Tag Archives: centers for disease control and prevention

Study: Global warming fuels rise in deadly waterborne illnesses

Rising global temperatures are clearly linked to increasing waterborne food poisoning, particularly from eating raw oysters, along with other nasty infections, a new study shows. About a dozen species of vibrio (VIB’-ree-oh) bacteria make people sick from eating raw or undercooked seafood or drinking or swimming in tainted water. It also causes cholera, although that was not the focus of the research. Lab-confirmed vibrio infections in the United States have increased from an average of about 390 a year from the late 1990s to an average of 1,030 in recent years, according to the Centers for Disease Control and Prevention. But most cases aren’t confirmed by tests and reported.

“It’s a remarkable increase on an annual basis,” said study lead author Rita Colwell of the University of Maryland, a top microbiologist who used to head the National Science Foundation.

The study examined Europe and North America, but the most consistent tracking of vibrio illnesses were in the United States. The CDC blames about 100 deaths a year on vibrio on average.

Even Alaska, where such outbreaks used to be unheard of because the bacteria needs warm water, is getting cases from people eating vibrio-infected oysters, Colwell said. Her study, published in Monday’s Proceedings of the National Academy of Sciences , highlights an unprecedented wave of vibrio illnesses from swimming in northern Europe during heat waves in 1994, 1997, 2003, 2006 and 2010.

Until now, researchers had indirectly linked climate change to an increase in illnesses from the bacteria, Colwell said. Using DNA, a 50-year database of plankton, water temperatures and disease reports, she shows a more comprehensive connection.

“Now we have linked very directly the increase and the trend in number of cases, so it’s all coming together in great detail,” Colwell said.

With the giant database of plankton and DNA, the international team of scientists was able to monitor how pervasive the vibrio bacteria have become in waterways around the world by creating an index. The index doesn’t show the number of vibrio, but its relative abundance, said study author Luigi Vezzulli of the University of Genoa. That index has about tripled in many of the areas they examined, including the North Atlantic.

That type of examination of vibrio levels in plankton hasn’t been done before and “is critical to understand the regional scale of changes in climate to potential increases in human risk,” said Erin Lipp, a University of Georgia, professor of environmental health sciences. She wasn’t part of the study but praised it as exciting and important.

 

Republicans hold Zika funding hostage in Planned Parenthood fight

As the Zika virus escalates into a public health crisis, members of Congress remain entrenched politically, with Republicans and Democrats pointing fingers over the failure to act as the number of mosquito-transmitted cases in the U.S. grows.

Health and Human Services Secretary Sylvia Burwell warned lawmakers this week that her budget for fighting Zika is running out quickly.

Without more money fast, she said, the “nation’s ability to effectively respond to Zika will be impaired.”

Yet lawmakers left Washington in mid-July for a seven-week recess without approving any of the $1.9 billion President Barack Obama requested in February to develop a vaccine and control the mosquitoes that carry the virus.

Abortion politics played a key role in the gridlock over the anti-Zika bill.

Republicans angered Democrats by adding a provision to a $1.1 billion take-it-or-leave-it measure that would have blocked Planned Parenthood clinics in Puerto Rico from receiving money.

U.S. Sen. Tim Kaine of Virginia, the Democratic candidate for vice president, has called for Congress to reconvene to immediately address the threat posed by Zika.

But Senate Majority Leader Mitch McConnell has signaled he is in no rush to return.

In an op-ed published recently in the Lexington Herald-Leader, the Kentucky Republican criticized Democrats for balking at passing the bill.

He said they’ll get another chance after Labor Day when Congress is back in session.

Here are key points to know about the anti-Zika legislation.

 

ZIKA MONEY BEING SPENT ‘AGGRESSIVELY, PRUDENTLY’

Burwell’s Aug. 3 letter seeks to counter Republicans who’ve criticized the Obama administration for not using several hundred million dollars already in the federal budget for Zika prevention.

The money was initially allotted for fighting Ebola but was redirected to address Zika.

U.S. Sen. Marco Rubio, R-Fla., said there’s no excuse for not spending money that Congress already has provided.

“Why are they holding that money back?” he asked.

Burwell said her agency is committed to using “scarce federal dollars aggressively and prudently.”

The U.S. Centers for Disease Control received the bulk of the $374 million “repurposed” for Zika domestic response efforts, she said, and it will exhaust the remainder of the money by Sept. 30.

Money for vaccine development will run out even sooner, she said.

The second phase of clinical trials would be delayed as a result, and Americans would have to wait longer for a vaccine, according to Burwell.

