The Prevention and Treatment of Pressure Ulcers in Adults by zbx34530


									May 11, 1998                                                                            Vol. 58, No. 10

The Prevention and Treatment of Pressure Ulcers in Adults
Pressure ulcers affect patients in nursing homes and hospitals and also at home. Recent studies show
an incidence of 7% to 24% for patients in hospitals and nursing homes respectively. Prevalence figures
range from 10% to 35% depending on the clinical venue and on the reporting of Stage 1 lesions.
Knowledge of the risk factors that predict pressure ulcers as well as an understanding of the principles
of effective ulcer management are essential for all physicians, nurses, and lay caregivers who deal with
patients at risk.

I                                                     Lesion Classification
   n terms of both patient suffering and
   heathcare resources consumed, the
   costs of pressure ulcers are enormous.             Classification of individual lesions is useful.
The mean length of treatment exceeds 100              Treatment choice is guided by lesion stage,
days per patient, and the dollar cost varies          and serial reassessment serves to document
from 2,000 to 10,000 dollars per episode of           patient progress. Staging can be performed
care.1 It is estimated that $400 million could        by any physician, nurse, or family member
be saved if evidence-based patient evaluation         who has had adequate instruction.
and preventive strategies reduced the nation-
wide incidence of pressure ulcers by 50%.2            Pressure Ulcer Classification*

