HICNet Medical News Digest Tue, 23 Aug 1994 Volume 07 : Issue 38 Today's Topics: [MMWR 12 Aug 94] Cryptosporidium Infections Associated Swimming Pools [MMWR] Lyme Disease [MMWR] Undervaccinated Children after Mass Vaccination Campaign [MMWR] Legionaire's Disease Breakout Associated with Cruise Ship [MMWR 19 Aug 94] Cigarette Brand Preferences Adolescent Smokers [MMWR] Effectiveness in Disease Prevention Medical-Care Spending [MMWR] Occupational Injury Deaths of Postal Workers +------------------------------------------------+ ! ! ! 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: Tue, 23 Aug 94 21:18:38 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR 12 Aug 94] Cryptosporidium Infections Associated Swimming Pools Message-ID: Cryptosporidium Infections Associated with Swimming Pools -- Dane County, Wisconsin, 1993 In March and April 1993, an outbreak of cryptosporidiosis in Milwaukee resulted in diarrheal illness in an estimated 403,000 persons (1). Following that outbreak, testing for Cryptosporidium in persons with diarrhea increased substantially in some areas of Wisconsin; by August 1, 1993, three of six clinical laboratories in Dane County were testing routinely for Cryptosporidium as part of ova and parasite examinations. In late August 1993, the Madison Department of Public Health and the Dane County Public Health Division identified two clusters of persons with laboratory-confirmed Cryptosporidium infection in Dane County (approximately 80 miles west of Milwaukee). This report summarizes the outbreak investigations. On August 23, a parent reported to the Madison Department of Public Health that her daughter was ill with laboratory-confirmed Cryptosporidium infection and that other members of her daughter's swim team had had severe diarrhea. On August 26, public health officials inspected the pool where the team practiced (pool A) and interviewed a convenience sample of patrons at the pool. Seventeen (55%) of 31 pool patrons interviewed reported having had watery diarrhea for 2 or more days with onset during July or August. Eight (47%) of the 17 had had watery diarrhea longer than 5 days. Four persons who reported seeking medical care had stool specimens positive for Cryptosporidium. On August 31, public health nurses at the Dane County Public Health Division identified a second cluster of nine persons with laboratory-confirmed Cryptosporidium infection while following up case-reports voluntarily submitted by physicians. Seven of the nine ill persons reported swimming at one large outdoor pool (pool B). Because of the potential for disease transmission in multiple settings, a community-based matched case-control study was initiated on September 3 to identify risk factors for Cryptosporidium infection among Dane County residents. Laboratory-based surveillance was used for case finding. A case was defined as Cryptosporidium infection that was laboratory-confirmed during August 1-September 11, 1993, in a Dane County resident who was also the first person in a household to have signs or symptoms (i.e., watery diarrhea of 2 or more days' duration). During the study interval, 85 Dane County residents with stool specimens positive for Cryptosporidium were identified. Sixty-five (77%) persons were interviewed; 36 (55%) had illnesses meeting the case definition. Systematic digit-dialing was used to select 45 controls, who were matched with 34 case-patients by age group and telephone exchange. All study participants were interviewed by telephone using a standardized questionnaire to obtain information on demographics, signs and symptoms, recreational water use, child-care attendance, drinking water sources, and presence of diarrheal illness in household members. The median age of ill persons was 4 years (range: 1-40 years). Reported signs and symptoms included watery diarrhea (94%), stomach cramps (93%), and vomiting (53%). Median duration of diarrhea was 14 days (range: 1-30 days). Swimming in a pool or lake during the 2 weeks preceding onset of illness was reported by 82% of case-patients and 50% of controls (matched odds ratio [MOR]=6.0; 95% confidence interval [CI]=1.4-25.3). Twenty-one percent of case-patients and 2% of controls (MOR=7.3; 95% CI=0.9-59.3) reported swimming in pool A. Fifteen percent of case-patients and 2% of controls (MOR=undefined [6/0]; p=0.02, paired sample sign test) reported swimming in pool B. When persons reporting pool A or B use were excluded from the analysis, the association with recreational water use was not statistically significant (MOR=3.4, 95% CI=0.8-15.7). Child-care attendance was reported for 74% of