“Now that the United States is in the height of mosquito season and with the progress in developing a Zika vaccine, the need for additional resources is critical,” Burwell wrote.

 

DON’T EXPECT CONGRESS TO INTERUPT ITS RECESS

U.S. Sen. Bill Nelson, a Florida Democrat, said Congress doesn’t have to interrupt its lengthy summer break to pass the bill.

But Republicans immediately dismissed his proposal.

Nelson’s state has become the epicenter for Zika in the U.S. Fifteen people are reported to be infected with the virus in Miami’s Wynwood arts district.

These are believed to be the first mosquito-transmitted cases in the mainland United States, a situation that Nelson said heightens the urgency to respond.

In an Aug. 2 letter to McConnell, Nelson said an anti-Zika bill could be passed in the Senate through a parliamentary procedure known as a pro forma session that requires the presence of only a few senators.

But even Nelson isn’t optimistic that will happen. And he took a jab at McConnell, predicting the Senate would move hurriedly if a transmitted Zika case is reported in Kentucky, McConnell’s home state.

Don Stewart, McConnell’s spokesman, said Nelson’s proposal isn’t at all plausible unless Democrats are willing to end their filibuster of the anti-Zika bill that the House already has passed.

Otherwise, the Senate would be only approving an earlier version of the legislation that Obama could not sign into law, Stewart said.

 

ZIKA IS RISKY FOR BUSINESS TOO

Zika is a looming economic development problem too, according to Rubio.

Many Florida businesses depend heavily on tourism and the state’s economy could be hurt if potential visitors decide to stay away, he said.

“I can foresee now when people that are planning to come to Florida, to go fishing perhaps, will decide to cancel their trip because they’re worried about mosquitoes and they’re worried about Zika,” Rubio said.

White House spokesman Josh Earnest said that it’s up to Congress to pass the legislation so that more can be done.

“They left on a seven-week recess a day early, at the height of mosquito season and basically told the American people, ‘good luck,”” Earnest said.

Wisconsin records first case of E. coli from flour contamination

Wisconsin has recorded its first case of E. coli linked to flour, becoming one of 20 states so far affected by a national outbreak of the disease connected to General Mills products.

Neighboring states have been the hardest hit by the outbreak of Escherichic coli infections. Illinois and Michigan have reported four cases each, and Minnesota has reported three. The other states have all reported two or fewer cases.

The Centers for Disease Control and Prevention has linked the contaminated flour to the General Mills facility in Kansas City, Missouri. On May 31, General Mills recalled several different sizes and varieties of Gold Medal Flour, Gold Medal Wondra Flour, and Signature Kitchens Flour due to possible E. coli contamination.

Ten people have been hospitalized due to the outbreak, but none has died.

CDC officials urge consumers to: dispose of recalled products, avoid eating raw dough, clean up thoroughly after baking, and contact health care providers if illness is suspected.

According to the Mayo Clinic, symptoms of infection typically begin three or four days after exposure, but they might begin as soon as one day afterward to more than a week later. Symptoms include:

  • Diarrhea, which may range from mild and watery to severe and bloody
  • Abdominal cramping, pain or tenderness
  • Nausea and vomiting.

The clinic advises contacting your doctor if your diarrhea is persistent, severe or bloody.

To learn how to identify the recalled brands, click here.

Confronting the ‘heroin tsunami’ in Kootenai County, Idaho

Crushing news came shortly after Cindy Schaffner heard sirens just a few blocks from her Post Falls home.

The sirens, Schaffner learned, were for her 19-year-old daughter, Cathryn Mason.

Cathryn, who loved the outdoors and was majoring in recreation management at North Idaho College, was in critical condition. She’d overdosed on heroin and alcohol.

Cathryn died two days later after she was taken off of life support. That was in May 2014.

“She was a very driven and focused person,” Schaffner said, fighting back tears. “She loved to go on hikes and was full of life. She was celebrating getting good grades for the semester.”

Schaffner said it was the first time she was aware of that her daughter had used drugs.

“She had a strong sense of morals and values and she had faith, but, for whatever reason, she decided to compromise those values,” Schaffner said. “It was a surprise to all of us because she wasn’t a user.”

Cathryn was caught on the edge of what officials refer to as the “heroin tsunami,” a nationwide opioid abuse epidemic that Kootenai County has not been immune to in recent years.

“We have seen a significant increase in the usage of heroin in our community,” Post Falls Police Chief Scot Haug said.