To address this important clinical problem,           Stage I: nonblanchable erythema of intact
the Agency for Health Care Policy and                 skin.
Research (AHCPR) sponsored panels to re-
view the literature and promulgate Clinical           Stage II: partial thickness skin loss involving
Practice Guidelines for preventing and treat-         epidermis and/or dermis. The ulcer is
ing pressure ulcers. Clinical Practice Guide-         superficial and presents clinically as an
line Number 3, released in 1992, addressed            abrasion, blister, or shallow crater.
the prediction and prevention of pressure             Stage III: full thickness skin loss involving
ulcers in adults. AHCPR Clinical Practice             damage or necrosis of subcutaneous tissue
Guideline Number 15, released in 1994,                that may extend down to, but not through,
addressed pressure ulcer management.                  underlying fascia. The ulcer presents
Unfortunately, recent studies suggest that            clinically as a deep crater with or without
many primary care providers are not well              undermining of adjacent tissue.
informed about pressure ulcers; as many as
70% of family physicians are unaware of               Stage IV: full thickness skin loss with
the guidelines.3                                      extensive destruction, tissue necrosis or
                                                      damage to muscle, bone, or supporting
Few prospective studies of preventive                 structures (for example, tendon or joint
and therapeutic programs are based on a               capsule). Note: Undermining and sinus tracts
complete implementation of the pressure               may also be associated with Stage IV pressure
ulcer guidelines. However, existing evidence          ulcers.
suggests a substantial benefit would be               *from the National Pressure Ulcer Advisory Panel
derived from preventive and treatment
programs designed on their principles.4                                                   Continued F
The guidelines are reviewed here because              Also in this issue:
they are evidence-based references that                   Cyclosporiasis Season Returns
give clinicians a better understanding of                 CDC Internet Site on Parasitic Disease
the key risk factors and treatment principles.            Rubella Update
                        Page 2                              May 11, 1998                                 DPN
                      As in all clinical staging systems, errors   Given these predisposing factors, it is not
                      do occur. Skin pigmentation may mask         surprising that the frail elderly in both
                      erythema, and the surface appearance         acute and long-term care settings are
                      of some pressure sores may reveal            disproportionately affected by this
                      deceptively minimal changes while            condition. The Norton Scale5 and
                      concealing extensive deep tissue             Braden Scale6 are tools used to assess
                      damage. It is important to note that         pressure ulcer risk. Both scales are
                      ulcers do not necessarily progress in        included in the AHCPR guideline,
                      order from Stage I through Stage IV          Pressure Ulcers in Adults: Prediction and
                      and that they do not necessarily heal in     Prevention. The Norton Scale is a 5-axis,
                      the reverse order.                           4-point scale yielding a numeric risk
                                                                   score from 0 to 20; the axes consist of the
                      Prediction and Prevention                    4 key clinical factors named above and
                                                                   general health status. The 6-axis, 4-
                      Assessing Risk. Established lesions          point Braden scale appears more
                      are characterized by both surface and        frequently in the recent geriatric care
                      deep tissue injury. Whether and how          literature. Caregivers can use either of
                      one lesion leads to the other is a subject   these simple scales to identify patients at
                      of some debate. Still, there is consensus    risk. (The AHCPR guidelines are available
                      that the genesis of pressure ulcers          online. See Note in References, Page 6.)
                      depends on the resistance of healthy
                      tissue to potentially disruptive mech-       Preventing Injury. Pressure ulcer
          The frail                                                prevention focuses on 3 strategies:
                      anical forces. Deep tissue ischemia and
                      epithelial injury are both caused by
disporportionally     three forces:                                •avoiding treatments that produce
  affected by this                                                   injury
        condition.    • pressure: compression of tissue            •addressing the remediable risk factors
                        caused by body weight                      •instituting measures that minimize the
                      • friction: disruption of a surface as it      impact of pressure, friction, and shear.
                        is moved against another
                      • shear: distortion of tissue causing        Treatments that are likely to promote
                        adjacent tissue layers to move in          injury include the use of topical agents
                        opposite directions as the skin drags      that lead to dry or irritated skin. The
                        across another surface                     AHCPR guideline lists 9 skin care recom-
                                                                   mendations; the one with the most sup-
                      A fourth factor, moisture, leads to          porting evidence is avoiding massage
                      softening and maceration of the              over bony prominences. Because
                      epithelium rendering it less resistant       improper routine care techniques can
                      to injury.                                   cause injury, the expert consensus
                                                                   recommendations include meticulous
                      The key clinical factors that lower          attention to proper positioning, trans-
                      resistance to injury are                     ferring, and turning techniques to
                                                                   minimize pressure, friction, and shear.
                      • immobility, by predisposing to pro-
                        longed pressure as well as to the          The most commonly remediable risk
                        friction and shear caused during           factors are poor nutrition, incontinence,
                        routine patient care                       and immobility. Successfully addressing
                      • incontinence, by causing excess            any of these requires a written thera-
                        moisture                                   peutic plan and a tool for monitoring
                      • nutritional deficits, by leading to a      patient progress. The need to identify
                        loss of subcutaneous tissue as well as     and change unsuccessful therapeutic
                        by impairing healing                       plans underscores the importance of
                      • altered level of consciousness, by         serial reassessment based on a formal
                        impairing a patient’s ability to sense
                        and respond to discomfort                                              Continued F
DPN                                 Vol. 58 No. 10                                Page 3
process. Serial nutritional assessments,     Patient Assessment
daily incontinence charts, and daily or
weekly skin assessments are useful           Dimensions of Assessment. Patient
monitoring tools. Each patient’s clinical    assessment has at least 5 dimensions:
situation determines the specific
treatment approach for each of the           • patient’s overall physical health
following risk factors:                      • presence of complications (eg, cellu-
                                               litis, osteomyelitis, sepsis, endocarditis,
• oral supplements versus enteral              or amyloidosis, among others)
  feedings for nutritional support           • nutritional status
• prompted voiding versus frequent           • presence and control of pain
  changes versus bladder                     • psychosocial assessment of the patient
  catheterization for incontinence             and family
• frequent repositioning and/or
  pressure-reducing devices for              Physical Assessment. Tools that help
  immobility                                 clinicians document and follow the
                                             extent and stage of individual pressure
There is research-based evidence to          ulcer lesions are important, but they do
support the recommendation that pa-          not replace comprehensive physical
tients at risk for developing pressure       assessment. A thorough, general history         ...neglecting
ulcers should be repositioned at least       and physical examination establishes
every 2 hours if consistent with overall     the patient’s overall physical baseline
patient goals. There is equally reliable     and is essential for identification of
                                                                                             requirements can
evidence that when patients at risk for      complications.                                  render all other
developing pressure ulcers are lying in                                                      interventions
bed, they should be placed on a pres-        Nutritional Assessment. Nutritional             ineffective.
sure-reducing device, such as a foam,        management is a vital part of caring for
static air, alternating air, gel, or water   patients with pressure ulcers. Initial and
mattress. There is expert consensus          follow-up nutritional screening is indi-
that pressure-relieving efforts should be    cated in every at-risk individual at least
directed to all weight-bearing bony          every 3 months. Nutritional support
prominences such as the heels, knees,        should provide at least 30 to 35 calories/
ankles, trochanters, hips, ischia, scapu-    kg/day and 1.25 to 1.50 grams of protein/
lae, and occiput by using pillows,           kg/day in order to establish positive
wedges, and proper body positioning.         nitrogen balance. Some patients may
For chair-bound patients, the consensus      require as much as 2.00 grams of protein/
recommendations include the use of           kg/day. It is impossible to overempha-
foam, air, or gel devices that reduce        size the importance of adequate nutri-
pressure as well as the avoidance of         tional support; neglecting nutritional
donut-type devices.                          requirements can render all other inter-
                                             ventions ineffective. Suspected or
Management of Pressure Ulcers in             proven vitamin and mineral deficiencies
Adult Patients                               should be managed with appropriate
AHCPR Guideline Number 15, devoted
to the management of patients with           Pain Assessment. Pain is a part of both
established Stage II-IV pressure ulcers,     pressure ulcer disease and its treatment.
is based on research involving adults.       Dressing changes and debridement can
It may, at the clinician’s discretion, be    be painful. Assessing pain in patients
applied to children but not to neonates.     who have decreased level of conscious-
It emphasizes three aspects of manage-       ness can challenge even astute clinical
ment: patient assessment, management         observers. The general principles of
of tissue loads, and ulcer care.             pain management are the following:

