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TABLE. Prevalence of arthritis among adults aged 18 years with diabetes and prevalence of physical inactivity among adults at
diabetes with
and without arthritis, by state/area — Behavioral Risk Factor Surveillance System, United States, 2005 and 2007
Arthritis among adults with diabetes

Physical inactivity among adults with diabetes
No. of
Weighted no.

Without arthritis

With arthritis
State/Area
respondents (in 1,000s)

%
(95% CI")

%
(95% CI)

%

(95% CI) Alabama

10,447
201

58.7
(55.0-62.2)

26.0
(21.1-31.7)

35.6

(31.2-402 Alaska

5,365

13

53.8
(45.4-62.1)

9.0
(5.1-15.4)

30.1

(20.1-423 Arizona

9,443
156

45.9
(40.0–51.9)

15.4
(10.0–23.1) 28.3

(21.8-35 Arkansas

11,013

100

55.4
(51.9–58.8)

24.4
(19.4–30.3)

30.8

(26.9-351 California

11,825
810

43.6
(39.5-47.8)

22.5
(17.1–29.0)

20.2

(15.7-256 Colorado

17,887

79

46.3
(42.7-49.8)

14.9
(11.5–19.0)

24.6

(20.6-29 Connecticut

12,777

82

44.8
(41.0–48.6)

16.8
(13.1-21.2)

27.4

(23.0-324 Delaware

8,183

30

54.1
(49.5-58.6)

18.1
(13.3-24.2)

27.9

(23.0-333 District of Columbia

7,700

16

48.2
(43.5-52.9)

22.8
(17.1-29.6)

29.2

(23.6-35.41 Florida

47,739

580

49.2
(46.1–52.3)

24.6
(20.9–28.6)

34.0 (30.1–38.01 Georgia

13,767
340

55.6
(52.0–59.1)

15.8
(12.7–19.6)

29.2

(25.4-333 Hawaii

13,019

31

42.6
(38.6–46.8)
19.5 (15.3–24.5) 24.5

(19.6-301, Idaho

11.049

41

53.7
(49.9–57.4)

15.3
(11.7-19.7)

24.7

(20.5-295 Illinois

10,313
398

50.2
(46.1-54.2)

21.8
(16.8–27.9)

29.5

(24.9_345. Indiana

11,626
220

57.0
(53.5-60.4)

22.0
(17.5-27.3)

29.6

(25.4-34 lowa

10,479

82

54.2
(50.5-58.0)

15.4
(11.8–19.9)

34.5

(29.8–395 Kansas

17,121

75

51.5
(48.6–54.5)

19.0
(16.0–22.5) 33.3

(29.9-3701 Kentucky

13,536

153

53.9
(50.2–57.6)

32.8
(27.6–38.4)

44.8

(40.349% Louisiana

9,620
157

54.1
(50.4-57.7)

28.7
(24.1-33.9)

42.8

(37.9 478 Maine

10,790

44

56.6
(52.7-60.5)

13.0
(9.4–17.8)

27.5

(23.3-322 Maryland

17,461

177

55.1
(51.9–58.3)

18.8
(15.4–22.7)

28.9

(25.1-329 Massachusetts

30,413

161

48.5
(45.6-51.4)

21.4
(18.1-25.2)

31.0

(27.4–34.8 Michigan

19,641
365

57.5
(54.8–60.2)

18.3
(15.2-21.9)

29.1

(26.0-323 Minnesota

7,603
106

47.8
(42.8–52.8)

16.0
(11.4-21.9)

20.3

(15.2-26 Mississippi

12,257

130

58.4
(55.4-61.4)

24.0
(20.2-28.3)

38.7

(35.0-42.61 Missouri

10,427
214

62.2
(57.9-66.3)

20.8
(14.6–28.7)

30.4

(25.9–352, Montana

10,978

23

52.9
(48.7–57.1)

16.7
(12.4–22.2)

23.4

(18.7-269 Nebraska

19,276

50

54.0
(50.3–57.6)

20.0
(16.1-24.6)

27.3

(23.1-31 9 Nevada

7,286

70

51.8
(46.1-57.4)

23.9
(17.2-32.1)

23.3

(17.5-30.3, New Hampshire

12,028

36

53.0
(49.3–56.6)

17.2
(13.6–21.6)

29.9

(25.6-345 New Jersey

20,899

273

50.2
(47.1-53.4)

24.6
(20.8–28.9)

32.6

(28.5-36.91 New Mexico

12,191

50

47.4
(43.6–51.2)

17.4
(13.7-21.8)

27.2

(23.0-31 81 New York

14,321
600

51.6
(48.0-55.1)

21.7
(17.4–26.6)

26.7

(22.7-32 North Carolina

32,038

320

56.1
(53.9–58.2)

21.1
(18.5-23.8)

32.4

(29.9_35.11 North Dakota

8,761

16

49.8
(45.4–54.3)

18.8
(14.0-24.7)

26.6

(21.6-323 Ohio

18,727
431

58.9
(55.7-61.9)

21.9
(17.8–26.7)

