HICNet Medical News Digest Mon, 08 Aug 1994 Volume 07 : Issue 33 Today's Topics: [MMWR 8 July 94] Medical Costs Attributable to Cigarette Smoking [MMWR] Risk of Traumatic Injuries from Helicopter Crashes [MMWR] Assessment of Vectorborne Diseases during Midwest Floods [MMWR] Adult Lead Blood Epidemology [MMWR] Availability of EpiInfo Version 6 [MMWR] Preventing Organic Dust Toxic Syndrome [MMWR] 1995 Symposium on Statistical Methods [MMWR 29 July 94] Respiratory Illiness Associate with Mushrooms [MMWR] Flood related mortalities +------------------------------------------------+ ! ! ! Health Info-Com Network ! ! Medical Newsletter ! +------------------------------------------------+ Editor: David Dodell, D.M.D. 10250 North 92nd Street, Suite 210, Scottsdale, Arizona 85258-4599 USA Telephone +1 (602) 860-1121 FAX +1 (602) 451-1165 Internet: mednews@stat.com Bitnet: ATW1H@ASUACAD Mosaic WWW: http://biomed.nus.sg/MEDNEWS/welcome.html Compilation Copyright 1994 by David Dodell, D.M.D. All rights Reserved. License is hereby granted to republish on electronic media for which no fees are charged, so long as the text of this copyright notice and license are attached intact to any and all republished portion or portions. The Health Info-Com Network Newsletter is distributed biweekly. Articles on a medical nature are welcomed. If you have an article, please contact the editor for information on how to submit it. If you are interested in joining the automated distribution system, please contact the editor. Associate Editors: E. Loren Buhle, Jr. Ph.D. Dept. of Radiation Oncology, Univ of Pennsylvania Tom Whalen, M.D., Robert Wood Johnson Medical School at Camden Douglas B. Hanson, Ph.D., Forsyth Dental Center, Boston, MA Lawrence Lee Miller, B.S. Biological Sciences, UCI Dr K C Lun, National University Hospital, Singapore W. Scott Erdley, MS, RN, SUNY@UB School of Nursing Jack E. Cross, B.S Health Care Admin, 882 Medical Trng Grp, USAF Albert Shar, Ph.D. CIO, Associate Prof, Univ of Penn School of Medicine Martin I. Herman, M.D., LeBonheur Children's Medical Center, Memphis TN Stephen Cristol, M.D., Dept of Ophthalmology, Emory Univ, Atlanta, GA Subscription Requests = mednews@stat.com anonymous ftp = vm1.nodak.edu; directory HICNEWS FAX Delivery = Contact Editor for information ---------------------------------------------------------------------- Date: Sun, 07 Aug 94 23:07:17 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR 8 July 94] Medical Costs Attributable to Cigarette Smoking Message-ID: Medical-Care Expenditures Attributable to Cigarette Smoking -- United States, 1993 Cigarette smoking is the most important preventable cause of morbidity and premature mortality in the United States; however, approximately 48 million persons aged greater than or equal to 18 years are smokers (1), and approximately 24 billion packages of cigarettes are purchased annually (2). Each year, approximately 400,000 deaths in the United States are attributed to cigarette smoking (3) and costs associated with morbidity attributable to smoking are substantial (4). To provide estimates for 1993 of smoking-attributable costs for selected categories of direct medical-care expenditures (i.e., prescription drugs, hospitalizations, physician care, home-health care, and nursing-home care), the University of California and CDC analyzed data from the 1987 National Medical Expenditures Survey (NMES-2) and from the Health Care Financing Administration (HCFA). This report summarizes the results of the analysis. The NMES-2 is a population-based longitudinal survey of the civilian, noninstitutionalized U.S. population (5). A cohort of 35,000 persons in 14,000 households was selected for face-to-face interviews four times during February 1987-May 1988. Respondents provided data about sociodemographic factors, health insurance coverage, use of medical care, and medical-care expenditures. Information also was collected about self-reported health status and health-risk behaviors including smoking, safety-belt nonuse, and obesity. The Medical Provider Survey, a supplement to NMES-2, provided confirmation of self-reported medical-care costs and supplied information about costs that survey respondents were unable to report. To estimate costs attributable to smoking, respondents were categorized as never smokers, former smokers with less than 15 years' exposure, former smokers with 15 or more years' exposure, and current smokers. First, the effect of smoking history on the presence of smoking-related medical conditions (i.e., heart disease, emphysema, arteriosclerosis, stroke, and cancer) was determined. Second, for each of the medical-care expenditure categories, the probability of having any expenditures and the level of expenditures were estimated as a function of smoking, medical conditions, and health status (6). All models controlled for age, race/ethnicity, poverty status, marital status, education level, medical insurance status, region of residence, safety-belt nonuse, and obesity. Data were weighted to project the estimated costs of smoking-attributable medical care to the noninstitutionalized U.S. population. These costs were then adjusted for 1993 by applying the category-specific smoking- attributable percentages to national health-care expenditure data for 1993 reported by HCFA (7). Nursing-home costs were estimated by applying the smoking-attributable percentage of hospital expenditures for persons aged greater than or equal to 65 years to total nursing-home expenditures reported by HCFA. Costs of smoking-attributable medical care also were categorized by source of payment (i.e., self pay, private insurance, Medicare, Medicaid, other federal, other state, and other). In 1987, the total medical-care expenditures for the five expense categories reported on NMES-2 was $308.7 billion; of this total, an estimated $21.9 billion (7.1%) was attributable to smoking (Table 1). Hospital expenses accounted for most ($11.4 billion) costs attributable to smoking, followed by ambulatory physician care* ($6.6 billion) and nursing-home care ($2.2 billion). Public funding (i.e., Medicare, Medicaid, and other federal and state sources) paid for 43.3% of the medical-care expenditures attributable to smoking (Table 2). The distribution of expenditures by source of payment varied substantially by age group. For persons aged greater than or equal to 65 years, public funding accounted for 60.6% of smoking-attributable costs, compared with 31.2% for persons aged less than 65 years. When the smoking-attributable percentages derived from NMES-2 were applied to HCFA national health-care expenditure data (6), estimated smoking-attributable costs for medical care in 1993 were $50.0 billion. Of these costs, $26.9 billion were for hospital expenditures, $15.5 billion for physician expenditures, $4.9 billion for nursing-home expenditures, $1.8 billion for prescription drugs, and $900 million for home-health-care** expenditures. Reported by: JC Bartlett, MPH, School of Public Health, LS Miller, PhD, School of Social Welfare, Univ of California- Berkeley; DP Rice, ScD, WB Max, PhD, Institute for Health and Aging, Univ of California-San Francisco. Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion; Public Health Practice Program Office, CDC. Editorial Note: The findings in this report indicate that cigarette smoking accounts for a substantial and preventable portion of all medical-care costs in the United States. For each of the approximately 24 billion packages of cigarettes sold in 1993, approximately $2.06 was spent on medical care attributable to smoking. Of the $2.06, approximately $0.89 was paid through public sources. From 1987 to 1993, the more than twofold increase in estimated direct medical-care costs attributable to smoking primarily reflect the substantial increase in medical-care expenditures during this period (7). In addition, the 1993 HCFA estimate of national health-care expenditures included expenses not covered by NMES-2 (e.g., hospitalization and other medical-care costs for persons too ill to respond to NMES-2). This analysis controlled for potential confounders such as sociodemographic status, health insurance status, and risk behaviors other than smoking. Previous estimates assumed the difference in medical-care use between smokers and nonsmokers was primarily attributable to smoking and did not account for other associated risk factors that may result in excessive medical expenditures (4). The smoking-attributable costs described in this report are underestimated for two reasons. First, the cost estimates do not include all direct medical costs attributable to cigarette smoking (e.g., burn care resulting from cigarette-smoking-related fires, perinatal care for low-birthweight infants of mothers who smoke, and costs associated with diseases caused by exposure to environmental tobacco smoke). Second, the indirect costs of morbidity (e.g., due to work loss and bed-disability days) and loss in productivity resulting from the premature deaths of smokers and former smokers were not included in these estimates. In 1990, estimated indirect losses associated with morbidity and premature mortality were $6.9 billion and $40.3 billion, respectively (3); these estimates suggest that the total economic burden of cigarette smoking is more than twice as high as the direct medical costs described in this report. References 1. CDC. Cigarette smoking among adults--United States, 1992, and changes in the definition of current cigarette smoking. MMWR 1994;43:342-6. 2. US Department of Agriculture. Tobacco situation and outlook report. Washington, DC: US Department of Agriculture, Economic Research Service, Commodity Economics Division, June 1994; publication no. TBS-227. 3. CDC. Cigarette smoking-attributable mortality and years of potential life lost--United States, 1990. MMWR 1993;42:645-9. 4. Herdman R, Hewitt M, Laschover M. Smoking-related deaths and financial costs: Office of Technology Assessment Estimates for 1990--OTA testimony before the Senate Special Committee on Aging. Washington, DC: US Congress, Office of Technology Assessment Testimony, May 6, 1993. 5. National Center for Health Services Research and Health Technology Assessment. National Medical Expenditure Survey. Methods II. Questionnaires and data collection methods for the household survey and the Survey of American Indians and Alaska Natives. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, National Center for Health Services Research and Health Technology Assessment, September 1989; DHHS publication no. (PHS)89-3450. 6. Duan W, Manning WG, Morris CN, Newhouse JP. A comparison of alternative models for the demand for medical care. Journal of Business and Economic Statistics 1983;1:115-26. 7. Burner ST, Waldo DR, McKusick DR. National health expenditures: projections through 2030. Health Care Financ Rev 1992;14(1). *Includes hospital-based outpatient and emergency care and care in physicians' offices. **In 1993, HCFA excluded all but Medicare- and Medicaid-certified care in this category. ------------------------------ Date: Sun, 07 Aug 94 23:08:44 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR] Risk of Traumatic Injuries from Helicopter Crashes Message-ID: <0w7Pqc2w165w@stat.com> Risk for Traumatic Injuries From Helicopter Crashes During Logging Operations -- Southeastern Alaska, January 1992-June 1993 Helicopters are used by logging companies in the Alaska panhandle to harvest timber in areas that otherwise are inaccessible and/or unfeasible for conventional logging (because of rugged terrain, steep mountain slopes, environmental restrictions, or high cost). The National Transportation Safety Board (NTSB) investigated six helicopter crashes related to transport of logs by cable (i.e., long-line logging*) that occurred in southeastern Alaska during January 1992-June 1993 and resulted in nine fatalities and 10 nonfatal injuries. This report presents case investigations of these incidents. Incident Reports Incident 1. On February 23, 1992, a helicopter crashed while transporting nine loggers. The copilot and five loggers died; five others were seriously injured. The NTSB investigation revealed that a long-line attached to the underside of the helicopter became tangled in the tail rotor during a landing approach, causing an in-flight separation of the tail section (1). Passenger flights with long-line and external attachments are illegal (2) and violate industry safety standards. Incident 2. On March 6, 1992, a helicopter crashed while preparing to pick up a load of logs with a long-line. The pilot and copilot were seriously injured. According to the pilot and copilot, the engine failed, and the pilot immediately released the external log load and attempted autorotation**. Incident 3. On November 10, 1992, a helicopter crashed while attempting to land at a logging site, sustaining substantial damage. The solo pilot was not injured. NTSB investigation revealed that the helicopter's long-line had snagged on a tree stump during the landing and that the company had no documented training program (1). Incident 4. On February 19, 1993, a helicopter crashed from a 200-foot hover after transporting two logs to a log-drop area. The pilot and copilot were killed. NTSB investigation revealed in-flight metal fatigue of a flight-control piston rod. Incident 5. On May 2, 1993, a helicopter crashed during an attempted emergency landing after using a long-line to lift a log 1200 feet above ground level followed by rapid descent to a 75-foot hover. The pilot died, and a logger on the ground was injured. NTSB investigation revealed an in-flight separation of the tail rotor and tail rotor gear box from the helicopter. The