case-patients aged less than 6 years and 44% of controls (MOR=2.9; 95% CI=0.8-10.7). Two case-patients reported child-care attendance and use of pool A or pool B. No case-patients reported travel to the Milwaukee area during the March-April outbreak, and no associations were found between illness and drinking water sources. To limit transmission of Cryptosporidium in Dane County pools, state and local public health officials implemented the following recommendations: 1) closing the pools that were epidemiologically linked to infection and hyperchlorinating those pools to achieve a disinfection (CT*) value of 9600; 2) advising all area pool managers of the increased potential for waterborne transmission of Cryptosporidium; 3) posting signs at all area pools stating that persons who have diarrhea or have had diarrhea during the previous 14 days should not enter the pool; 4) notifying area physicians of the increased potential for cryptosporidiosis in the community and requesting that patients with watery diarrhea be tested for Cryptosporidium; and 5) maintaining laboratory-based surveillance in the community to determine whether transmission was occurring at other sites (e.g., child-care centers and other pools). On August 27, pool A was closed and hyperchlorinated for 18 hours; on September 3, pool B closed early for the season. Because many control measures were initiated less than 1 week before many pools closed for the season (after September 5), their impact on transmission could not be evaluated adequately. Reported by: J Bongard, MS, Dane County Public Health Div, Madison; R Savage, MS, Madison Dept of Public Health; R Dern, MS, St. Mary's Medical Center, Madison; H Bostrum, J Kazmierczak, DVM, S Keifer, H Anderson, MD, State Epidemiologist for Occupation and Environmental Health, JP Davis, MD, State Epidemiologist for Communicable Diseases, Bur of Public Health, Wisconsin Div of Health. Div of Parasitic Diseases, National Center for Infectious Diseases; Div of Field Epidemiology, Epidemiology Program Office, CDC. Editorial Note: Person-to-person, waterborne, and zoonotic transmission of Cryptosporidium has been well documented (2). A marked seasonality has been reported, with peaks occurring in North America during late summer and early fall (3,4). Cryptosporidiosis associated with use of swimming pools has been reported previously (5-7) but is probably underrecognized. Infection with Cryptosporidium resulting from recreational water use may contribute to the observed seasonal distribution. The March-April 1993 Milwaukee waterborne outbreak stimulated increased testing for Cryptosporidium in Dane County, increasing the likelihood of outbreak detection. However, the number of cases described in this report was not sufficient to conduct a stratified matched analysis. Confounding of the associations found for child-care attendance and pool use is possible, although child-care attendance was reported in only one case for each implicated pool. Cryptosporidium oocysts are small (4-6 u), are resistant to chlorine, and have a high infectivity. The chlorine CT of 9600 needed to kill Cryptosporidium oocysts is approximately 640 times greater than required for Giardia cysts (8). The ability of pool sand-filtration systems to remove oocysts under field conditions has not been well documented, but would not be expected to be effective. Results of an infectivity study suggest that the infective dose among humans for Cryptosporidium is low (H. DuPont, University of Texas Medical School at Houston, personal communication, 1994). Because of the large number of oocysts probably shed by symptomatic persons, even limited fecal contamination could result in sufficient oocyst concentrations in localized areas of a pool to cause additional human infections. This investigation underscores the potential for transmission of Cryptosporidium in swimming pools. Health-care providers should consider requesting Cryptosporidium testing of stool specimens from persons with watery diarrhea, and public health departments should consider establishing surveillance for Cryptosporidium to facilitate prompt recognition of outbreaks. Maintaining the high levels of chlorine necessary to kill Cryptosporidium in swimming pools is not feasible; therefore, such recreational water use should be recognized as a potential increased risk for cryptosporidiosis in immumocompromised persons, including those with human immunodeficiency virus infection, in whom this infection may cause lifelong, debilitating illness (9). References 1. Mac Kenzie WR, Hoxie NJ, Proctor ME, et al. A massive outbreak in Milwaukee of Cryptosporidium infection transmitted through the public water supply. N Engl J Med 1994;331:161-7. 