Outbreak of Syphilis Among Men Who Have Sex with Men Southern

FROM THE CENTERS FOR DISEASE CONTROL AND PREVENTION

Bureau of the Census.2 The 1999 rates reported in whites (0.5); the 1999 rate Primary and and numbers of cases were compared for blacks declined 10% compared with with data for 19983 and 1997.4 1998. The rate for Hispanics in- Secondary Syphilis— In 1999, 6657 cases of P&S syphilis creased 20% (from 1.5 in 1998 to 1.8 United States, 1999 were reported in the United States (2.5 in 1999). The increase in rate for His- per 100,000 population), a 5.4% de- panics was attributed to an increased MMWR. 2001;50:113-117 crease from the 7035 cases (rate: 2.6) number of cases in men; the number reported in 1998 and a 22% decrease of cases in women remained stable. 1 table, 1 figure omitted from the 8556 cases (rate: 3.2) re- Rates for American Indians/Alaska Na- IN OCTOBER 1999, CDC, IN COLLABO- ported in 1997. The South continues to tives and for Asians/Pacific Islanders ration with other federal partners, have the highest rate in the country were unchanged from 1998 (2.7 and launched the National Plan to Elimi- (4.5).* From 1998 to 1999, rates de- 0.4, respectively). nate Syphilis in the United States. In clined 10% in the South (from 5.0 to Rates for P&S syphilis in 1999 were 1998, Congress initiated funding for the 4.5) and 12.5% in the Northeast (0.8 45% higher for men (2.9) than for syphilis elimination effort. Syphilis elimi- to 0.7). The rate for the West re- women (2.0). The male-to-female rate nation is defined as the absence of sus- mained unchanged (1.0), and the rate ratio in 1999 was 1.5:1, and has been tained transmission (i.e., no transmis- for the Midwest increased from 1.9 in increasing since 1994, when it was 1:1. sion after 90 days of the report of an 1998 to 2.2 in 1999. P&S syphilis rates The increase occurred in all racial/ imported index case). The national goal have declined in 28 states since 1998, ethnic groups except Asians/Pacific Is- for syphilis elimination is to reduce pri- and 39 states have rates below the na- landers and American Indians/Alaska mary and secondary (P&S) syphilis to tional health objective for 2000 of 4.0. Natives. The greatest increase oc- Ͻ1000 cases (rate: 0.4 per 100,000 Nine of the 11 states that have rates curred among Hispanics, from 2.3:1 in population) and to increase the num- above the 2000 objective are in the 1998 to 2.9:1 in 1999. An increase in ber of syphilis-free counties to 90% by South. The rates for 1999 increased in the male-to-female rate ratio occurred 2005.1 To describe the epidemiology of 14 states; increases were largest in In- in 16 (62%) of the 26 states that re- syphilis in the United States, CDC ana- diana (from 3.6 to 7.6), Oklahoma (2.9 ported Ն25 cases in 1999. The male- lyzed notifiable disease surveillance data to 5.6), and Washington (0.8 to1.4). to-female rate ratio was remarkably high for 1999. This report summarizes the re- In 1999, of 3115 U.S. counties, 2473 in some cities, such as Seattle (38:1) and sults of that analysis, which indicate that, (79.4%) reported no cases of P&S syphi- San Francisco (25:1).