company had been using a flight procedure that would have heavily loaded the helicopter drive train (1). Incident 6. On May 8, 1993, a helicopter crashed after attempting to lift a log from a logging site with a long-line. The pilot and copilot sustained minor injuries, but the aircraft was substantially damaged. NTSB investigation found that the engine failed because machine nuts had come loose from the engine or its housing and became caught in the engine. The helicopter crashed when the pilot attempted autorotation. Investigation Findings Statewide occupational injury surveillance in Alaska through a federal-state collaboration was established in mid-1991, with 1992 being the first full year of comprehensive population-based occupational fatality surveillance for Alaska. During the time these incidents occurred, an estimated 25 helicopters in Alaska were capable of conducting long-line logging operations; approximately 20 were single-engine models from one manufacturer (Federal Aviation Administration [FAA], unpublished data, 1993). Approximately 50 helicopter pilots were employed in long-line logging operations in southeastern Alaska (FAA and Alaska Department of Labor, unpublished data, 1993). Using these denominators, the events in this report are equivalent to an annual crash rate of 16% (six crashes per 25 helicopters per 18 months), 0.24 deaths per long-line helicopter in service per year (nine deaths per 25 helicopters per 18 months), and an annual fatality rate for long-line logging helicopter pilots of approximately 5000 deaths per 100,000 pilots (four pilot deaths per 50 pilots per 18 months).*** In comparison, during 1980-1989, the U.S. fatality rate for all industries was 7.0 per 100,000 workers per year; Alaska had the highest overall occupational fatality rate of any state (34.8 per 100,000 per year) for the same period (4). According to NTSB investigations to determine probable cause, all six crashes involved "...improper operational and/or maintenance practices" that reflected a lack of inspections of long-line helicopter logging operations (1). In incidents 4, 5, and 6, investigative evidence also indicated that log loads routinely exceeded weight and balance limits for the aircraft. Following increased inspections, no additional logging-related helicopter crashes were reported through June 30, 1994. Reported by: G Bledsoe, Occupational Injury Prevention Program, Section of Epidemiology, Div of Public Health, JP Middaugh, State Epidemiologist, Alaska Dept of Health and Social Svcs; D Study, Labor Standards and Safety Div, Occupational Safety and Health, Alaska Dept of Labor. National Transportation Safety Board, Anchorage, Alaska. Alaska Activity, Div of Safety Research, National Institute for Occupational Safety and Health, CDC. Editorial Note: The incidents in this report demonstrate that long-line helicopter logging is a technology application with an unusually high risk for occupational fatalities. General aviation regulations restrict the number of hours pilots can fly during given time periods; however, long-line helicopter logging involves carrying loads outside the rotorcraft, and there are no legal limitations on crew flight hours. Although flight-crew work schedules and daily flight hours vary greatly by logging company, flight-crew duty periods can exceed 10 hours per day for 10 consecutive days. Helicopter logging operations often place heavy demands on helicopter machinery and associated equipment. The highly repetitive lift/transport/drop cycles are frequently conducted at or beyond maximum aircraft capacity in remote areas, where rugged terrain, extremely steep mountain slopes (as great as 70 degrees), and adverse weather conditions prevail. Complex operations under such circumstances may increase the likelihood of both human error and machine failure (5). In addition, conditions are unfavorable for successful autorotation during most helicopter long-line logging operations. Regardless of where helicopter logging operations are conducted, the jurisdictional responsibility for inspection rests with the FAA office nearest the main or registered corporate office for the helicopter company (in all of the cases in this report, these offices were in the contiguous United States). This necessitates travel of great distances to conduct helicopter logging inspections, and remote operations may escape or evade inspection for long periods. The NTSB has recommended that operational and maintenance oversight responsibilities for remote sites be assigned to the nearest FAA office (1). In response to these incidents, the Alaska Federal-State Interagency Collaborative Working Group on the Prevention of Occupational Traumatic Injuries**** met in a special session on July 8, 1993, to discuss approaches for reducing the number of such crashes and ameliorating the outcome of crash injuries. Based on these and other findings, the working group made the following recommendations (6): -- All helicopter logging pilots and ground crews should receive specific training in long-line operations. -- Companies should follow all manufacturers' recommendations for more frequent helicopter maintenance (because of intensity of use) and for limits on maximum allowable loads. -- Companies should establish and observe appropriate limits on helicopter-crew flight time and duty periods. -- Companies should consider using multi-engine rotorcraft. -- Specific industrywide operating standards and procedures should be developed. -- Companies should provide training in on-site emergency medical care for helicopter logging crews at all work locations. -- State, regional, and local agencies involved in emergency medical services education should make low-cost emergency medical training available to persons likely to work in a helicopter logging environment. -- All flights over water should include appropriate survival equipment for all crew and passengers, who should wear personal flotation devices at all times during flights over water. References 1. National Transportation Safety Board. NTSB safety recommendation A-93-78 through -80. Washington, DC: National Transportation Safety Board, June 17, 1993. 2. Office of the Federal Register. Code of Federal Regulations, Vol 14, part 133. Washington, DC: US Department of Transportation, Federal Aviation Administration, January, 1992. 3. Roland HE Jr, Detwiler JF. Fundamentals of fixed and rotary wing aerodynamics. Los Angeles: University of Southern California, November 1967. 4. Jenkins EL, Kisner SM, Fosbroke DE, et al. Fatal injuries to workers in the United States, 1980-1989: a decade of surveillance. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, NIOSH, 1993. 5. Aircraft accident investigation manual. Los Angeles: University of Southern California, Institute of Safety and Systems Management, December 1992. 