Haug said the rise of heroin usage is due to two reasons. It is not only used as a recreational drug for the intense euphoria it induces, but it is an opioid painkiller that people turn to when they are taken off prescription medications or those medications aren’t offering as much relief as desired.

Heroin is synthesized from morphine, a naturally occurring substance extracted from the seed pod of the Asian opium poppy plant. It appears as a “China white” or brown powder or as a sticky black substance as “black tar” heroin.

Heroin can be injected, inhaled by snorting or sniffing, or smoked. All three methods deliver the drug to the brain rapidly, contributing to its health risks and high risk for addiction.

“Some experts believe that heroin is more addictive than meth and more difficult to detox off of,” Haug said.

The street value of heroin is about $300 per gram, according to police. It is usually sold by the “point” — or tenth of a gram — for $30.

While Cathryn, who graduated from Post Falls High in 2012, was not on painkillers, her sudden and unexpected death shows how lethal heroin can be, Schaffner said.

“Some do it for years and years, while others may try it once and it kills them,” she said. “It’s like playing Russian roulette.”

Rising numbers

News earlier this month that multiple law enforcement agencies had busted an alleged heroin ring that included a Coeur d’Alene physician put a local point on the severity of the problem nationally.

At least 28,648 people in the U.S. died of causes linked to opioid drugs in 2014, according to the U.S. Centers for Disease Control, almost as many as are killed annually in car crashes. The class of drugs includes heroin and prescription painkillers such as oxycodone.

A CDC report released last year revealed the number of U.S. heroin users has grown by nearly 300,000 over a decade.

Haug said heroin has surpassed methamphetamine as the most common drug behind marijuana in the community.

PFPD processed no heroin into its evidence storage in 2010, but it obtained 20 heroin items in 2013, 19 in 2014 and 21 in 2015 (the numbers do not reflect heroin-related medical calls).

Haug said he’s aware of several heroin-related deaths across Kootenai County around the time that Cathryn died. Investigations into some of those cases, including Cathryn’s death, continue.

Haug said his department receives heart-wrenching calls on almost a weekly basis from families of those using heroin who are desperate for help.

“But many times the users don’t want help,” he said. “The challenge for us is that we can’t knock down doors and force people to get help, but we point them and their families in the right direction when there’s opportunities.”

Kootenai County Sheriff Ben Wolfinger said the rise in heroin has a ripple effect in the community, from law enforcement to substance abuse councils to the mental health sector.

“It’s not just a law enforcement problem; it’s a community problem,” he said.

Dr. Joseph Abate, medical director at the nonprofit Heritage Health, said he believes one reason heroin has regained momentum is because it’s cheaper than some prescription painkillers.

“That’s an attraction to people who are using opioids without a doctor’s recommendation,” Abate said. “But people who have been on opioids with a doctor’s recommendation turn to heroin too because they have a problem with tolerance to pain, especially younger people. They may start on low doses of pain medication, then they take more and more to get the same amount of relief. It may not make sense to you or I, but to patients who are trying to get relief . 

“Part of the rise of heroin is that people start on painkillers for legitimate reasons and then it just gets out of control. In the past people received the message that pain could be controlled with the right dosage, but now we’ve learned the hard way that it does nothing more than make a person worse over the long term rather than better.”

Spirit Lake Police Chief Keith Hutcheson said as prescription drugs have become more regulated in response to the rise in addictions, people revert to illegal drugs such as heroin. It’s a vicious cycle, he said.

“Instead of buying pills on the street, they’re now buying heroin because it’s cheaper and they can get a higher high for a longer time,” Hutcheson said.

Combating the epidemic

One of the ways Heritage Health is trying to right the ship when no opioid is enough is to educate on “mindfulness-based solutions.”

“It’s thinking of pain differently, just something you learn to deal with,” Abate said. “It’s not us saying that pain is all in your head. What we’re saying is how you perceive your pain makes a difference in what you search for as the solution.”

Part of the program is sharing with others how pain affects your daily life and how you label it.

“A lot of people don’t have a chance to tell about how it affects your life,” Abate said.

Abate said if the only weapon in one’s toolbox to fight pain is opioids, it’s not likely you’ll find relief in a fashion that will allow you to live a reasonable life. Mindfulness solutions, exercise, physical therapy and acupuncture are other tools people can use to treat pain.

“There are better ways to treat pain rather than assuming the only thing that will make it go away is pain medicine,” he said. “If people are willing to look at why the pain is not very well-controlled, we can offer them other options so they are safely and reasonably treated without fear of an unintentional overdose.”

