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eim P, Price LB, Klevytska AM, et al. Multiple-locus variable-numer tandem repeat analysis reveals genetic relationships within Bacillus thracis. J Bacteriol 1999;182:298–336.
DC. Update: investigation of bioterrorism-related anthrax and terim guidelines for exposure management and antimicrobial therapy, ctober 2001. MMWR 2001;50:909-19.
DC. Inhalation anthrax associated with dried animal hidesennsylvania and New York City, 2006. MMWR 2006;55:280–2. HS Borders. Report on the management of an anthrax incident in he Scottish borders, July 2006 to May 2007. Available at http:// ws.bbc.co.uk/1/shared/bsp/hi/pdfs/13_12_07_anthrax.pdf. ales ME, Dannenberg AL, Brachman PS, et al. Epidemiologic sponse to anthrax outbreaks: field investigations, 1950-2001. Emerg fect Dis 2002;8:1163-74.
old H. Anthrax: a report of one hundred seventeen cases. Arch Interl Med 1955;96:387-96.
anter DA, Gunning D, Rodgers P, et al. Remediation of Bacillus thracis contamination in the U.S. Department of Justice mail facilV. Biosecur Bioterror 2005;3:119-27.
S Department of Agriculture. Animal product manual. 2nd edition. 'ashington, DC: US Department of Agriculture; 2008. Available at -tp://www.aphis.usda.gov/import_export/plants/manuals/ports/
ussell AD, Yarnych VS, Koulikovskii A (eds). Guidelines on disinfecɔn in animal husbandry for prevention and control of zoonotic disses. Geneva, Switzerland: World Health Organization; 1984. Available http://whqlibdoc.who.int/hq/pre-wholis/who_vph_84.4.pdf. urnbull PCB. Guidelines for the surveillance and control of anthrax humans and animals. Geneva, Switzerland: World Health Organition; 1986. Available at http://www.who.int/csr/resources/publicaons/anthrax/WHO_EMC_ZDI_98_6.
ctronic Record Linkage to Identify aths Among Persons with AIDS District of Columbia, 2000-2005
estimated 1 million persons in the United States are livvith human immunodeficiency virus (HIV)/acquired unodeficiency syndrome (AIDS); approximately 500,000 ns with AIDS have died since 1981 (1,2). In 2005, the ict of Columbia (DC) had an estimated adult AIDS
prevalence rate of 2%, one of the highest AIDS prevalence rates in the United States (2). Accurate death ascertainment is an important part of HIV/AIDS surveillance. Manual methods can substantially underestimate deaths by missing death certificates that do not mention HIV infection or deaths of residents that occur in other states. CDC and the Council of State and Territorial Epidemiologists (CSTE) recommend performing electronic record linkages to ascertain deaths. annually as part of routine HIV/AIDS surveillance activities (3). In 2007, to identify all deaths that occurred during 2000– 2005 among persons with AIDS who resided or received their diagnosis in DC, the HIV/AIDS Administration of the DC Department of Health, with assistance from CDC, performed an electronic record linkage. This report summarizes the results of that linkage, which determined that 54% of deaths among persons with AIDS had not been reported previously to the DC HIV/AIDS Reporting System (HARS). The results indicated that electronic record linkage for death ascertainment is necessary to more accurately estimate the prevalence of persons living with HIV/AIDS.
HARS is a confidential, name-based reporting system developed by CDC to manage HIV/AIDS surveillance data. HARS contains vital status information but does not contain information on cause of death. Until November 2006, DC records in HARS were limited to AIDS patients because nonAIDS patients with HIV infection were not reported by name in DC. To perform the electronic record linkage, Link Plus, a free program developed at CDC (4), was used to link AIDS patients in the HARS data file to records in two other computer data files: 1) the DC Vital Records Division's electronic death certificate file (eDCF) and 2) the Social Security Administration's Death Master File (SSDMF). The eDCF includes all deaths that occur in DC, regardless of state of residence, and some deaths of DC residents that occur in Maryland or Virginia. The SSDMF contains information on all deaths reported to the Social Security Administration, regardless of state of residence or where the death occurred. The eDCF has information on causes of death, but the SSDMF does not.
Analysis was limited to deaths that occurred during 20002005. The variables used for record linkage were name, date of birth, Social Security number, and sex. Three linkages were performed (Figure). Linkage 1 and linkage 2 matched the HARS file to eDCF and SSDMF records, respectively, to identify deaths among persons listed in HARS with reported AIDS. HARS cases that were successfully linked to eDCF or SSDMF records were categorized by whether the death had been previously reported to HARS.
