Fatal infectious disease surveillance in a medical examiner database (1).Increasing infectious disease Infectious disease
A pathological condition spread among biological species. Infectious diseases, although varied in their effects, are always associated with viruses, bacteria, fungi, protozoa, multicellular parasites and aberrant proteins known as prions. deaths, the emergence of new infections, and bioterrorism have made surveillance for infectious diseases infectious diseases: see communicable diseases. a public health concern. Medical examiners A public official charged with investigating all sudden, suspicious, unexplained, or unnatural deaths within the area of his or her appointed jurisdiction. A medical examiner differs from a Coroner in that a medical examiner is a physician. and coroners certify approximately 20% of all deaths that occur within the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. and can be a key source of information regarding infectious disease deaths. We hypothesized that a computer-assisted search tool (algorithm) could detect infectious disease deaths from a medical examiner database, thereby reducing the time and resources required to perform such surveillance manually. We developed two algorithms, applied them to a medical examiner database, and verified the cases identified against the opinion of a panel of experts. The algorithms detected deaths with infectious components with sensitivities from 67% to 94%, and predictive value pre·dic·tive value
The likelihood that a positive test result indicates disease or that a negative test result excludes disease.
a measure used by clinicians to interpret diagnostic test results. positives ranging from 8% to 49%. Algorithms can be useful for surveillance in medical examiner offices that have limited resources or for conducting surveillance across medical examiner jurisdictions.
Infectious disease deaths in the United States substantially declined during the first 8 decades of the 20th century as a result of public health interventions health intervention Health care An activity undertaken to prevent, improve, or stabilize a medical condition . However, the end of the century was marked by an increase in infectious disease deaths primarily due to AIDS and pneumonia and influenza (1,2). Increasing infectious disease deaths, the emergence of new infections, and the real or perceived threat of bioterrorist activities have made surveillance for infectious diseases a public health need (3,4).
Infectious disease mortality trends have been described by review of International Classification of Diseases (ICD ICD International Classification of Diseases (of the World Health Organization); intrauterine contraceptive device.
abbr. )-coded death certificate data (2). Although useful in identifying trends, this process has certain limitations, including the following: causes of death are inaccurately certified, are not autopsy verified, and are erroneously coded; and ICD codes are not arranged to facilitate aggregation of infectious disease mortality data or designed to identify new infectious diseases (5). Medical examiners and coroners are also a source of surveillance data for infectious disease deaths. These investigators certify (i.e. ,enter information about the cause and manner of death on death certificates) approximately 20% of all deaths that occur within the United States (6). Medicolegal death medicolegal death Forensic medicine Any death that requires official–medical examiner or coroner investigation Examples Unexpected or violent death, death of an infant or child, unidentified or prominent person, anyone not under a doctor's care; death investigation systems are often biased towards the investigation of violent or unnatural deaths unnatural death Forensic medicine A death that is '…caused by external causes–injury or poisoning… which includes death… due to intentional injury such as homicide or suicide, and death caused by unintentional injury in an . However, sudden natural deaths, unexplained deaths, and deaths of public health importance are also investigated by these agencies (5,7-11).
Natural disease deaths investigated by medical examiners and coroners are often caused by infectious processes (12). Additionally, their investigation frequently includes a complete autopsy. In recent years, medical examiners and coroners have recognized outbreaks of hantavirus pulmonary syndrome hantavirus pulmonary syndrome An often fatal RTI caused by a hantavirus; the first cluster occurred in the Four Corners region of Southwestern US Epidemiology Mean age 32, 61% ♀, 72% Native American Case definition Unexplained bilateral interstitial and invasive pneumococcal pneumococcal /pneu·mo·coc·cal/ (-kok´al) pertaining to or caused by pneumococci. disease, identified cases of human plague, and participated in the investigation of West Nile West Nile may refer to:
In general, medical examiners are appointed physician pathologists, usually with special training in performing forensic autopsies forensic autopsy A postmortem examination of a body performed with the intent of determining the cause and manner of a death in question; a complete FA may require evaluation of evidence attached to the body and/or found at the scene, and reconstruction of the and medicolegal death investigations; coroners are usually elected officials, may not be physicians, and rely on other medical personnel for death investigation and autopsy services (18). Medical examiner/coroner systems are varied across the United States, ranging from states with only medical examiners, states with only coroners, and states with mixed medical examiner and coroner systems (18). Overall, medical examiner systems have larger jurisdictions and operate with more resources than coroner systems. Medical examiner systems are more likely to have electronic death investigation records.
