The Public Health Service has previously made recommendations on reducing the risk of HIV infection through consistent use of condoms (18). Additional recommendations include a guideline for manufacturers published by FDA that recommends proper labeling of condoms to include adequate instructions for use (Center for Devices and Radiological Health, FDA; letter to all U.S. condom manufacturers, importers, and repackagers, April 7, 1987). Users can increase the efficacy of condoms in preventing infection by using a condom properly from start to finish during every sexual exposure. It is unknown whether brands of condoms with increased thickness offer any more protection for anal or vaginal intercourse than thinner brands. Even with a condom, anal intercourse between an infected individual and an uninfected partner poses a risk of transmitting HIV and other sexually transmitted infections because condoms may break.

The following recommendations for proper use of condoms to reduce the transmission of STD are based on current information:

1. Latex condoms should be used because they offer greater protection against viral STD than natural membrane condoms (7).

2. Condoms should be stored in a cool, dry place out of direct sunlight.

3. Condoms in damaged packages or those that show obvious signs of age (e.g., those that are brittle, sticky, or discolored) should not be used. They cannot be relied upon to prevent infection.

4. Condoms should be handled with care to prevent puncture.

5. The condom should be put on before any genital contact to prevent exposure to fluids that may contain infectious agents. Hold the tip of the condom and unroll it onto the erect penis, leaving space at the tip to collect semen, yet assuring that no air is trapped in the tip of the condom.

6. Adequate lubrication should be used. If exogenous lubrication is needed, only water-based lubricants should be used. Petroleum- or oil-based lubricants (such as petroleum jelly, cooking oils, shortening, and lotions) should not be used since they weaken the latex.

7. Use of condoms containing spermicides may provide some additional protection against STD. However, vaginal use of spermicides along with condoms is likely to provide greater protection.

8. If a condom breaks, it should be replaced immediately. If ejaculation occurs after condom breakage, the immediate use of spermicide has been suggested (19). However, the protective value of postejaculation application of spermicide in reducing the risk of STD transmission is unknown.

9. After ejaculation, care should be taken so that the condom does not slip off the penis before withdrawal; the base of the condom should be held while withdrawing. The penis should be withdrawn while still erect.

10. Condoms should never be reused.

Condoms should be made more widely available through health-care providers who offer services to sexually active men and women, particularly in STD clinics, family planning clinics, and drug-treatment centers. These same facilities should become more assertive in counseling patients on STD prevention. Recommendations for prevention of STD, including HIV infection, should emphasize that risk of infection is most effectively reduced through abstinence or sexual intercourse with a mutually

Condoms - Continued

faithful uninfected partner. Condoms do not provide absolute protection from any infection, but if properly used, they should reduce the risk of infection.

Reported by: Center for Devices and Radiological Health, Food and Drug Administration. Div of Sexually Transmitted Diseases, Center for Prevention Svcs; AIDS Program, Center for Infectious Diseases, CDC.

References

1. Conant M, Hardy D, Sernatinger J, Spicer D, Levy JA. Condoms prevent transmission of AIDS-associated retrovirus [Letter]. JAMA 1986;255:1706.

2. Judson FN, Bodin GF, Levin MJ, Ehret JM, Masters HB. In vitro tests demonstrate condoms provide an effective barrier against Chlamydia trachomatis and herpes simplex virus [Abstract 176]. In: Program and abstracts of the fifth international meeting of the International Society for STD Research, Seattle, Washington, August 1-3, 1983.

3. Conant MA, Spicer DW, Smith CD. Herpes simplex virus transmission: condom studies. Sex Transm Dis 1984;11:94-5.

4. Smith L Jr, Oleske J, Cooper R, et al. Efficacy of condoms as barriers to HSV-2 and gonorrhea: an in vitro model [Abstract 77]. In: Program and abstracts of the first Sexually Transmitted Diseases World Congress, San Juan, Puerto Rico, November 15-21, 1981.

5. Katznelson S, Drew WL, Mintz L. Efficacy of the condom as a barrier to the transmission of cytomegalovirus. J Infect Dis 1984;150:155-7.

6. Minuk GY, Bohme CE, Bowen TJ, et al. Efficacy of commercial condoms in the prevention of hepatitis B virus infection. Gastroenterology 1987;93:710-4.

7. Van de Perre P, Jacobs D, Sprecher-Goldberger S. The latex condom, an efficient barrier against sexual transmission of AIDS-related viruses. AIDS 1987;1:49-52.

8. Goldsmith M. Sex in the age of AIDS calls for common sense and 'condom sense.' JAMA 1987;257:2261-6.

9. Stone KM, Grimes DA, Magder LS. Personal protection against sexually transmitted diseases. Am J Obstet Gynecol 1986;155:180-8.

