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The American Diabetes Association and the American College of Sports Medicine agree that increasing physical activity among persons with diabetes is an important public health goal to 1) reduce blood glucose and risk factors for complications (e.g., obesity and hypertension) in persons with diabetes and 2) improve cardiovascular disease outcomes (1,2). Among adults with diabetes, co-occurring arthritis might present an underrecognized barrier to increasing physical activity, but to date this has not been directly studied. To estimate the prevalence of 1) diagnosed arthritis among adults with diabetes and 2) physical inactivity among adults with diabetes by arthritis status, CDC analyzed combined 2005 and 2007 data from the Behavioral Risk Factor Surveillance System (BRFSS). This report describes the results of that analysis, which indicated that 1) arthritis prevalence was 52.0% among adults with diagnosed diabetes and 2) the prevalence of physical inactivity was higher among adults with diabetes and arthritis (29.8%) compared with adults with diabetes alone (21.0%), an association that was independent of age, sex, or body mass index (BMI). The higher prevalence of physical inactivity among adults who have both diabetes and arthritis suggests that arthritis might be an additional barrier to increasing physical activity. Health-care providers and public health agencies should consider addressing this barrier with arthritis-specific or general evidence-based self-management and exercise programs.
The BRFSS survey is a state-based, random-digit–dialed telephone survey of the civilian, noninstitutionalized U.S. adult population aged ≥18 years and is conducted in all 50 states, the District of Columbia (DC), Guam, Puerto Rico, and the U.S. Virgin Islands. Diabetes was defined as a "yes" response to the question, "Have you ever been told. by a doctor that you have diabetes?" Doctor-diagnosed arthritis was defined as a "yes" response to the question, "Have you ever been told by a doctor or other health professional that you have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?" This question is included in the BRFSS core questionnaire in oddnumbered years only. Physical activity level of respondents was determined from six questions* that asked about fre
*Available at http://www.cdc.gov/brfss/questionnaires/pdf-ques/2005brfss.pdf and http://www.cdc.gov/brfss/questionnaires/pdf-ques/2007brfss.pdf.
quency and duration of participation in nonoccupation. activities (i.e., lifestyle activities) of moderate and vigoro intensity; those reporting no participation in such act. ties were classified as inactive (i.e., engaged in no nonow pational physical activity), and all others as active. B was calculated from self-reported height and weight. To obtain adequate sample sizes for greater statist power, CDC combined data for the 50 states and DC from 2005 and 2007, calculated estimates, and applied annual average weighting; 95% confidence intervals (CI were calculated using sample design factors to account: the multistage probability sample. To assess factors pote tially confounding an association between doctor-diagnos arthritis and physical inactivity among those with diabotes, data were combined across states/areas in unadjust and adjusted (by age, sex, and BMI) logistic regression models. Age groups were 18-44 years, 45-64 years, 2 ≥65 years. BMI groups were underweight/normal weg (BMI <25.0), overweight (BMI 25.0 to <30.0), and obes (BMI ≥30). Statistical significance was determined: nonoverlapping CIs. State-level estimates then were calc lated for the 50 states and DC (reported medians were bax. on these areas) and for Guam, Puerto Rico, and the US Virgin Islands. Council of American Survey Organizations (CASRO) response rates among the 50 states, DC, and the three territories for 2005 ranged from 34.6% (New Jers to 67.4% (Alaska) (median: 51.1%), and cooperation rate ranged from 58.7% (California) to 85.3% (Minnesot (median: 75.1%).* CASRO response rates for 2007 rang from 26.9% (New Jersey) to 65.4% (Nebraska) (median 50.6%), and cooperation rates ranged from 49.6% (New Jersey) to 84.6% (Minnesota) (median: 72.1%).§
During 2005 and 2007, the prevalence of arthritis amo adults with diabetes was 52.0% (CI = 51.3%-52.7% compared with 26.9% (CI = 26.7%-27.1%) for all adu:) aged ≥18 years. The prevalence of arthritis among perser with diabetes was higher than in the general populati for both sexes: males (45.9% [CI = 44.8%–47.1%) vers 22.6 [CI = 22.3% -22.9%]); females (58.0% [CI = 57.1059.0%] versus 30.9% [CI = 30.7%-31.2%]), respective In addition, arthritis prevalence among persons with diabe tes was higher than in the general population for all age grou (i.e., 18-44 years, 45-64 years, and ≥65 years): 27.6 (CI = 25.7%-29.7%) versus 11.0% (CI = 10.8%-11.2 51.8% (CI = 50.8%-52.9%) versus 36.4% (CI = 36.1~|
2005 BRFSS data quality report available at http://www.cdc.gov technical_infodata/pdf/2005 summarydataqualityreport.pdf.
$ 2007 BRFSS data quality report available at http://www.cdc.gov technical_infodata/pdf/2007summarydataqualityreport.pdf.