6. Helicopter logging: Alaska's most dangerous occupation? State of Alaska Epidemiology Bulletin, August 16, 1993; bulletin no. 32. *A typical long-line logging helicopter carries an approximately 200-foot load cable (i.e., long-line), which is attached by a hook to the underside of the helicopter. A second hook is fixed to the free end of the cable, where a choker cable (an apparatus designed to cinch or =FEchoke=FE around suspended logs) is connected to one to four logs per load. **Autorotation allows a helicopter to make an unpowered descent by maximizing on the windmilling effect and orientation of the main rotor=FEforward airspeed and altitude can be converted to rotor energy to reduce the rate of descent. Successful autorotation depends on helicopter airspeed and altitude when the maneuver is attempted (3). Most helicopters conduct long-line logging operations with minimal or no forward airspeed at less than 400 feet above ground level, while optimal conditions for autorotation require an altitude of at least 500 feet above ground level and airspeed of more than 60 knots per hour. ***These rates refer to the period of intense collaborative investigation and may not represent incidence over a longer period of time; however, they accurately reflect the high risk of helicopter long-line logging during that interval. ****Representatives from the Alaska Department of Health and Social Services, Alaska Department of Labor, FAA, CDC's National Institute for Occupational Safety and Health, NTSB, Occupational Safety and Health Administration, U.S. Coast Guard, and the U.S. Forest Service. ------------------------------ Date: Sun, 07 Aug 94 23:11:41 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR] Assessment of Vectorborne Diseases during Midwest Floods Message-ID: <727Pqc3w165w@stat.com> Rapid Assessment of Vectorborne Diseases During the Midwest Flood -- United States, 1993 Heavy spring and summer rainfall during 1993 caused the most extensive flash and riverine flooding ever recorded in the upper midwestern United States. In portions of the flood region,* standing water provided large expanses of habitat capable of producing large populations of the mosquitoes Culex pipiens and Cx. tarsalis. These species can rapidly amplify transmission of the arboviruses that cause St. Louis encephalitis (SLE) and western equine encephalitis (WEE). Although information from state health departments in the disaster area indicated minimal SLE or WEE activity in the region before the flooding, large vector populations in certain areas following the flooding increased the potential for exposure of residents and emergency workers to arboviral infection. To determine the risk for arboviral disease in the disaster area, CDC, in collaboration with state and local health departments, conducted surveillance during August-September 1993. This report summarizes the results of the surveillance activity. The risk for SLE or WEE amplification was low in the northern part of the flood region because flooding occurred during late summer, vector population densities were moderate, and nighttime temperatures were below 50 F (10 C). To verify the low risk, mosquito-based surveillance was conducted in Iowa, Minnesota, Nebraska, North Dakota, and South Dakota during August 2-7. Because larger mosquito populations and higher average temperatures (that may facilitate virus amplification) were observed in the southern part of the flood region, intensive surveillance for SLE and WEE was conducted in Illinois, Iowa, Kansas, and Missouri from August 1 through September 21. Mosquitoes were collected in carbon dioxide-baited light traps and sorted by species. Known vector species were grouped into pools of up to 100 mosquitoes and tested for the presence of SLE antigen (using an antigen-capture enzyme-linked immunosorbent assay) and/or WEE virus (using a Vero cell culture plaque assay). WEE virus was detected in one pool of Cx. tarsalis collected in Deuel County, South Dakota; no evidence of SLE activity was detected in any of the 186,501 mosquitoes tested from throughout the region (Table 1). In Iowa, state-based sentinel chicken surveillance revealed no evidence of SLE or WEE activity. In Illinois, state-based wild bird surveillance identified SLE virus in one of 2073 birds tested. Two human cases of SLE were reported from the nine-state area; one occurred within the disaster area. Sporadic cases of SLE frequently occur in the Midwest; these cases were not related to flooding in 1993. Because surveillance data indicated minimal risk for arboviral disease above background levels in the disaster area, contingency plans for large-scale mosquito adulticiding were not implemented. Reported by: J Anders, Div of Microbiology, LA Shireley, MPH, State Epidemiogist, North Dakota State Dept of Health and Consolidated Laboratories. L Volmer, Office of Communicable Disease Prevention and Control, K Forsch, State Epidemiologist, South Dakota State Dept of Health. MT Osterholm, PhD, State Epidemiologist, Minnesota Dept of Health. WL Schell, JP Davis, MD, State Epidemiologist, Div of Health, Wisconsin Dept of Health and Social Svcs. WA Rowley, Dept of Entomology, Iowa State Univ; R Currier, LA Wintermeyer, MD, State Epidemiologist, Iowa Dept of Public Health. WL Kramer, TJ Safranek, MD, State Epidemiologist, Nebraska Dept of Health. D Alfano, Bur of Disease Control, Kansas Dept of Health and Environment. LD Haramis, Vector Surveillance and Control, Illinois Dept of Public Health. W Kottkamp, St. Louis County Dept of Health-Vector Control, St. Louis; CL Frazier, Southeast Missouri State Univ, Cape Girardeau; FT Satalowich, Vector Control, Missouri Dept of Health. US Navy Disease Vector Ecology and Control Center, Naval Air Station, Jacksonville, Florida; US Navy Disease Vector Ecology and Control Center, Alameda, California; US Navy Environmental and Preventive Medicine Unit No. 2, Norfolk, Virginia. US Air Force Reserve 910 AG/DOS. Emergency Response Coordination Group, Vienna, Ohio. National Center for Environmental Health; Medical Entomology/Ecology Br, Div of Vector-Borne Infectious Diseases, National Center for Infectious Diseases, CDC. Editorial Note: Although natural disasters that result in flooding often are followed by a proliferation of mosquitoes, in the United States such disasters are rarely followed immediately by epidemics of arboviral disease. Surveillance data in this report confirmed that, in 1993, flood-related risk for epidemic mosquitoborne arboviral infections was low in the upper midwestern United States. Despite the presumed low risk for mosquitoborne arboviral disease after flood-related natural disasters, surveillance for arboviruses can assist in determining prevalence in large vector populations and the need for mosquito control. Because the 1993 Midwest flood was more widespread than previous floods