Influenza Activity— United States, 2000-01 Season

This report summarizes influenza activity in the United States during November 26, 2000-January 13, 2001. Influenza activity was low to moderate but increasing in the United States. Since October 1, the most frequently isolated viruses were influenza A (H1N1) and were well matched antigenically with the 2000-01 influenza A (H1N1) vaccine strain.

THIS REPORT SUMMARIZES INFLUENZA ACtivity in the United States during October 1-November 25, 2000. 1* Influenza activity was low during this period, and influenza virus isolates were reported from 11 states. The viruses most frequently isolated were influenza A (H1N1) and were well matched by the 2000-01 influenza vaccine strains.
During October 1-November 25, 1% of patient visits to U.S. sentinel physicians were for influenza-like illness (ILI). † During the week ending November 25 (week 47), among each of the nine surveillance regions, patient visits for ILI were at baseline levels (0-3%); 24 state and territorial health departments reported no influenza activity, 24 reported sporadic activity, and two (Kentucky and Texas) reported regional activity. 1 ‡ No states reported widespread activity. The 122 Cities Mortality Reporting System attributed 6.5% of total deaths to pneumonia and influenza (P&I). This percentage was below the epidemic threshold of 7.9% for week 47. Deaths attributed to P&I have remained below the epidemic threshold for each week since October 1. 1 § During October 1-November 25, World Health Organization (WHO) collaborating laboratories and National Respiratory and Enteric Virus Surveillance System laboratories in the United States tested 8511 specimens for influenza; 118 (1.4%) were positive for laboratory-confirmed influenza. Of these, 101 (86%) were influenza A and 17 (14%) were influenza B. The percentage of positive influenza infections identified each week, an important early indicator of influenza activity, increased from zero for the week ending Octo-ber 21 to 4% for the week ending November 25. Typically, during peak influenza activity, approximately 30%-34% of specimens submitted for respiratory virus testing have tested positive for influenza viruses. Of the 101 influenza A isolates collected, 86 (85%) have been subtyped; 79 (92%) were A (H1N1) and seven (8%) were A (H3N2 CDC Editorial Note: All four influenza surveillance system components indicated that influenza activity was low during October-November 25 in the United States, and lower than the same period in 1999. However, the percentage of respiratory specimens that were laboratory-confirmed influenza each week began to increase during this period, and influenza activity is expected to increase during the next few weeks to months. Both influenza A and influenza B viruses were isolated. So far this season, the viruses isolated most frequently were influenza A (H1N1); however, it is too early to know what strain(s) will predominate. Seasonal epidemics caused by influenza A (H1N1) viruses have been less severe than seasons in which influenza A (H3N2) vi-ruses predominated. 2 Although a very small number of influenza isolates have been characterized antigenically so far this season, all were well matched to the 2000-01 influenza vaccine strains.
The best prevention against influenza is vaccination. This season, a quantity of influenza vaccine similar to 1999-2000 will be available; however, vaccine distribution has been delayed. 3,4 This delay may have limited the opportunity for vaccination of persons at high risk for complications from influenza, household contacts of high-risk persons, and health-care providers who care for high-risk persons; therefore, vaccination efforts for these groups should continue during December, January, and beyond, if necessary. Efforts also should be made to vaccinate persons aged 50-64 years. Unvaccinated persons can benefit from influenza vaccination even after influenza activity has begun in their community.
As of December 4, approximately 51.2 million (68%) of the 75 million doses of influenza vaccine projected to be produced this year had been distributed. CDC has contracted with Aventis Pasteur to produce 9 million of the 75 million doses, and this vaccine will be available for distribution beginning in mid-December. 5 Information on vaccine prices and ordering procedures is available on the World-Wide Web, http: //www.cdc.gov/nip/flu-vac-supply. The deadline for placing applications for orders is December 15, 2000. As of December 4, applications had been received for approximately 46% of this vaccine.