8%), and 62.4% (CI = 61.3%-63.5%) versus 56.2% 55.8%-56.6%), respectively. Prevalence of physical -ctivity was lowest among adults without arthritis or diaes (10.9% [CI = 10.7%-11.1%]), higher among adults h arthritis alone (17.3% [CI = 17.0% -17.6%]) and petes alone (21.0% [CI = 20.0% -22.1% ] ), and highamong adults with both conditions (29.8% [CI = 0%-30.7%]) (Figure). In logistic regression analyses, the djusted odds ratio (OR) for the association between doc-diagnosed arthritis and physical inactivity among adults h doctor-diagnosed diabetes was 1.6 (CI 1.3-1.7); usted for age and sex, the OR was 1.4 (CI 1.3-1.5); and usted for age, sex, and BMI, the OR was 1.3 (CI = 1.2–1.4). state-specific analyses, the state median prevalence estimate physical inactivity among adults with diabetes and arthriwas 28.9% (range: 20.2% in California to 46.4% in Tensee). The state median prevalence estimate of physical ctivity among adults who had diabetes and no arthritis 19.5% (range: 9.0% in Alaska to 30.2% in West Virginia) ble).
ported by: J Bolen, PhD, J Hootman, PhD, CG Helmick, MD, lurphy, PhD, G Langmaid, Div of Adult and Community Health, Caspersen, PhD, Div of Diabetes Translation, National Center for onic Disease Prevention and Health Promotion, CDC.
itorial Note: In the United States, approximately 20.6 lion adults were reported to have diabetes in 2005 (3), h nearly seven in 10 having diabetes diagnosed by a Ith professional. In addition, during 2003-2005, roximately 46.4 million adults had arthritis (4). cause physical activity is a recommended selfnagement strategy for both conditions, examining the ect of co-existing arthritis and diabetes on physical vity levels is warranted.
The results of this analysis indicated that, during 2005 I 2007, doctor-diagnosed arthritis affected approximately f of adults with doctor-diagnosed diabetes. The prevace of self-reported physical inactivity was significantly her among those with arthritis and diabetes than among se with diabetes alone. This association remained sigcant after adjustment for age, sex, and BMI, factors that 3ht have otherwise explained the association. Statecific estimates were consistent with the overall findings, h state-to-state differences likely attributable to differes in the distribution of factors associated with both ritis and physical inactivity in the state population. ause BRFSS data are cross-sectional, they can only demtrate an association; the temporal sequence of condition et is unknown.
The associations between arthritis and physical inactivamong adults with diabetes found in this analysis sug
gest that arthritis might be a barrier to being physically active in this population. Being more physically active (e.g., through aerobic exercise or strength training) can benefit persons with either arthritis or diabetes and those with both conditions (1). Persons with diabetes who are inactive and become more active benefit from improved physical function and glucose tolerance (5), but they face the same common barriers to being more physically active as most adults, such as lack of time, competing responsibilities, lack of motivation, and difficulty finding an enjoyable activity (6). Those who also have arthritis face additional diseasespecific barriers, such as concerns about aggravating arthritis pain (6) and causing further joint damage, and they might be unsure about which types and amounts of activity are safe for their joints. Health-care providers interested in improving diabetes management might want to especially consider arthritis-related barriers among persons with diabetes who are physically inactive.
Specially tailored self-management education interventions, such as the Chronic Disease Self Management Program (7) and the arthritis-specific Arthritis Foundation Self-Help Program, help adults learn to manage arthritis pain and discuss how to safely increase physical activity (8). In addition, several exercise programs, including EnhanceFitness (2), the Arthritis Foundation Exercise Program, and the Arthritis Foundation Aquatics Program (8),
I available in many communities and are appropriate for lts with diabetes and arthritis. Self-directed physical vities, including joint-friendly activities such as walk▼, swimming, and biking, also are appropriate for adults Th both conditions.