                                                                          Continued F
                            Page 4                                    May 11, 1998                                          DPN
                          • When possible, prevent pain; give               indeed important, the reality of clinical
                            analgesics prior to painful procedures.         practice is that the optimal choice of
                          • When pain prevention is not possible,           support surface depends on the patient’s
                            treat the source of pain.                       risk factors, the locations and stages of
                          • Use NSAID analgesics only for mild              existing lesions, comorbid conditions,
                            pain.                                           and even the care setting itself, rather
                          • Use narcotic analgesics for moderate            than solely on tissue pressure relief. Table
                            and severe pain.                                1, reproduced here from the AHCPR
                          • Use nonpharmacologic pain manage-               guideline, summarizes the characteristics
                            ment as an adjunct rather than as a             of common support surfaces.
                            primary pain management strategy.
                                                                            The key principles for selecting an
                          The World Health Organization’s                   effective support surface are
                          Analgesic Ladder is a useful guide to
                                                                            • An adequate static support surface
                          pain management.7
                                                                              prevents the patient from bottoming
                                                                              out. Placing an outstretched hand
                          Psychosocial Assessment. Patient and
                                                                              (palm up) under the mattress or
                          family goals and expectations are
    Individuals who                                                           overlay below the pressure ulcer or
                          important in any therapeutic program.
       tolerate sitting   For patients who can undertake
                                                                              below the part of the body at risk for a
   must be taught to                                                          pressure ulcer must reveal at least an
                          rehabilitation, it is crucial that health
reposition themselves                                                         inch of support material. If it does not,
                          care providers understand their
   every 15 minutes.                                                          the patient has bottomed out, and the
                          motivations, treatment preferences,
                          resources, and needs. The patient and               support surface is inadequate.
                          family should participate actively in the         • No static surface fully addresses
                          process of setting meaningful clinical              moisture.
                          goals.                                            • Dynamic surfaces are indicated in
                                                                              patients who bottom out on static
                          Management of Tissue Loads                          beds; whose ulcers fail to show improve-
                                                                              ment in 2 to 4 weeks; whose ulcers are
                          Support Surfaces. The words pressure                Stage III-IV and involve multiple
                          ulcers evoke images of devices that, by             surfaces; or who suffer excess
                          reducing pressure, should eliminate the             moisture from wound drainage or
                          disease itself. While relieving pressure is         incontinence.

