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Inside: Continuing Education Examination Inside: Inside: Continuing Continuing Medical Medical Education Education for forU.S. U.S. Physicians Physiciansand andNurses Nurses March 31, 2000 / Vol. 49 / No. RR-2 Recommendations and Reports CDC Recommendations Regarding Selected Conditions Affecting Women’s Health U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Disease Control and Prevention (CDC) Atlanta, GA 30333 2 MMWR March 31, 2000 The MMWR series of publications is published by the Epidemiology Program Office, Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services, Atlanta, GA 30333. SUGGESTED CITATION Centers for Disease Control and Prevention. CDC Recommendations Regarding Selected Conditions Affecting Women’s Health. MMWR 2000;49(No. RR-2):[inclusive page numbers]. Centers for Disease Control and Prevention .................. Jeffrey P. Koplan, M.D., M.P.H. Director The production of this report as an MMWR serial publication was coordinated in Epidemiology Program Office ............................................ Barbara R. Holloway, M.P.H. Acting Director Office of Scientific and Health Communications ...................... John W. Ward, M.D. Director Editor, MMWR Series Recommendations and Reports ................................... Suzanne M. Hewitt, M.P.A. Managing Editor Darlene D. Rumph-Person Project Manager and Editor Patricia A. McGee Project Editor Beverly H. Holland Visual Information Specialist Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services. Copies can be purchased from Superintendent of Documents, U.S. Government Printing Office, Washington, DC 20402-9325. Telephone: (202) 512-1800. Vol. 49 / No. RR-2 MMWR i Foreword As the nation’s prevention agency, CDC strives to accomplish its vision of “Healthy People in a Healthy World...Through Prevention.” For women, this involves working to better understand the health issues that have an adverse impact on women, disproportionately affect women, occur only in women, or have an impact on infant outcomes as a direct result of a pregnancy-related event. Women’s health once focused primarily on puberty, pregnancy, and menopause. Now, women’s health is recognized as being broad in focus and warranting additional attention and study and involves not only chronic conditions but individual lifestyle choices and environmental and organizational factors. This publication focuses on some of the specific issues affecting women’s health: falls and resulting hip fractures, sports injuries, breast and cervical cancer, and congenital toxoplasmosis. For each report, prevention recommendations and specific research recommendations are provided. Much still needs to be done. The publication addresses diverse and seemingly unconnected women’s health issues; however, these issues are very much connected, and several themes run throughout each of the reports. For example: • Prevention — whether primary or secondary — continues to reduce or prevent injury, disease, death, and disability. Prevention is an essential component to maintaining health. • Science continues to strengthen and support public health action on the individual, local, and national level. • Although much progress has been made in the area of women’s health to reduce morbidity and mortality, more prevention research needs to be done. • Public health affects every phase of our lives: how we live, work, and play. Whether the topic is falls in the home, injuries associated with leisure or workrelated activities, screening for toxoplasmosis, or implementation of an early detection program, prevention plays a vital role. Our partners in prevention (e.g., other health agencies, business, education, communities, and individuals) also play a vital role by developing and implementing prevention strategies and policies and by promoting healthy behaviors and environments. After reviewing each of these reports, examine current practices that have an impact on women’s health where you live, work, and play. Are there opportunities for improvement? As costs related to disease, disability, and injury continue to increase, the role of prevention to maintain health becomes more critical. Prevention is about staying healthy and living well—and prevention works for women. Yvonne Green Associate Director Office on Women’s Health ii MMWR March 31, 2000 Contents Reducing Falls and Resulting Hip Fractures Among Older Women ..................................................................................... 1 Background ...................................................................................................... 4 Scope of the Problem ...................................................................................... 4 Etiologic or Risk Factors .................................................................................. 5 Recommendations for Prevention.................................................................. 6 Primary Prevention ................................................................................... 6 Secondary Prevention ............................................................................... 8 Program and Research Agenda ...................................................................... 8 Conclusion ....................................................................................................... 9 References ...................................................................................................... 