Ogden CL, Johnson CL. Prevalence and trends in obesity among U.S. adults, 1999-2000. JAMA. 2002;288:1723-1727.
- Freedman DS, Khan LK, Serdula MK, Galuska DA, Dietz WH. Trends and correlates of class 3 obesity in the United States from 1990-2000. JAMA 2002;288:1758-1761.
- NHLBI. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: The evidence report. NIH Pub. No. 98-4083, September 1998, 228 pgs.
- NHLBI. The practical guide to the identification, evaluation, and treatment of overweight and obesity in adults. NIH Pub. No. 00-4084, October 2000, 56 pgs.
- Calle EE, Thun MJ, Petrelli JM et al. Body-mass index and mortality in a prospective cohort of US adults. N Engl J Med. 1999;341:1097-1105.
- Depression defined as two or more weeks within the past year or two years of life feeling depressed or sad AND more than one day of the past week feeling depressed.
- The survey question reads: “Are you limited in any way in any activities because of physical, mental or emotional problems?”
- For children, overweight was defined as BMI > 95th percentile for age and gender, Youth Risk Behavior Survey 2001.
- Rippe JM, Hess Stacey. The role of physical activity in the prevention and management of obesity. J Am Diet Assoc 1998;98(suppl2):S31-S38.
Update on HIV/AIDS in Vermont
The Vermont Quarterly AIDS Report has been revised to include data on individuals infected with HIV. The report will be mailed each quarter to infectious disease physicians, AIDS service organizations, counseling and testing clinics, and others on the Vermont Quarterly HIV/AIDS Report mailing list. To request that your name be added to this mailing list, please contact the Department of Health at (802) 863-7245. In addition, this report will be published twice each year in the Disease Control Bulletin.
For national surveillance purposes, the Centers for Disease Control and Prevention (CDC) assigns HIV and AIDS cases to the state of residence at the time of diagnosis of HIV infection or AIDS, respectively. This convention prevents duplication in the national database of individuals who have been reported to surveillance systems in more than one state.
The Vermont data reported in the Vermont Quarterly HIV/ AIDS Report include only individuals who were Vermont residents at the time of their diagnosis. The actual number of people living with HIV/AIDS in Vermont changes over time as people move into and out of the state. In addition, the CDC estimates that one quarter of individuals living with HIV in the United States are not aware of their infection and are therefore not included in surveillance statistics.
The Vermont HIV data reported include only living individuals who are infected with HIV who have not developed AIDS. The data on persons living with HIV/AIDS include persons living with HIV and persons living with AIDS. The numbers are subject to change as additional surveillance data are received. National data obtained from CDC surveillance reports are provided for comparison when available. The demographic characteristics (i.e., gender, age category, and race/ethnicity) presented in the Vermont report, as well as the mode of exposure to HIV, provide information that is essential for understanding the scope of the HIV/AIDS epidemic and for planning prevention and service delivery programs.
Since AIDS became reportable in 1982, 430 Vermont residents diagnosed with AIDS have been reported to the Department of Health; 220 of those individuals are believed to be currently living with AIDS. An additional 166 Vermont residents infected with HIV have been reported to the Department of Health since HIV infection became reportable in Vermont in March 2000. Of those, 159 individuals are believed to be currently living with HIV.
Eighty-eight percent of AIDS cases reported among Ver-mont residents have been among men, while 82 percent of cumulative AIDS cases in the United States are among men. In Vermont, 59 percent of cumulative AIDS cases are among men who have sex with men, while 17 percent are among injection drug users. In the U.S., only 46 percent of cumulative AIDS cases have been among men who have sex with men, while injection drug use accounts for one quarter of cases nationally.
The map of Vermont shown above indicates the number of HIV and AIDS cases reported to the Department of Health through September 30, 2002 by county of residence at the time of diagnosis. Chittenden County, with 24 percent of the state’s current population, accounts for 39 percent of the HIV/ AIDS cases reported.