Four prescription antiviral medications are approved for treating uncomplicated influenza: Amantadine is approved to treat influenza A in persons aged Ն1 year, rimantadine for treating influenza A in adults, Zanamivir for treating influenza A and B in persons aged Ն7 years, and Oseltamivir for treating influenza A and B in persons aged Ն18 years. These four antiviral FROM THE CENTERS FOR DISEASE CONTROL AND PREVENTION agents can reduce the duration of influenza symptoms by approximately 1 day if treatment is started within 48 hours of symptom onset, but the agents differ in routes of administration, contraindications, adverse effects, and cost. Three antiviral medications are approved for chemoprophylaxis of influenza but are not substitutes for influenza vaccination. Amantadine and rimantadine are approved for chemoprophylaxis of influenza A in persons aged Ն1 year. Oseltamivir recently was approved for chemoprophylaxis of influenza A and B in persons aged Ն13 years. Chemoprophylactic use of antiviral drugs can be helpful in controlling influenza outbreaks in specific situations (e.g., in long-term-care facilities). Long-term antiviral chemoprophylaxis also might be indicated for highrisk institutionalized persons or persons at high risk for complications from influenza if vaccine is unavailable, ineffective (e.g., in severely immunocompromised persons), or contraindicated. Widespread use of antiviral drugs as chemoprophylaxis for influenza is not recommended.
CDC collects and reports U.S. influenza surveillance data during October-May. This information is updated weekly and is available through CDC voice information system, telephone (888) 232-3228, the fax information system, telephone (888) 232-3299 (request document number 361100), or on the World-Wide Web, http://www.cdc.gov /ncidod/diseases/flu/weekly.htm.
*The four components of the influenza surveillance system have been described. 1 Information reported as of November 30, 2000. †Temperature Ն100.0 F ( Ն37.8 C) and either cough or sore throat in the absence of a known cause. ‡Levels of activity are (1) no activity; (2) sporadicsporadically occurring ILI or culture-confirmed influenza with no outbreaks detected; (3) regionaloutbreaks of ILI or culture-confirmed influenza in counties with a combined population of Ͻ50% of the state's population; and (4)  . This report summarizes the results of a descriptive analysis of scooter-related injuries during the past 34 months and provides recommendations to reduce these injuries. CPSC and CDC analyzed preliminary data from CPSC's National Electronic Injury Surveillance System (NEISS) from January 1998 through October 2000 and the Injury and Potential Injury Incident File (IPII) during January-October 2000. NEISS is a probability sample of 100 U.S. hospitals with 24-hour emergency depart-ments (EDs) and more than six beds. NEISS collects data from these hospitals on all persons seeking treatment for consumer product-related injury in the hospitals' EDs. Estimates of injuries in the United States associated with specific consumer products or activities can be made from NEISS data. Data were weighted according to the probability of hospital selection in the NEISS sample to provide estimates for the U.S. population. 2 IPII consists of anecdotal information reported to CPSC from many sources (e.g., coroners and medical examiners; newspaper reports; consumer complaints through the CPSC hotline or CPSC's World-Wide Web site; and referrals from federal, state, and local officials). NEISS was used to estimate scooter-related injuries, and IPII was used to identify scooter-related deaths. Because the new scooters were introduced in large numbers into the United States market in 2000, the 1998 and 1999 data relate to the older versions of scooters.
During January-October 2000, an estimated 27,600 * (95% confidence limits [CL]=22,190-33,010) persons sought ED care for scooter-related injuries. In August, September, and October 2000, the estimated number of injuries requiring ED care was 6,529 (95% CL=4,610-8,450), 8,628 (95% CL = 6,090-11,170), and 7,359 (95% CL = 5,200-9,520), respectively; October data are incomplete and may change slightly as additional injury reports are filed. The estimated number of injuries during August-October represents 80% of the estimated total number of injuries for all of 2000. Each of the preceding 3 months also exceeded the 12-month total for either 1998 or 1999. The estimated number of injuries seen in EDs in September 2000 was nearly 18 times higher than in May 2000.
