Fever, endometritis, hemorrhage, retained products of conception, and convulsions each were significantly more frequent for PGF2a abortions. In addition, PGF2a abortions required operative treatment of complications significantly more often than saline abortions, including laparotomy, hysterotomy, and hysterectomy as well as curettage or manual evacuation of the uterus.

Lengths of hospital stay were similar for patients in both groups (mean 2.1 days), although PGF2a produced significantly shorter induction-to-abortion times: 24.8 vs. 29.2 hours. On the other hand, PGF2a abortion patients were significantly more likely to be readmitted to a hospital than saline abortion patients.

D&E vs. Saline: JPSA/CDC studied 6,213 D&E and 8,662 saline instillation patients in the 13- to 20-week interval. Characteristics of women in these 2 groups were again similar: most were young, unmarried, primigravidas, and free of preexisting medical conditions. D&E abortions utilized suction curettage frequently in conjunction with crushing forceps or sharp curettage. Cervical dilatation was accomplished by using graduated metal dilators.

D&E in the 13- to 20-week interval was significantly safer than saline instillation. The major complication rate for D&E was 0.69%, while that of saline instillation was 1.78%. The relative risk of sustaining 1 or more major complications was 2.6 times higher for saline instillation than for D&E.

D&E was significantly safer than saline instillation in the 13- to 16 and 17- to 20-week intervals. Standardized for preexisting medical conditions, prophylactic antibiotic administration, and level of training of the operator, D&E remained significantly safer than saline.

Fever, endometritis, hemorrhage, retained products of conception, and urinary tract infection were each signifi

cantly more frequent among saline instillation patients, while cervical injury and uterine perforation were significantly more frequent in D&E patients. Rates of uterine perforation, however, did not increase significantly with advancing gestational age.t

D&E patients required curettage or manual evacuation of the uterus as treatment of a complication significantly less often than saline instillitation patients, although cervical suturing as a treatment was significantly more frequent among D&E patients. D&E patients spent significantly less time in the hospital (mean 0.2 days). Readmission rates were not significantly different for the 2 groups.

Editorial Note: Current tenets hold that intraamniotic prostaglandin F2a is the safest available method of midtrimester abortion, that saline instillation is less safe than PGF2a, and that D&E beyond the twelfth menstrual week is both unsafe and impractical (1,2). Among the patients in JPSA/CDC, however, midtrimester D&E was significantly safer than saline, which was significantly safer than PGF2aStatistical testing showed that chance is an unlikely explanation for the differences observed.

Reported by Abortion Surveillance Br, Family Planning Evaluation Div, Bur of Epidemiology, CDC; and C Tietze, MD, The Population Council, New York City.

References

1. Anderson GG, Hobbins JC, Rajkovic V, et al: Midtrimester therapeutic abortion using intraamniotic PGF20 in Bergstrom S (ed): Advances in the Biosciences 9. Oxford, Pergamon Press, 1973 2. Brenner WE: Second trimester interruption of pregnancy, in Taymor ML. Green TH Jr (eds): Progress in Gynecology, Vol. VI. New York, Grune & Stratton, Inc, 1975

† Gestational age was calculated for 94% of patients by subtracting the date of the last menstrual period from the date of abortion; the physician's estimate of gestational age was used for the 6% of patients for whom 1 or both dates were unknown.

In response to a recent request from the HEW Refugee Task Force, the Center for Disease Control collected data on the health status of Indo-Chinese refugees in this country. Information was obtained directly from a random sample of the refugees and their sponsors in 3 widely separated cities in the United States March 1-May 30, 1976. One of every 2 families in Atlanta, Georgia, and Fort Smith, Arkansas, and 1 of every 6 families in San Diego, California, were part of the study. The sample totaled 83 families and 396 people.

Dental problems were the most common health problem found; 48% of the refugees reported such illness. Respiratory disease, undiagnosed fevers, and obstetrical and gynecological problems were also found.

There were 5 cases of communicable disease of public health importance in this group for a prevalence rate of 1.2%. These cases included 2 cases of tuberculosis, and 1 case each of Hansen's disease, syphilis, and malaria. All 5 patients were under treatment.

Health care access varied markedly by region. Threefourths of the refugees were covered by a health insurance plan. Private plans predominated in Atlanta and Fort Smith while public coverage via Medi-Cal predominated in San Diego. Ninety percent of the refugees sampled in San Diego were covered by some insurance plan.

Reported by the Center for Disease Control.

Wyoming is the first state in the union to have more than 70% of its population 18 years and older inoculated with influenza vaccine. In the period October 4 - November 15, 1976, 155,213 persons or 73.2% of those 18 and older received influenza vaccine in 164 mass vaccination clinics conducted thoroughout the state in all population

aggregates of more than 100 persons.