For additional information or to request HIV or AIDS Case Report Forms, please contact the Department of Health at (802) 863-7240
Vermont Quarterly HIV/AIDS Report
Vermont Data through 09/30/02
U.S. Data through 12/31/01
|Persons Living with HIV 1,2||Persons Living with AIDS||Persons Living with HIV/AIDS||Cumulative AIDS Cases|
|African American, Not Hispanic||15||9%||22||10%||42%||37||10%||35||8%||38%|
|Asian/Pacific Islander||<3||< 1%||< 3||< 1%||1%||<3||<1%||< 3||< 1%||1%|
|American Indian/Alaskan Native||<3||< 1%||< 3||< 1%||< 1%||<3||<1%||< 3||< 1%||< 1%|
|Mode of Exposure: Adult|
|Men who have sex with men (MSM)||90||57%||115||53%||45%||205||55%||251||59%||46%|
|Injecting drug use (IDU)||23||15%||38||18%||27%||61||16%||73||17%||25%|
|Receipt of blood transfusion or tissue||<3||<1%||5||2%||6||2%||9||2%||1%|
|Other/risk not reported or identified||18||11%||14||6%||32||9%||20||5%||10%|
|Mode of Exposure: Pediatric (<13 yrs)|
|Mother with/at risk for HIV infection||<3||< 1%||< 3||33%||N/A8||< 3||25%||4||57%||91%|
|Receipt of blood transfusion or tissue||<3||< 1%||< 3||33%||< 3||25%||< 3||14%||4%|
|Hemophilia/Coagulation disorder||<3||< 1%||< 3||33%||< 3||25%||< 3||14%||3%|
|Other/risk not reported or identified||<3||100%||< 3||<1%||< 3||25%||< 3||14%||2%|
- Includes only persons reported with HIV infection who have not developed AIDS.
- A total of 166 cases of HIV infection have been reported to the Vermont Department of Health. Of these, 159 are believed to be living.
- Vermont data include only those people who were residents of Vermont at the time of initial diagnosis.
- The HIV/AIDS Surveillance Program does not typically release data with values < 3.
- Race/Ethnicity is unknown for one individual living with HIV.
- Source of US Data: CDC. HIV/AIDS Surveillance Supplemental Report, 2001.7 (No.1), 2001 and CDC, HIV/AIDS Surveillance Report, 2001.13(no.2), 2001.
- National data are available for different age categories and are not directly comparable.
- National pediatric data among persons living with AIDS, categorized by mode of exposure, are not currently available.
- Source of US Data: CDC. HIV/AIDS Surveillance Report, 2001.12(No. 2), 2001.
- These exposure categories are all included in the category "Other" in the national data.
Update: Vermont’s Pre-Event Smallpox Vaccination Plan
On December 9, 2002, the Vermont Department of Health submitted to the Centers for Disease Control and Prevention (CDC) a plan for vaccinating up to 2000 individuals against smallpox. Consistent with President Bush’s announcement of December 13, 2002, the department plans to offer voluntary vaccination to public health response teams and to health care response teams throughout the state. These are the people who would be called upon to investigate and care for the first case or cases of smallpox in Vermont and put into place additional control measures to prevent additional cases. The plan, with minor revisions, was accepted by the CDC on December 23, 2002.
Low risk, high impact event
The risk of smallpox appearing anywhere on earth is considered to be low. The last case occurred in 1977 and the disease was declared eradicated in 1980. Risk of disease exists, however, because of questionable security surrounding laboratory stock of the virus maintained in the former Soviet Union. There are concerns that smallpox virus could be used for bioterrorism. In the past, up to 30 percent mortality has been associated with epidemic smallpox, with significant morbidity and sequelae, including scarring and blindness.
Routine immunization against smallpox was discontinued in the United States in 1972. Individuals who were immunized prior to that time are considered to be susceptible to disease; they might have limited protection against severe disease.
Planning efforts essential
The public health and health care response teams to be immunized during Phase 1 of the pre-event smallpox vaccination program comprise one aspect of the overall smallpox response plan submitted to the CDC by the Vermont Department of Health on December 1, 2002. In the event of a case of smallpox in Vermont, the public health teams will be performing case investigations, contact tracing, and vaccination for indicated contacts and members of the public. The health care teams will be diagnosing and providing care to hospitalized patients with smallpox. Law enforcement and EMS are also represented on these teams to assist with security and transport of patients, personnel, and vaccine.
Public health and health care response teams will have both local and regional representation to assure the widest possible coverage of the state. Public health response teams include members of the Health Department staff from the central office in Burlington as well as district office staff. Health care response teams include staff members at each Vermont hospital as well as providers who will be able to travel among hospitals to provide needed expertise and care.
Assuring the safety of vaccine recipients
The vaccine, which is comprised of live vaccinia virus (a relative of the smallpox virus), has a number of potential side effects, and a large part of the pre-event vaccination plan is concerned with the careful education and screening of potential vaccinees to ensure that people with contraindications do not receive the vaccine. Vaccine is only being offered to individuals who received a smallpox immunization in the past and who do not have any contraindications.
Persons with the following conditions should not be vaccinated:
- Allergy to smallpox vaccine or its components.
- Moderate or severe acute illness (until illness has resolved).
- Currently breastfeeding (due to close contact between breastfeeding mothers and infants).