Approximately 85% of persons treated in EDs were children aged Ͻ15 years, and 23% were aged Ͻ8 years; two thirds were male. The most common type of injury was a fracture or dislocation (29%), of which 70% were to the arm or hand. Other injuries included lacerations (24%), contusions/ FROM THE CENTERS FOR DISEASE CONTROL AND PREVENTION abrasions (22%), and strains/sprains (14%). Forty-two percent of all injuries occurred to the arm and hand, 27% to the head and face, and 24% to the leg and foot.
Two persons have died while using a scooter. An adult fell and struck his head while showing his daughter how to ride the scooter. A 6-year-old boy rode into traffic and was struck by a car.

CDC Editorial Note:
The findings in this report demonstrate the rapid increase in injuries associated with riding the new lightweight, folding, unpowered scooters, which are a fastgrowing activity in the United States. Because these scooters are a recent phenomenon, scientific data about the efficacy of safety equipment to protect against scooter-related injuries are not available. However, lessons learned from similar recreational activities (e.g., in-line skating) can guide users in adopting reasonable safety precautions, such as wearing protective gear.
On the basis of data from in-line skating and bicycling, many of these injuries might have been prevented or reduced in severity had protective equipment been worn. Helmets can prevent 85% of head injuries, 3 elbow pads can prevent 82% of elbow injuries, and knee pads can prevent 32% of knee injuries. 4 Although wrist guards are effective in preventing injuries among in-line skaters, the protection they provide against injury for scooter riders is unknown because wrist guards may make it difficult to grip the scooter handle and steer it.
The public health community can be proactive and support efforts to decrease scooter-related injury in children by increasing awareness among parents and health-care providers of the injury potential and the need for safety measures when using scooters. Many children may not be prepared developmentally to handle the multitask challenges they may experience while riding a scooter. Changes in the product and rider behavior also may make riding scooters safer. The mechanisms and circumstances of scooter-related injury require further research.
On the basis of evidence of injury prevention effectiveness for other related activities, the following recommendations may help prevent scooterrelated injuries: • Wear a helmet that meets the standard established by CPSC; • Use knee and elbow pads; • Ride scooters on smooth, paved surfaces without traffic, and avoid streets and surfaces with water, sand, gravel or dirt; • Do not ride scooters at night; and • Young children should not use scooters without close supervision.
*Estimates are based on the approximate range at the 95% confidence level of relative sampling error. For this analysis, the corresponding relative sampling error for the estimated number of injuries during January-October is 0.1. DIABETES IS THE LEADING CAUSE OF end-stage renal disease (ESRD) (i.e., kidney failure requiring dialysis or kidney transplantation), and ESRD treatment has increased among American Indians/Alaska Natives (AI/ANs). 1,2 To assess trends in the incidence of ESRD attributable to diabetes mellitus (ESRD-DM) treatment among AI/ANs with diabetes, CDC and the Indian Health Service (IHS) analyzed data from the U.S. Renal Data System (USRDS). This report summarizes the findings of the analysis, which indicate that the incidence of ESRD-DM treatment is increasing among AI/ANs with diabetes, particularly young AI/ANs. USRDS is a surveillance system for ESRD supported by the Health Care Financing Administration (HCFA), the federal agency that administers the Medicare program which reimburses Ͼ90% of the ESRD treatment in the United States. 1 USRDS collects, analyzes, and distributes information about the incidence, prevalence, treatment, and costs of ESRD, 1 including demographic (e.g., age, sex, and race) and ESRD-related information (e.g., first date of treatment and primary cause of renal failure), ESRD-DM * (i.e., listed in USRDS as the primary cause of renal failure), and first treatment (e.g., kidney dialysis, peritoneal dialysis, or kidney transplantation) in each year during 1990-1996. The incidence of ESRD-DM treatment was calculated using annual age-specific and sexspecific diabetes prevalence estimates from the IHS outpatient database 3 and annual estimates of the AI/AN population from the U.S. Bureau of the Census. Incidence of ESRD-DM treatment was age-adjusted by the direct method based on the 1980 U.S. population with diabetes. 