in the region, the risk for arboviral disease was unknown. Surveillance provided an accurate determination of the risk for transmission of arboviral infection and obviated the expense of large-scale mosquito control. For example, the total allocation for arbovirus surveillance in the disaster area was approximately $390,000 (range: $32,275 [Illinois] to $150,000 [Missouri]). If surveillance had not been implemented in the area, prophylactic mosquito control most likely would have been conducted. The estimated cost of mosquito control for the St. Louis metropolitan area alone was $1.6 million. If other metropolitan areas in the flood region also were treated, the total estimated cost of prophylactic mosquito control would have exceeded $10 million. These findings suggest that arbo- virus surveillance programs to determine public health risk can prevent unnecessary expenditures associated with application of insecticides. In addition to large-scale application of insecticides, the primary public health interventions to prevent mosquitoborne arboviral outbreaks include community alerts that warn residents to avoid mosquito exposure during twilight hours by staying inside screened or air-conditioned buildings or by using repellents or other personal protection measures. The decision to use large-scale application of insecticides to reduce vector population densities is complex and depends on many factors, including detection of early-season arbovirus transmission, indicating increased risk for human infection. Timely intervention, however, requires an active program of mosquito and avian surveillance and appropriate mosquito-control measures. Reasons also may exist for emergency control of mosquitoes that are not related to disease transmission after a disaster. Pest (i.e., nonvector) mosquito species may cause severe nuisance problems that compromise emergency-response operations. CDC recommends control of pest mosquitoes when 1) emergency-response or reconstruction efforts are substantially hampered by large populations of mosquitoes, 2) normal civil services (e.g. police, fire, emergency medical services, power, and water and sewage services) in the disaster area are substantially disrupted, or 3) large nuisance mosquito populations place additional stress on the human population (1). Surveillance protocols and control methods vary by the mosquito species. Decisions to control pest mosquitoes are based on criteria that differ from those to control vector mosquitoes. No large-scale emergency control of pest mosquitoes was conducted in the 1993 flood disaster. In the disaster area, the risk for epidemic transmission of arboviruses during 1994 is being monitored by human, bird, and mosquito surveillance. Winter snows and spring rains contributed to flooding and standing water in some areas of the midwestern United States that experienced flooding in 1993. As a result, mosquitoes in these localities may be more abundant than usual during the 1994 arbovirus transmission season. Reference 1. CDC. Emergency mosquito control associated with Hurricane Andrew--Florida and Louisiana, 1992. MMWR 1993;42:240-2. *Illinois, Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota, and Wisconsin. ------------------------------ Date: Sun, 07 Aug 94 23:13:00 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR] Adult Lead Blood Epidemology Message-ID: Adult Blood Lead Epidemiology and Surveillance -- United States, 1992-1994 CDC's National Institute for Occupational Safety and Health Adult Blood Lead Epidemiology and Surveillance program (ABLES) monitors elevated blood lead levels (BLLs) among adults in the United States (1). Twenty-two states currently report surveillance results to ABLES. Beginning in 1993, ABLES began detecting both new cases and persons with multiple reports over time. In this report, ABLES provides data for the first quarter of 1994 and compares annual data for 1993 and 1992. During January 1-March 31, 1994, the number of reports of elevated BLLs increased over those reported for the same period in both 1992 and 1993 in all reporting categories (Table 1); this increase is consistent with the increase from 1992 to 1993 in total annual BLL reports (2). The number of reports of adults with elevated BLLs reflects monitoring practices by employers. Variation in national quarterly reporting totals, especially first-quarter totals, may result from 1) changes in the number of participating states; 2) timing of receipt of laboratory BLL reports by state-based surveillance programs; and 3) interstate differences in worker BLL testing by lead-using industries. The reported number of adults with elevated BLLs increased from 8886 in 1992 to 11,240 in 1993 (Table 2); this increase resulted in part from a net gain of two reporting states (three additions and one deletion) to ABLES in 1993. A total of 6584 new case reports* accounted for 59% of the total cases (11,240) reported during 1993. Fifty-two percent of persons reported in 1992 were reported again to the system during 1993. Reasons for repeat reports of elevated BLLs include 1) recurring exposure resulting from lack of existing control measures and inapropriate worker-protection practices; 2) routine tracking of elevated employee BLLs below the medical removal limits; and 3) increased employer monitoring during medical removal. Increased testing of workers in construction trades--as new workplace medical-monitoring programs are established to comply with new Occupational Safety and Health Administration regulations (3)--also may partially explain increases in reports of elevated BLLs. These data suggest that work-related lead exposure is an ongoing occupational health problem in the United States. By expanding the number of participating states, reducing variability in reporting, and distinguishing between new and recurring elevated BLLs in adults, ABLES can enhance surveillance for this preventable condition. Reported by: NH Chowdhury, MBBS, Alabama Dept of Public Health. C Fowler, MS, Arizona Dept of Health Svcs. FJ Mycroft, PhD, Occupational Health Br, California Dept of Health Svcs. BC Jung, MPH, Connecticut Dept of Public Health and Addiction Svcs. M Lehnherr, Occupational Disease Registry, Div of Epidemiologic Studies, Illinois Dept of Public Health. R Gergely, Iowa Dept of Public Health. E Keyvan-Larijani, MD, Lead Poisoning Prevention Program, Maryland Dept of the Environment. R Rabin, MSPH, Div of Occupational Hygiene, Massachusetts Dept of Labor and Industries. A Carr, MBA, Bur of Child and Family Svcs, Michigan Dept of Public Health. D Solet, PhD, Div of Public Health Svcs, New Hampshire State Dept of Health and Human Svcs. B Gerwel, MD, Occupational Disease Prevention Project, New Jersey Dept of Health. R Stone, PhD, New York State Dept of Health. S Randolph, MSN, North Carolina Dept of Environment, Health, and Natural Resources. E Rhoades, MD, Oklahoma State Dept of Health. M Barnett, MS, State Health Div, Oregon Dept of Human Resources. J Gostin, MS, Occupational Health Program, Div of Environmental Health, Pennsylvania Dept of Health. R Marino, MD, Div of Health Hazard Evaluations, South Carolina Dept of Health and Environmental Control. D Perrotta, PhD, Bur of Epidemiology, Texas Dept of Health. D Beaudoin, MD, Bur of Epidemiology, Utah Dept of Health. L Toof, Div of Epidemiology and Health Promotion, Vermont Dept of Health. J Kaufman, MD, Washington State Dept of Labor and Industries. D Higgins, Wisconsin Dept of Health and Social Svcs. Div of Surveillance, Hazard Evaluations, and Field Studies, National Institute for Occupational Safety and Health, CDC. References 1. CDC. Surveillance of elevated blood lead levels among adults-- United States, 1992. MMWR 1992;41:285-8. 