The findings in this report are subject to at least five itations. First, doctor-diagnosed arthritis, doctorgnosed diabetes, and activity level are self-reported in FSS and have not been confirmed by a health-care proer or objective monitoring; however, such self-reports e been shown to be valid for surveillance purposes (9,10). · ond, BRFSS is a telephone survey and does not include sons without landline telephones, persons in the mili7, or those residing in institutions. Third, comparisons tabular data between states should be made with cau1 because the prevalence estimates are not adjusted for ulation characteristics (e.g., age) that might explain erences. Unadjusted data are presented in this report to vide actual estimates for state-level program planning. irth, BRFSS response rates were low for both survey years. FSS weighting procedures partially correct for response. The effect of low response rates is uncertain. ally, the findings in this report do not account for s with undiagnosed diabetes. n 2007, CDC released a reference guide for planning 7sical activity interventions for older adults, including se with diabetes (2). This guide suggests different proms sensitive to the medical needs of persons with diabeand those with chronic disease complications or physical itations, and promotes active aging among persons not limited by complications or limitations of diabetes or ritis. Because arthritis appears to be an additional barto increasing physical activity, state-level diabetes proms whose aim is to increase physical activity among adults h diabetes might meet their own goals more readily by egrating their efforts with arthritis programs.
Sigal RJ, Kenny GP, Wasserman DH, Castaneda-Sceppa C. Physical activity/exercise and type 2 diabetes: technical review. Diabetes Care 2004;27:2518–39.
Moran SA, Caspersen CJ, Thomas GD, Brown DR, The Diabetes and Aging Work Group. Reference guide of physical activity programs for older adults: a resource for planning interventions. Atlanta, GA: US Department of Health and Human Services, CDC, National Center for Chronic Disease and Health Promotion; 2007. Available at http://www.cdc.gov/diabetes/pubs/pdf/refguideofactivity.pdf. CDC. National diabetes fact sheet: general information and national estimates on diabetes in the United States, 2005. Atlanta, GA: US Department of Health and Human Services, CDC; 2005. Available at http://www.cdc.gov/diabetes/pubs/factsheet05.htm.
ditional information available at http://www.cdc.gov/arthritis/campaigns/ ysical_activity/index.htm.
4. CDC. Prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation-United States, 2003-2005. MMWR 2006;55: 1089-92.
5. Sigal RJ, Kenny GP, Boule NG, et al. Effects of aerobic training, resistance training, or both on glycemic control in type 2 diabetes. Ann Intern Med 2007;147:357-69.
6. Wilcox S, Der Ananian C, Abbott J, et al. Perceived exercise barriers, enablers, and benefits among exercising and non exercising adults with arthritis: results from a qualitative study. Arthritis Rheum 2006;55: 616-27.
7. Lorig KR, Bodenheimer T, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. JAMA 2002;288:2469–75. 8. Brady TJ, Kruger J, Helmick CG, Callahan LF, Boutaugh ML. Intervention programs for arthritis and other rheumatic diseases. Health Educ Behav 2003;30:44-63.
9. Sacks JJ, Harrold LR, Helmick CG, Gurwitz JH, Emani S, Yood RA. Validation of a surveillance case definition for arthritis. J Rheumatol 2005;32:340-7.
10. Beckles GL, Engelgau MM, Narayan KM, Herman WH, Aubert RE, Williamson DF. Population-based assessment of the level of care among adults with diabetes in the US. Diabetes Care 1998;21:1432–8.
Progress Toward Interruption of Wild Poliovirus Transmission Worldwide, January 2007-April 2008
In 1988, the World Health Assembly resolved to eradicate poliomyelitis. Subsequently, the Global Polio Eradication Initiative reduced the global incidence of polio associated with wild polioviruses (WPVs) from an estimated 350,000 cases in 1988 to 1,997 reported cases in 2006 and reduced the number of countries that have never succeeded in interrupting WPV transmission from 125 to four (Afghanistan, India, Nigeria, and Pakistan) (1–4). Type 2 WPV (WPV2) circulation was last observed in October 1999 (5). In February 2007, the World Health Organization (WHO) convened a stakeholders meeting to agree on an accelerated polio-eradication effort to be used during 2007-2008 and establish milestones to monitor progress. Programmatic strategies implemented in 2007 included expanded use of type 1 monovalent oral poliovirus vaccine (OPV) (mOPV1) to eliminate type 1 WPV (WPV1) transmission before type 3 WPV (WPV3)* (6) and targeted use of type 3 monovalent OPV (mOPV3) in selected areas (1-4). This report summarizes these strategies and overall progress toward reaching the milestones, including a decline in the overall number of WPV cases to 1,310 in 2007 and substantial progress toward interruption of WPV1 circulation in India in 2008.
* WPV1 is more likely to cause paralytic disease and have a wide geographic spread than WPV3.