Medical examiner and coroner databases contain predominantly noninfectious disease cases. Therefore, manually reviewing these databases to identify infectious disease cases is inefficient. Developing an automated system that would identify a subset of cases that are likely infectious, and then manually reviewing these cases to identify infectious disease deaths, could reduce the resources that would be necessary to perform infectious disease surveillance. We hypothesized that a computer-assisted search tool could quickly and efficiently detect infectious disease deaths from a computerized medical examiner database, thereby reducing the number of records that would need to be manually reviewed to perform infectious disease surveillance with medical examiner and coroner data.
The New Mexico New Mexico, state in the SW United States. At its northwestern corner are the so-called Four Corners, where Colorado, New Mexico, Arizona, and Utah meet at right angles; New Mexico is also bordered by Oklahoma (NE), Texas (E, S), and Mexico (S). Office of the Medical Investigator (OMI (1) See Open Market.
(2) (Open Microprocessor Initiative, Brussels, Belgium) An organization that functions under the umbrella of the European Commission. It funds projects that research and develop advanced microcontroller technologies. ) is a statewide centralized cen·tral·ize
v. cen·tral·ized, cen·tral·iz·ing, cen·tral·iz·es
1. To draw into or toward a center; consolidate.
2. medical examiner agency based at the University of New Mexico The University of New Mexico (UNM) is a public university in Albuquerque, New Mexico. It was founded in 1889. It also offers multiple bachelor's, master's, doctoral, and professional degree programs in all areas of the arts, sciences, and engineering. School of Medicine. OMI annually performs approximately 90% of the autopsies in New Mexico (5). In 1995, New Mexico had a midyear population of 1,682,417; that year, 12,545 deaths occurred in the state (Figure 1) (19,20). We obtained a database of all deaths ([N.sub.tot] = 4,722) in New Mexico during 1995 that came under the jurisdiction of OMI. From this database, autopsied deaths were identified ([n.sub.aut] = 1,429). A case-patient was defined as a person who died in New Mexico during 1995 who had an infectious disease identified at the time of death and who underwent autopsy by OMI. An expert review panel (Infectious Disease Death Review Team [IDDRT]) reviewed all autopsy records and identified deaths that met the case definition ([n.sub.cd] = 125). On the basis of the findings at autopsy, we further categorized cat·e·go·rize
tr.v. cat·e·go·rized, cat·e·go·riz·ing, cat·e·go·riz·es
To put into a category or categories; classify.
cat cases as an infectious cause of death (ICOD ICOD Instant Capacity On Demand
ICOD International Centre for Ocean Development
ICOD intelligence cutoff data (US DoD)
ICOD International Center for Organizational Development
ICOD Intelligence Cut-Off Date
ICOD Information Cut-Off Date ) ([n.sub.cod] = 99) and infection incidental to death ([n.sub.inc] = 26).
[FIGURE 1 OMITTED]
In addition to cause of death (disease or injury that initiates the fatal sequence of events), OMI cases are classified in terms of manner of death (circumstances, i.e., natural, accident, homicide, suicide, or undetermined). Deaths that were considered natural or of undetermined manner comprised 33% (471/1,429) of all OMI autopsies in 1995 and 85% (106/125) of the deaths identified as infectious disease-related by the expert panel. The manner of death was classified as an accident in 39% (561/1,429) of all autopsied persons and in 13% (16/125) of deaths that were identified as infectious disease-related by the expert panel. Homicides and suicides accounted for 28% (395/1,429) of OMI autopsies.