Abate said while there are good substance abuse treatment programs available, there aren’t a lot of affordable ones. He said providers also need to be educated on who the highest-risk populations are before prescribing medication.

Abate said there has been a push in recent years for providers to monitor patients more closely and lower the maximum doses of painkillers. He said emergency doctors will now often times refer frequent patients back to their primary care providers for pain medication.

At the national level, President Barack Obama will ask Congress for $1.1 billion in his next budget to combat the opioid abuse epidemic, which has emerged as a 2016 campaign issue. The amount Obama wants to spend over two years is slightly more than the $1 billion he’s requested to expedite cancer treatments.

“Prescription drug abuse and heroin use have taken a heartbreaking toll on too many Americans and their families while straining resources of law enforcement and treatment programs,” the White House said in a statement.

Abate said the number of people who seek urgent medical care after using heroin is limited.

“We usually don’t see them,” he said. “They don’t wander into the clinic looking for care. They’re more likely to be found by law enforcement.”

Lisa Aitken, Kootenai Health spokeswoman, said there also hasn’t been an increase in people coming to the hospital’s emergency room with heroin-related issues.

“That’s definitely not to say that the use of heroin is not on the rise; they are just not making it to the hospital at this point,” she said. “It’s sad to think that there are people not coming to the hospital if they are in need of medical care related to heroin use.”

Schaffner said that since her daughter died, young women who have struggled or have been tempted have gravitated toward her for support.

“You need to have open communication with your kids and you’ve got to know where they are at,” she said. “If they think you are overbearing, too bad. It’s for their own good.”

Schaffner said she still struggles with what caused Cathryn to make a “foolish choice.” She said her faith and two other daughters have helped her from “rolling into a ditch” after the tragedy.

“You’ve got to stay focused on the things you do have,” Schaffner said. “You can’t stop living when other people love you and need you. I have good memories of Cathryn, and I think about her every day. There’s a purpose and reason for things and some day I’ll understand.”

Published via the AP member exchange. 


Young people fuel rise in sexually transmitted diseases, with record number of chlamydia cases

A U.S. sexually transmitted diseases epidemic is increasing and the most common infection, chlamydia, has risen to record levels, government officials say.

Reported cases of chlamydia, gonorrhea and syphilis all increased in 2014. Chlamydia cases had dipped in 2013, but last year’s total of more than 1.4 million — or 456 cases per 100,000 — was the highest number of annual cases of any condition ever reported to the federal Centers for Disease Control and Prevention. The chlamydia rate was up almost 3 percent from 2013, the CDC reported.

Sexually transmitted diseases are among more than 70 diseases that are reportable to the CDC, including measles, chickenpox and tuberculosis. Flu is reported differently, by hospitalizations.

“America’s worsening STD epidemic is a clear call for better diagnosis, treatment, and prevention,” said the CDC’s Dr. Jonathan Mermin.

Gonorrhea cases totaled 350,062, up 5 percent from 2013, and the most contagious forms of syphilis jumped 15 percent to 20,000. As in previous years, the syphilis increase was mainly in gay and bisexual men.

Most gonorrhea and chlamydia infections were in 15-to 24-year-olds, an ongoing trend. Both can cause infertility in women but can be treated with antibiotics. They often have no symptoms, and while yearly screening is recommended for sexually active women younger than 25, many don’t get tested and infections go untreated, the CDC said.

Wisconsin reported 27,168 cases of STDs diagnosed in 2014, which amounts to 483 per 100,00. Chlamydia led the pack with 22,837 new cases.

Syphilis cases in Wisconsin were the highest in the past decade, while chlamydia and gonorrhea were slightly lower than last year.

Eighty-seven percent of reported syphilis cases were among men, while 70 percent of chlamydia cases were among women.

Sixty-seven percent of all STD cases were reported among women.

Milwaukee County reported the highest STD rate, with 1,250 cases per 100,000 residents, according to the Wisconsin Sexually Transmitted Disease Surveillance Data, reported by the Wisconsin Department of Health Services. The zip codes just west of Lake Michigan in the northern two-thirds of Milwaukee County were hit hardest.

Menominee, Kenosha, Dane and Racine rounded out the state’s top five counties, in that order.

Nationwide, Bible Belt cities topped the STD list.

Montgomery, with a population of 201,332, reported 1,899.29 cases per 100,000. Following Montgomery is St. Louis, which had 1,867.54 reported cases per 100,000, and, with a population of only 25,545, West Memphis, Arkansas, ranked third, with 1,717.20 reported cases per 100,000.