                          Table 1. Selected Characteristics for Classes of Support Surfaces
                          Performance                         Low-air      Alternating   Static      Foam        Standard
                          Characteristics     Air-fluidized   loss beds    Air           Flotation   Mattress    Mattress

                          Increased support     Yes             Yes         Yes            Yes       Yes          No

                          Low moisture          Yes             Yes         No             No        No           No

                          Reduced heat          Yes             Yes         No             No        No           No

                          Shear reduction       Yes             ?           Yes            Yes       No           No

                          Pressure              Yes             Yes         Yes            Yes       Yes          No

                          Dynamic               Yes             Yes         Yes            No        No           No

                          Cost per day         High             High        Moderate       Low       Low          Low

                                                                                                                Continued F
DPN                                   Vol. 58 No. 10                              Page 5
Repositioning. The treatment of estab-        spaces without overpacking deep ulcers;
lished ulcers requires a more aggressive      to keep the ulcer bed moist and free of
approach than the every-2-hour sched-         exudate; and to keep the surrounding
ule recommended for preventing them.          intact skin dry. Wet-to-dry saline
Repositioning every hour is preferred.        dressings that are appropriate for
Individuals who tolerate sitting must be      mechanical debridement are not
taught to reposition themselves every 15      appropriate for promoting the healing          It is equally
minutes.                                      of clean ulcers. Dressings must be clean,      important to
                                              but sterile dressings are not necessary.       distinguish simple
Ulcer Care                                                                                   colonization and
                                              Bacterial Control. Once the skin barrier       contamination
Ulcer care consists of debridement,           is disrupted, bacterial contamination          from infection.
wound cleansing, dressings, manage-           follows. Avoiding gross contamination
ment of bacterial invasion, and surgical      of established ulcers by feces is important.
interventions.                                It is equally important to distinguish
                                              simple colonization and contamination
Debridement. Sharp debridement is             from infection. Wound cleansing is the
appropriate for infected tissue, especially   appropriate management of coloniza-
when there is evidence of cellulitis or       tion and contamination. A 2-week trial
sepsis; it should be followed with clean,     of topical antimicrobial therapy can be
dry dressings. Enzymatic, mechanical,         tried in situations where all other factors
and autolytic debridement, using a            are being properly managed and there is
variety of dressings, are appropriate in      still no clinical improvement. Swab cul-
nonurgent situations. Heel ulcers with        tures of decubitus lesions are misleading;
a dry eschar should not be subjected to       they identify only surface contaminants
debridement.                                  and often lead to misguided therapy.

Wound Cleansing. Wound cleansing is           Overt infection is usually accompanied
appropriate for removing the devitalized      by a distinct change in the physical
tissue remnants of debridement as well        appearance of the ulcer (findings of           Swab cultures
as for removing exudates. Normal              cellulitis) or fever. The best approach to     of decubitus lesions
saline applied under 8 psi of jet pressure    ulcer wound culture is deep tissue             are misleading...
or delivered with a very gentle mecha-        biopsy by needle aspiration. Quantita-         and often lead to
nical force with a fabric (fine gauze or      tive bacterial culture is useful; bacterial    misguided therapy.
sponge) is the least toxic cleansing me-      levels exceeding 100,000 organisms per
thod. While low pressure irrigation           gram of tissue may impair wound
systems such as a spray bottle or bulb        healing. Bone biopsy with culture is the
syringe are ineffective, high pressure        gold standard for diagnosing osteomye-
systems can be injurious. The highest         litis; the positive predictive value of
WaterPik™ settings or canister systems        leukocytosis, elevated erythrocyte sedi-
that create >15 psi of irrigation pressure    mentation rate, and abnormal plain x-
cause tissue destruction and embed            ray combined is only 68%. Systemic
bacteria in deep tissues. Because the         infections—cellulitis, bacteremia, sepsis,
same cleansing that removes or destroys       and osteomyelitis—all require systemic
bacteria can also remove or destroy the       antibiotic therapy.
new cell layers upon which ulcer heal-
ing depends, it is important to avoid         The final issue regarding bacterial
antiseptics and high pressure irrigation      control is the prevention of cross-
devices.                                      contamination. Body substance
                                              isolation, the use of disposable gloves,
Dressings. Serial reassessment of             attention to hand washing and proper
wound healing is the single most impor-       disposal of used dressings are all
tant guide to dressing selection. The         essential to prevent the spread of
general principles are to obliterate dead     bacterial pathogens between patients.