10 Exercise-Related Injuries Among Women: Strategies for Prevention from Civilian and Military Studies ............................................................... Background .................................................................................................... Definitions ............................................................................................... Scope of the Problem .................................................................................... Findings from Civilian Studies ............................................................... Findings from Military Studies ............................................................... Risk Factors for Exercise-Related Injuries ............................................. The Relation Between Sex and Level of Physical Fitness .................... Recommendations for Prevention................................................................ Research Agenda ........................................................................................... Research Needs ....................................................................................... Conclusion ..................................................................................................... References ...................................................................................................... 13 16 18 18 18 20 20 27 27 29 29 30 31 Vol. 49 / No. RR-2 MMWR Implementing Recommendations for the Early Detection of Breast and Cervical Cancer Among Low-Income Women ..................... Introduction .................................................................................................... Scope of the Problem .................................................................................... Breast Cancer .......................................................................................... Cervical Cancer ........................................................................................ Etiologic Factors ............................................................................................ Breast Cancer .......................................................................................... Cervical Cancer ........................................................................................ Recommendations for Prevention................................................................ Breast Cancer .......................................................................................... Cervical Cancer ........................................................................................ Implementation of the National Breast and Cervical Cancer Early Detection Program ..................................................................... Research Agenda ........................................................................................... Conclusion ..................................................................................................... References ...................................................................................................... Preventing Congenital Toxoplasmosis ........................................................ Introduction .................................................................................................... Scope of the Problem .................................................................................... Burden of Toxoplasmosis in the United States ..................................... Diagnosis and Treatment ........................................................................ Etiologic Factors ............................................................................................ Recommendations for Prevention................................................................ Research Agenda ........................................................................................... NWTPCT Recommendations for Research ............................................ CDC Priorities .......................................................................................... Conclusion ..................................................................................................... References ...................................................................................................... Exhibit ............................................................................................................ Participants in the National Workshop on Toxoplasmosis: Preventing Congenital Toxoplasmosis .................................................. iii 35 38 38 38 40 41 41 42 42 42 44 45 51 53 53 57 60 60 60 62 63 64 65 65 65 66 67 70 74 iv MMWR March 31, 2000 Vol. 49 / No. RR-2 MMWR Reducing Falls and Resulting Hip Fractures Among Older Women 1 2 MMWR March 31, 2000 The material in this report was prepared for publication by: National Center for Injury Prevention and Control ............................................................... Stephen B. Thacker, M.D., M.Sc. Acting Director Division of Unintentional Injuries Prevention ................. Christine Branche, Ph.D. Director Vol. 49 / No. RR-2 MMWR 3 Reducing Falls and Resulting Hip Fractures Among Older Women Judy A. Stevens, Ph.D. Sarah Olson, M.S. National Center for Injury Prevention and Control Division of Unintentional Injury Prevention Abstract Scope of the Problem: Fall-related injuries are the leading cause of injury deaths and disabilities among older adults (i.e., persons aged ³65 years). The most serious fall injury is hip fracture; one half of all older adults hospitalized for hip fracture never regain their former level of function. In 1996, a total of 340,000 hospitalizations for hip fracture occurred among persons aged ³65 years, and 80% of these admissions occurred among women. From 1988 to 1996, hip fracture hospitalization rates for women aged ³65 years increased 23%. Etiologic or Risk Factors: Risk factors