ATW1H%ASUACAD.BITNET@oac.ucla.edu (Dr David Dodell) (08/20/89)
--- begin part 2 of 3 cut here ---
includes the National Insitutes of Health, the Food and Drug Administration
and several lesser known agencies.
"What is enough (money for AIDS)?" he asked rhetorically. "We can't drop
infant mortality or cancer. We could drop any other of these and do more on
AIDS, but I don't think that is what the nation wants us to do."
Pelosi, expressing concern that three specific early treatment
demonstration programs for which she won congressional authorization have not
been funded, acknowledged that "there has to be a bigger pie" and that the
congressional appropriations committees do not like to be "too specific" in
how they allocate money.
On the other hand, she said, health programs have little hope of getting a
larger slice of the federal budget pie "unless the (HHS) department is going
to squeak a lot louder."
Mason assured the congresswoman that HHS Secretary Louis Sullivan "is a
very squeaky secretary."
Still, Mason suggested that most of the money appropriated to the
department is very specifically defined.
"We have been getting very clear guidance except when we get an
authorization without an appropriation," he said.
The human resources and intergovernmental relations subcommittee of the
House Committee on Government Operations, which held Tuesday's hearing, does
not have jurisdiction for legislation either authorizing or appropriating
money for HHS programs.
UNICEF: ONE MILLION CHILDREN DIE OF PREVENTABLE DISEASES
Nearly one million children die of preventable diseases in bangladesh
annually, a bangladesh official said here today. speaking at a meeting to
launch a one-year-long program of immunization in dhaka city, abdul malek,
mayor of dhaka, said bangladesh has the second highest child mortality in the
world after nepal and six percent of all child and infant deaths occur in this
country. most of the victims die of tuberculosis, polio, pertussis and measles
which can be prevented through immunization, he said. earlier this year, the
united nations international children's emergency fund (unicef) announced a
10-year-long immunization program in bangladesh to save about 200,000 children
Health InfoCom Network News Page 10
Volume 2, Number 30 August 19, 1989
less than one-year old annually from dying of some infectious diseases. the
immunization program in bangladesh is the second largest unicef assisted
program in the world and unicef contribution to bangladesh is rising from 21
million u.s. dollars to 25 million dollars during the current year.
Health InfoCom Network News Page 11
Volume 2, Number 30 August 19, 1989
===============================================================================
Center for Disease Control Reports
===============================================================================
Morbidity and Mortality Weekly Report
Thursday August 10, 1989
Epidemiologic Notes and Reports
Non-A, Non-B Hepatitis -- Illinois
From November 15, 1988, through June 30, 1989, 17 cases of non-A, non-B
(NANB) hepatitis were reported to the Wabash County (Illinois) Health
Department. In Wabash County, a small rural county in southern Illinois
(estimated 1987 population: 13,800), only one other case of NANB hepatitis had
been reported since 1982.
Of the 17 reported cases, 14 met a case definition for NANB hepatitis: an
acute illness with symptoms and signs of hepatitis, elevated serum alanine
aminotransferase (ALT) levels greater than 2.5 times the upper limit of
normal, and negative serologic markers for acute hepatitis A and B. Interviews
with local physicians and review of the county hospital's medical records and
emergency room log books detected no other cases among Wabash County residents
since September 1988, but three cases were identified in neighboring counties
(Figure 1). Based on cases reported from January through June 1989, the annual
rate of NANB hepatitis for Wabash County was 87.0 per 100,000 population, more
than 100 times higher than the rate for all of Illinois during 1988 (0.7 per
100,000). Of the 17 cases in Wabash and neighboring county residents, six
(35%) were male; 16 (94%) were white, and one was American Indian; and the
median age was 28 years (range: 14-36 years). Nine (53%) patients were
clinically jaundiced, and nine (53%) required hospitalization for their acute
illness. Peak ALT values at onset of illness ranged from 201 to 3950 (median:
1493).
Patients were contacted to identify potential risk factors for acquiring
NANB hepatitis. For 12 patients, information was obtained by interview, and
for five, from medical chart review. Seven (41%) patients admitted to
intravenous (IV)-drug use, and five (29%) were suspected IV-drug users. Of the
seven who admitted IV-drug use, four used heroin and/or cocaine; one used
heroin, cocaine, and methamphetamine; one used only methamphetamine; for one,
the drug was unknown. Three of the 12 patients reported drinking greater than
55 ounces of alcohol per week. None of the patients reported blood
transfusion within 6 months before onset of illness; none reported employment
in a health-care setting with frequent blood exposure; and none reported
sexual contact within 6 months before onset of illness with a person known to
have had NANB hepatitis.