FIGURE. Electronic linkages used to ascertain deaths among persons with AIDS - District of Columbia (DC), 2000–2005
Total AIDS deaths: 2,557
Linkage 1: DC HIV/AIDS Reporting System (HARS) linked to electronic death certificate file (eDCF)
Linkage 2: HARS linked to Social Security Death Master file (SSDMF)
Result: 2,460 deaths, including 1,123 previously reported to DC HARS
HARS deaths not
linked to either SSDMF or eDCF: 140
Linkage 3: HARS linked to the subset of eDCF
Result: 97 deaths of persons newly identified from HIV-specific death certificates that had not been matched to known persons with AIDS in HARS
HARS deaths linked
Deaths of persons with cause of death information available: 1,562
To identify potential new AIDS cases never previously reported to HARS, linkage 3 identified those death certificates within eDCF that indicated HIV infection as a cause of death but had not been linked to HARS via linkage 1. To ensure that these HIV-specific death certificates did not match any previously reported AIDS cases in HARS, a manual search of HARS records was conducted for matches after not finding them by electronic linkage. The remaining nonmatching HIV-specific death certificates were then matched to associated medical records to confirm that decedents met the surveillance case definition for HIV infection (5,6). If medical records were unavailable to corroborate the death certificate information, HIV/AIDS remained unconfirmed for the decedent because the surveillance case definition for HIV infection cannot be met by a death certificate alone (3). Multiple logistic regression was performed, and adjusted odds ratios were calculated to examine factors independently associated with whether a death was previously unreported to HARS before the electronic record linkage.
Linkage 1 and linkage 2 identified 2,460 deaths that occurred during 2000-2005 among persons with AIDS. Of these deaths, 1,337 (54%) had not been reported previously to HARS (Table 1). Among these previously unreported deaths, 320 (24%) were linked only to eDCF, 577 (43%) were linked only to SSDMF, and 440 (33%) were linked to both (Table 1).
Cause of death information was available for 1,562 (63%) of the 2,460 deaths. The underlying cause of death was HIV infection in 1,056 deaths (68%) and other causes (not HIV infection) in 506 deaths (32%) (Table 2). Of those 506 deaths attributed to other underlying causes, 112 (22%) death cer
tificates mentioned HIV infection as a cont
Electronic linkage 3 identified 216 death cr tificates in eDCF that mentioned HIV infec tion as a cause of death but did not electronica match that information with reported AIDS patients in the HARS data file and thus might represent previously unreported HIV/AIDS cases. Overall, (45%) cases were confirmed as new HIV/AIDS cases based on information from medical records. Of the other potential; cases, 69 (32%) were matched manually to HARS patients (and therefore represented previously reported cases missed » by linkage 1); 29 (13%) had only death certificate evidence ef HIV infection available and thus remained unconfirmed; and 21 (10%) had no mention of HIV on the printed death cer tificate or medical records and were assumed to be erroneous.. Reported by: T Jolaosho, MHS, J Gauntt, MS, T West-Ojo, MPH. MSPH, HIV/AIDS Admin, District of Columbia Dept of Hea AD Castel, MD, Dept of Epidemiology and Biostatistics, Ge= Washington Univ School of Public Health and Health Sves, Disna Columbia. RM Selik, MD, T Durant, PhD, Div of HIVAIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and 13 Prevention; PJ Peters, MD, E Tai, MD, EIS officers, CDC. Editorial Note: This report provides the first comparison electronic record linkage with manual methods of AIDS de ascertainment in the United States. More than half (54%) deaths among AIDS patients during 2000-2005 in DC not been reported to HARS and were discovered by electrons record linkage with eDCF and SSDMF. This suggests electronic record linkage is essential for complete ascerta ment of deaths among persons with HIV/AIDS and accurate estimations of HIV/AIDS prevalence.
Death ascertainment in DC has relied on vital records sta members manually reviewing death certificates and sending records that mention HIV to HIV/AIDS surveillance st members, who then manually matched the death certificates to HARS. Because this manual method is dependent upon death certificates mentioning HIV infection, deaths with not HIV underlying causes were less likely to be reported as
LE 1. Number and percentage of deaths among persons with AIDS linked electronically to the electronic Death Certificate File ;F) and Social Security Death Master File (SSDMF), by reporting status — District of Columbia, 2000-2005
LE 2. Number and percentage of deaths not previously reported to HARS,* by selected characteristics - District of Columbia, -2005
<ual contact with a person known to be HIV-infected or at high risk for HIV infection (e.g., history of IDU or MSM). udes mother-child transmission (n = 13) and transfusion (n = 3).
death in a person with AIDS. Antiretroviral therapy has reduced the percentage of deaths attributed to HIV infection and, therefore, limited the effectiveness of a manual death ascertainment method (7,8). Electronic record linkage has the advantage of being able to find deaths from all causes among persons with HIV/AIDS because electronic linkage can efficiently process large numbers of death records without being limited to death records that mention HIV infection.
Manual review of death certificates for a state generally is limited to persons who died in that state. A more complete ascertainment of deaths requires electronic linkage to a national death data file, such as SSDMF or the National Death Index. In this study, SSDMF and eDCF provided complementary and independent death information, with most deaths linked to only one of these data files. More deaths linked to SSDMF than eDCF, underscoring the importance of linking to a national death data file. The National Death Index, accessible through CDC's National Center for Health Statistics (9), is a national death certificate data file that is not limited to decedents with a Social Security number and includes information on causes of death. The National Death Index could be used to help ascertain deaths among AIDS patients; however, the index is more expensive to researchers because of fees charged to remunerate the state vital records offices that compile the data.
