Impact of arthritis and other rheumatic conditions on the health-care system--United States, 1997.

Arthritis and other rheumatic conditions are the leading cause of disability in the United States, affecting approximately 43 million persons and costing $65 billion in 1992. By 2020, these numbers will increase as the population ages. This report examines several measures of the impact of arthritis on the U.S. health-care system; the findings indicate that arthritis and other rheumatic conditions have a large impact on hospitalizations, ambulatory-care visits, and home health care, with women accounting for most of this impact and all persons aged <65 years accounting for a substantial portion.

ARTHRITIS AND OTHER RHEUMATIC CONditions are the leading cause of disability in the United States, 1 affecting approximately 43 million persons 2 and costing $65 billion in 1992. 3 By 2020, these numbers will increase as the population ages. 4 This report examines several measures of the impact of arthritis on the U.S. health-care system; the findings indicate that arthritis and other rheumatic conditions have a large impact on hospitalizations, ambulatorycare visits, and home health care, with women accounting for most of this impact and all persons aged Ͻ65 years accounting for a substantial portion.
The impact on the health-care system was measured using the most recent data on inpatient care, ambulatory care, and home health care. The 1997 National Hospital Discharge Survey was used to measure the number of discharges (by first-listed discharge diagnosis), days of care, and average length of stay at short-stay, nonfederal hospitals. The 1997 National Ambulatory Medical Care Survey and the 1997 National Hospital Ambulatory Medical Care Survey were used to measure the number and percentage (recorded by principal diagnosis and setting) of ambulatory-care visits. The 1996 National Home and Hospice Care Survey was used to measure the number and percentage (recorded by first diagnosis at admission) of home healthcare discharges and the average length of service. Arthritis and other rheumatic conditions (e.g., lupus, bursitis, and fibromyalgia) were defined using the National Arthritis Data Workgroup definition. 4* When appropriate, data were examined by age group (Ͻ15, 15-44, 45-64, and Ն65 years) and sex. Data were analyzed using SUDAAN, 5 and the results were weighted to account for the complex sample design.
Persons with arthritis and other rheumatic conditions accounted for 2.4% (approximately 744,000) of all hospital discharges and 2.4% (approximately 4 million) of days of care in 1997, with an average length of stay similar to that for all conditions (approximately 5 days). Of these discharges, women accounted for 60.7% and persons aged less than 65 years for 44.2%. Persons with arthritis and other rheumatic conditions accounted for 4.6% (approximately 44 million) of all ambulatory-care visits, including 38.9 million visits to physicians' offices, 2.9 million visits to outpatient departments, and 2.2 million visits to emergency departments. Of these visits, women accounted for 63% and persons aged Ͻ65 years accounted for 68%. Arthritis and other rheumatic conditions accounted for 4.8% (approximately 372,000) of all discharges from home health care, with an average length of service of 88.7 days. Most (60%) home health-care discharges were attributable to osteoarthritis. Of these discharges, women accounted for approximately 70% and persons aged Ͻ65 years for approximately 26%.

CDC Editorial Note:
The findings in this report indicate that arthritis and other rheumatic conditions cause large numbers of persons to receive care in hospital, ambulatory, and home health settings. Women and all persons aged less than 65 years accounted for much of this impact. The impact of arthritis has been underrecognized, and key interventions that reduce arthritis pain and health-care costs have been underused. 6 Primary (e.g., weight control and injury prevention), secondary (e.g., early diagnosis and appropriate management), and tertiary (e.g., self-management and rehabilitation services) prevention measures can help reduce this impact. 7 These findings are subject to at least one limitation. These data sources do not measure health care in other settings important to persons with arthritis, such as rehabilitation services, chiropractors' offices, physical and occupational therapy services, and mental health services.
Recognition of arthritis and other rheumatic conditions as a large public health problem is increasing; the problem has been addressed in the National Arthritis Action Plan: A Public Health Strategy 7 and the first-ever draft objectives for arthritis in the national health objectives for 2010. 8 Future research will expand analyses of health-care system data to explore arthritis trends, the interaction of arthritis and other chronic conditions, and other settings of care. In 1999, CDC is initiating funding to increase public health activities targeting arthritis prevention at the national and state levels. State-level arthritis programs should consider collaboration with components of the health-care system because of the large impact of arthritis.
Cost-effectiveness of the Arthritis Self-help Course. Arch Intern Med 1998;158:1245-9. 7. CDC. National Arthritis Action Plan: a public health strategy. Atlanta, Georgia: Arthritis Foundation, Association of State and Territorial Health Officials, and CDC, 1999.