in 1999, P&S syphilis declined to a rate lis, compared with 2430 (78.0%) coun- Reported by: State and local health depts. Epidemi- of 2.5 cases per 100,000 population, the ties reporting no cases in 1998 and 2324 ology and Surveillance Br, Statistics and Data Man- lowest rate ever reported, and that syphi- (74.6%) in 1997. In 1999, 2850 (91.5%) agement Br, Div of Sexually Transmitted Disease Pre- vention, National Center for HIV, STD, and TB lis transmission increasingly is concen- counties reported rates below the 2000 Prevention, CDC. trated in a few geographic areas. objective. Of the 265 counties (8.5% of Summary data for syphilis cases re- all counties) with P&S syphilis rates CDC Editorial Note: The number and ported to state health departments and above the 2000 objective, 243 were in rate of P&S syphilis cases reported in the District of Columbia for 1999 were the South. In 1999, 22 counties and Bal- 1999 were the lowest ever reported in sent quarterly and annually to CDC. timore, Maryland; Danville, Virginia; and the United States1 with a 22% decline in These data included the number of St. Louis, Missouri, accounted for 50% both cases and rates since 1997, reflect- syphilis cases by patients’ county of resi- of all reported P&S syphilis cases in the ing the substantial progress that has been dence, sex, stage of disease, racial/ United States. The overall rate for 63 of made since efforts to eliminate syphilis ethnic group, and age group. Data on the largest cities in the United States began. The disease has become increas- reported P&S syphilis were analyzed for (population Ͼ200,000) was 5.1 cases ingly concentrated in a few geographic this report because these cases better per 100,000 persons; 24 large cities had areas; in 1999, 50% of P&S syphilis represented incidence (i.e., newly ac- rates higher than the 2000 objective. Cit- cases occurred in Ͻ1% of counties; quired infections within the evaluated ies with the highest rates of P&S syphi- approximately 80% of counties reported time) than reported cases of latent in- lis were Indianapolis, Indiana (50.0); no cases of syphilis. Although syphilis fection, which are usually acquired Nashville, Tennessee (46.8); and Balti- rates remain higher in the South than months or years before diagnosis. P&S more, Maryland (38.1). in other regions, the South had a 32% syphilis rates were calculated by using The 1999 reported rate of P&S syphi- decline in the P&S syphilis rate from population denominators from the U.S. lis in blacks (15.2) was 30 times the rate 1997 to 1999, illustrating that the

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greatest improvements in disease con- however, the increases also may be at- trol have taken place where syphilis inci- tributed to increases in populations that Outbreak of Syphilis dence has been greatest. Eliminating have been difficult to reach for pur- syphilis would reduce the likelihood of poses of syphilis prevention and con- Among Men Who human immunodeficiency virus (HIV) trol, such as MSM, who previously have Have Sex With transmission and improve reproduc- not been a focus of the national syphi- tive health by preventing spontaneous lis elimination effort. Men—Southern abortions, stillbirths, and developmen- The findings in this report are sub- California, 2000 tal disabilities caused by congenital ject to at least three limitations. First, the syphilis. In addition, syphilis elimina- quality of surveillance activities and data MMWR. 2001;50:117-120 tion would help to rebuild the capacity vary at local and state levels. Second, of communities to control infectious dis- sexually transmitted disease reporting is 1 figure omitted eases and reduce racial disparities.1 incomplete. Finally, cases among pa- SYPHILIS IS A SEXUALLY TRANSMITTED DIS- Syphilis continues to disproportion- tients attending public sector clinics may ease (STD) caused by infection with the ately affect minority populations de- be more likely to be reported than cases spirochete Treponema pallidum, and like spite progress in reducing this racial dis- diagnosed in the private sector, which other genital ulcer diseases, syphilis en- parity. P&S syphilis rates for blacks have could magnify the racial/ethnic differ- hances the transmission of human im- remained substantially higher than those ences in reported rates; persons of mi- munodeficiency virus (HIV).1 During for whites. However, the magnitude of nority race/ethnicity may be more likely the 1990s, syphilis occurred predomi- this difference has decreased 30% since to attend public clinics. nantly among heterosexual blacks in the 1997. The persistence of racial dispari- The variation in the