2. Casemore DP. Epidemiologic aspects of human cryptosporidiosis. Epidemiol Infect 1990;104:1-28. 3. Wolfson JS, Richter JM, Waldron WA, Weber DJ, McCarthy DM, Hopkins CC. Cryptosporidiosis in immunocompetent patients. N Engl J Med 1985;312:1278-82. 4. Skeels MR, Sokolow R, Hubbard CV, Andrus JK, Baisch J. Cryptosporidium infection in Oregon public health clinic patients, 1985-1988: the value of statewide laboratory surveillance. Am J Public Health 1990;80:305-8. 5. Sorvillo FJ, Fujioka K, Nahlen B, et al. Swimming-associated cryptosporidiosis. Am J Public Health 1992;82:742-4. 6. Bell A, Guasparini R, Meeds D, et al. A swimming pool-associated outbreak of cryptosporidiosis in British Columbia. Can J Public Health 1993;84:334-7. 7. CDC. Surveillance for waterborne disease outbreaks--United States, 1991-1992. MMWR 1993;42(no. SS-5):1-22. 8. Current WL, Garcia LS. Cryptosporidiosis. Clin Microbiol Rev 1991;4:305-8. 9. Navin TR, Juranek DD. Cryptosporidiosis: clinical, epidemiologic, and parasitologic review. Rev Infect Dis 1984;6:313- 27. *CT=pool chlorine concentration (in parts per million) multiplied by time (in minutes). ------------------------------ Date: Tue, 23 Aug 94 21:19:17 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR] Lyme Disease Message-ID: Lyme Disease -- United States, 1993 In 1982, CDC initiated surveillance for Lyme disease (LD), and in 1990, the Council of State and Territorial Epidemiologists adopted a resolution making LD a nationally notifiable disease. This report summarizes surveillance data for LD in the United States during 1993. LD is defined as the presence of an erythema migrans rash or at least one objective sign of musculoskeletal, neurologic, or cardiovascular disease and laboratory confirmation of infection (1). In 1993, 8185 cases of LD were reported to CDC by 44 state health departments, 1492 (15%) fewer cases than were reported in 1992 (9677) (Figure 1). Most cases were reported from the northeastern, mid-Atlantic, north-central, and Pacific coastal regions (Figure 2). Six states (Alaska, Arizona, Colorado, Mississippi, Montana, and South Dakota) reported no LD cases. The overall incidence rate was 3.3 per 100,000 population. Eight states in established LD-endemic northeastern and upper north-central regions reported rates of more than 3.3 per 100,000 (Connecticut, 41.3; Rhode Island, 27.3; Delaware, 21.0; New York, 15.5; New Jersey, 10.1; Pennsylvania, 8.9; Wisconsin, 8.2; and Maryland, 3.8); these states accounted for 6962 (85%) of the cases reported nationally. Of the total cases, 6132 (75%) were reported from 81 counties that had at least five cases and had rates of at least 10 per 100,000 population. Most (83%) of the decrease in 1993 resulted from reductions in the numbers of case reports from four states in which LD is endemic (California, Connecticut, New York, and Wisconsin). New York, which reported 34% of the U.S. cases in 1993, accounted for 41% of the decrease (609 cases), and Connecticut accounted for 27% of the decrease (410 cases). Thirteen states reported small increases in the number of cases. New Jersey had the largest increase (786 cases, compared with 681 in 1992). The age distribution of persons reported with LD was bimodal, with peaks occurring for children aged 5-14 years (1098 cases) and adults aged 30-49 years (2298 cases). Males (51%) and females were nearly equally affected. Reported by: State health departments. Bacterial Zoonoses Br, Div of Vector-Borne Infectious Diseases, National Center for Infectious Diseases, CDC. Editorial Note: LD, the most commonly reported vectorborne infectious disease in the United States (2), is caused by the spirochete Borrelia burgdorferi and is transmitted by the bite of an infected Ixodes tick. In the northeastern and upper north-central regions of the United States, the principal tick vector is Ixodes scapularis (black-legged tick), and in Pacific coast states, the principal vector is Ixodes pacificus (western black-legged tick). LD risks are geographically limited; rates vary substantially by town or other geopolitical area within counties (3,4), and the distribution of vector ticks varies greatly, even within individual residential properties (5). LD can be prevented by avoiding contact with the tick vector or by applying insect repellents and acaricides as directed, wearing long pants and long-sleeved shirts, tucking pants into socks, checking regularly for ticks, and promptly removing attached ticks. The decrease in reported cases