Expert Review Panel
The IDDRT included specialists in infectious diseases, forensic and clinical pathology clinical pathology
1. The practice of pathology as it pertains to the care of patients.
2. The subspecialty in pathology concerned with the theoretical and technical aspects of laboratory technology that pertain to the , epidemiology, and information technology and was in operation in New Mexico, under the auspices of the OMI, from late 1994 to mid-1996 (5,12). One forensic pathologist member of the IDDRT routinely reviewed all OMI autopsy records and identified those deaths that were possibly infectious disease-related for review by the expert panel.
We randomly divided ICOD cases into two groups: one group ([n.sub.dg] = 49) was used for algorithm development (i.e., development group); the other group ([n.sub.tg] = 50) was used for algorithm validity testing (i.e., test group). To develop the algorithm, we reviewed the autopsy record for each case in the development group. We developed two separate algorithms based on two separate, but related, datasets (Figure 2). These datasets are described below.
[FIGURE 2 OMITTED]
The first algorithm (algorithm 1) was based on data (i.e., truncated truncated adjective Shortened dataset) equivalent to information found on the death certificate: demographic variables (e.g., age, sex, and race); cause and manner of death; plus a brief description of the circumstances of death (i.e., a short narrative reported by the death scene investigator). This dataset is referred to as the "truncated" dataset. We used this dataset because we wanted to evaluate the usefulness of death certificate information for this method because this information may be readily available to persons performing surveillance activities. We developed an algorithm based on the development group of cases ([n.sub.dg] = 49). After the algorithm was developed, we added the test group of cases ([n.sub.tg] = 50) to the noninfectious cases ([n.sub.ani ani (ä`nē), bird: see cuckoo.
(1) See animated cursor.
(2) (Automatic Number Identification) A telephone service that transmits the billing number (BN) and the telephone number of the ] = 1,330) and applied the algorithm to this database ([n.sub.ta] = 1,380) to test the algorithm's ability to detect infectious disease deaths from the truncated database.
The second algorithm (algorithm 2) was developed on the basis of the full text of the pathologists' dictated autopsy records (i.e., full-text set), which included pathologic observations, pathologic diagnoses, and causes of death. This dataset contains much more detailed information than the truncated dataset. It represents data that may be available from medical examiner offices, in addition to the death certificate. Because we found a low predictive value positive (PVP See portable video player. ) and low specificity when algorithm 1 was applied to the full-text dataset, we chose to develop algorithm 2 in a different manner. We randomly selected approximately half (n = 649) of the autopsy-categorized deaths of noninfectious causes ([n.sub.ani] = 1,380) to include in the development of algorithm 2 to reduce the number of false-positive cases the algorithm identified (i.e., cases identified by the algorithm as infectious disease-related but not actually infectious disease-related after expert review). Therefore, the total number of deaths from all manners used for algorithm 2 development was 698 ([n.sub.dg2] = 698), and the total number of deaths used for testing algorithm 2 was 732 ([n.sub.ta2] = 732). Algorithm development and text searching were performed by using a commercially available software package (AskSam 3.0 Professional, Seaside Software, Inc., Perry, FL).
For developing both algorithms, we manually searched and indexed potential keywords for identifying deaths caused by infectious diseases. From this process, a list of approximately 20 keywords and rules was compiled (i.e., algorithm; see Appendix). These keywords included entire intact words, words put in a wildcard See wild cards and wildcard mask. format (e.g., bacter *, which would flag the words bacterial and bacteremia bacteremia: see septicemia.
Presence of bacteria in the blood. Short-term bacteremia follows dental or surgical procedures, especially if local infection or very high-risk surgery releases bacteria from isolated sites. ), and words in a fuzzy search An inexact search for data that finds answers that come close to the desired data. It can get results when the exact spelling is not known or help users obtain information that is loosely related to a topic. format (e.g., one letter in the word could be wrong, and the word would still be flagged in the record, thus decreasing misclassification caused by misspelling mis·spell·ing
1. The act or an instance of spelling incorrectly.
2. A word spelled incorrectly.
Noun 1. and data entry errors). Rules included searching for words in specific database fields (e.g., undetermined in the cause of death field) and proximity rules (e.g., immune within two words of deficiency).