2. CDC. Adult blood lead epidemiology and surveillance--United States, fourth quarter, 1993. MMWR 1994;43:246-7. 3. Office of the Federal Register. Code of federal regulations: occupational safety and health standards. Subpart Z: toxic and hazardous substances--lead. Washington DC: Office of the Federal Register, National Archives and Records Administration, 1993. (29 CFR section 1926, part II). *At least one report of an adult with an elevated BLL ( greater than or equal to 25 ug/dL) who had not been reported previously in 1992. Of the newly reported cases in 1993, 257 (4%) were reported by new ABLES states (for which all cases are considered new). ------------------------------ Date: Sun, 07 Aug 94 23:14:08 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR] Availability of EpiInfo Version 6 Message-ID: <067Pqc5w165w@stat.com> Availability of Version 6 of Epi Info The Epi Info computer programs produced by CDC and the World Health Organization provide public-domain software for word processing, database management, and statistics work in public health; more than 40,000 documented copies of Version 5 are in use in 117 countries. Version 6 of Epi Info was released in June 1994. Version 6 features a configurable pull-down menu, facilities for producing and using hypertext (active text), additional statistics, and many programming improvements. As with previous versions, it runs on IBM*-compatible computers under DOS and requires 640 K of memory (RAM), although use of a hard disk is recommended. A 600-page manual is included on the disks and is available in printed form. Copies of Epi Info and a companion program for geographic mapping (Epi Map) are available from USD, Inc., 2075A West Park Place, Stone Mountain, GA 30087; telephone (404) 469-4098; fax (404) 469-0681. There are charges for Epi Info and Epi Map. Epi Info and Epi Map are available on the worldwide Internet using the following access information: Site: FTP.CDC.GOV; User ID: anonymous; Directory for Epi Info: /PUB/EPI/EPIINFO; Directory for Epi Map: /PUB/EPI/EPIMAP. The compressed files occupy 3-4 megabytes for each product. *Use of trade names and commercial sources is for identification only and does not imply endorsement by the Public Health Service or the U.S. Department of Health and Human Services. ------------------------------ Date: Sun, 07 Aug 94 23:15:46 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR] Preventing Organic Dust Toxic Syndrome Message-ID: NIOSH Alert: Request for Assistance in Preventing Organic Dust Toxic Syndrome CDC's National Institute for Occupational Safety and Health (NIOSH) periodically issues alerts on workplace hazards that have caused death, serious injury, or illness to workers. One such alert, Request for Assistance in Preventing Organic Dust Toxic Syndrome (1), was recently published and is available to the public.* This alert warns agricultural workers who inhale contaminated organic dust that they can develop serious respiratory illness. One of the most common illnesses is organic dust toxic syndrome (ODTS), a respiratory and systemic illness that can follow exposures to heavy concentrations of organic dusts contaminated with microorganisms. An estimated 30%-40% of workers exposed to such organic dusts will develop ODTS. The alert describes four incidents in which 29 agricultural workers developed ODTS. Also described are the various medical conditions that ODTS includes and the health effects associated with the syndrome. The alert provides recommendations for minimizing the risk for exposure to organic dusts and for the use of respirators. Reference 1. NIOSH. Request for assistance in preventing organic dust toxic syndrome. Cincinnati: US Department of Health and Human Services, Public Health Service, CDC, 1994; DHHS publication no. (NIOSH)94-102. *Single copies of this document are available without charge from the Publications Office, Division of Standards Development and Technology Transfer, NIOSH, CDC, Mailstop C-13, 4676 Columbia Parkway, Cincinnati, OH 45226-1998; telephone (800) 356-4674 ([513] 533-8328 for persons outside the United States); fax (513) 533-8573. ------------------------------ Date: Sun, 07 Aug 94 23:16:40 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR] 1995 Symposium on Statistical Methods Message-ID: 1995 Symposium on Statistical Methods CDC and the Agency for Toxic Substances and Disease Registry; the Atlanta chapter of the American Statistical Association; the Biostatistics Division, Emory University School of Public Health; and the Department of Statistics, University of Georgia, will cosponsor a statistical methods symposium entitled "Small Area Statistics in Public Health: Design, Analysis, Graphic and Spatial Methods" January 25-26, 1995, in Atlanta. A short course, "Geographic Information Systems: Concepts and Perspectives for Small Area Analysis in Public Health," will be offered January 24, 1995, in conjunction with the symposium. The symposium will include invited plenary presentations and contributed papers. Abstracts will be accepted in the following areas: "borrowed strength" methods for small-area estimation; use of small-area statistics in environmental health issues; small-area statistics and ethnic subpopulations; estimation and forecasting from small samples; detection of temporal and spatial trends in disease patterns; geographic information systems; mapping and graphic methods for public health research; and confidentiality and data-accessibility issues. Abstracts should be postmarked no later than August 1, 1994. Abstract, registration, and cost information is available from CDC's Division of Surveillance and Epidemiology, Epidemiology Program Office, Mailstop C-08, 1600 Clifton Road, NE, Atlanta, GA 30333; telephone (404) 639-0080. Additional information regarding scientific content of the symposium is available from the Chair, 1995 CDC and ATSDR Symposium on Statistical Methods, telephone (404) 488-4300 (Internet: SJS1@CEHEHL1.EM.CDC.GOV). ------------------------------ Date: Sun, 07 Aug 94 23:18:28 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR 29 July 94] Respiratory Illiness Associate with Mushrooms Message-ID: Respiratory Illness Associated with Inhalation of Mushroom Spores -- Wisconsin, 1994 During April 8-14, 1994, eight persons aged 16-19 years from southeastern Wisconsin visited physicians for respiratory illness associated with inhalation of Lycoperdon perlatum (i.e., puffball mushrooms). On April 19, the Bureau of Public Health, Wisconsin Division of Health, was notified of these cases. This report summarizes the case investigations. On April 3, the adolescents attended a party during which they inhaled and chewed puffball mushrooms. It was unknown whether other persons at the party participated in this activity. No illicit drugs were reportedly used at the party. Three persons reported nausea and vomiting within 6-12 hours after exposure. Within 3-7 days after exposure, all patients developed cough, fever (temperature up to 103 F [39.4 C]), shortness of breath, myalgia, and fatigue. Five persons required hospitalization; two were intubated. Two patients had a history of asthma and were using steroid inhalers. Chest radiographs on all hospitalized patients indicated bilateral reticulonodular infiltrates. Two patients underwent transbronchial lung biopsy, and one had an open lung biopsy. Histopathologic examination of the lung biopsy specimens revealed an inflammatory process and the presence of yeast-like structures consistent with Lycoperdon spores. Fungal cultures of the lung biopsy tissue were negative. All hospitalized patients received corticosteroids, and four received antifungal therapy with either amphotericin B or azole drugs. All patients recovered within 1-4 weeks with no apparent sequelae. Reported by: TA Taft, MD, RC Cardillo, MD, D Letzer, DO, CT Kaufman, DO, Milwaukee; JJ Kazmierczak, DVM, JP Davis, MD, Communicable Disease Epidemiologist, Bur of Public Health, Wisconsin Div of Health. Div of Respiratory Disease Studies, National Institute for Occupational Safety and Health; Div of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, CDC. Editorial Note: Lycoperdonosis is a rare respiratory illness caused by inhalation of spores of the mushroom Lycoperdon. Puffballs, which are found worldwide, grow in the autumn and can be edible then. In the spring, they desiccate and form spores that can be easily released by agitating the mushroom (1). One puffball species (L. marginatum) can produce psychoactive effects (2). Only three cases of lycoperdonosis have been reported previously (1,3)--two in children and one in an adolescent. These three patients had inhaled large quantities of puffball spores, one unintentionally and two deliberately (as a folk remedy to control nosebleed). All patients had evidence of bilateral infiltrates on chest radiographs. Whether the pulmonary process results from a hypersensitivity reaction, an actual infection by the spores, or both is unknown. The efficacy of using antifungal agents to treat lycoperdonosis is unknown. Physicians should be aware of this illness, especially in children and young adults presenting with a compatible clinical history and progressive respiratory symptoms. References 1. Strand RD, Neuhauser EBD, Sornberger CF. Lycoperdonosis. N Engl J Med 1967;277:89-91. 2. Lincoff G, Mitchel DH. Toxic and hallucinogenic mushroom poisoning. Williams WK, ed. New York: Van Nostrand Reinhold Company, 1977. 3. Henriksen NT. Lycoperdonosis. Acta Paediatr Scand 1976;65:643-5. ------------------------------ Date: Sun, 07 Aug 94 23:19:38 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR] Flood related mortalities Message-ID: Epidemiologic Notes and Reports Flood-Related Mortality -- Georgia, July 4-14, 1994 On July 3, 1994, tropical storm Alberto struck the Florida panhandle with maximum sustained winds of 60 miles per hour. On July 4, as the center of the storm deteriorated over Columbus, Georgia, a cold front pushed through Alabama and southwestern Georgia from the northwest, producing warm, moist air and unstable weather resulting in heavy, prolonged thunderstorms. Rainfall totals in some areas of south central Georgia were 12-15 inches during a 24-hour period; Americus, Georgia, recorded 24 inches on July 6 (W. Zaleski, National Weather Service, personal communication, 1994). Several rivers, cresting up to 20 feet above flood stage, inundated major portions of the state. Flood waters forced closure of 175 roads in 30 counties, and more than 100 dams and recreational watersheds were either damaged or destroyed. Forty-three (27%) of Georgia's 159 counties were declared federal disaster areas, and seven additional counties were declared state disaster areas. This report summarizes preliminary findings of surveillance for deaths associated with the floods. To assess mortality associated with flooding, CDC obtained epidemiologic information from medical examiners and coroners (ME/Cs) in 48 of the 50 counties declared disaster areas and in two counties adjacent to disaster areas. ME/Cs were asked about the number of deaths in their counties attributable to flooding during July 4-14 and for information about the circumstances of each death. A flood-related death was defined as a death that resulted from the floods during July 4-14, as determined by the ME/C in each county. From July 4 through July 14, ME/Cs classified 30 deaths as flood related. Two deaths were excluded from further analyses because they involved motor-vehicle crashes not directly related to flooding. Of the 28 remaining deaths, 27 occurred in 10 of the federally declared disaster counties; one occurred in an adjacent county (Figure 1). Fifteen deaths occurred in Sumter County; local officials attributed approximately 50% of these deaths to the rupture of seven to nine small earthen dams in the county. Waters from the dams inundated surrounding creeks, sweeping away many of the persons who died. Decedents ranged in age from 2 to 84 years (mean: 31 years; median: 28 years); 20 were male (Table 1). Eighteen deaths occurred on July 6*. For 27 of 28 decedents, drowning was reported as the cause of death and "accident"** as the manner of death; the cause and manner of one flood-related death are unknown. Of the 27 drownings, 20 were motor-vehicle-related (e.g., victims drove into low-lying areas, across washed-out bridges, or off the road into deep water). Reported by: C Duke, Coroner, Baker County, Newton; E Bon, Coroner, Bibb County, Macon; J Reeves, Deputy Coroner, Butts County, Jackson; B Miller, Coroner, Calhoun County, Morgan; B Chancellor, Coroner, Chattahoochee County, Cusseta; M Griffin, Coroner, Clay County, Fort Gaines; P Dickson, Coroner, Clayton County, Jonesboro; D Millians, Coroner, Coweta County, Newnan; G O'Neal, Coroner, Crawford County, Knoxville; A