in 1993 may reflect a combination of three factors: decreased reporting by physicians, decreased case detection (6), and a true decrease in the number of cases. In Connecticut and New York, vector surveillance data suggest that I. scapularis population densities were lower in 1993 than in previous years. The decrease in New York also may be attributed to limitations in staffing and decreased reporting by physicians (D. White, Bureau of Communicable Diseases, New York State Department of Health, personal communication, 1994). The increase in New Jersey was attributed to an increase in reported cases from Hunterdon County as a result of improved reporting by physicians and a true increase in disease incidence (CDC, unpublished data, 1993). The actual incidence of LD in the United States is unknown, and estimates are subject to the influences of underreporting, misclassification, and overdiagnosis. Accurate surveillance data are needed to target populations for LD prevention strategies (e.g., vaccination). In 1993, two U.S. manufacturers received Food and Drug Administration approval to conduct field trials of LD vaccines in humans. One manufacturer is conducting Phase III efficacy trials involving approximately 10,000 participants from endemic areas of the north central, mid-Atlantic, and New England states. The second manufacturer is conducting Phase II safety and immunogenicity trials involving approximately 400 persons residing in New England. Results of Phase I trials conducted in the United States have been published (7), and preliminary results of Phase II safety and efficacy trials (8,9) suggest the vaccine is safe and immunogenic. Both candidate vaccines use a recombinant outer-surface protein as the immunogen. The candidate vaccines stimulate production of antibodies that target B. burgdorferi in the midguts of infected ticks while they extract blood from a vaccinated animal (10). Reliable identification of risks is required for targeting individually applied interventions for LD. LD surveillance data will be needed to determine the effectiveness of control and prevention efforts. References 1. CDC. Case definitions for public health surveillance. MMWR 1990;39(no. RR-13):19-21. 2. Dennis DT. Epidemiology. In: Coyle PK, ed. Lyme disease. St. Louis: Mosby-Year Book, 1993:27-37. 3. Cartter ML, Mshar P, Hadler JL. The epidemiology of Lyme disease in Connecticut. Conn Med 1989;53:320-3. 4. White DJ, Chang H-G, Benach JL, et al. The geographic spread and temporal increase of the Lyme disease epidemic. JAMA 1991;266:1230- 6. 5. Maupin GO, Fish D, Zultowsky J, Campos EG, Piesman J. Landscape ecology of Lyme disease in a residential area of Westchester County, New York. Am J Epidemiol 1991;133:1105-13. 6. CDC. Lyme disease--United States, 1991-1992. MMWR 1993;42:345-8. 7. Keller D, Koster FT, Marks DH, Hosbach P, Erdile LF, Mays JP. Safety and immunogenicity of a recombinant outer surface protein A Lyme vaccine. JAMA 1994;271:1764-8. 8. Hoecke CV, De Grave D, Hauser P, Lebacq E. Evaluation of three formulations of a candidate vaccine against Lyme disease in healthy adult volunteers. In: Proceedings of the VI International Congress on Lyme Borreliosis. Bologna, Italy: International Congress on Lyme Borreliosis, 1994:123-6. 9. Hosbach P, Koster F, Wormser G, et al. Clinical studies in humans of outer surface protein A (Osp A) vaccine for Lyme disease [Abstract]. In: Proceedings of the VI International Congress on Lyme Borreliosis. Bologna, Italy: International Congress on Lyme Borreliosis, 1994. 10. Fikrig E, Telford SR, Barthold SW, Kantor FS, Spielman A, Flavell RA. Elimination of Borrelia burgdorferi from vector ticks feeding on Osp A-immunized mice. Proc Natl Acad Sci 1992;89:5418- 21. ------------------------------ Date: Tue, 23 Aug 94 21:20:13 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR] Undervaccinated Children after Mass Vaccination Campaign Message-ID: Assessment of Undervaccinated Children Following a Mass Vaccination Campaign -- Kansas, 1993 A 1992 retrospective survey by the Kansas Department of Health and Environment (KDHE) of children entering school in Kansas indicated that 52% were completely vaccinated by 24 months of age (i.e., received four doses of diphtheria and tetanus toxoids and pertussis vaccine [DTP], three doses of poliomyelitis vaccine, and one dose of measles-mumps-rubella vaccine [MMR]). In response to this low vaccination coverage rate, the KDHE set a goal for 1995 of completely vaccinating 90% of children by age 24 months. A major new initiative--Operation Immunize (OI)--undertaken to accomplish this goal consisted