for falls include increasing age, muscle weakness, functional limitations, environmental hazards, use of psychoactive medications, and a history of falls. Age is also a risk factor for hip fracture. Women aged ³85 years are nearly eight times more likely than women aged 65–74 years to be hospitalized for hip fracture. White women aged ³65 years are at higher risk for hip fracture than black women. Other risk factors for hip fracture include lack of physical activity, osteoporosis, low body mass index, and a previous hip fracture. Recommendations for Prevention: Because approximately 95% of hip fractures result from falls, minimizing fall risk is a practical approach to reducing these serious injuries. Research demonstrates that effective fall prevention strategies require a multifaceted approach with both behavioral and environmental components. Important elements include education and skill building to increase knowledge about fall risk factors, exercise to improve strength and balance, home modifications to reduce fall hazards, and medication assessment to minimize side effects (e.g., dizziness and grogginess). Program and Research Needs: Coordination needs to be improved among the diverse Federal, state, and local organizations that conduct fall prevention activities. The effectiveness of existing fall prevention programs among specific groups of women (e.g., those aged ³85 years or living with functional limitations) needs careful evaluation. New primary fall prevention approaches are needed (e.g., characterizing footwear that promotes stability), as well as secondary prevention strategies (e.g., protective hip pads) that can prevent injuries when falls occur. Finally, efforts are needed to increase collaboration among national experts from various disciplines, to reach consensus regarding priority research areas and program issues, and to work toward long-term strategies for reducing falls and fall-related injuries among older adults. Conclusion: Persons aged ³65 years constitute the fastest-growing segment of the U.S. population. Without effective intervention strategies, the number of hip fractures will increase as the U.S. population ages. Fall prevention programs have reduced falls and fall-related injuries among high-risk populations using multifaceted approaches that 4 MMWR March 31, 2000 include education, exercise, environmental modifications, and medication review. These programs need to be evaluated among older adults aged ³65 years who are living independently in the community. In addition, secondary prevention strategies are needed to prevent hip fractures when falls occur. Effective public health strategies need to be implemented to promote behavioral changes, improve current interventions, and develop new fall prevention strategies to reduce future morbidity and mortality associated with hip fractures among older adults. BACKGROUND Older adults (i.e., persons aged ³65 years) are the fastest-growing segment of the U.S. population. In 1990, 13% of the population was aged ³65 years; by 2050, this proportion will nearly double to 23% (1 ). The number of persons aged ³65 years is projected to increase from 31.0 million in 1990 to 68.1 million by 2040; for persons aged ³85 years, the relative growth is even faster (1 ). This report summarizes current knowledge about falls and hip fracture among women aged ³65 years and describes both primary and secondary strategies for preventing fall-related injuries. When discussing research results, the term “significant” refers to a documented p-value of p £ 0.05. SCOPE OF THE PROBLEM Falls are the leading cause of injury deaths and disabilities among persons aged ³65 years. In the United States, one of every three older adults falls each year (2,3 ). In 1997, nearly 9,000 persons aged ³65 years died from falls (4 ). Of those who fall, 20%–30% sustain moderate to severe injuries that reduce mobility and independence and increase the risk for premature death (5 ). Older adults are hospitalized for fall-related injuries five times more often than they are for injuries from other causes (5 ), and women are nearly three times more likely than men to be hospitalized for a fall-related injury (5 ). The most prevalent fall-related injuries among older adults are fractures of the hip; spine; upper arm; forearm; and bones of the pelvis, hand, and ankle (6 ). Of these, the most serious injury is hip fracture, a leading cause of morbidity and excess mortality among older adults (7 ). During 1988–1996, the estimated number of hospital admissions for hip fracture increased from 230,000 to 340,000 (Figure 1). In 1996, 80% of the admissions for hip fracture occurred among women (8 ). The rate of hospitalization for hip fracture differs by sex. The hip fracture hospitalization rate for persons aged ³65 years is significantly higher for women than men (9 ). During 1988–1996, the rates for women increased significantly, from 972 per 100,000 to 1,356; for men, rates remained stable (9 ). A Healthy People 2010 objective is to reduce the hip fracture hospitalization rate among women aged ³65 years to no more than 879 per 100,000 (objective 15-28a). Hip fracture hospitalization rates are substantially higher for white women than black women. In 1996, the hospitalization rate for white women aged ³65 years was 1,174 per 100,000, five times the rate for black women (9 ). A Healthy People 2010 objective is to reduce hip fracture hospitalization rates among white women aged ³65 years to no more than 932 per 100,000 (objective 15-28a). The overall increase in hip fracture hospitalization rates can be explained in part by the increasing U.S. population of very old adults (i.e., persons aged ³85 years). Today, a