demographic South and in large cities. However, re- ties in syphilis incidence is, in part, at- characteristics of syphilis patients over cent outbreaks of syphilis have oc- tributable to differences between blacks time and among regions highlights the curred among men who have sex with and whites regarding poverty and in ac- need to recognize and respond to the men (MSM).2,3 A large syphilis out- cess to and use of health-care services, changing epidemiology of this disease. break occurred among MSM during especially in the rural South.5,6 In addi- Because increases in syphilis may emerge January-July 2000 in southern Califor- tion, rates increased 20% among His- in areas or subpopulations that are not nia. During the outbreak period, the panics, due to an increase among males. specifically targeted by ongoing elimi- proportion of primary and secondary Historically, rates of syphilis have nation efforts, it is necessary to continu- (P&S) syphilis cases among MSM in- been higher for men than women. The ally reassess and refine surveillance, pre- creased to 51% from 26% for the same male-to-female rate ratio peaked at 3.5:1 vention, and control strategies. period in 1999. This report summa- in 1980 during the height of syphilis To sustain progress toward syphilis rizes the findings of an investigation of transmission among men who have sex elimination, communities must under- this syphilis outbreak, which indicate with men (MSM) and decreased to 1:1 stand local patterns of syphilis transmis- a substantial increase in the number of in 1994; since then, it has increased sion and develop intervention strate- syphilis cases among MSM, many of gradually. The causes of the increasing gies, including education, risk reduction, whom are HIV-positive. These data sug- trend in the male-to-female rate ratio are and screening of persons at risk for this gest that concern about HIV infection not understood completely. However, disease. Syphilis elimination must also may be declining among MSM and em- one important factor is the develop- be viewed as an entry point for building phasize the importance of strengthen- ment since 1997 of several large out- broader public health capacity to con- ing efforts to prevent HIV infection in breaks of syphilis among MSM, many of trol infectious diseases and to ensure re- this population in the United States. whom were co-infected with HIV.7-9 In productive health among historically un- California law requires that reactive outbreaks in King County, Washing- derserved communities.1 syphilis serologic results and suspected ton; Chicago, Illinois; and southern Cali- cases of syphilis be reported to local fornia, 20%-73% of MSM with syphilis REFERENCES health departments. Suspected and con- also had HIV infection. Substantial in- 9 available firmed syphilis cases are then reported

creases in syphilis among MSM also have *Northeast=Connecticut, Maine, Massachusetts, New to the California Department of Health been reported in other U.S. cities. Hampshire, New Jersey, New York, Pennsylvania, Services and CDC. Public health staff Despite national progress toward Rhode Island, and Vermont; Midwest=Illinois, Indi- interview all persons with syphilis to col- ana, Iowa, Kansas, Michigan, Minnesota, Missouri, Ne- syphilis elimination, increases in rates braska, North Dakota, Ohio, South Dakota, and Wis- lect clinical, demographic, and epide- have occurred in several states and cit- consin; South=Alabama, Arkansas, Delaware, District miologic data and to assure that these per- of Columbia, Florida, Georgia, Kentucky, Louisiana, ies. The increase in rates in these states Maryland, Mississippi, North Carolina, Oklahoma, sons receive appropriate treatment. The may, in part, reflect improved report- South Carolina, Tennessee, Texas, Virginia, and West behavioral data collected include sex and Virginia; West=Alaska, Arizona, California, Colo- ing and case finding resulting from the rado, Hawaii, Idaho, Montana, Nevada, New Mexico, number of sex partners, self-reported HIV national syphilis elimination effort; Oregon, Utah, Washington, and Wyoming. serostatus, drug use, and location where