of three statewide vaccination campaigns on weekends during 1993-1994. This report summarizes the results of an assessment of the short-term impact of OI on children who remained undervaccinated following the first campaign. OI was designed to reach children, particularly those aged less than 24 months, who were not up-to-date with their vaccinations. An extensive promotional effort was made throughout the state to encourage participation in OI. Vaccinations were available free or at reduced cost at 192 sites in the state during the campaigns. During the first campaign (April 24-25, 1993), 7120 children were vaccinated; 2616 (37%) were aged less than 24 months. Of the children aged less than 24 months, 71% were not up-to-date with their vaccinations; 29% were due for their next series of vaccinations but were not yet considered behind schedule. OI reached 6% of the estimated 31,498 children (based on the 1992 retrospective survey) aged less than 24 months in Kansas who were not up-to-date. A follow-up study begun in November 1993 assessed the vaccination status of children aged less than 24 months who were vaccinated during the April campaign but who needed additional vaccinations to be brought up-to-date during the next 6 months. OI records were available for 331 of these children. Each child's vaccination status was determined as of October 25, 1993 (6 months after the first OI campaign), using the recommendations of the Advisory Committee on Immunization Practices for DTP, polio, and MMR (1). Information on vaccinations was obtained from local health departments, parents, and physicians. Children were considered up-to-date if they were within 1 month of being age-appropriately vaccinated by October 25, 1993. If the local health department had no record of vaccinations given since April 24-25, 1993, and the child's parents could not be contacted by phone and did not respond to two written requests for information, the child was considered lost to follow-up. As of October 25, 1993, 102 (31%) children were up-to-date; 35 (11%) had received additional vaccinations but remained behind schedule; 102 (31%) had received no additional vaccinations; and 92 (28%) were lost to follow-up. Reported by: S Dismuke, MD, Univ of Kansas Medical Center, Kansas City; N McWilliams, Johnson County Health Dept, Mission; S Bowden, M Burt, J Hansen, M Miller, L Perry, A Pelletier, MD, Acting State Epidemiologist, Bur of Disease Control, Kansas Dept of Health and Environment. Div of Field Epidemiology, Epidemiology Program Office, CDC. Editorial Note: Mass vaccination campaigns have been successful in developing countries (2-4); however, during the past decade, mass campaigns have not been used widely in the United States. Mass campaigns such as OI can focus public attention on the control of vaccine-preventable diseases and increase support for vaccination programs. However, mass campaigns are resource-intensive, and in some cases, increases in vaccination coverage rates have been difficult to sustain (5,6). Options for the evaluation of OI were limited by the low incidence in Kansas of the vaccine-preventable diseases targeted by OI and the lack of current data on the vaccination status of Kansas children. The only population-based vaccination data available in Kansas are from retrospective surveys of children entering school. When collected, these data are 3-4 years old and therefore are not useful for evaluating the immediate impact of a mass vaccination campaign. Calculating the limited percentage of the target population reached by OI provided one measure of the campaign's effectiveness; the study also sought to assess the ongoing impact of the campaign on children's vaccination status. This study indicated that many children reached by OI did not maintain up-to-date vaccination status during the 6 months after the campaign. The experience with OI demonstrates that reaching undervaccinated children with mass campaigns can be difficult, even when the level of effort and commitment are high, as in Kansas. When used, mass campaigns should be an adjunct to ongoing, comprehensive vaccination programs (as outlined in the Childhood Immunization Initiative [7]), which are designed to meet local needs. Such programs for routine vaccination should include efforts to reduce barriers to vaccination, establish vaccination record information systems, improve surveillance, and use vaccination coverage assessments to monitor program performance. References 1. ACIP. General recommendations on immunization. MMWR 1989;38:205- 14,219-27. 2. CDC. Update: eradication of paralytic poliomyelitis in the Americas. MMWR 1992;41:681-3. 