Blood specimens were obtained in late May and in June from 12 of the
patients and 28 of their household, sexual, and needle-sharing contacts. All
contacts denied symptoms of hepatitis. However, four had abnormal ALT values:
three with histories of IV-drug use (elevations of 57-91 units/liter (upper
limits of normal range from 36 to 53)) and a 6-year-old boy (ALT of 430) whose
mother was a case-patient. All contacts were negative for IgM antibody to
hepatitis B core antigen; of those with elevated ALT values, all were negative
for IgM antibody to hepatitis A virus. Serologic testing of patients and
contacts using a new assay for a parenterally transmitted NANB hepatitis virus
is pending (1). Efforts will be made to obtain follow-up specimens to
determine the extent of transmission to household and sexual contacts.
IV-drug use has existed in the county for many years; most drug users are
Health InfoCom Network News Page 12
Volume 2, Number 30 August 19, 1989
thought to reside within the community and to have limited interaction with
drug users from other areas. However, the apparent index patient was an IV-
drug user who had lived intermittently in other states; he had recently
returned to the area and became ill 1 week after arrival in November. Before
his illness, he shared needles with another person who became ill 4 weeks
later. Among the cases in March and April, two distinct clusters occurred that
involved persons who were both friends and known or suspected IV-drug users.
During the New Year holiday, some of these persons attended parties at which
IV drugs were reportedly used. One IV-drug user reported that, because the
area's needle supply had been scarce during the past year, needle-sharing had
increased.
Reported by: MR Lynn, MP Henry, MA, Wabash County Health Dept, Mount Carmel;
JM Ottolini, CW Langkop, MSPH, JD Roder, RJ Martin, DVM, Div of Infectious
Diseases, Illinois Dept of Public Health. Hepatitis Br, Div of Viral and
Rickettsial Diseases, Center for Infectious Diseases, CDC.
Editorial Note: Parenterally transmitted NANB hepatitis accounts for 20%-40%
of acute viral hepatitis in the United States. Although it has traditionally
been considered a transfusion-associated disease, studies of community-
acquired NANB hepatitis and data from the CDC national surveillance system
have shown that 23%-42% of NANB hepatitis cases are associated with IV-drug
use (2,3); in addition, 8%-11% are attributed to blood transfusion and 4%-8%
to health-care occupational exposure. However, for as many as 57%, no source
of infection can be identified (3). In this outbreak, the high proportion of
ill persons who were confirmed or suspected IV-drug users and the lack of an
identifiable common hepatotoxic chemical or drug suggest that the etiologic
agent is parenterally transmitted NANB hepatitis virus.
Community-based outbreaks of parenterally transmitted NANB hepatitis have
not been reported previously in the United States. Large outbreaks of NANB
hepatitis occur in developing countries (4); however, in these settings, the
disease is transmitted enterically and is caused by an agent distinct from
that causing paren terally transmitted NANB hepatitis (5). This enterically
transmitted form of disease is not believed to occur in the United States
except for occasional imported cases (6).
The role of person-to-person contact in the transmission of NANB hepatitis
in the United States has not been well defined. Transmission between spouses
has been observed (7). In addition, a recent case-control study of patients
with acute NANB hepatitis showed that contact with multiple heterosexual
partners and household or sexual contact with a person who had had hepatitis
were associated with risk for disease (8).
A portion of the genome of a virus that is probably a major cause of
parenterally transmitted NANB hepatitis was recently cloned and a candidate
serologic assay was developed (1,9). The assay should assist with studies of
the mechanisms and extent of transmission of NANB hepatitis outside the
transfusion setting, such as transmission by household and sexual contact.
Previous studies of household and sexual transmission of NANB hepatitis using
ALT testing have been limited by the lack of specificity of ALT values and the
possibility of asymptomatic, biochemically silent transmission.
IV-drug use traditionally has been considered a problem of urban areas.