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the patient had met sex partners while and 26 (40%) reported using illicit The findings in this report are sub- the patient probably was infected. drugs. Crystal methamphetamine, the ject to at least two limitations. First, in- Because of the increase in the number of drug reported most frequently, had formation was abstracted from public reported cases of syphilis in 2000, staff been used by 18%. health records for which data had not re-evaluated and reinterviewed syphilis Local response to the outbreak in- been collected systematically because case-patients reported during January cluded a media campaign, community of variations in interview style and 1999–July 2000. Case-patients were education, outreach, and syphilis screen- documentation. Second, because be- defined as persons with a reactive syphi- ing. The media campaign used radio, havioral risk data were available only lis serologic test result and symptoms of print, and Internet advertisements to for some case-patients, the proportion P&S syphilis. Men were identified as raise awareness of the outbreak and to of case-patients with each reported be- MSM if they reported having had any promote syphilis testing. Local health de- havioral risk may be inaccurate. male sex partners during the interview partments and community groups used A high proportion of cases was iden- period. mobile vans to conduct syphilis screen- tified by private providers, and commu- During January-July 2000, 130 case- ing at bathhouses, gay bars, HIV treat- nication between public health officials patients were reported, 66 (51%) of ment sites, and other locations (e.g., and HIV care and local primary-care pro- whom were MSM compared with 26 parks and selected street corners) that viders was crucial in responding to the (26%) of 100 for the same period in MSM case-patients had identified as outbreak. The standard of care for MSM, 1999.4 Of the 66 MSM case-patients, 15 places for meeting sex partners. regardless of HIV status, should con- (23%) had primary syphilis, and 51 tinue to include counseling about safer Reported by: KT Bernstein, ScM, R Tulloch, J Montes, (77%) had secondary syphilis. MSM case- MA, G Bolan, MD, Sexually Transmitted Disease Con- sex. For MSM who are HIV positive or patients were from the following health trol Br, California Dept of Health Svcs; IE Dyer, MPH, are at risk for HIV, voluntary screening 41 M Lawrence, MPA, AP Kaur, MPH, D Kodagoda, MPH, jurisdictions: Los Angeles County, Or- H Rotblatt, P Kerndt, MD, Los Angeles County Sexu- for syphilis and other STDs is an essen- ange County,10 City of Long Beach ally Transmitted Disease Program, Los Angeles; R Gunn, tial component of quality care. MSM who MD, County of San Diego Sexually Transmitted Dis- (eight), San Diego County (six), and Riv- ease Program, San Diego; N DeAugustine, Preventive do not know their HIV serostatus and erside County (one). Overall, 47% of Health Bur, City of Long Beach Dept of Health and Hu- who have an STD should be offered HIV cases were diagnosed at private medical man Svcs, Long Beach; P Weismuller, DrPH, Orange screening to facilitate early access to care County Sexually Transmitted Disease Program, Or- clinics, 18% at HIV early intervention ange County, California. Div of Sexually Transmitted for those who are HIV positive. Partner- programs, and 17% at STD clinics. The Disease Prevention, National Center for HIV, STD, and ships with clinicians and community TB Prevention; and EIS officers, CDC. median age of MSM case-patients was 35 organizations that serve MSM will con- years (range: 20-54 years); 27 (41%) were CDC Editorial Note: The results of this tinue to be critical for the development white, 24 (36%) were Hispanic, 12 (18%) investigation and other similar out- of targeted and effective prevention mes- were black, and two (3%) were Asian/ breaks suggest that an increasing num- sages. In this outbreak, community orga- Pacific Islander; race/ethnicity was un- ber of MSM are participating in high- nizations and state and local health known for one (2%). Of the 57 who risk sexual behavior that places them at departments facilitated rapid outreach knew their HIV serostatus, 34 (60%) re- risk for syphilis and HIV infection.5,6 and education in the community. The ported that they were HIV positive. The Similar trends have been reported inter- role of outreach efforts and the media year of diagnosis was known for 27 of nationally.7 These data are consistent campaign in arresting the outbreak is the 34 HIV-positive MSM; the median with reports from behavioral surveys that being evaluated. time since diagnosis of HIV infection was indicate some MSM are participating in This outbreak, unlike other recent 4 years (range: 0-19 years). For those activities that increase their risk for syphilis outbreaks,10 involved primar- whose HIV diagnosis had been made Ͻ1 acquiring and transmitting HIV and ily white and Hispanic MSM with ac- year before the diagnosis of syphilis, the other STDs.8 Several factors may have cess to health care, most of whom were number of months since HIV diagnosis contributed to this change, including the HIV positive. As syphilis