Persons with the following conditions or close contacts with the following conditions should not be vaccinated:
- Eczema or atopic dermatitis (even if the condition is mild, currently inactive, or experienced as a child).
- Skin conditions such as burns, chickenpox, shingles, impetigo, herpes, severe acne, or psoriasis (people with these skin conditions should not get vaccinated until the condition has resolved).
- Weakened immune system (includes cancer treatment, organ transplant, HIV, or medications to treat autoimmune disorders).
- Pregnancy or plans to become pregnant within 1 month.
If an individual is a contact to a confirmed case of smallpox, there are NO contraindications to vaccination, which, if provided within three days of exposure, can prevent the development of disease and, if provided within four to seven days of exposure, can decrease the severity of disease and risk of death.
Vaccinations will be starting as soon as vaccine is provided by CDC to the state and appropriate education has been provided to allow individuals to make informed decisions about volunteering. At the time this article was written (12/31/02), vaccine shipment was expected to occur in late January, 2003. Mass immunization of the public is not indicated at this time.
Several resources available to inform health care providers about the pre-event smallpox immunization initiative are listed here and are available at:
- Smallpox Fact Sheet (pdf file)
- Smallpox Vaccine Information Statement (pdf file)
- Smallpox Vaccine Fact Sheet (pdf file)
- Smallpox Vaccine Contraindications Fact Sheet (pdf file)
- Post-vaccination Fact Sheet (pdf file)
- Adverse Reactions Fact Sheet (pdf file)
Childhood Overweight Prevention and WIC
Objective 19-3 of Healthy People 2010 is to “reduce the proportion of children and adolescents who are overweight or obese.” This is also a Leading Health Indicator, meaning it is a major public health concern in the United States. More and more children are becoming overweight at an earlier age, primarily due to changes in eating patterns and decreases in physical activity. Current treatment methods are largely unsuccessful; once individuals become overweight, they remains overweight and will likely suffer associated health problems.
An overweight child is more likely to experience health problems as an adult: continued overweight, high blood pressure, cardiovascular disease, diabetes, respiratory difficulties, and psychological and social problems. These problems negatively affect quality of life and place a burden on our health systems.
The Body Mass Index (BMI) is the most widely accepted clinical measure of weight status. A child who has a BMI above the 95th percentile compared to their age and gender group, using standards established with national surveys, is considered to be overweight. If their BMI is between the 85th and 95th percentiles, the child is considered at risk of overweight. While the terms “overweight” and “obesity” are used interchangeably in the general population, “obesity” has a more negative connotation (Higgins et al 2001). In some settings, “overweight” refers to excess body weight including all tissues, while “obesity” refers only to excess body fat. Until more accurate definitions and measures of overweight and obesity in children are defined, we have chosen to use the more neutral term of “overweight”.
Risk and Prevention
Every racial and ethnic group is subject to the environmental influences responsible for the increase in childhood overweight. It appears that low socioeconomic status might also be a risk factor for overweight in young children (Gerald 1994, Sherman 1995). Several studies of low-income pre-school children attending Head Start programs have found a high prevalence of overweight ranging from 10 percent (Weicha 1994) to 32 percent (Hernandez 1989).
Prevention of overweight among children is imperative for stemming the epidemic for the entire population (International Obesity Task Force, 1999, NHLBI Obesity Education Initiative Expert Panel, 1998). Fifty percent of overweight children and teens will become overweight adults (Dietz 1998). Approximately 26–41 percent of overweight preschool children will become overweight adults (Serdula et al. 1993).
Treatment of overweight is difficult, costly, and less effective than is preventing it from occurring in the first place. Early childhood is an especially critical period for overweight intervention (Wisemandle et al 2000). By intervening in childhood, before risky behaviors are established, weight modification can be more successful than in adults. Interventions are also more successful in younger rather than in older school-aged children (Davis & Christofel 1994, Epstein et al 1995).
Focusing on weight status alone introduces the risk of Vermont Department of Health, Disease Control Bulletin weight-based stigmatization among children. Weight loss among young children might ultimately result in retardation of linear growth, increased risk of subsequent osteoporosis (Van Loan et al 2001), impaired intellectual development (Kenyon 2000), eating disorders, poor self-esteem, and even weight gain (Neumark-Sztainer et al 1996; Stice et al 1999).
Instead of losing weight, it is recommended that children “grow” into their weight by reducing the rate of weight gain as they grow in height. Children as young as 6 years of age are becoming less physically active (Goran et al 1998). Promotion of healthy diet and physical activity should be the emphasis of overweight prevention programs designed for children. Most overweight interventions have been designed for adults; the few prevention programs for children have targeted mainly older children and adolescents (Harvey-Berino et al 2000). New, innovative strategies to prevent overweight among young children need to be developed.