United States
Influenza activity began to increase in mid-January 1999 and peaked during the weeks ending February 6 through February 27. The predominant virus was influenza A(H3N2), although influenza type B viruses also circulated widely and were reported in all nine influenza surveillance regions. Influ-enza A(H1N1) viruses were sporadically isolated during the season in six of nine regions. During the weeks ending February 6 through February 27, 1999, Ͼ40 state and territorial epidemiologists reported widespread or regional influenza activity, * with widespread activity first reported from a state during the week ending January 16 and reported last during the week ending April 10. Beginning the week ending January 23, the proportion of patient visits to U.S. influenza sentinel physicians attributed to influenza-like illness (ILI) increased above baseline levels (0-3%) to 4% and remained elevated for 7 consecutive weeks. The proportion of visits for ILI was at baseline levels in all surveillance regions by the week ending March 20.
Beginning the week ending January 30, the proportion of deaths attributed to pneumonia and influenza (P&I) reported by 122 U.S. cities exceeded the epidemic threshold † for 12 consecutive weeks. During the week ending March 13, the proportion of deaths attributed to P&I peaked at 8.8%.
Of  Most influenza A(H3N2) isolates were A/Sydney/5/97-like viruses. A small percentage were distinguishable antigenically by hemagglutinationinhibition testing. However, these viruses were heterogeneous, and antigenic and genetic analysis did not reveal the emergence of a representative variant. Therefore, A/Sydney/5/97 will be retained as the influenza A(H3N2) 1999-2000 vaccine component. A

CDC Editorial Note:
During the 1998-99 influenza season, both influenza A(H3N2) and influenza B viruses circulated worldwide, and influenza A(H3N2) predominated in the United States. This is the third consecutive year that influ-enza A(H3N2) viruses have predominated in the United States and the fourth consecutive year in which the proportion of deaths caused by P&I reported by 122 U.S. cities was elevated for several consecutive weeks. Overall, the 1998-99 influenza vaccine strains were well matched with the circulating virus strains.
Although influenza epidemics generally peak during December-March each year in temperate regions of the Northern Hemisphere, sporadic cases of influenza and occasionally large outbreaks can occur during the summer. 2,3 In temperate regions of the Southern Hemisphere, the influenza season generally peaks during May-August. Influenza epidemics can occur any time of the year in the tropics. Therefore, U.S. physicians should continue to include influenza in the differential diagnosis of febrile respiratory illness during the summer, particularly among travelers to the tropics or Southern Hemisphere or among persons traveling with large international groups.
The identification of two cases of human influenza A(H9N2) infection in Hong Kong underscores the need for continued international virologic surveillance for influenza and the timely subtyping of influenza type A isolates. No plans exist to produce a vaccine against influenza A(H9N2). However, several laboratories are working to develop a candidate vaccine should the need arise.
Strains to be included in the influenza vaccine usually are selected during the preceding January through March because of scheduling requirements for production, quality control, packaging, distribution, and vaccine administration before the onset of the next influenza season. Recommendations of the Advisory Committee on Immunization Practices for the use of vaccine and antiviral agents for prevention and control of influenza were published in an MMWR Recommendations and Reports on April 30, 1999. 4 Outbreak of Poliomyelitis-Angola, 1999 MMWR. 1999;48:327-329 ON MARCH 23, 1999, THE PEDIATRIC Hospital in Luanda, Angola, reported 21 cases (three deaths) of acute flaccid paralysis (AFP). By April 3, 102 AFP cases had been reported in Luanda and neighboring areas of Bengo province. A preliminary investigation by the Ministry of Health (MOH) indicated that these cases primarily occurred among children aged Ͻ5 years; 90% had received two or fewer doses of oral poliovirus vaccine (OPV), 4% had received three doses, and 6% had received four doses. Many casepatients resided in overcrowded municipalities where families displaced by civil war had settled. On the basis of preliminary data, MOH suspected the outbreak was poliomyelitis and began planning a vaccination campaign to control the epidemic. Surveillance was strengthened to identify and rapidly investigate reports of AFP cases to determine the extent of the outbreak.
On April 8, the National Institute of Virology in South Africa isolated wild poliovirus type 3 from 11 (50%) of 22 stool specimens from AFP cases submitted by MOH. By April 11, the number of AFP cases increased to 276 (19 deaths). By April 25, 634 AFP cases (39 deaths) were reported. Field investigations confirmed two cases of AFP in children aged Ͻ5 years in Benguela, a city approximately 300 miles (480 km) south of Luanda. On April 17 and 18, a mass vaccination campaign was carried out targeting 526,036 children. OPV was administered to 634,368 children aged Ͻ5 years in Luanda and the rest of the province. A World Health Organization (WHO) team is assisting with the investigation of the outbreak. Three rounds of National Immunization Days (NIDs) * at monthly intervals are planned to begin in July.