rates decline was not available. availability of highly active antiretrovi- and the epidemiology of syphilis Although data on behavioral risks ral therapy (HAART).9 Since the intro- changes, outbreak recognition through were not collected systematically, in- duction of HAART in 1996, acquired surveillance and the collection of en- terview records indicate that of the 66 immunodeficiency syndrome inci- hanced behavioral risk data will be im- MSM, 33 (50%) reported that they had dence and deaths have declined sub- portant in preventing syphilis and HIV had anonymous sex, 17 (26%) had met stantially, decreasing the actual and per- transmission. State and local health de- sex partners in bathhouses, two (3%) ceived threat of HIV to MSM.8 Because partments should review HIV/STD and had met sex partners through the In- syphilis increases the likelihood of behavioral surveillance data on MSM ternet, and four (6%) had had sex with acquiring and transmitting HIV infec- and other at-risk populations to de- a commercial sex worker. Overall, 13 tion, the increase in P&S syphilis among tect outbreaks and implement appro- (20%) MSM reported using a condom MSM may indicate an increase in the priate public health actions. Increased during the most recent sexual contact, incidence of HIV infection. prevention efforts in MSM communi-

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ties are critical in preventing STD and 29, and April 5, 2001, from noon to 3:30 nary heart disease (CHD) remains the HIV transmission. PM eastern time. leading cause of death in the United The program will provide the most States,1,2 and the decline in rates from REFERENCES current information in the field of im- CHD that began during the 1960s 1. Fleming DT, Wasserheit JN. From epidemiologic munization. Session one will cover prin- slowed during the 1990s.3 This report synergy to public health policy and practice: the con- tribution of other sexually transmitted diseases to sexual ciples of vaccination, general recom- provides national and state-specific transmission of HIV infection. Sex Transm Infect 1999; mendations on vaccination, and death rates for CHD and for acute myo- 48:773-7. 2. CDC. Resurgent bacterial sexually transmitted dis- strategies to improve vaccination cov- cardial infarction (AMI). During 2001, ease among men who have sex with men—King County, erage levels; session two will cover per- approximately 1.1 million persons are Washington, 1997-1999. MMWR 1999;48:773-7. 1 3. CDC. Primary and secondary syphilis—United tussis, pneumococcal disease (child- expected to have a CHD event. Pre- States, 1999. MMWR 2001;50:113-7. hood), poliomyelitis, and Haemophilus vention remains the key strategy for re- 4. California Department of Health Services. Sexu- influenzae type b; session three will cover ducing CHD mortality. ally transmitted diseases in California 1999. Sacra- mento, California: California Department of Health Ser- measles, rubella, varicella, and vaccine National and state mortality statis- vices, 2001 (in press). safety; and session four will focus on tics are based on information from 5. CDC. Gonorrhea among men who have sex with men—selected sexually transmitted disease clinics, hepatitis B, hepatitis A, influenza, and death certificates filed in state vital sta- 1993-1996. MMWR 1997;46:889-92. pneumococcal disease (adult). tistics offices and are compiled by 6. CDC. Increases in unsafe sex and rectal gonorrhea among men who have sex with men—San Francisco, Participants will be able to interact CDC’s National Center for Health Sta- California, 1994-1997. MMWR 1999;48:45-8. with instructors through toll-free tele- tistics.4 Demographics (e.g., age and 7. Stolte JG, Dukers NH, de Wit JB, Fennema JS, Goud- phone, fax, and TTY lines. Continuing race/ethnicity) listed on death certifi- smit J, Coutinho RA. Increases in STDs among men who have sex with men (MSM) and in risk behavior education for various professions will be cates are reported by funeral directors among HIV-positive MSM in Amsterdam, possibly re- offered based on 14 hours of instruction. or provided by family members of the lated to HAART-induced immunologic and virologic improvements. In: Program and abstracts of the 8th Information and registration are avail- decedent. CHD deaths are those in conference on Retroviruses and Opportunistic Infec- able through state or county health de- which the underlying cause of death tions; Chicago, Illinois, February 2001. 