Algorithm Implementation and Analysis
The algorithms were applied to the remaining set of records, which included all 1995 OMI autopsied cases except for the development group set of cases ([n.sub.trc] = 1,380 for the truncated dataset; [n.sub.ft] = 732 for the full-text dataset). We applied algorithm 1 to both the truncated and full-text datasets and applied algorithm 2 to the full-text dataset to determine whether an advantage existed in developing an algorithm that used the data from full-text instead of data that could be obtained from death certificates. We determined the sensitivity and PVP of the results by applying the algorithm to this database. Thus, we compared the cases identified from the database by using the algorithm with cases identified by the expert review panel.
Algorithm 1: Truncated Dataset
Algorithm 1 classified 131 (10%) of 1,380 ([n.sub.ta]) autopsied deaths from the truncated dataset as infectious disease-related (Table and Figure 3). Overall sensitivity for identifying both ICOD and incidental infectious diseases was 67% (51/76), and the overall PVP was 39% (51/131). Implementation of the algorithm for surveillance for infectious disease deaths would have resulted in a 91% decrease (131 vs. 1,380) in the number of death records to review. The algorithm identified ICOD cases with a sensitivity of 92% (46/50) and a PVP of 49% (46/94).
[FIGURE 3 OMITTED]
Algorithm 1 identified deaths classified as natural or undetermined and with an ICOD and incidental infections from the truncated dataset with a sensitivity of 73% (46/63) and a PVP of 49% (46/94). Implementation of the algorithm for surveillance for infectious disease deaths would have resulted in a 78% decrease (94 vs. 437) in the number of death records to review. The algorithm identified deaths with both a natural or undetermined cause and an ICOD with a sensitivity of 93% (42/45) and a PVP of 45% (42/94).
Algorithm 1: Full-Text Dataset
When algorithm 1 was applied to the full-text dataset, it classified 937 (68%) of 1,380 deaths as infectious disease-related. Sensitivity for accurately detecting all deaths classified as natural or undetermined, for detecting deaths caused by all infections, and for detecting those with an ICOD only, ranged from 88% to 92% (Table). However, PVP ranged from 5% (for all causes of deaths, ICOD only) to 17% (for those classified as natural or undetermined, classified as ICOD, or identified as incidental infections). Implementation of the algorithm for surveillance of infectious disease deaths would have resulted in a 32% decrease (937 vs. 1,380) in the number of death records to review for all causes of death, and a 26% decrease (315 vs. 427) for only natural and undetermined causes of death.
Algorithm 2: Full-Text Dataset
Algorithm 2 (developed on the basis of the full-text dataset, which included panel-confirmed infectious disease deaths and 50% of the noninfectious disease-related deaths) was applied to the full-text dataset only. The sensitivity of the algorithm to identify infectious disease-related deaths ranged from 90% (all deaths; ICOD only) to 94% (natural or undetermined; ICOD or incidental infections). PVP ranged from 13% (all deaths; ICOD only) to 30% (natural or undetermined; ICOD or incidental infections). Implementation of the algorithm for surveillance of infectious disease deaths would have reduced by 51% (356 vs. 732) the number of death records to review for deaths from all causes and reduced by 24% the records to review (196 vs. 257) of those deaths categorized as having natural and undetermined causes.
A simple computer text search tool (i.e., algorithm) can efficiently detect infectious disease deaths from a medical examiner's database, demonstrating that this technique can be an essential tool in the surveillance for infectious diseases of public health importance. Medical examiners are a critical public health resource for fatal infectious disease surveillance (5,12). Ideal surveillance at medical examiner offices would include active case finding, as has been implemented in a pilot program in New Mexico funded by the Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. (21). Because infectious disease surveillance that uses medical examiner data does not occur in a standardized standardized
pertaining to data that have been submitted to standardization procedures.
standardized morbidity rate
see morbidity rate.
standardized mortality rate
see mortality rate. manner, a computer text search tool could be implemented by jurisdictions that otherwise might not have the resources to perform these activities. Implementation of this technique nationally would require large-scale development of electronic databases in medical examiner's offices and subsequent incorporation of this surveillance tool into routine activities. However, this method is also applicable to surveillance for fatal infectious diseases and other conditions at all medical facilities that collect text-based clinical data, such as emergency departments, inpatient and outpatient settings, and poison control centers poison control center Toxicology A nonprofit facility, often affiliated with a university or hospital, that provides emergency toxicology assessments by telephone, and treatment recommendations, primarily to parents of children who swallowed a household product, .