The findings in this report are subject to at least one limitation. The DC findings might not be entirely generalizable to the 50 states because DC's close proximity to other states might increase the frequency of out-of-state deaths that are not reported to the DC Vital Records Division. The conditions that led to underestimation of deaths, however, including the frequency of deaths with causes other than HIV infection and the possibility that HIV-infected persons might die in another state, affect many areas of the United States.
Electronic linkage of the HIV/AIDS case registry with a state's death-certificate registry and with a national death registry such as SSDMF is a more efficient and thorough method to ascertain deaths among persons with HIV/AIDS than manual linkage limited to in-state death certificates that mention HIV. Improved death ascertainment can enable more accurate estimates of HIV/AIDS prevalence and a more effective allocation of HIV prevention and treatment resources. These findings support the CDC/CSTE recommendation to perform electronic record linkage to ascertain deaths annually as part of routine HIV/AIDS surveillance activities (3). Most state HIV/AIDS surveillance programs have followed this recommendation (CSTE, unpublished data, 2007), but a barrier in some areas has been the lack of personnel skilled at computer programming to perform these electronic linkages.
This report is based, in part, on contributions by F John. Clarke, PhD, Research and Analysis Div, and J Davidson-Rara Vital Records Div, State Center for Health Statistics Admin. De of Health, District of Columbia.
1. Glynn M, Rhodes P. Estimated HIV prevalence in the United Sta the end of 2003. [Abstract] 2005 National HIV Prevention Cos ence, June 12-15, Atlanta, GA. Available at http://www.aegis.com conferences/NHIVPC/2005/T1-B1101.html.
2. CDC. Cases of HIV infection and AIDS in the United States dependent areas, 2005: HIV/AIDS surveillance report, 2005. Val Revised ed. Atlanta, GA: US Department of Health and Hu Services, CDC; 2007. Available at http://www.cdc.gov/hiv/topsurveillance/resources/reports/2005 report/default.htm.
3. CDC and Council of State and Territorial Epidemiologists. Tech guidance for HIV/AIDS surveillance programs, volume I: policies procedures. Atlanta GA: US Department of Health and Huma Services, CDC; 2005.
4. National Program of Cancer Registries. Link Plus. Atlanta, GA S Department of Health and Human Services, CDC; 2007. Available a http://www.cdc.gov/cancer/npcr/tools/registryplus/lp.htm.
5. CDC. 1993 revised classification system for HIV infection and exparc surveillance case definition for AIDS among adolescents and ada MMWR 1992;41(No. RR-17):1–19.
6. CDC. Guidelines for national human immunodeficiency virus case surveillance, including monitoring for human immunodeficiency vir infection and acquired immunodeficiency syndrome. MMWR 1944 48(No. RR-18).
7. Mocroft A, Brettle R, Kirk O, et al. Changes in the cause of death among HIV positive subjects across Europe: results from the EuroSIDA stuct, AIDS 2002;16:1663–71.
8. Sackoff JE, Hanna DB, Pfeiffer MR, Torian LV. Causes of death among persons with AIDS in the era of highly active antiretroviral therap New York City. Ann Intern Med 2006;145:397–406.
9. CDC. National Death Index. Hyattsville, MD: US Department Health and Human Services, CDC, National Center for Health Stat tics. Available at http://www.cdc.gov/nchs/ndi.htm.
Notice to Readers
World Elder Abuse Awareness Day 2008 – June 15, 2008
By 2030, nearly one in five persons in the United Stats (approximately 72 million persons) will be aged ≥65 yers (1). As the number of older adults grows, so does the number of persons who might experience elder abuse or neglect, and associated injuries, social isolation, diminished well being, and increased risks for suicide and premature death.
World Elder Abuse Awareness Day, June 15, 2008, is a cam paign coordinated by the International Network for the re vention of Elder Abuse to raise awareness of elder abuse and neglect worldwide. The theme of this year's campaign is My World... Your World... Our World - Free of Elder Abuse In support of this campaign, organizations around the world are hosting events to increase recognition of elder abuse and
neglect as public health and human rights issues and raise awareness of the many factors that can lead to or limit abuse. Additional information regarding World Elder Abuse Awareness Day activities is available from the International Network for the Prevention of Elder Abuse at http://www.inpea.net.
1. Administration on Aging. Older population by age: 1900 to 2050. Washington, DC: US Department of Health and Human Services; 2005. Available at http://www.aoa.gov/prof/statistics/online_stat_data/ agepop2050.asp.
FROM THE NATIONAL CENTER FOR HEALTH STATISTICS
Age-Adjusted Percentage of Adults Aged >40 Years with Diagnosed
* 95% confidence interval.
During 2003-2006, non-Hispanic white adults aged >40 years with diabetes were more likely than their non-
SOURCE: National Health and Nutrition Examination Survey data, 2003-2006. Available at http://www.cdc.gov/