10. Fischl MA, Dickinson GM, Scott GB, Klimas N, Fletcher MA, Parks W. Evaluation of heterosexual partners, children, and household contacts of adults with AIDS. JAMA 1987;257:640-4.

11. Mann J, Quinn TC, Piot P, et al. Condom use and HIV infection among prostitutes in Zaire [Letter]. Lancet 1986;316:345.

12. Hicks DR, Martin LS, Getchell JP, et al. Inactivation of HTLV/LAV-infected cultures of normal human lymphocytes by nonoxynol-9 in vitro [Letter]. Lancet 1985;2:1422-3.

13. Rietmeijer CAM, Krebs JW, Feorino PM, Judson FN. Condoms as physical and chemical barriers against human immunodeficiency virus. JAMA (in press).

14. Rosenberg MJ, Rojanapithayakorn W, Feldblum PJ, Higgins JE. Effect of the contraceptive sponge on chlamydial infection, gonorrhea, and candidiasis: a comparative clinical trial. JAMA 1987;257:2308-12.

15. Martin JL. The impact of AIDS on gay male sexual behavior patterns in New York City. Am J Public Health 1987;77:578-81.

16. Research and Designs Corporation, Communication Technologies. Designing an effective AIDS prevention campaign strategy for San Francisco: results from the 3rd probability sample of an urban gay male community. San Francisco: Research and Designs Corporation, Communication Technologies, 1986.

17. Centers for Disease Control. Antibody to human immunodeficiency virus in female prostitutes. MMWR 1987;36:157-61.

18. Centers for Disease Control. Additional recommendations to reduce the sexual and drug abuse-related transmission of human T-lymphotropic virus type Ill/lymphadenopathyassociated virus. MMWR 1986;35:152-5.

19. Hatcher R, Guest F, Stewart F, et al. Contraceptive technology 1986-1987. New York: Irvington Publishers, 1987.

Perspectives in Disease Prevention and Health Promotion

Progress Toward Achieving the National 1990 Objectives
for Injury Prevention and Control

The nation's health objectives, established in 1979 (1), include goals for preventing and controlling injuries. Nine of these objectives address intentional and unintentional injuries and have helped to set the priorities for injury control. Work-related injuries and some aspects of intentional injury prevention are addressed in other reviews of the 1990 objectives. The nine injury control objectives are presented below along with a status report and a discussion of pertinent risk factors and indicators as well as strategies for progress.

By 1990, the motor vehicle fatality rate should be reduced to no greater than 18.0/100,000 population (baseline rate in 1978: 23.6/100,000).

Status: The 1984 rate was 19.6/100,000. This objective is projected to be met, despite increases of 9% in the population, 13% in licensed drivers, 19% in registered motor vehicles, and 21% in the total vehicle miles traveled (2). According to data from the National Highway Traffic Safety Administration (NHTSA), the mortality rate per miles driven decreased from 3.26 deaths per 100 million miles traveled in 1978 to 2.48 deaths per 100 million miles traveled in 1986 (2). Motor vehicle crashes in 1986 resulted in 46,056 deaths (2).

The reduction in alcohol-related fatalities from 1982 through 1986 was a major contributor to the decreases in motor fatalities and fatality rates. The proportion of driver fatalities that involved a blood alcohol concentration (BAC) ≥0.10 mg/dL decreased from 44% in 1982 to 39% in 1986. Among youthful drivers (20-24 years of age), the proportion of fatalities involving a BAC ≥0.10 mg/dL dropped from 40% in 1982 to 34% in 1986. Arrests for alcohol-impaired driving increased from about 0.5 million in 1978 to 1.7 million in 1986. The legal age for the purchase or public possession of alcoholic beverages is now 21 years in all but one state.

The increasing use of seat belts was another major contributor to declines in motor vehicle fatality rates (3). From 1978 to 1986, overall use of seat belts increased from under 13% to over 39% (4). Twenty-nine states and the District of Columbia have now adopted laws making the use of seat belts mandatory.

By 1990, the motor vehicle fatality rate for children under 15 should be reduced to no greater than 5.5/100,000 children (baseline rate in 1978: 9.0/100,000).

Status: The 1984 rate was 6.6/100,000. If the current rate of decline continues, this objective will be met by 1990. According to data from NHTSA, the 1986 fatality rate was 25% below the 1978 rate, and the number of deaths decreased from 4,209 in 1978 to 3,160 in 1986 (2). Use of child restraints increased 413%, from approximately 15% in 1979 to 77% in 1986 (3). In 1978, one state had a law mandating the use of safety belts for children, but, by 1986, all 50 states and the District of Columbia had child-restraint laws.