The sensitivity of the algorithm varied depending on whether it was applied to dictated autopsy records, including all pathologic diagnoses, or to a truncated dataset containing records equivalent to that found on a death certificate (i.e., basic demographic information and causes of death). The expense of improved sensitivity is that more records must be reviewed because of false-positive results. Algorithm application on the truncated dataset achieved a sensitivity similar to that achieved with the full-text dataset, and with a higher PVP, for deaths in which an infection is a cause of death rather than incidental to the death. In addition, for the full-text dataset, sensitivity and PVP were not substantially compromised by including in the search, infections incidental to the cause of death. Clearly, incidental infections are found among persons who die from homicide, suicide, or accidents. Recognizing incidental infections could be critical for surveillance systems designed to identify chronic infections such as tuberculosis and hepatitis C Hepatitis C Definition
Hepatitis C is a form of liver inflammation that causes primarily a long-lasting (chronic) disease. Acute (newly developed) hepatitis C is rarely observed as the early disease is generally quite mild. . Sensitivity was not compromised by including deaths from all causes rather than deaths from natural and undetermined causes. PVP was increased somewhat by restricting the search to deaths classified as natural and deaths classified as undetermined. Still, medical examiner-based infectious disease surveillance could effectively use complete data sets rather than data subsets.
This study was possible because of the findings from the expert review of infectious disease deaths which could be compared with data generated by the algorithm. This panel reviewed records from approximately 90% of all autopsies that occurred in New Mexico in 1 year and, of these deaths, likely ascertained all OMI cases with an infectious disease component. However, the implementation of such a review process using manually retrieved cases might not be feasible in medical examiner jurisdictions with limited resources and a large case volume. A computerized algorithm could allow for surveillance in settings where it otherwise might be impossible. Minimal resources would be required to run the necessary software and review results on a daily basis. Required software is inexpensive, and running the algorithm would require minutes per day. Staff to interpret the results is the main resource that would be required. These results demonstrated a substantial decrease in the number of records that would need to be reviewed with algorithm implementation, compared with those required by manual review alone.
In the future, search algorithms In computer science, a search algorithm, broadly speaking, is an algorithm that takes a problem as input and returns a solution to the problem, usually after evaluating a number of possible solutions. could be used in settings where the records from several medicolegal medicolegal /med·i·co·le·gal/ (med?i-ko-le´g'l) pertaining to medical jurisprudence.
Of, relating to, or concerned with medicine and law. jurisdictions (e.g., a region consisting of more than one city, county, or state) are combined. As outbreaks of infectious diseases, whether naturally occurring or bioterrorism-related, might span jurisdictional boundaries, computerized records could be compiled from different areas and an algorithm applied to seek patterns or clusters of deaths of one type during a given period. To carry out such cross-regional surveillance, standardized platforms of data collection that would allow for data aggregation are required. Similar algorithms could be used as permanent or temporary surveillance systems designed to detect bioterrorism-related deaths or particular outbreaks. In addition, these algorithms could be modified to evaluate notifiable disease no·ti·fi·a·ble disease
A disease that must be reported to public health authorities at the time it is diagnosed because it is potentially dangerous to human or animal health. Also called reportable disease. reporting in a jurisdiction. Artificial intelligence techniques could be used to improve algorithm accuracy. Artificial intelligence technology could take algorithm development from rules derived from human testing of specific terms and conditions (as performed in this study), to algorithm development with computer intelligence techniques that develop computer-derived rules. Finally, algorithms could be developed that would identify deaths caused by noninfectious conditions of public health importance.