4 In 1990, 394 AIs/ANs with diabetes began treatment for ESRD-DM; in 1996, 719 began treatment. During 1990-1996, of 3884 AI/ANs with diabetes who began treatment for ESRD-DM, 2221 (57%) were women. During this period, the age-adjusted incidence of ESRD-DM treatment increased 24%, from 472 to 584 per 100,000 persons with diabetes. The relative increase in the age-adjusted incidence was 32% among women and 14% among men. In 1996, the age-adjusted incidence of ESRD-DM treatment among AI/ANs with diabetes was 584 per 100,000 persons with diabetes compared with 378 among the entire U.S. population with diabetes. 4 Incidence of ESRD-DM treatment among AI/ANs with diabetes increased with age. In 1996, incidence ranged from 278 per 100,000 persons with diabetes among AI/ANs aged Ͻ45 years to 723 among those aged Ն65 years. During 199-1996, incidence increased 58% among AI/ANs aged Ͻ45 years, 9% among those aged 45-64 years, and 34% among those aged Ն65 years. CDC Editorial Note: ESRD-DM is a disabling and costly condition that disproportionately affects AI/ANs and is associated with high mortality. 1 The data analyzed in this report suggest that the incidence of ESRD-DM treatment among the AI/AN population with diabetes is increasing. The increase in treatment, especially among those aged Ͻ45 years, contributes further to the large and growing public health problem of diabetes among AI/ANs. 3,5 Reasons for the increased incidence of ESRD-DM treatment need further research; however, possible factors include higher incidence of ESRD-DM, changes in treatment and care practices, greater recognition of the etiologic role of diabetes in ESRD, better access to or acceptance of treatment, or a combination of these factors. Risk factors for developing ESRD-DM include familial and genetic factors, duration of diabetes, hypertension, and hyperglycemia. 2 The findings in this report are subject to at least four limitations. First, the data are for persons receiving ESRD treatment as reported to HCFA and do not include patients who die of ESRD before receiving treatment and those who are not reported to HCFA. Second, racial/ethnic misclassification of AI/ANs in USRDS data may result in an under-estimation of incidence. 6 Third, underreporting of AI/ANs in U.S. census counts may result in an overestimation of incidence. Finally, IHS data may not account for the total AI/AN population and may result in overestimation or underestimation of the number of AI/ANs with diabetes and, therefore, the incidence of ESRD-DM. Although these biases may have affected the magnitude of incidence estimates, trends in incidence would not be affected if the biases remained constant over time.

End-Stage Renal
The increased incidence of ESRD-DM treatment poses a public health challenge for AI/AN communities. Moreover, during 1990-1996, the ageadjusted prevalence of diabetes among AI/ANs increased by 24% compared with 14% among the U.S. general population. 3 Interventions are needed to prevent both diabetes and diabetesrelated renal disease among AI/ANs. Regular exercise, improved nutrition, and reduced body weight may prevent or delay the onset of diabetes. 7 Among persons with diabetes, aggressive blood sugar and hypertension control and the use of angiotensin-converting enzyme inhibitors may prevent or delay the development of ESRD-DM. [8][9][10] In 1998, IHS granted $30 million to tribal governments to help develop and implement interventions to prevent diabetes and its complications. In 1999, CDC, IHS, and other organizations established the National Diabetes Prevention Center in Gallup, New Mexico, to provide guidance and technical support to AI/AN communities throughout the United States and to develop, evaluate, and disseminate culturally appropriate interventions. CDC and the National Institutes of Health cosponsor the National Diabetes Education Program (NDEP) to promote early diagnosis and improve the treatment and outcomes of persons with diabetes. In 1999, in collaboration with IHS and other partners, NDEP launched a diabetes awareness campaign focused on the importance of controlling diabetes. Additional information about NDEP is available from the World-Wide Web, http://ndep.nih.gov/; http://www.cdc .gov/diabetes; or by telephone (800) 438-5383. CDC assists the National IHS Diabetes Program by providing technical assistance on the surveillance of diabetes and its complications among AIs/ANs. The continued surveillance of diabetes and its complications will be an important tool for monitoring the effectiveness of on-going and future prevention strategies.