                                                                          Continued F
  Page 6                              May 11, 1998                                         DPN
Surgical Interventions. There are             References
numerous surgical procedures that may         1. Xakellis GC, Frantz R. The cost of healing
be appropriate for individuals with           pressure ulcers across multiple health care
pressure ulcers. These include simple         settings. Adv Wound Care 1996 Nov-Dec;
closure, skin grafts, skin flaps,             9(6):18-22.
myocutaneous flaps, and other                 2. Bergstrom N, Braden B, Boynton P, Bruch S.
procedures. Many ulcers, including            Using a research-based assessment scale in
advanced lesions, will heal with              clinical practice. Nurs Clin North Am 1995
nonsurgical management. The choice            Sep30;(3):539-51.
of surgery should be determined by the        3. Kimura S, Pacala JT. Pressure ulcers in
patient’s treatment preferences, quality      adults: family physicians’ knowledge, attitudes,
of life, potential for rehabilitation,        practice preferences, and awareness of AHCPR
nutritional status, risk of recurrence,       guidelines. J Fam Pract 1997 Apr;44(4):361-8.
and the clinician’s appraisal of the          4. Regan MB, Byers PH, Mayrovitz HN. Efficacy
patient’s ability to tolerate the operative   of a comprehensive pressure ulcer prevention
blood loss and postoperative immobility       program in an extended care facility. Adv
that surgery entails.                         Wound Care 1995 May-Jun;8(3):49, 51-2, 54-5.
                                              5. Norton D. Calculating the risk: reflections on
Summary                                       the Norton Scale. Decubitus 1989 Aug;2(3):24-
                                              31. Published erratum in Decubitus 1989
Pressure ulcers account for substantial
morbidity in patients who have impair-        6. Braden BJ. Clinical utility of the Braden Scale
ments in mobility, continence, nutrition,     for predicting pressure sore risk. Decubitus 1989
level of awareness, and overall physical      Aug;2(3):44-6, 50-1.
status. There are well-validated tools        7. Jacox A, Carr DB, Payne R, et al. Management
for assessing pressure ulcer risk, and        of Cancer Pain. Clinical Practice Guideline No. 9.
these can be used to guide preventive         AHCPR Publication No. 94-0592. Rockville,
strategy before pressure ulcers occur.        MD. Agency for Health Care Policy and
                                              Research, US Department of Health and Human
                                              Services, Public Health Service, March 1994.
Once established, pressure ulcer lesions
heal very slowly. The rate of healing is      Additional Resources
often impaired by nutritional deficits;
therefore early attention to nutrition is     Panel for the Prediction and Prevention of Pressure
                                              Ulcers in Adults. Pressure Ulcers in Adults: Predic-
important. The care of patients with          tion and Prevention. Clinical Practice Guideline,
established pressure ulcers can be very       No. 3. Rockville, MD: USDHHS, Public Health Ser-
labor intensive. It requires close            vice, Agency for Health Care Policy and Research..
cooperation among individual patient,         AHCPR Publication No. 92-0047. May 1992.
family, nurses, physical therapists,          Bergstrom N, Bennett MA, Carlson CE, et al.
nutritionists, primary care physicians        Treatment of Pressure Ulcers. Clinical Practice
and surgeons. The role of the AHCPR           Guideline, No. 15. Rockville, MD: USDHHS, Public
pressure ulcer prevention and treatment       Health Service, Agency for Health Care Policy and
                                              Research. AHCPR Publication No. 95-0652.
guidelines is to help both institutions       December 1994.
and primary care clinicians devise more
effective patient care plans.                 Note:     The AHCPR-sponsored Clinical Practice
                                              Guidelines, The 1996 Guide to Clinical Preventive
                                              Services, and NIH Consensus documents are all
                                              available online at the National Library of
Prepared by Leslie L. Cortés, MD,
                                              Medicine: Also
Director, Medical Quality Assurance,          relevant to pressure ulcer care, and available at
Texas Department of Human Services.           this website, are The Guidelines on Acute Pain
                                              Management in Adults, Management of Cancer
                                              Pain, and Urinary Incontinence - 1996 Update.
DPN                                 Vol. 58 No. 10                             Page 7