The recognition of a high prevalence of drug use and an associated epidemic of
a bloodborne disease in this rural community and the increased recognition of
outbreaks of hepatitis A and B among drug users in rural settings (10-12)
emphasize that IV-drug use is not limited to urban areas. This recognition
also underscores the need for prevention and treatment programs in many
Health InfoCom Network News Page 13
Volume 2, Number 30 August 19, 1989
geographic areas.
References
1. Kuo G, Choo Q-L, Alter HJ, et al. An assay for circulating antibodies to a
major etiologic virus of human non-A, non-B hepatitis. Science 1989;244:362-
4.
2. Alter MJ, Hadler SC, Francis DP, Maynard JE. The epidemiology of non-A,
non-B hepatitis in the United States. In: Dodd RY, Barker LF, eds. Infection,
immunity, and blood transfusion. New York: Alan R. Liss, 1985:71-9.
3. CDC. Hepatitis surveillance report no. 52. Atlanta: US Department of
Health and Human Services, Public Health Service, 1989:25-7.
4. Ramalingaswami V, Purcell RH. Waterborne non-A, non-B hepatitis. Lancet
1988;1:571-3.
5. Krawczynski K, Bradley DW. Enterically transmitted non-A, non-B hepatitis:
identification of virus-associated antigen in experimentally infected
cynomolgus macaques. J Infect Dis 1989;159:1042-9.
6. De Cock KM, Bradley DW, Sandford NL, Govindarajan S, Maynard JE, Redeker
AG. Epidemic non-A, non-B hepatitis in patients from Pakistan. Ann Intern Med
1987;106:227-30.
7. Guyer B, Bradley DW, Bryan JA, Maynard JE. Non-A, non-B hepatitis among
participants in a plasmapheresis stimulation program. J Infect Dis
1979;139:634-40.
8. Alter MJ, Coleman PJ, Alexander WJ, et al. Importance of heterosexual
activity in the transmission of hepatitis B and non-A, non-B hepatitis. JAMA
1989;262:1201-5.
9. Choo Q-L, Kuo G, Weiner AJ, Overby LR, Bradley DW, Houghton M. Isolation
of a cDNA clone derived from a blood-borne non-A, non-B viral hepatitis
genome. Science 1989; 244:359-62.
10. CDC. Hepatitis B--New Bern, North Carolina. MMWR 1979;28:373-4.
11. CDC. Fulminant hepatitis B among parenteral drug abusers--Kentucky,
California. MMWR 1984;33:70,76-7.
12. Harkess J, Gildon B, Istre GR. Outbreaks of hepatitis A among illicit drug
users, Oklahoma, 1984-87. Am J Public Health 1989;79:463-6.
Health InfoCom Network News Page 14
Volume 2, Number 30 August 19, 1989
Progress Toward Eradicating Poliomyelitis from the Americas
The World Health Organization (WHO) estimates that greater than 250,000 cases
of paralytic poliomyelitis occur each year worldwide (WHO, unpublished data,
1986). The introduction and widespread use of inactivated poliovirus vaccine
(IPV) in 1955 and live, attenuated oral poliovirus vaccine (OPV) in 1961
dramatically affected the reported incidence of poliomyelitis in the United
States and other developed countries (1).
During the early 1980s, intensive, biannual national vaccination campaigns
substantially reduced the number of polio cases in Brazil (2). In addition,
from 1975 to 1984, the number of countries in the Western Hemisphere reporting
cases decreased from 19 to 11. These successes led the Pan American Health
Organization (PAHO) in 1985 to establish a goal of and a plan for eradication
of the indigenous transmission of wild polioviruses from the Americas by the
end of 1990. A major objective of the plan was to establish regional and
national surveillance systems so that 1) all cases of acute flaccid paralysis
could be rapidly investigated to determine whether they were polio-related and
2) control measures to stop transmission could be rapidly implemented after
the report of a suspected case of polio. A second major objective was to
increase vaccination levels with three doses of OPV to at least 80% in
children by 1 year of age in each country of the region by 1990.
Progress has been made since the goal was announced, particularly since
April 1987, when the plan received formal funding. The intensification of
surveillance activities since 1986 resulted in a 77% increase in notification
of acute flaccid paralysis regionwide in 1988 over that in 1985 (Table 1).