8. Stall R, Hays R, Waldo C, Ekstrand M, McFarland partment immunization programs. A listed on the death certificate by a phy- W. The gay ’90s: a review of research in the 1990s list of state immunization coordinators sician, medical examiner, or coroner is on sexual behavior and HIV risk among men who have sex with men. AIDS 2000;14:S1-S14. is available on the NIP World-Wide International Classification of Diseases, 5 9. Scheer S, Chu PL, Klausner JD, Katz MH, Schwarcz Web site, http://www.cdc.gov/nip/ed Ninth Revision, codes 410.0-414.9. SK. Effect of highly active antiretroviral therapy on di- /coordinators.htm. Course participants CHD includes AMI (410), other acute agnoses of sexually transmitted diseases in people with AIDS. Lancet 2001;357:432-5. will be required to obtain their own copy and subacute forms of ischemic heart 10. CDC. Outbreak of primary and secondary syphi- of the primary course text, Epidemiol- disease (411), old myocardial infarc- lis—Guilford County, North Carolina, 1996-1997. MMWR 1998;47:1070-3. ogy and Prevention of Vaccine-Prevent- tion (412), angina pectoris (413), and able Diseases, 6th edition (2000). The text other forms of chronic ischemic heart is available from the Public Health Foun- disease (414.0-414.9). Populations at Satellite Broadcast dation for $25; telephone (877) 252- risk are defined on the basis of U.S. Bu- 1200; World-Wide Web site, http:// reau of Census estimates of resident on Epidemiology bookstore.phf.org. All other course ma- populations. Age-adjusted estimates are and Prevention of terials will be provided on site. standardized to the 2000 U.S. population. Because only 0.2% of CHD deaths Vaccine-Preventable and 0.3% of AMI deaths occur among Diseases Mortality From persons aged Ͻ35 years, the age- adjusted death rates have been limited Coronary Heart to persons aged Ն35 years. MMWR. 2001;50:99 Disease and The annual percentage change in CDC’S NATIONAL IMMUNIZATION PRO- U.S. death rates for CHD during gram (NIP) and the Public Health Train- Acute Myocardial 1950-1959, 1960-1969, 1970-1979, ing Network (PHTN) will co-sponsor a 1980-1989, and 1990-1997 was live satellite broadcast for physicians, Infarction— 2.1, 0.2,−3.1,−3.3, and−2.7, respec- nurses, nurse practitioners, physician as- United States, 1998 tively.3 During 1998, CHD was re- sistants, pharmacists, residents, medi- ported as the underlying cause of cal and nursing students, and their col- MMWR. 2001;50:90-93 459,841 deaths; 203,551 (44%) were at- leagues who either give vaccinations or tributed to AMI. During 1998, age- 3 tables omitted set policy in their workplace. The four- specific death rates per 100,000 per- part series, “Epidemiology and Preven- DESPITE IMPROVED CLINICAL CARE, sons increased among successive age tion of Vaccine-Preventable Diseases,” heightened public awareness, and wide- groups for CHD and AMI. Among per- will be broadcast on March 15, 22, and spread use of health innovations, coro- sons aged Ն85 years, the 1998 CHD

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death rate was 3743.9, which was three ing 2001, approximately 650,000 will be blood pressure, high cholesterol, ciga- times higher than the rate among per- first events and 450,000 will be recur- rette smoking, physical inactivity, and sons aged 75-84 years (1252.2), seven rences. Each year, approximately poor nutrition). Myocardial damage, times higher than among persons aged 220,000 fatal CHD events occur sud- disability, and death can be forestalled 65-74 years (487.2), and 21 times denly among unhospitalized persons.1 if affected persons recognize AMI warn- higher than among persons aged 55-64 The slowing decline in CHD death rates ing symptoms and reach medical care years (180.7). may be explained by the pattern of CHD quickly.8 To reduce delays in receiv- The age-adjusted death rate among risk factors reported during the 1990s.3 ing treatment8 and preventing disabil- persons aged Ն35 years was higher Minimal, if any, improvement has oc- ity following a CHD event, emergency among men than women (222.4 ver- curred in preventive behaviors (e.g., ad- medical care often can be obtained rap- sus 135.8 per 100,000 for CHD and 99.7 equate physical activity, cessation of idly by telephoning 911. Other inter- versus 58.8 per 100,000 for AMI, smoking, and the control of high blood ventions consist of therapeutic mea- respectively). CHD death rates were pressure).3 In addition, an increase has sures to minimize the risk for a second highest among white men (440.0) and been reported in caloric consumption heart attack and subsequent heart fail- second highest among black men and the prevalence of obesity and dia- ure,9 education to promote physician (421.6). AMI deaths were similar betes.3 Factors that may have contrib- adherence to clinical practice guide- among both groups (196.7 and 198.7 uted to the racial/ethnic differences, par- lines, and recommendations for the ap- for white and black men, respec- ticularly those between black and white propriate treatment of CHD patients. tively). Compared with white men, women, include differences in CHD risk American Indian/Alaska Native men factors, case fatality rates, medical care, REFERENCES and Asian/Pacific Islander men had socioeconomic status, and state of resi- 1. American Heart Association. 