Cyclosporiasis Season Returns
The first confirmed case of cyclospo-        commonly reported symptoms were
riasis in Texas this year was diagnosed      fatigue (97%), bloating (92%), loss of
on March 9, 1998. A 68-year-old              appetite (88%), abdominal cramps
woman from Dallas was found to have          (88%), nausea (84%), and headache
Cyclospora oocysts in a stool sample         (80%). The median incubation period
submitted to a commercial laboratory.        was 7 days (Range: 1-14 days).
Cyclosporiasis is caused by a parasite
named Cyclospora cayetanensis. Promi-        From April 1 through May 31, 1997,
nent symptoms include watery diar-           41 outbreaks of cyclosporiasis (762
rhea, nausea, abdominal cramps, and          cases total) were reported in 13 states
fatigue. Fever is rare. Symptoms may         and Canada. Fresh raspberries were the
persist for many weeks, and the illness      only food in common to all 41 events
can be severe in immunocompromised           and were the only type of berry served       Diagnosis of
patients. Diagnosis of cyclosporiasis        at 9 events. The associations between        cyclosporiasis
requires visual identification by an expe-   cyclosporiasis and consumption of the        requires visual
rienced parasitologist of oocysts in stool   raspberry-containing food item were          identification of
stained using the Ziehl-Neelson acid-fast    statistically significant for 15 events,     oocysts by an
staining procedure.                          including the 1997 Houston outbreak.
                                             In Houston, all but one banquet atten-
Cyclospora outbreaks occurred season-        dee ate a cream dessert that contained a
ally in Texas from March through May         layer of fresh raspberries, strawberries,
in both 1996 and 1997. One outbreak of       blackberries, and blueberries. All ill
cyclosporiasis occurred among 89 per-        attendees (100%), compared with 70%
sons who attended a luncheon held on         of well attendees, ate some of the berries
April 25, 1997, in Houston. Of the 89,       in the dessert (Relative risk =undefined,
59 (67%) attendees were ill. Cyclospora      p<0.001). For 31 of the 33 events with
oocysts were observed in stool speci-        product traceback data, the contami-
mens of 12 ill persons. All 12 experi-       nated raspberries either definitely or
enced diarrhea. The median duration          probably came from Guatemala.
of diarrhea was 4 days. The most

CDC Internet Site on Parasitic Disease
The Centers for Disease Control (CDC) and Prevention Division of Parasitic
Disease (DPD) Internet website (DPDx) is The
DPDx offers two complementary functions:
A reference and training section, which includes an image library and a review of
recommended procedures for collecting, shipping, processing, and examining bio-
logic specimens. Users may store and copy material as they wish.
A diagnostic assistance section provides registered users with assistance in identify-
ing parasites. Users can even send digital images to DPD staff for expedited review
and consultation. This assistance is free of charge.
Laboratorians and other health professionals are invited to join the network to be
developed within this website. Further development of the site will rely heavily on
input from website users, who can send comments by clicking on the “Contact Us”
buttons found on most pages of the DPDx website.
For further information contact Phuc Nguyen-Dinh, MD, MPH, at (770) 488-4435; FAX:
(770)-4884253; email:
                              Disease Prevention News (DPN)
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                              1100 West 49th Street
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The electronic versions of Disease Prevention News
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Chair, Texas Board of Health
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Commissioner of Health
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State Epidemiologist, Associate Commissioner for
Disease Control and Prevention
Michael Kelley, MD, MPH
Chief, Bureau of Communicable Disease Control
Kate Hendricks, MD, MPH&TM
Medical Editor
Mark Gregg, MA
Director, Public Health Professional Education
Susan Hammack, MEd
Managing Editor
Linda Darlington
Production Assistant

     Rubella Update
     The last issue of Disease Prevention News (DPN) contains an alert regarding an ongoing rubella
     outbreak in Mexico that has resulted in a dramatic increase in reported rubella in Texas. As of
     April 30, new Texas cases associated with the rubella outbreak in Mexico continue to be reported.
     Health officials in Mexico report that the total rubella cases since January 1 number over 8,500, with
     greater than 1,500 cases in Tamaulipas and almost 1,000 in Chihuahua. The table below provides
     updated data on Texas cases. (See DPN Vol. 58, No. 9, April 27, 1998, for a comprehensive outbreak
     report that includes a case definition and detailed specimen submission guidelines.)

                                    Reported Cases of Rubella in Texas by County: 1997 and 1998
                                       County                        1997              1998
                                       Bell                           0                  1
                                       Cameron                        7                 22
                                       Dallas                         2                  1
                                       Harris                         1                  6
                                       Hidalgo                        0                  2
                                       Midland                        1                  0
                                       Montgomery                     1                  0
                                       Nueces                         0                  2
                                       Tarrant                        0                  1
                                       Travis                         0                  2
                                       TOTAL                         12                 37

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