3. CDC. National Immunization Days and status of poliomyelitis eradication--Philippines, 1993. MMWR 1994;43:6-7,13. 4. Expanded Program on Immunization. Planning principles for accelerated immunization activities. Geneva: World Health Organization, 1985. 5. Jorgenson DM, Zenker P, Quinlisk MP. Effectiveness of a one-day vaccination campaign-- Oklahoma [Abstract]. In: Abstracts of the 41st Annual Conference of the Epidemic Intelligence Service, Atlanta, April 6-10, 1992. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1992. 6. Abdool Karim SS, Abdool Karim Q, Dilraj A, Chamane M. Unsustainability of a measles immunisation campaign--rise in measles incidence within 2 years of the campaign. S Afr Med J 1993;83:322-3. 7. CDC. Reported vaccine-preventable diseases--United States, 1993, and the Childhood Immunization Initiative. MMWR 1994;43:57-60. ------------------------------ Date: Tue, 23 Aug 94 21:21:34 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR] Legionaire's Disease Breakout Associated with Cruise Ship Message-ID: Update: Outbreak of Legionnaires' Disease Associated with a Cruise Ship, 1994 On July 15, 1994, CDC was notified by the New Jersey State Department of Health of six persons with pneumonia who had recently traveled to Bermuda on the cruise ship Horizon (1). In conjunction with local and state health departments, an investigation was initiated; as of August 10, a total of 14 passengers had Legionnaires' disease (LD) confirmed by either sputum culture (one patient), detection of antigens of Legionella pneumophila serogroup 1 (Lp1) in urine by radioimmunoassay (seven patients) (2), or fourfold rise in titer of antibodies to Lp1 between acute- and convalescent-phase serum specimens (six patients). Possible cases in 28 other passengers with pneumonia that occurred within 2 weeks after sailing aboard the Horizon are under investigation. Cases have occurred from nine separate week-long cruises during April 30- July 9, 1994. To identify the source of Legionella sp., a case-control study was conducted, and environmental sampling of the ship's water system was performed. Exposure to the whirlpool baths was strongly associated with illness (odds ratio=16.4; 95% confidence interval=3.7-72.3). Cultures taken from a sand filter used for recirculation of whirlpool water yielded an isolate of Lp1; this isolate and the clinical isolate had matching monoclonal antibody subtyping patterns (3). A variety of interventions were completed, including hyperchlorination of the ship's potable water supply, removal of the whirlpool filters, and discontinuation of the whirlpool baths. Following completion of these interventions, on July 30 the Horizon resumed its weekly sailing schedule from New York City to Bermuda. Reported by: I Guerrero, MD, Community Medical Center, Toms River; C Genese, MJ Hung, S Paul, MD, H Ragazzoni, DVM, J Brook, MD, L Finelli, PhD, KC Spitalny, MD, State Epidemiologist, New Jersey State Dept of Health. BA Mojica, MD, KJ Mahoney, MSW, RT Heffernan, MPH, Div of Disease Intervention, New York City Dept of Health; SF Kondracki, DL Morse, MD, State Epidemiologist, New York State Dept of Health. ML Cartter, MD, J Hadler, MD, State Epidemiologist, Connecticut Dept of Public Health and Addiction Svcs. JT Rankin, Jr, DVM, State Epidemiologist, Pennsylvania Dept of Health. C Groves, MS, Maryland State Dept of Health and Mental Hygiene. Div of Quarantine, National Center for Prevention Svcs; Office of the Director, National Center for Environmental Health; Div of Field Epidemiology, Epidemiology Program Office; Childhood and Respiratory Diseases Br, Div of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, CDC. Editorial Note: This outbreak represents the first documented instance of LD aboard a cruise ship docking in U.S. ports. Whirlpool spas previously have been associated with transmission of Legionella (4,5); hyperchlorination of water systems and replacement of filter devices have successfully terminated outbreaks of LD linked to whirlpool spas. CDC recommends post-intervention environmental sampling of whirlpool circulation systems in conjunction with ongoing surveillance for cases of pneumonia to ensure the efficacy of these interventions. Suspected cases of LD among Horizon passengers should be reported to CDC through state and local health departments. Additional recommendations to reduce the transmission of Legionella sp. from whirlpool baths and aboard cruise ships will be the subject of a special meeting of public health officials, LD experts, and members of the whirlpool and cruise line industries; the meeting is tentatively scheduled for the fall of 1994 in Atlanta. Additional information about the meeting is available from CDC's Office of the Director, National Center for Environmental Health, telephone (404) 488-7093. References 1. CDC. Outbreak of pneumonia associated with a cruise ship, 1994. MMWR 1994;43:521. 