28.3

(24.8–31.9 Oklahoma

21,170

142

55.5
(52.5–58.4)

20.9
(17.3–25.1)

34.1

(30.7-3771 Oregon

16,966

95

50.4
(47.1-53.7)

14.9
(11.7-18.7)

23.9

(20.5-277) Pennsylvania

26,609

455

57.0
(53.8-60.3)

19.9
(16.5-23.8)

28.0

(24.5-31.7 Rhode Island

8,475

31

56.7
(52.3–61.0)

20.4
(15.4–26.5)

32.5

(27.3–38.2 South Carolina

18,835

176

56.0
(53.4–58.6)

20.2
(16.6-24.3)

29.0

(26.1-32.1) South Dakota

13,786

19

50.9
(47.4–54.5)

16.2
(12.8-20.2)

27.2

(23.4-313 Tennessee

9,781
266

57.4
(52.9–61.8)

32.9
(26.8–39.7)

46.4

(41.3–516 Texas

23,760

691

46.3
(43.7-49.0)

20.0
(17.3–23.0)

32.3

(28.8-36.0 Utah

10,216

47

49.8
(45.3–54.3)

14.1
(10.0–19.6)

24.5

(19.2-308) Vermont

13,699

17

53.0
(49.1–57.0)

13.9
(10.3–18.5)

25.1

(21.0-29.8 Virginia

11,696
234

55.5
(51.7–59.2)

14.8
(11.4-19.0)

26.3

(22.2-30.8; Washington

49,183

162

50.8
(48.8–52.8)

14.9
(12.9–17.1)

23.9

(21.6-263 West Virginia

7,998

90

58.8
(55.3–62.3)

30.2
(25.1-36.0)

39.0

(34.843.4) Wisconsin

12,335

153

56.9
(52.8-60.9)

11.1
(8.1–15.2)

23.5

(19.3–28.4) Wyoming

11,169

14

52.6
(48.8–56.3)

14.7
(11.2–18.9)

27.7

(23.3-327, Median**

53.7
(51.5-55.1)
19.5 (17.2–20.9)

28.9

(27.4-29.9 Guam

657

2

37.4

(25.4–51.2) Puerto Rico

7,723
163

46.3
(43.1-49.6)

45.7
(40.9–50.7)

55.4

(50.9-59.8) U.S. Virgin Islands

4,960

2

31.8
(27.1-36.9)

20.8
(15.7-27.1)

(24.1-41.11 * Includes all respondents reporting no activity when asked six questions about frequency and duration of participation in nonoccupational activities of moderate and viga intensity (i.e., lifestyle activities). All other respondents were classified as active. Questions available at http://www.cdc.gov/brfss/questionnaires/pdf-ques 2005briss po 3

32.0

http://www.cdc.gov/brfss/questionnaires/pdf-ques/2007brfss.pdf.
t Includes all 50 states, the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands.
§ Weighted annual average number of adults with diabetes who also have arthritis.
1 Confidence interval.

Does not include Guam, Puerto Rico, or the U.S. Virgin Islands.

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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-man

agement of chronic disease in primary care. JAMA 2002;288:2469–75. 8. Brady TJ, Kruger J, Helmick CG, Callahan LF, Boutaugh ML. Inter

vention 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.

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available in many communities and are appropriate for ults with diabetes and arthritis. Self-directed physical vities, including joint-friendly activities such as walk5, swimming, and biking, also are appropriate for adults h both conditions. S 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 mili1, or those residing in institutions. Third, comparisons tabular data between states should be made with cau1 because the prevalence estimates are not adjusted for vulation 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 pers with undiagnosed diabetes. n 2007, CDC released a reference guide for planning ísical 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 writis. Because arthritis appears to be an additional bar· to 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. erences 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.

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.

ditional information available at http://www.cdc.gov/arthritis/campaigns/ ysical_activity/index.htm.

*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 (OPV) 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 with

ongoing polio transmission (i.e., northern Nigeria and the northern Indian states of Uttar Pradesh and Bihar) (2,3).

children in 2007 was substantially higher in pci. affected (18%) areas in Nigeria than in polio-free 123 (2%). In India, the government maintained intensive larg scale SIAs in districts of Bihar and western Uttar Prai: with the highest polio risk, primarily using mOPVla. concentrating on improving coverage among childr. aged <2 years. The proportion of zero-dose children in 's dia was <1% in both polio-affected areas and polio-ta areas. Afghanistan and Pakistan implemented an approa that included improved cross-border synchronizatior : polio campaigns. In addition, access during SIAs in in cure areas of Afghanistan that previously were inaccent by vaccinators improved beginning September 2007, 2 ter obtaining the support of antigovernment groups; nork theless, the proportion of zero-dose children overall for was 9% in those areas. Otherwise, the proportion of ze: dose children was essentially the same in both countries polio-affected areas (<1%) and polio-free areas (<1%.

areas

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

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 i WPV (i.e., the nonpolio AFP rate; target for certificates more than one case per 100,000 persons aged <15 years and 2) the proportion of AFP cases with adequate stu: 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%, fro.. 68,519 cases in 2006 to 77,433 cases in 2007, primari as a result of increased reporting from India. Since 2001. target reporting rate for all polio-endemic countries an. countries at high risk for WPV importation has been ma than two nonpolio AFP cases per 100,000 persons agai <15 years (8). In 2007, all four polio-endemic countris and the eight countries with cases reported in 207 (because of reintroduced WPV) reached this target rate.