This study documents a first step in using computer-assisted text search tools to implement and improve infectious disease surveillance with medical examiner data. Research on computerized disease identification through medical information is in the early stages (22). Improvements in the algorithm, in algorithm development techniques (such as improving search terms), and in applying algorithms in more diverse ways could enhance the accuracy and usefulness of this method. Currently, increased national and international attention is focused on infectious disease surveillance. Novel surveillance strategies that provide timely and detailed data will likely become important adjuncts to traditional surveillance for fatal infectious diseases.
Table. Sensitivity and predictive value positive (PVP) of algorithm 1 and algorithm 2 applied to the truncated and full-text datasets, compared by manner of death and infection as cause of death Truncated dataset Natural and undetermined All causes of death causes of death Sensitivity PVP Sensitivity PVP ICOD and incidental infections (a) Algorithm 1 67% 39% 73% 49% (51/76) 1 (51/131) 1 (46/63) 2 (46/94) 2 Algorithm 2 n/a ICOD only (a) Algorithm 1 92% 49% 93% 45% (46/50) 3 (46/94) 3 (42/45) 4 (42/94) 4 Algorithm 2 n/a Full-text dataset Natural and undetermined All causes of death causes of death Sensitivity PVP Sensitivity PVP ICOD and incidental infections (a) Algorithm 1 92% 8% 87% 17% (70/76) 5 (70/937) 5 (55/63) 6 (55/315) 6 Algorithm 2 93% 20% 94% 30% (71/76) 7 (71/356) 7 (58/62) 8 (58/196) 8 ICOD only (a) Algorithm 1 88% 5% 89% 13% (44/50) 9 (44/937) 9 (40/45) 10 (40/315) 10 Algorithm 2 90% 13% 91% 21% (45/50) 11 (45/356) 11 (41/45) 12 (41/196) 12 (a) ICOD, infectious cause of death. (b) Number in bold in lower right corner of each cell corresponds to results of 2 x 2 table shown in Figure 3.
We acknowledge the valuable contributions to this research by Willie Anderson Willie Anderson could refer to:
(1) Findings from this study were presented at the 39th Annual Meeting of the Infectious Diseases Society of America The Infectious Diseases Society of America (IDSA) is a medical association representing physicians, scientists and other health care professionals who specialize in infectious diseases. , San Francisco, California “San Francisco” redirects here. For other uses, see San Francisco (disambiguation).
The City and County of San Francisco (EN IPA: [sænfrənˈsɪskoʊ] , October 25-28, 2001.
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(4.) Berkelman RL, Pinner RW, Hughes JM. Addressing emerging microbial microbial
pertaining to or emanating from a microbe.
the breakdown of organic material, especially feedstuffs, by microbial organisms. threats in the United States. JAMA 1996;275:315-7.
(5.) Nolte KB, Wolfe MI. Medical examiner and coroner surveillance for emerging infections. In: Scheld WM., Craig WA, Hughes JM, editors. Emerging infections 3. Washington: American Society of Microbiology microbiology: see biology.
Scientific study of microorganisms, a diverse group of simple life-forms including protozoans, algae, molds, bacteria, and viruses. Press;1999. p. 201-17.
(6.) Hanzlick RL, Parrish RG. Epidemiologic aspects of forensic pathology Noun 1. forensic pathology - the branch of medical science that uses medical knowledge for legal purposes; "forensic pathology provided the evidence that convicted the murderer"
forensic medicine . In: Froede RC, editor. Clinics in laboratory medicine; forensic pathology, part 1. Philadelphia: W.B. Saunders Co.; 1998. p. 23-37.
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or Manes or Manichaeus
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(13.) Jones AM, Mann J, Braziel R. Human plague in New Mexico: report of three autopsied cases. J Forensic Sci 1979;24:26-38.
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(15.) Centers for Disease Control and Prevention. Hemorrhage hemorrhage (hĕm`ərĭj), escape of blood from the circulation (arteries, veins, capillaries) to the internal or external tissues. The term is usually applied to a loss of blood that is copious enough to threaten health or life. and shock associated with invasive pneumococcal infection in healthy infants and children New Mexico, 1993-1994. JAMA 1995;273:280-1.