Despite this increase, the incidence of confirmed* polio reported in the
region has declined. In 1988, 335 confirmed cases were reported in the
Americas (Table 1), representing a 64% decline from 1986 (930 cases) and a 49%
decline from 1987 (652 cases). In addition, the stable, low level of polio
activity in the region during 1988, as well as the absence of large outbreaks
(Figure 1) (such as occurred in Brazil in 1986), suggest that transmission of
polio has been substantially suppressed. In 1989, as of July 22, 66 confirmed
cases of polio have been reported, representing a 71% decrease from the 224
cases reported during the same period in 1988.
Since 1987, the laboratory network for characterizing polioviruses
isolated from stool specimens obtained from persons with suspected polio has
been greatly strengthened. Preliminary laboratory data for 1988 indicate that
32** wild polioviruses were isolated from patients in five countries, compared
with 43 isolates from patients in six countries in 1987.
The decrease in the proportion of "municipios" (counties or districts)
with confirmed polio cases in the region during 1985-1988 also indicates
substantial progress (Table 2). Only 1.9% of the nearly 14,400 municipios
reported confirmed polio cases in 1988, suggesting that circulation of wild
poliovirus is focal and confined to a small proportion of geopolitical units.
Regionwide data on polio vaccination levels, which have been available
since 1978, should be interpreted with caution because of changes over time in
the methodology for assessing coverage, in the personnel assessing the data,
and in the population estimates used as denominators in the calculations.
Regionwide OPV coverage of children by 1 year of age based on three doses of
vaccine was estimated at 82% in 1988. However, four countries (Brazil, Cuba,
Mexico, and Paraguay), constituting 56% of the total annual birth cohort in
the region, rely primarily on biannual national vaccination campaigns for
routine vaccination of infants and report OPV coverage based on two doses of
vaccine. A separate analysis was done that comprises only the 35 countries
Health InfoCom Network News Page 15
Volume 2, Number 30 August 19, 1989
that report data based on three doses of vaccine (Figure 2). A steady increase
in OPV coverage based on three doses occurred during 1980-1988 in these
countries, reaching an all-time high of 71% in 1988. Nonetheless, the goal of
achieving vaccination levels of at least 80% in these countries by 1990 will
be difficult to achieve. Special vaccination efforts, including house-to-house
vaccination, are under way in several countries to attempt to achieve this
goal.
Reported by: Expanded Programme on Immunization, Pan American Health
Organization, Washington, DC. International Health Program Office; Respiratory
and Enterovirus Br, Div of Viral Diseases, Center for Infectious Diseases;
Surveillance, Investigations, and Research Br, Div of Immunization, Center for
Prevention Svcs, CDC.
Editorial Note: The eradication of smallpox in 1977 suggested the potential
for eradication of other infectious diseases. In 1985, PAHO embarked on an
initiative to eradicate the indigenous transmission of wild polioviruses in
the Western Hemisphere by 1990. Reported polio in the region declined by 64%
during 1986-1988; a record low of 335 confirmed cases was reported in 1988.
The circulation of wild poliovirus is probably focal within the region. Polio
surveillance systems are functioning well in all countries of the region.
Despite improvement in capability of isolating wild polioviruses since 1987,
the decrease in the number of wild virus isolates provides additional evidence
of progress in interrupting circulation of wild poliovirus in the region. If
the current level of effort is sustained and special efforts are directed
toward the remaining foci of infection, eradication of polio from the Americas
probably can be achieved.
Even though progress toward polio elimination has been substantial,
indigenous polio transmission may continue in at least one country after 1990.
Those countries at highest risk include Brazil, Colombia, Guatemala, Haiti,
Mexico, and Peru. Technical and operational problems must still be addressed
and overcome if the initiative is to succeed.
Financial support is crucial to the success of the project. In addition to
ongoing support by the governments of the member states of PAHO, several donor
agencies have contributed to a grant totaling $47.6 million for 1987-1991
(U.S. Agency for International Development ($20.6 million), Rotary
International ($10.7 million), Inter-American Development Bank ($6.6 million),
United Nations Children's Fund ($5.0 million), and PAHO/WHO ($4.7 million)).
Overall project direction and management have been provided by PAHO's Expanded
Programme on Immunization office.
The prospect of polio eradication in the Americas led the 41st World
Health Assembly of WHO to adopt a resolution in May 1988 to eradicate
poliomyelitis from the world by the year 2000 (4). The U.S. government is
committed to providing technical and financial assistance for the eradication
effort.