Global Polio Laboratory Network

In 2007, WHO accredited 98% of the 145 global pole virus network laboratories, which together analyzed approc mately 157,000 stool specimens from persons with 1FT In addition, the laboratory network finalized implement

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of a testing approach in countries of WHO regions h WPV circulation that reduces poliovirus confirmation ne by 50% (to 21 days), compared with previous thods. SØ The percentage of stool specimens tested from io-endemic regions in laboratories with capacity for both is isolation in cell culture and differentiation of wild or -cine-like viruses increased from 57% in 2006 to 69% 2007.

PV Incidence
is of April 30, 2008, a total of 1,310 polio cases with
set of paralysis in 2007 had been reported worldwide
ble), a decrease of 34% from the 1,997 cases reported
2006. With the strategic emphasis on WPV1 elimina-
7, WPV1 cases decreased 81% from 1,666 in 2006 to
| cases in 2007; however, WPV3 cases tripled from 331
2006 to 989 in 2007 (Figure 1). The reported number
polio-affected districts in all countries decreased 26%
m 463 in 2006 to 342 in 2007. A total of 106 (8%)
S

cases in 2007 were in countries where WPV was reintroduced through importation, compared with 1,301 (40%) of 3,234 cases during 2004–2005 (9). As of April 30, a total of 134 WPV1 cases and 220 WPV3 cases with onset of paralysis in 2008 had been reported (Figure 2), compared with 64 WPV1 cases and 66 WPV3 cases reported during the same period in 2007.

India. Reported WPV1 cases declined 87% in India, from 646 in 2006 to 83 in 2007, associated with expanded use of mOPV1 (3). Western Uttar Pradesh, which had been the primary reservoir of WPV1 circulation in recent years, reported five WPV1 cases in 2007. The number of WPV1affected districts declined 61%, from 114 in 2006 to 45 in 2007. However, a WPV3 outbreak involving Uttar Pradesh and spreading to Bihar resulted in an increase in WPV3 cases from 28 in 2006 to 787 in 2007; the number of WPV3-affected districts increased from seven in 2006 to 77 in 2007. Primary use of mOPV1 in SIAs during 2006-2008 has accelerated the decline in WPV1 cases; as of April 30, 2008, only four cases had been reported in 2008 (in New Delhi, Orissa, Bihar, and West Bengal), compared with 26 cases during the same period in 2007.

dditional information available at http://www.who.int/immunization_ wonitoring/Supplement_polio_lab_manual.pdf.

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BLE. Number and rate of acute flaccid paralysis (AFP) cases in 2007 and number of wild poliovirus (WPV)-confirmed cases of iomyelitis in 2007, January-April 2007, and January-April 2008, by World Health Organization (WHO) region and country*

% AFP No. of

cases with reported Nonpolio adequate AFP cases AFP ratet specimens

No. of WPV-confirmed cases (no. of WPV type 1 cases) jion/Country

2007
2007
2007$

2007

January-April 2007 January-April 2008 ican

12,077
4.0

366 (193)

76 (28)

137 (120) gola

281
3.0
91
8 (8)
0 (0)

3 (1) Tad

163
2.9
88
21 (18)

(0)

2 (0) mocratic Republic [ the Congo

2,040

5.6
85
41 (41)
12 (12)

1 (1) ger

231
3.3
92
11 (10)
3 (1)

5 (5) geria

4,277

5.9
94
285 (116)

61
(15)

126 (113) itern Mediterranean 9,396

4.2
91
58 (34)
14 (9)

10 ghanistan

1,116

6.8
92
17 (6)
0 (0)

5 (4) kistani

4,425

5.7
91
32 (19)
7 (2)

4 (4) malia

184
4.0
91
8 (8)
7 (7)

0 (0) dan

493
3.1
91
1 (1)

(0)

1** (1) Ith-East Asian

46,133

7.4
84
886 (94)

40 (27)

206 (4) 41,531

9.3
84

870
(83)
39 (26)

203 rma (Myanmar)

413
2.0
91
11 (11)

(1)

0 pal

343
3.2
83
5 (0)
0 (0)

3 erican

2,151

1.3

78 opean

1,445

1.0

82 stern Pacific

6,231 al

77,433
4.2

1,310 (321)

130 (64)

354 (134) ata reported to WHO as of April 30, 2008. Only countries with WPV in 2007 are included. Central African Republic has reported a WPV1 case in 2008. Then averaging global, regional, or national surveillance indicators, suboptimal performance-quality indicators in smaller areas might be masked. er 100,000 persons aged <15 years. wo stool specimens collected at an interval of >24 hours within 14 days of paralysis onset and adequately shipped to a WHO-accredited laboratory. ountries where WPV transmission has never been interrupted. ending final allocation of case.

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