Rounding out the top 10 cities were: New Orleans, Killeen, Texas, Fayetteville, North Carolina, Norfolk Naval Base in Norfolk, Virginia, Fort Hood in Killeen, Texas and Fort Bragg in Fayetteville, N.C.

The military stations took the fifth, ninth and 10th spots, respectively.

Gay rights group endorses once-a-day pill intended to prevent HIV infection

The nation’s largest LGBT civil rights group over the weekend endorsed efforts to promote the use of a once-a-day pill to prevent HIV infection and called on insurers to provide more generous coverage of the drug.

Some doctors have been reluctant to prescribe the drug, Truvada, on the premise that it might encourage high-risk, unprotected sexual behavior. However, its preventive use has been endorsed by the U.S. Centers for Disease Control and Prevention, the World Health Organization and many HIV/AIDS advocacy groups.

The Human Rights Campaign joined those ranks with the release of a policy paper strongly supporting the preventive use of Truvada. It depicted the drug as “a critically important tool” in combatting HIV, the virus that causes AIDS.

“HRC does not take this position lightly,” the policy paper said. “We recognize there is still ongoing debate … and that there are those out there who will disagree with our stance.”

Truvada has been around for a decade, serving as one of the key drugs used in combination with others as the basic treatment for people with HIV. In 2012, the Food and Drug Administration approved it for pre-exposure prophylaxis, or PrEP – in other words, for use to prevent people from getting sexually transmitted HIV in the first place.

“Today, there is an unprecedented chance to end the HIV/AIDS epidemic, in part through PrEP’s aggressive prevention of new HIV infections,” said Chad Griffin, president of the Human Rights Campaign. “There is no reason – medical or otherwise – to discourage individuals from taking control of their sexual health and talking to their doctor about PrEP.”

The CDC says studies have shown that Truvada, when taken diligently, can reduce the risk of getting HIV by 90 percent or more. Research discussed at the International AIDS Conference in July found that use of the drug does not encourage risky sex and is effective even if people skip some doses.

As part of its announcement, the Human Rights Campaign called on insurers, regulators and Truvada’s manufacturer to take steps to reduce costs, raise public awareness, and make the option available to all medically qualified individuals who could benefit from it, regardless of ability to pay.

The cost of Truvada varies widely; a New York State Health Department fact sheet gives a range of $8,000 to $14,000 per year. The manufacturer, California-based Gilead Sciences Inc., has a program that provides assistance to some people who are eligible to use Truvada but cannot afford it.

The Human Rights Campaign urged all states to emulate Washington state, which implemented a program earlier this year offering assistance in paying for PrEP. The preventive option also was endorsed by New York Gov. Andrew Cuomo when he announced initiatives in June aimed at ending the state’s AIDS epidemic by 2020.

The HRC called on state insurance regulators to take action against any insurers who deny legitimate claims from patients who’ve been prescribed PrEP by their doctors.

A prominent provider of services to HIV-positive people, the Los Angeles-based AIDS Healthcare Foundation, remains a vocal critic of the preventive use of Truvada. In an ad campaign launched in August, the foundation says many gay men fail to adhere to Truvada’s once-a-day regimen and describes government promotion of the drug as “a public health disaster in the making.”

On Oct. 10, an alliance of about two-dozen HIV/AIDS organizations in New York released an open letter to the Healthcare Foundation, asking it not to extend the ad campaign to their state.

“We believe your campaign could prevent people at risk for HIV from using this potential lifesaving medication,” the letter said.

The Healthcare Foundation’s president, Michael Weinstein, said his organization did plan to run ads soon in New York City asserting there is data casting doubts on Truvada’s effectiveness.

“Censoring the discussion is not the answer,” he said.

Weinstein also noted that – according to figures from Gilead – only a few thousand people thus far have filled prescriptions for Truvada.

“If people really felt it was the answer, it’s hard to imagine it wouldn’t have spread like wildfire,” Weinstein said. “It’s obvious there is enormous ambivalence in the medical community.”

According to the CDC, there are about 50,000 new HIV infections annually, with gay and bisexual men accounting for nearly 63 percent of them.

On the Web…

Human Rights Campaign: http://www.hrc.org/

AIDS Healthcare Foundation: http://www.aidshealth.org/(hash)/

CDC factsheet: http://www.cdc.gov/hiv/pdf/PrEP-GL-Patient-Factsheet-PrEP-English.pdf 

Life expectancy continues to grow in U.S.