2001 Heart and stroke statistical update. Dallas, Texas: American Heart 6 much lower death rates for CHD (246.7 dence. Association, 2000. Available at http://www and 258.3, respectively) and AMI The findings in this report are sub- .americanheart.org/statistics/index.html. Accessed Feb- (120.9 and 109.1, respectively). Black ruary 2001. ject to at least two limitations. First, the 2. CDC. Decline in deaths from heart disease and women had the highest death rates for data are subject to misclassification of stroke—United States, 1900-1999. MMWR 1999;48: CHD (301.9) and AMI (140.4), fol- 649-56. race/ethnicity in the population cen- 3. Cooper R, Cutler J, Desvigne-Nickens P, et al. Trends lowed by white (263.8 and 113.2 for sus and on death certificates, which may and disparities in coronary heart disease, stroke, and CHD and AMI, respectively), Ameri- other cardiovascular diseases in the United States. Cir- result in undercounting of deaths culation 2000;102:3137-47. can Indian/Alaska Native, (160.2 and among American Indians/Alaska Na- 4. Murphy SL. Deaths: final data for 1998. National 69.3 for CHD and AMI, respectively) vital statistics reports; Vol 48, no. 11. Hyattsville, Mary- tives, Asians/Pacific Islanders, and His- land: National Center for Health Statistics, 2000. and Asian/Pacific Islander (148.1 and panics and overcounting of deaths 5. World Health Organization. Manual of the inter- 62.2 for CHD and AMI, respectively) among black and white populations.7 national statistical classification of diseases, injuries, and women. Compared with black and causes of death based on the recommendations of the Second, there is no medical record veri- Ninth Revision Conference, 1975. Geneva, Switzer- white men and women, Hispanics had fication of death certificate data on mul- land: World Health Organization, 1977. lower death rates for CHD (285.4 and 6. Williams JE, Massing M, Rosamond WD, Sorlie PD, tiple-cause mortality records. The re- Tyroler HA. Racial disparities in CHD mortality from 189.8 for men and women, respec- liability and accuracy of underlying 1968-1992 in the state economic areas surrounding tively) and AMI (121.6 and 76.7 for the ARIC study communities. Ann Epidemiol 1999;9: cause depends on the certifier of each 472-80. men and women, respectively). State death and the state and national no- 7. Rosenberg HM, Maurer JD, Sorlie PD, et al. Qual- variations in age-adjusted death rates sologists who determine the codes and ity of death rates by race and Hispanic origin: a sum- for CHD and AMI ranged from 208.1 mary of current research, 1999. Vital Health Stat 1999; the underlying causes. 2:1-13. (New Mexico) to 440.6 (New York) for CDC funds 25 state-based cardio- 8. Goldberg RJ, Mooradd M, Gurwitz JH, et al. Im- CHD and from 80.5 (New Mexico) to pact of time to treatment with tissue plasminogen ac- vascular health programs designed to tivator on morbidity and mortality following acute myo- 252.6 (Arkansas) for AMI. prevent the first heart attack and pro- cardial infarction: the second national registry of myocardial infarction. Am J Cardiol 1998;82:259-64. Reported by: Cardiovascular Health Studies Br, Div of mote a greater decline in death and dis- 9. Smith SC, Blair SN, Criqui MH, et al. Preventing heart Adult and Community Health, National Center for ability from CHD. Measures intended attack and death in patients with coronary disease. Cir- Chronic Disease Prevention and Health Promotion; and culation 1995;92:2-4. EIS officers, CDC. to prevent a first AMI promote policy changes (e.g., health-care providers *References to sites of nonCDC organizations on the Internet are provided as a service to MMWR readers CDC Editorial Note: An estimated 12 implementing American Heart Asso- and do not constitute or imply endorsement of these million persons in the United States have ciation AMI prevention guidelines) and organizations or their programs by CDC or the U.S. 3 Department of Health and Human Services. CDC is CHD. Of the 1.1 million persons who behavioral changes that affect cardio- not responsible for the content of pages found at these are expected to have a CHD event dur- vascular-related risk factors (e.g., high sites.

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