Routine OPV Vaccination
Routine vaccination remains an integral component of the polio eradication initiative. Global routine vaccination coverage for infants with 3 doses of trivalent OPV (tOPV) was estimated at 80% in 2006 (7), an increase from 73% in 2001. Estimated coverage varied among WHO regions: 65% in the South-East Asian, 75% in the African, 86% in the Eastern Mediterranean, and >93% in the Western Pacific, European, and Americas regions. In the four polioendemic countries, 3-dose tOPV coverage was estimated at 77% in Afghanistan, 58% in India, 61% in Nigeria, and 83% in Pakistan; however, substantially lower coverage (<40%) has been reported in subnational areas with ongoing polio transmission (i.e., northern Nigeria and the northern Indian states of Uttar Pradesh and Bihar) (2,3).
Supplementary Immunization Activities (SIAs)$ in 2007
In 2007, 164 SIAS were conducted in 27 countries (60 national immunization days, 86 subnational immunization days, and 18 mop-up rounds with OPV), using a total of 2.32 billion OPV doses delivered to 400 million children aged <5 years. Use of mOPV1 increased from 22% of all administered SIA doses in 2005 to 46% in 2006 and to 52% in 2007, reflecting the programmatic emphasis on interrupting WPV1 transmission (6). A total of 76 (46%) of the 164 SIAs were conducted in the four polio-endemic countries: 25 in India, 19 in Pakistan, and 16 each in Afghanistan and Nigeria. Of the remaining 88 SIAs, 56 (34% of all SIAs) were conducted in eight countries where WPV was reintroduced through importation, and 32 (20% of all SIAs) were conducted in 15 countries with no WPVconfirmed cases in 2007 in response to earlier outbreaks or as a precaution against poliovirus importations.
To improve SIA quality, strategies that were introduced in 2006 in the four polio-endemic countries were continued in 2007. Nigeria continued "immunization-plus days" that offered other vaccines (e.g., measles, hepatitis B, and diphtheria and tetanus toxoids and pertussis vaccines) and health interventions (e.g., bednets and deworming medication) in addition to OPV during SIAS (2). Despite repeated SIAS and because of lower routine vaccination coverage in high-risk areas, the proportion of “zero-dose
children"** in 2007 was substantially higher in pc. affected (18%) areas in Nigeria than in polio-free art (2%). In India, the government maintained intensive larg scale SIAS in districts of Bihar and western Uttar Prade with the highest polio risk, primarily using mOPV1 r. concentrating on improving coverage among child aged <2 years. The proportion of zero-dose children in 2 dia was <1% in both polio-affected areas and polio-tie areas. Afghanistan and Pakistan implemented an approa that included improved cross-border synchronization. « polio campaigns. In addition, access during SIAs in ins cure areas of Afghanistan that previously were inaccessit. by vaccinators improved beginning September 2007, ter obtaining the support of antigovernment groups; ne::theless, the proportion of zero-dose children overall for 200 was 9% in those areas. Otherwise, the proportion of zer dose children was essentially the same in both countries polio-affected areas (<1%) and polio-free areas (<1%..
Acute Flaccid Paralysis (AFP) Surveillance
The quality of AFP surveillance is monitored by two pe formance indicators: 1) the rate of AFP cases not caused: WPV (i.e., the nonpolio AFP rate; target for certification more than one case per 100,000 persons aged <15 years and 2) the proportion of AFP cases with adequate sto. specimens (target for certification: >80%). In 2007, ea WHO region maintained sensitivity of AFP surveillance: detect paralytic polio cases at certification-standard leve (Table). Globally, AFP case reporting increased 13%, from 68,519 cases in 2006 to 77,433 cases in 2007, primar as a result of increased reporting from India. Since 2005 target reporting rate for all polio-endemic countries and countries at high risk for WPV importation has been mat than two nonpolio AFP cases per 100,000 persons age <15 years (8). In 2007, all four polio-endemic countrie and the eight countries with cases reported in 200 (because of reintroduced WPV) reached this target rate.
Global Polio Laboratory Network
In 2007, WHO accredited 98% of the 145 global pola virus network laboratories, which together analyzed approx mately 157,000 stool specimens from persons with AFT In addition, the laboratory network finalized implement
Most recent year for which data are available; WHO/UNICEF estimates. Mass campaigns conducted during a brief period (days to weeks) in which 1 dose of OPV is administered to all children aged <5 years, regardless of vaccination history.
"Angola, Chad, Democratic Republic of the Congo, Burma (Myanmar), Nepal, Niger, Somalia, and Sudan.
Children aged 6-35 months with nonpolio acute flaccid paralysis who h never been vaccinated with OPV, according to vaccination histories provic their mothers.
#Two specimens collected ≥24 hours apart, both within 14 days of parathe onset, and shipped on ice or frozen ice packs to a WHO-accredited laborat*% arriving at the laboratory in good condition.