CDC Editorial Note:
The outbreak in Angola represents one of the largest epidemics of poliovirus type 3 in the vaccine era and one of the largest polio epidemics recorded in Africa. 1 Preliminary data from the investigation suggest that the outbreak primarily resulted from failure to vaccinate, with a high proportion (approximately 90%) of casepatients being unvaccinated or partially vaccinated (three or fewer doses of OPV).
With the intensification of civil war at the end of 1998, large groups of displaced persons moved from areas where vaccination services had been suboptimal to the capital, Luanda, and other cities. Sub-National Immunization Days (SNIDs) † were conducted in national and provincial capitals of Angola in 1996, and NIDs were conducted in districts under government control: 147 (89%) of 165 districts in 1997, and 121 (73%) of 165 districts in 1998. 2,3 Excluding districts not under government control from the denominator, Ն90% coverage was obtained in each round of NIDs. Estimated vaccination coverage for the 1998 NIDs was Ͻ50% in three of Angola's 18 provinces.
Displaced persons settled in crowded areas where sanitation is poor and water supply inadequate and created an ideal environment for the spread of poliovirus. Movement of refugees out of the country increases the probability that the epidemic will spread into neighboring countries, some of which have been reporting no cases of polio. These countries have been informed and are increasing surveillance in border zones and developing plans to vaccinate refugee children from Angola.
Travelers to Angola are advised to review their polio vaccination history to ensure that they have received a complete primary series of three doses before initiating travel. 4 In addition, travelers who already have received a complete primary series should receive an additional dose of either inactivated poliovirus vaccine (IPV) or OPV before leaving for Angola. If there is insufficient time before travel to administer a threedose primary vaccination series, then travelers should receive a minimum of a dose of either IPV or OPV, depending on age and vaccination history. 4 To achieve the target of polio eradication by 2000, implementation of polio eradication strategies in Angola needs to be accelerated and to reach all areas of the country, including those not under government control. The planned three rounds of NIDs during July-September are a significant step in this direction, but success will depend on achieving high vaccination coverage levels in all areas of the country. In Angola and other countries in conflict, reaching agreements for cease fires to carry out vaccination campaigns for polio eradication are becoming increasingly urgent.

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*Nationwide mass campaigns over a short period (days to weeks), in which two doses of oral poliovirus vaccine are administered to all children in the target age group (usually aged Ͻ5 years), regardless of vaccination history, with an interval of 4-6 weeks between doses. †Focal mass campaigns in high-risk areas over a short period (days to weeks) in which two doses of OPV are administered to all children in the target age group, regardless of vaccination history, with an interval of 4-6 weeks between doses.