2. Kohler RB, Zimmerman SE, Wilson E, et al. Rapid radioimmunoassay diagnosis of Legionnaires' disease: detection and partial characterization of urinary antigen. Ann Intern Med 1981;94:601-5. 3. Joly JR, McKinney RM, Tobin JO, Bibb WF, Watkins ID, Ramsay D. Development of a standardized subgrouping scheme for Legionella pneumophila serogroup 1 using monoclonal antibodies. J Clin Microbiol 1986;23:768-71. 4. Vogt RL , Hudson PJ, Orciari L, Heun EM, Woods TC. Legionnaires' disease and a whirlpool spa [Letter]. Ann Intern Med 1987;107:596. 5. Spitalny KC, Vogt RL, Orciari LA, Witherell LE, Etkind P, Novick LF. Pontiac fever associated with a whirlpool spa. Am J Epidemiol 1984;120:809-16. ------------------------------ Date: Tue, 23 Aug 94 21:36:29 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR 19 Aug 94] Cigarette Brand Preferences Adolescent Smokers Message-ID: Changes in the Cigarette Brand Preferences of Adolescent Smokers -- United States, 1989-1993 Approximately three million U.S. adolescents are smokers, and they smoke nearly one billion packs of cigarettes each year (1). The average age at which smokers try their first cigarette is 14- 1/2 years, and approximately 70% of smokers become regular smokers by age 18 years (2). Evaluating the changes in the brand preferences of young smokers can help identify factors that influence adolescents' brand choice and may suggest smoking-prevention strategies (3,4). This report examines changes in the brand preferences of teenaged smokers from 1989 to 1993 using data from CDC's 1993 Teenage Attitudes and Practices Survey (TAPS-II) and comparing them with data from the 1989 TAPS. For TAPS, data on knowledge, attitudes, and practices regarding tobacco use were collected from a national household sample of adolescents (aged 12-18 years) by telephone interviews. For TAPS-II, interviews were conducted during February-May 1993. Of the 9135 respondents to the 1989 TAPS, 7960 (87.1%) participated in TAPS-II (respondents were aged 15-22 years when TAPS-II was conducted).* In addition, 4992 (89.3%) persons from a new probability sample (n=5590 persons aged 10-15 years) participated in TAPS-II. Data for the 12-18-year-olds in each survey were analyzed (n=9135 for TAPS; n=7311 for TAPS-II). Because numbers for other racial groups were too small for meaningful analysis, data are presented for black, white, and Hispanic adolescents only. Data were weighted to provide national estimates, and confidence intervals (CIs) were calculated by using the standard errors estimated by SUDAAN (5). Adolescent current smokers** were asked if they usually bought their own cigarettes, and if so, which brand they usually bought. Of the 1031 current smokers aged 12-18 years interviewed in 1993, 724 (70%) reported that they usually bought their own cigarettes; the brand they usually bought was ascertained for 702 (97%). Marlboro, Camel, and Newport were the most frequently purchased brands for 86% of the adolescents (Table 1). Marlboro was the most commonly purchased brand for both male (59% [95% CI= plus or minus 6.0%]) and female (61% [95% CI= plus or minus 5.8%]) adolescents; the second most commonly purchased brand among males was Camel (16% [95% CI= plus or minus 5.0%]) and among females was Newport (15% [95% CI= plus or minus 3.9%]). Marlboro was the most commonly purchased brand among white (64% [95% CI= plus or minus 4.3%]) and Hispanic (45% [95% CI= plus or minus 14.9%]) adolescents; black adolescents most frequently purchased Newport (70% [95% CI= plus or minus 14.1%]). Younger smokers (aged 12-15 years) were more likely than older smokers (aged 16-18 years) to buy Newport and less likely to buy Marlboro; purchasing frequency for Camel cigarettes was similar among all adolescents. Among adolescents nationwide, Marlboro was the most commonly purchased brand (Table 1). However, by region***, Camel was most commonly purchased in the West (27% [95% CI= plus or minus 10.8%]), and Newport, in the Northeast (30% [95% CI= plus or minus 8.8%]). From 1989 to 1993, substantial changes in brand preference occurred among adolescents (Table 2). The percentage of adolescents purchasing Marlboro cigarettes decreased 8.7 percentage points (13% decrease), the percentage of adolescents purchasing Camel cigarettes