(16.) Sampson BA, Ambrosi C, Charlot A, Reiber K, Veress JF, Armbrustmacher V. The pathology of human West Nile virus West Nile virus, microorganism and the infection resulting from it, which typically produces no symptoms or a flulike condition. The virus is a flavivirus and is related to a number of viruses that cause encephalitis. infection. Hum Pathol 2000;31:527-31.
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(19.) Population Estimates Program, Population Division. State population estimates: annual time series, July 1, 1990, to July 1, 1999. Washington: U.S. Census Bureau Noun 1. Census Bureau - the bureau of the Commerce Department responsible for taking the census; provides demographic information and analyses about the population of the United States
Bureau of the Census , 2001. [Accessed November 7, 2003]Available from: URL URL
in full Uniform Resource Locator
Address of a resource on the Internet. The resource can be any type of file stored on a server, such as a Web page, a text file, a graphics file, or an application program. : http://www.census.gov/population/estimates/state/st-99-3.txt.
(20.) Centers for Disease Control and Prevention. Data warehouse. Atlanta: National Center for Health Statistics National Center for Health Statistics (NCHS) is part of the Centers for Disease Control and Prevention (CDC), which is part of the United States Department of Health and Human Services.
NCHS is the United States' principal health statistics agency. ; 2001. [Accessed November 11, 2003] Available from: URL: http://www. cdc.gov/nchs/datawh/statab/unpubd/mortabs/gmwkiii.htm.
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(22.) Hung J, Posey A posey can be a flower bouquet. As a surname it is of French and English origins, originating and or derived from the greek word Desposyni. People whose surname is or was Posey include:
A man who has been freed from slavery.
pl -men History a man freed from slavery
Noun 1. R, Thorton T. Electronic surveillance of disease states: a preliminary study in electronic detection of respiratory diseases Noun 1. respiratory disease - a disease affecting the respiratory system
respiratory disorder, respiratory illness
adult respiratory distress syndrome, ARDS, wet lung, white lung - acute lung injury characterized by coughing and rales; inflammation of the in a primary care setting. Proc AMIA Symp 1998;688-92.
Dr. Wolfe is a medical epidemiologist in the Division of HIV/AIDS HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome Prevention, National Center for HIV, STD, and TB Prevention The National Center for HIV, STD, and TB Prevention (NCHSTP) is a part of the Centers for Disease Control and Prevention and is responsible for public health surveillance, prevention research, and programs to prevent and control human immunodeficiency virus (HIV) infection and at the Centers for Disease Control and Prevention. He was previously an Epidemic Intelligence Service The Epidemic Intelligence Service is a program of the United States' Centers for Disease Control and Prevention. Established in 1951 due to biological warfare concerns arising from the Korean War, it has become a hands-on two-year postgraduate training program in epidemiology, with Officer in the National Center For Environmental Health.
Address for correspondence: Mitchell Wolfe, Centers for Disease Control and Prevention, 1600 Clifton Road Clifton Road is main street in Clifton neighborhood of Saddar Town in Karachi, Sindh, Pakistan.
Its name dates from the British Colonial rule, and its market is posh areas of Karachi. , NE, Mailstop E46, Atlanta, GA 30333, USA; email: firstname.lastname@example.org
Mitchell I. Wolfe, * Kurt B. Nolte, * ([dagger]) and Steven S Ste´ven
n. 1. Voice; speech; language.
Ye have as merry a steven
As any angel hath that is in heaven.
2. An outcry; a loud call; a clamor.
To set steven
to make an appointment. . Yoon *
* Centers for Disease Control and Prevention, Atlanta, Georgia, USA; and ([dagger]) Office of the Medical Investigator, University of New Mexico School of Medicine, Albuquerque, New Mexico “Albuquerque” redirects here. For other uses, see Albuquerque (disambiguation).
Albuquerque (pronounced [ˈæl.bə.kɚ.kiː], Spanish: [al.βu. , USA