By 1990, the death rate from falls should be reduced to no more than 2.0/100,000 population (baseline rate in 1978: 6.2/100,000).

Status: The 1984 rate was 5.1/100,000. This objective is not expected to be met by 1990, although the trend in the number of fatalities due to falls has been and continues to be decreasing. However, this objective has been met for persons under 65 years of age, whose mortality rate from falls was 1.5/100,000 in 1984. The overall

mortality rate from falls is affected by the disproportionately high rate among the elderly. In 1984, rates for the elderly ranged from 10.2/100,000 for 65- to 74-year-olds to 147.0/100,000 for persons 85 years of age and older. The downward trend of the overall crude fatality rate from falls may plateau or begin to rise as the proportion of the U.S. population aged 65 years or older increases. In addition, National Center for Health Statistics, CDC, mortality data may undercount fatalities from falls more than other fatalities. Because the fatal events that often follow hip fractures (e.g., pneumonia or pulmonary embolism) occur long after the fall, deaths may be misclassified (5,6).

Medical and behavioral factors that lead to falls include disorders of gait and balance and the use of certain prescription and nonprescription drugs (including alcohol). Environmental factors implicated as contributors to falls include items such as poor lighting and loose rugs. Survival after injury is greatly influenced by the immediate management of head trauma and hip fracture and by the subsequent prevention of venous thrombosis, pulmonary embolism, and pneumonia.

Advances in knowledge about these factors and their roles in fall-related mortality could highlight opportunities to prevent falls and fatalities from falls. Focused prevention efforts, based on clearly defined priorities, can help coordinate the activities of many governmental and nongovernmental entities in addressing this problem.

By 1990, the home injury fatality rate for children under 15 years of age should be no greater than 5.0/100,000 children (baseline rate in 1978: 6.0/100,000).

Status: The 1984 rate was 4.9/100,000. This objective has already been achieved. For nearly 50 years, home injury deaths and mortality rates for children under 15 years of age have steadily declined. In 1984, almost 40% of the injury deaths involving children under 5 years of age occurred in the home. The home injury fatality rate is highest for children under 1 year of age; however, the rate for this age group declined from 14.7/100,000 in 1979 to 11.9/100,000 in 1984.

The causes of home injury deaths include fires, drowning, suffocation, falls, firearms, and poisoning. Since 1978, home injury deaths have decreased in every category except poisoning. Deaths in that category increased from a rate of 0.12/100,000 population in 1978 to 0.15/100,000 in 1984. For children under 1 year of age, suffocation is now the most prevalent cause of death, whereas, for children 10 to 14 years of age, deaths are most often due to fires and unintentional firearm injuries. By 1990, the death rate from drowning should be reduced to no more than 1.5/100,000 persons (baseline rate in 1978: 3.2/100,000).

Status: The 1984 rate was 2.3/100,000. This objective is not expected to be met by 1990. During the last decade, boating activities, which have increased greatly, have exposed more people to the risk of drowning. Nonetheless, boating-related drownings declined from 1,242 to 944 between 1978 and 1984, and the rate decreased from 0.6/100,000 to 0.4/100,000 population, nearly a 29% reduction in the rate of such fatalities. Alcohol use by boat operators is increasingly recognized as contributing to boating fatalities (7). From 1978 to 1984, nonboating drownings decreased from 5,784 to 4,444, and the rate of such drownings decreased nearly 27%, from 2.6/100,000 to 1.9/100,000. Despite improved safety in residential swimming pools and spas, approximately 300 children under 5 years of age drown each year in this setting (8).

Injury Prevention - Continued

By 1990, residential fire deaths should be reduced to no more than 4,500 per year (baseline deaths in 1978: 5,401).

Status: The number of deaths in 1984 was 4,466. This objective was reached in 1984. The overall annual mortality rate due to residential fires decreased 21%, from 2.4/100,000 persons in 1978 to 1.9 in 1984. For males, the mortality rate due to residential fires decreased 20%, from 3.0/100,000 in 1978 to 2.4/100,000 in 1984. For females, the rate decreased 26%, from 1.9/100,000 in 1978 to 1.4/100,000 in 1984.

Mortality rates due to residential fires differ markedly for blacks and whites. In 1984, the rate among blacks was 4.8/100,000; it was 1.5/100,000 among whites. By region, the mortality rate due to residential fires was highest in the South and lowest in the West. By age group, it was highest for persons 65 years of age or older (4.6/100,000) and second highest for children under 5 years of age (4.1/100,000).

TABLE II. Notifiable diseases of low frequency, United States

*Four of the 53 reported cases for this week were imported from a foreign country or can be directly traceable to a known internationally imported case within two generations.