Global eradication of poliomyelitis can be accomplished by a strategy that
includes achievement and maintenance of high immunization levels, effective
surveillance to detect all new cases, and a rapid vigorous response to the
occurrence of new cases (5). International collaboration will be necessary to
achieve this goal. Operational obstacles must be overcome to ensure
vaccination of all persons, and research efforts must be directed at improving
vaccination schedules and/or formulations of existing vaccines. Eradication of
polio in the Americas is an essential first step in the strategy toward global
eradication.
Health InfoCom Network News Page 16
Volume 2, Number 30 August 19, 1989
References
1. Kim-Farley RJ, Bart KJ, Schonberger LB, et al. Poliomyelitis in the USA:
virtual elimination of disease caused by wild virus. Lancet 1984;2:1315-7.
2. Risi JB Jr. The control of poliomyelitis in Brazil. Rev Infect Dis
1984;6(suppl 2):S400-3.
3. Health and Welfare Canada. A case of paralytic poliomyelitis--Ontario.
Canada Dis Weekly Rep 1988;14:229-30.
4. World Health Assembly. Global eradication of poliomyelitis by the year
2000. Geneva: World Health Organization, 1988. (Resolution WHA41.28).
5. Hinman AR, Foege WH, de Quadros CA, Patriarca PA, Orenstein WA, Brink EW.
The case for global eradication of poliomyelitis. Bull WHO 1987;65:835-40.
*The following case definitions for paralytic poliomyelitis have been
implemented by PAHO: A suspected case is any acute onset of paralysis in a
person less than 15 years of age for any reason other than severe trauma, or
paralytic illness in a person of any age in which polio is suspected. The
classification of a suspected case is temporary; within 48 hours of
notification, the case should be reclassified as "probable" or "discarded." A
probable case is a suspected case with acute flaccid paralysis and no other
cause that can be immediately identified. The classification of a probable
case is also temporary, and within 10 weeks of its onset the case should be
reclassi fied as "confirmed" or "discarded." A probable case is classified as
confirmed if there is: 1) laboratory confirmation (wild virus grown from stool
or a greater than or equal to 4-fold rise in poliovirus neutralization
antibody titer between acute and convalescent serum specimens); 2)
epidemiologic linkage to a probable or confirmed case; 3) residual paralysis
60 days after onset; 4) death; or 5) lack of follow-up of the case.
**Does not include a wild poliovirus type 1 isolate from a patient in Canada
(3).
Health InfoCom Network News Page 17
Volume 2, Number 30 August 19, 1989
Urogenital Anomalies in the Offspring of Women Using Cocaine during
Early Pregnancy -- Atlanta, 1968-1980
Recent clinical and animal studies have suggested a possible association
between maternal cocaine use early in pregnancy and the occurrence of
congenital urogenital anomalies. To study that association, CDC analyzed data
obtained in 1982-1983 from the population-based Atlanta Birth Defects Case-
Control Study (ABDCCS). The results suggest that mothers who reported cocaine
use early in pregnancy had a nearly fivefold higher risk of having babies with
urinary tract anomalies than mothers who reported no cocaine use (1).
The ABDCCS collected information from parents of babies with major
congenital anomalies who were born in the metropolitan Atlanta area from 1968
through 1980 and who were identified through the Metropolitan Atlanta
Congenital Defects Program. Of 7133 eligible case-babies, interviews were
completed by 4929 (69%) of case-mothers. Birth certificates were used to
identify babies without birth defects born in the same area. Controls were
matched with case-babies by race, hospital of birth, and calendar quarter of
birth. Of 4246 control-babies, 3029 (71%) of control-mothers completed
interviews. Data on maternal cocaine use and other maternal exposures were
obtained through telephone interviews (2,3). Maternal cocaine use during early
pregnancy was defined as reported cocaine use at any time from 1 month before
pregnancy through the first 3 months of pregnancy.
Urinary tract anomalies* occurred in 276 babies and genital organ
anomalies in 79; frequency-matched controls numbered 2837 and 2973,
respectively. To assess the potential contribution of maternal recall bias, a
second control group comprising all babies born with other major congenital
anomalies was selected for each defect category. Conditional logistic
regression was used to control for sampling design and potentially confounding
variables.
Cocaine use early in pregnancy was reported by 1.4% of mothers of babies
with urinary tract anomalies and by 0.5% of their controls, and 0.8% of
mothers of babies with genital organ anomalies and 0.5% of their controls.