Posey, Deputy Coroner, Crisp County, Cordele; B Cooper, Coroner, Decatur County, Bainbridge; J Burton, MD, Medical Examiner, DeKalb County, Decatur; R Bowen, Coroner, Dooly County, Cordele; S Mackey, Deputy Coroner, Doughtery County, Albany; S Manry, Deputy Coroner, Early County, Blakely; C Mowell, Coroner, Fayette County, Fayetteville; D McGowan, Chief Investigator, Fulton County Medical Examiner's Office, Atlanta; J Kennebrew, Coroner, Harris County, Hamilton; R Stewart, Coroner, Henry County, McDonough; D Galpin, Coroner, Houston County, Warner Robins; J Bridge, Coroner, Jones County, Gray; J Smith, Coroner, Lamar County, Barnesville; S Braden, Sheriff, Lee County, Smithville; J Swank, Chief Investigator, Macon County, Montezuma; J Tante, Coroner, Marion County, Buena Vista; J Worley, Coroner, Meriweather County, Alvaton; T Toole, Coroner, Miller County, Colquitt; A Dillon, Coroner, Monroe County, Forsyth; V Novak, Deputy Coroner, Muscogee County, Columbus; B Johnson, Coroner, Newton County, Covington; K Rookes, Acting Coroner, Peach County, Fort Valley; B Hudson, Coroner, Pike County, Meansville; C Young, Coroner, Pulaski County, Hawkinsville; I Bellflower, Coroner, Quitman County, Georgetown; D Crozier, Deputy Coroner, Randolph County, Cuthbert; H Ellison, MD, Coroner, Rockdale County, Conyers; J Wall, Coroner, Schley County, Ellaville; G Skipper, Coroner, Seminole County, Donaldsonville; R Buchanan, Coroner, Spaulding County, Griffin; L McClung, Coroner, S Moreno, Fire Chief, Sumter County, Americus; L Stone, Coroner, Stewart County, Lumpkin; J Cosby, Coroner, Talbot County, Talbotton; B Goddard, Coroner, Taylor County, Reynolds; E Jenkins, Coroner, Terrell County, Dawson; E Lucas, Deputy Coroner, Troup County, West Point; T Cochran, Upson County, Thomaston; S Potter, Coroner, Webster County, Preston; R Coker, Coroner, Wilcox County, Pitts; J Banks, Coroner, Worth County, Sylvester; K Toomey, MD, State Epidemiologist, J Drinnon, Div of Public Health, Georgia Dept of Human Resources. K Davis, Federal Emergency Management Agency; M Johnson, Southeast Regional Climatological Center, Columbia, South Carolina. W Zaleski, National Weather Svc, Peachtree City, Georgia. Surveillance and Programs Br; Disaster Assessment and Epidemiology Section, Health Studies Br, Div of Environmental Hazards and Health Effects, Emergency Response Coordination Group, National Center for Environmental Health, CDC. Editorial Note: Floods account for an estimated 40% of natural disasters worldwide (1). In the United States, floods cause an average of 146 deaths per year. Most flood-related deaths are attributed to flash floods (2) (i.e., flooding that occurs within a few hours of heavy or excessive rain, when a dam or levee fails, or following a sudden release of water impounded by an ice jam [1]). Most flash floods occur during July-September (3) and are usually caused by slow-moving or localized and heavy thunderstorm activity. When these conditions exist, tributary streams can crest their banks in hours, or even minutes, after the onset of heavy rain (1). The rapid onset of high-rising waters often makes effective warning and escape difficult and increases the risk for death (4). The leading cause of death from flash floods is drowning, and more than 50% of drownings in flash floods are associated with motor vehicles (5). Victims are often unwilling to abandon their cars, trucks, or boats and can be trapped inside. In Georgia, drowning was the cause of 96% of flood-related deaths, and 74% of these were motor-vehicle related. Surveillance data from ME/Cs have provided timely information on mortality associated with natural disasters (6,7). Data from ME/Cs in past disasters have been used to develop recommendations for preventing flood- and other disaster-related deaths (7). During the 1993 midwestern floods, ME/C surveillance data were used to monitor flood-related mortality and to develop prevention strategies, including disseminating information about flood and postflood hazards to groups at increased risk and identifying water tributaries that posed hazards for flooding. Similarly, the surveillance findings from Georgia suggest that deaths from floods may be prevented by identifying flood- and flash-flood-prone areas and then advising persons to take appropriate actions when the potential exists for a flash flood. For example, motorists should be warned not to drive through areas in imminent danger of flash floods or onto roads and bridges covered by rapidly moving water (8). If vehicles are necessary to evacuate a community, particularly a mobile home community, safe evacuation routes should be identified in advance. In addition, deaths may be prevented by inspecting and requiring safety certification of dams located in flood-prone areas. References 1. French JG. Floods. In: Gregg MB, ed. The public health consequences of disasters. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1989:39-49. 2. Federal Emergency Management Agency. A report to US Senate Committee on Appropriation. Washington, DC: Federal Emergency Management Agency, 1992. 3. French J, Ing R, Von Allmen S, Wood R. Mortality from flash floods: a review of National Weather Service reports, 1969-81. Public Health Rep 1983;6:584-8. 4. National Weather Service/American Red Cross/Federal Emergency Management Agency. Flash floods and floods...the awesome power!: a preparedness guide. Washington, DC: US Department of Commerce, National Oceanic and Atmospheric Administration, National Weather Service/American Red Cross, 1992; report no. NOAA/PA 92050, ARC 4493. 5. Frazier K. The violent face of nature: severe phenomena and natural disasters. New York: William Morrow and Company Inc, 1979. 6. CDC. Medical examiner/coroner reports of deaths associated with Hurricane Hugo--South Carolina. MMWR 1989;38:754,759-62. 7. CDC. Flood-related mortality--Missouri, 1993. MMWR 1993;42:941- 3. 8. CDC. Beyond the flood: a prevention guide for personal health and safety. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1993. *Because some decedents were not found until after high waters subsided, it was sometimes difficult to verify exact date and time of death; therefore, all dates reflect the day on which the decedent was found. **"Manner of death" and "accident" are medicolegal terms used on death certificates and refer to the circumstances under which a death occurs; "cause of death" refers to the injury or illness responsible for the death. When a death occurs under "accidental" circumstances, the preferred term within the public health community for the cause of death is "unintentional injury". ------------------------------ End of HICNet Medical News Digest V07 Issue #33 *********************************************** --- Editor, HICNet Medical Newsletter Internet: david@stat.com FAX: +1 (602) 451-1165 Bitnet : ATW1H@ASUACAD