If you’re 65 and living in Hawaii, here’s some good news: Odds are you’ll live another 21 years. And for all but five of those years, you’ll likely be in pretty good health.

Hawaii tops the charts in the government’s first state-by-state look at how long Americans age 65 can expect to live, on average, and how many of those remaining years will be healthy ones.

Retirement-age Mississippians fared worst, with only about 17 1/2 more years remaining and nearly seven of them in poorer health.

U.S. life expectancy has been growing steadily for decades, and is now nearly 79 for newborns. The figures released by the U.S. Centers for Disease Control and Prevention estimate life expectancy for people 65 years old, and what portion will be free of the illnesses and disabilities suffered late in life.

“What ultimately matters is not just the length of life but the quality of life,” said Matt Stiefel, who oversees population health research for Kaiser Permanente.

The World Health Organization keeps “healthy life expectancy” statistics on nearly 200 countries, and the numbers are used to determine the most sensible ages to set retirement and retirement benefits. But the measure is still catching on in the United States; the CDC study is the first to make estimates for all 50 states.

Overall, Americans who make it to 65 have about 19.1 years of life ahead of them, including nearly 13.9 in relatively good health, the CDC estimated.

But the South and parts of the Midwest clearly had lower numbers. That’s not a surprise, experts said.

Southern states tend to have higher rates of smoking, obesity, diabetes, heart disease and a range of other illnesses. They also have problems that affect health, like less education and more poverty.

These are issues that build up over a lifetime, so it’s doubtful that moving to Hawaii after a lifetime in the South will suddenly give you more healthy years, they said.

After Mississippi, Kentucky, West Virginia and Alabama had the lowest numbers for both life expectancy and healthy life expectancy. States with the best numbers included Florida – a magnet for healthy retirees – as well as Connecticut and Minnesota.

The estimates were made using 2007 through 2009 data from the census, death certificates and telephone surveys that asked people to describe their health. The CDC’s Paula Yoon cautioned not to make too much of the differences between states. Results could have been swayed, for example, by how people in different states interpreted and answered the survey questions.

Other findings:

– Nationally, women at 65 can expect nearly 15 more years of healthy life. Men that age can expect about 13 years.

– Blacks fared much worse than whites. They could expect 11 years of healthy life, compared to more than 14 for whites.

The CDC report makes “painfully clear” the disparities in the health of whites and blacks in their final years, said Ellen Meara, a health economist at Dartmouth College.

At a glance

State, Life, expectancy aftee 65, healthy life expectancy after 65

Alabama, 17.6, years, 11.1, years

Alaska, 19.1, 14.1

Arizona, 20.2, 15

Arkansas, 18.1, 12.2

California, 20.3, 14.7

Colorado, 19.8, 15.3

Connecticut, 20.2, 15.7

Delaware, 19.2, 14.7

D.C., 19, 14.1

Florida, 20.4, 15.4

Georgia, 18.2, 12.4

Hawaii, 21.3, 16.2

Idaho, 19.4, 14.2

Illinois, 19.1, 13.5

Indiana, 18.5, 13.2

Iowa, 19.4, 14.8

Kansas, 19, 14.2

Kentucky, 17.6, 11

Louisiana, 17.9, 12

Maine, 19, 14.7

Maryland, 19.2, 14.4

Massachusetts, 19.7, 15

Michigan, 18.8, 13.9

Minnesota, 20.1, 15.6

Mississippi, 17.5, 10.8

Missouri, 18.5, 13

Montana, 19.2, 14.6

Nebraska, 19.3, 14.5

Nevada, 18.7, 13.7

New, Hampshire, 19.4, 15.1

New, Jersey, 19.6, 14

New, Mexico, 19.6, 13.9

New, York, 20, 14.5

North, Carolina, 18.6, 12.7

North, Dakota, 19.9, 14.6

Ohio, 18.5, 13.2

Oklahoma, 17.7, 12

Oregon, 19.3, 15

Pennsylvania, 18.9, 13.9

Rhode, Island, 19.4, 14.5

South, Carolina, 18.5, 12.9

South, Dakota, 19.8, 15

Tennessee, 18, 11.9

Texas, 18.9, 12.9

Utah, 19.8, 15

Vermont, 19.4, 15.2

Virginia, 18.9, 14.2

Washington, 19.4, 15.1

West, Virginia, 17.5, 11

Wisconsin, 19.5, 14.9

Wyoming, 19, 14.4

State, average, 19.1, 13.9