The risk for urinary tract anomalies was greater in infants born to
mothers who reported using cocaine early in pregnancy (adjusted odds
ratio=4.8, 95% CI=1.2-20.1). For genital organ defects, the adjusted odds
ratio for self-reported cocaine users compared with nonusers was 2.3 (95%
CI=0.7-7.9). The urogenital anomalies observed in infants of mothers exposed
to cocaine were congenital hydronephrosis, the prune belly sequence, renal and
ureteral agenesis, ambiguous genitalia, hypospadias with and without
congenital chordee, and bifid scrotum.
Comparisons of exposure histories for mothers of babies with urogenital
anomalies and babies with all other major birth defects also produced
statistically significant odds ratios.
Reported by: Birth Defects and Genetic Diseases Br, Div of Birth Defects and
Developmental Disabilities, Center for Environmental Health and Injury
Control, CDC.
Editorial Note: Cocaine use in the United States has increased substantially
during the past decade (4-6). Between 1979 and 1984, the number of women
admitted to drug abuse treatment programs increased 378% (6). In 1985, an
estimated 4.4 million women, most of whom were of childbearing age, had used
cocaine at least once during the previous year, and an estimated 1.1 million
women were regular users (7). In addition, in some areas of the country the
number of babies exposed to cocaine before birth has dramatically increased in
Health InfoCom Network News Page 18
Volume 2, Number 30 August 19, 1989
the past few years (8-10).
Although understanding of the adverse effects of cocaine use by pregnant
women is limited, several studies suggest an association between cocaine use
and abruptio placentae, spontaneous abortions, prematurity, impaired fetal
growth, congenital urogenital anomalies, and neurobehavioral deficits (9-12).
The ABDCCS is the first population-based case-control study to examine the
association of maternal cocaine use with congenital urogenital anomalies. The
findings are consistent with previous animal and clinical studies and suggest
that women who report cocaine use early in pregnancy are at increased risk for
bearing infants with urinary tract anomalies.
The pharmacokinetic effects of cocaine use could account for some of the
congenital urinary tract anomalies among the infants of mothers reporting
cocaine use early in pregnancy. Cocaine, which readily crosses the placenta,
increases the circulating levels of norepinephrine and dopamine, thereby
causing reduced blood flow to the fetus and systemic vasoconstriction. As a
result, fetal hypoxia, infarction of specific organ/systems, and subsequent
vascular disruption of morphogenesis are possible. Cocaine use during
gestation could also be associated with other defects caused by fetal vascular
disruptions (e.g., gastroschisis).
Potential methodologic concerns must be considered when this study is
interpreted. Self-reports of cocaine use underestimate the number of users
when compared with urine tests (10); thus, reliance on self-reports in the
ABDCCS may have underestimated the true risk of urogenital anomalies
associated with cocaine use. In addition, this study encompassed a period when
cocaine was used less frequently than it is currently. Although confounding is
a potential problem, adjusting the data for factors (such as maternal age,
alcohol use, and use of illicit drugs other than cocaine) known to be
associated with cocaine use and birth defects did not alter the study results.
Finally, use of control-babies with other major birth defects to assess recall
bias found no evidence of differential recall.
Because of the small number of babies with urogenital anomalies identified
among mothers reporting cocaine use, the results of this study should be
confirmed by larger studies in areas where current data can be obtained. In
addition, prospective epidemiologic studies using a biologic marker of cocaine
use may assist in determining the specific spectrum of malformations
associated with maternal cocaine use. This study further emphasizes the need
for pregnant women and women at risk for pregnancy to avoid substances that
may harm the mother and/or the fetus.
References
1. Chavez GF, Mulinare J, Cordero JF. Maternal cocaine use during early
pregnancy as a risk factor for congenital urogenital anomalies. JAMA
1989;262:795-8.
2. Erickson JD, Mulinare J, McClain PW, et al. Vietnam veterans' risks for
fathering babies with birth defects. JAMA 1984;252:903-12.
3. CDC. Vietnam veterans' risks for fathering babies with birth defects.
Atlanta: US Department of Health and Human Services, Public Health Service,
1984.
4. National Institute on Drug Abuse. National Survey on Drug Abuse: main
findings, 1982. Rockville, Maryland: US Department of Health and Human
--- end part 2 of 3 cut here ---