Fit WIC Activity Kit
The Vermont Department of Health WIC Program, as part of a five-state consortium project, is just completing a three-year USDA Special Project Grant to study childhood obesity prevention. Each state was charged with developing strategies to address the increasing rates of overweight in young children. Vermont focused on giving parents tools and information to help them teach their young children to be more physically active. These resources are presented in a “tool kit” format, the Fit WIC Activity Kit. The contents were developed and chosen based on Social Cognitive Theory concepts, a methodology often used as the backbone of behavioral interventions.
The kit incorporates educational messages for parents, instructions for developmentally appropriate games that will help children learn important play skills, and props that include a music tape, bean bags, and a beach ball. This intervention model offers the kit to all participating WIC children ages 3 to 5, not just those identified as overweight. Pre- and post-test data collection in both intervention and control populations showed the kit to be well used and effective.
Ninety-five percent of mothers who received a kit reported using it several times a week, and almost all said they planned to continue using it in the future. Mothers felt using the kit improved their ability to teach their child active play skills, and those who used the Fit WIC materials saw a significant improvement in several of their child’s physical activity skills and in their ability to transition children from active to quiet play. Based on the positive intervention results, the Fit WIC Activity Kit is now being disseminated statewide through the WIC program and its collaborative partners such as Head Start, Healthy Child Care Vermont and Success By Six.
For more information, contact Karen Flynn administrator of the WIC program at 802-652-4171.
Vermont: Selected Reportable Diseases December 28,2002
Notice: Azithromycin Dosing for Genital Chlamydia Infection
According to the Sexually Transmitted Diseases Treatment Guidelines 2002 from the Centers from Disease Control and Prevention [Morbidity and Mortality Weekly Report 2002;51(RR-6):33, available on the Internet at www.cdc.gov/ mmwr/preview/mmwrhtml/rr5106a1.html, the recommended treatment regimen for chlamydial genital infection in adolescents and adults is: doxycycline 100 mg orally twice a day for seven days OR azithromycin 1 gram orally in a single
dose. IF azithromycin is provided to the patient as a Zithromax Z-pak®, the patient should be instructed to take four (250 mg) capsules at one time as a single dose; the usual Z-pak® dosing for respiratory infections (i.e., two [250 mg] capsules on day one followed by one [250 mg] capsule on days two–five) is NOT the proper dosage for chlamydial genital infections.
Hypothermia, a core temperature less than 35oC (95oF), occurs in individuals in all areas of the United States, but is more common in the north. Whether the onset is acute or chronic, the underlying problem is related to one or more of these physiological processes: decreased heat production, increased heat loss, or impaired thermoregulatory ability.
Degrees of Hypothermia
The signs and symptoms are progressive as core temperature falls and generally develop in approximately this order:
- mild (32-35°C/89.6-95°F): vigorous shivering, confusion, altered judgment, and difficulty with coordination and movement of fine muscles
- moderate (29-32°C/84.2-89.6°F): cessation of shivering, depressed mental status, arrhythmias, bradycardia, respiratory depression, and hypotension
- severe (<29°C/84.2°F): very cold skin, rigidity of muscles, unresponsiveness, apnea, pulselessness and ventricular fibrillation
Risk Factors for Hypothermia
Anyone exposed to excessive cold is at risk, but factors associated with increased risk include:
- extremes of age, including the young and especially those over 65 years
- medications that impair the ability to regulate temperature, such as benzodiazepines, neuroleptics, beta-blockers, and alcohol
- various medical conditions
- environmental conditions: low ambient temperature, homelessness, lack of clothing sufficient for the environment
Wet clothing should be removed and replaced with warm, dry clothing. In patients who are awake use hot water bottles at the axillae, groin, and abdomen; warm bath or shower.
Treatment of the unconscious patient includes:
- airway management
- preventing significant motion because of the risk of causing ventricular fibrillation
- warmed humidified oxygen and intravenous fluids
- slow core rewarming, e.g., warmed blankets
- transport to a hospital
- wear appropriate clothing for the environment
- avoid alcohol
- assure adequate heat in the home
- be aware of signs and symptoms
Report Disease: Vermont Toll-Free 1-800-640-4374 or 1-802-863-7240
Vermont Department of Health
Division of Health Surveillance P.O. Box 70 Burlington, VT 05402-0070
Agency of Human Services
Paul E. Jarris, MD, MPH
THIS BULLETIN IS PRODUCED BY THE DISEASE CONTROL BULLETIN EDITORIAL STAFF.
Curt Lohff, MD, MPH
Report Disease: Vermont Toll-Free 1-800-640-4374 or 1-802-863-7240