(1)

The early success of the program is attributed to: Identifying the program as a local effort in response to a need to protect the local community, rather than as part of a state or national campaign:

(2) Using local leaders to promote and implement the campaign;

(3) Emphasizing local media as the primary means of informing the public of the need for the program; and (4)

Making the vaccine not only available but truly accesEpidemiologic Notes and Reports

and times to meet the convenience of the persons being immunized.

Reported by HS Parish, MD, State Epidemiologist, Wyoming State Dept of Health & Social Services; and National Influenza Immunization Program, CDC.

A 32-year-old man from a rural area in Missouri became ill on October 10 with a cough, sore throat, low grade fever, and malaise. An acute serum sample was obtained on October 20, and a convalescent serum sample was drawn on November 13. The state laboratory found that titers to A/ Victoria/75 and B/Hong Kong/72 remained stable while the titer to A/New Jersey/76 increased from 1:10 to 1:80. CDC has confirmed these findings.

A serologic survey on 20 persons in the community who had recently had febrile upper respiratory infections and on the man's son showed single positive titers to A/New Jersey in 4 persons, 3 of whom were over the age of 55 and one, aged 20, who had a titer of 1:10. Initial investigation sug

gests a slight increase in febrile upper respiratory tract infections in early November in that area. While the work of the index patient did take him to rural areas, he had no known contact with swine. An investigation is currently underway by the state Department of Health and Welfare and CDC.

In the absence of virus isolation or other serologic conversions in the community, the significance of this finding is uncertain.

Reported by JL Meyer, MD, Concordia; HD Donnell Jr, MD, Missouri State Dept of Health & Welfare; and the National Influenza Immunization Program, CDC.

H.

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Epidemiologic Notes and Reports

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During the 3-month interval June 28-September 30, 1976, 151 isolates of coxsackieviruses A9, B2, B3, and B4 were made from 117 patients at the Nassau County (New York) Medical Center. This compares with an average annual incidence of 44 isolations of these same agents for the years 1970-1975 (Table 1). Coxsackie B3 was isolated from 52 of the 117 patients, B4 from 51.

Eighty-two percent of the cases were in children less than 10 years of age, 25% occurring in children under 1 year old. Although mild symptomology was most common, more severe symptoms and diseases, such as paralysis and hepatitis, occasionally were seen (Table 2).

Twenty-six patients (22%) were diagnosed clinically as having aseptic meningitis. Virus was isolated from cerebrospinal fluid in 6, and from the throat, nasopharynx, or rectum in the remaining 20. One patient, a 13-year-old girl, presented with temporary bilateral paralysis to the midthigh; coxsackie B4 was isolated from her rectal swabs. Three children presented with jaundice. Coxsackie B3 was isolated from 2 of the children initially: from the throat and nasopharynx of a 5-day-old male, and from throat swabs of a 4-week-old female. Coxsackie B4 was isolated from rectal swabs of the third child at age 4 weeks, and coxsackie B3 from rectal and nasopharyngeal swabs at 6 weeks.

Two children, aged 7 and 10 days, died of coxsackievirus infection. In the first case, the mother developed a fever on the second postpartum day, and the next day her male infant developed fever and aseptic meningitis; he died 4 days thereafter. Rectal swabs of the mother and throat, nasopharyngeal, and rectal swabs, and lung tissue of the infant all grew coxsackie B4. In the second case a 10-dayold male infant presented with a history of poor feeding, fever, and cyanotic episodes; he died on the day of admission. The baby's mother had had fever shortly after delivery but was not cultured. Nasopharyngeal swabs of the infant grew coxsackie B2, and autopsy confirmed a diagnosis of acute myocarditis.

Reported by MH Kaplan, MD, SW Klein, MD, and J McPhee, MS, Nassau County Medical Center; DO Lyman, MD, State Epidemiologist, New York State Dept of Health; and Enteric Viral Diseases Section, Viral Diseases Div, Bur of Epidemiology, CDC.

Editorial Note: Most of the 60 "common" enterovirus serotypes that are prevalent during the summer months appear to cause localized or occasional national epidemics at irregular intervals. The clinical spectrum of disease caused by the different agents is remarkably similar, though there are notable exceptions, such as the association of cardiac disease with coxsackie B viruses, and vesicular exanthema with coxsackie A viruses.

In addition to the clinical syndromes already mentioned, rash is frequently noted and may be of a considerable aid in diagnosis. It is commonly pink, discrete, and maculopapular, although occasionally it is petechial, urticarial, or telangiectatic, and especially with some coxsackie A infections, vesicular. Other syndromes include pericarditis and various types of respiratory tract disease such as upper respiratory infection, croup, and bronchiolitis. Paralysis is a rare but well-recognized complication of infection. Hepatitis is also uncommon, occurring primarily in infants with generalized severe infection.