increased 5.2 percentage points (64% increase), and the percentage purchasing Newport cigarettes increased 4.5 percentage points (55% increase). These changes did not completely correlate with changes in overall cigarette market share during 1989-1993. During this period, the overall market share for Camel and Newport remained nearly unchanged, but the overall market share for Marlboro decreased by 2.8 percentage points (11% decrease). For Marlboro cigarettes, the decreases in brand preference were greatest among white adolescents, younger smokers, and adolescents residing in the Northeast, Midwest, and West (Table 1) (6). Increases in brand preference for Camel cigarettes were greatest among white adolescents and adolescents residing in the Midwest and West, and increases for Newport cigarettes were greatest among younger smokers and adolescents residing in the Northeast. Reported by: D Barker, MHS, Robert Wood Johnson Foundation, Princeton, New Jersey. Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. Editorial Note: Because cigarette sales to adolescents constitute a small percentage of the total market, overall market share can only be used to estimate the brand preferences of adults. TAPS and TAPS-II indicate that brand preference is more tightly concentrated among adolescents than among adults. In both surveys, at least 85% of adolescent current smokers purchased one of three brands (i.e., Marlboro, Camel, or Newport); however, the three most commonly purchased brands among all smokers accounted for only 35% of the overall market share in 1993. The three most commonly purchased brands among adolescent smokers were the three most heavily advertised brands in 1993 (7), suggesting that cigarette advertising influences adolescents' brand preference. In 1993, Marlboro, Camel, and Newport ranked first, second, and third (7), respectively, in advertising expenditures. However, Camel and Newport ranked seventh and fifth, respectively, in overall market share (8 ). Similarly, the increases in adolescents' brand preference for Camel cigarettes and the decrease in preference for Marlboro cigarettes from 1989 to 1993 are not explained by changes in overall market share for these brands. These changes reflect variability in brand-specific advertising expenditures: from 1989 to 1993, Marlboro advertising decreased from $102 million to $75 million (7,9), while Camel advertising increased from $27 million to $43 million (7,9). In contrast, the increased preference for Newport cigarettes does not reflect the decrease in Newport advertising expenditures from $49 million to $35 million from 1989 to 1993 (7,9). The regional differences in brand preference of adolescents and changes in those preferences during 1989-1993 suggest that analysis of the relation between regional advertising expenditures and brand preferences may help to clarify the role of cigarette advertising in influencing adolescents' brand preference. The findings that black adolescents most commonly purchased mentholated brands (i.e., Newport and Kool) and that Hispanic adolescents most commonly purchased Marlboro are consistent with a previous report (6). Racial/ethnic differences in brand preferences of adolescents may be influenced by differences in socioeconomic status and by social and cultural phenomena that require further explanation. The findings of TAPS-II are subject to at least two limitations. First, the potential exists for nonresponse bias in the follow-up of TAPS respondents. For example, smoking prevalence estimates derived from TAPS-II are lower than those based on other national surveys; TAPS respondents who were successfully followed up in TAPS-II were less likely to be smokers in 1989 than those who could not be reinterviewed (Office on Smoking and Health, unpublished data, 1994). Second, the small number of black and Hispanic adolescents in TAPS-II lessens the reliability of the brand preference estimates for these subgroups. Because cigarette advertising may influence brand choice of adolescents (an important component of smoking behavior), legislation may be needed to restrict cigarette advertising to which young persons are likely to be exposed (10). In addition, antitobacco advertising may be an effective public health strategy to prevent smoking initiation and encourage smoking cessation among adolescents. Understanding the influence of advertising on adolescent smoking behavior may assist in clarifying the potential role of antismoking advertisements. At least two states (California and Massachusetts) have allocated resources derived from state excise cigarette tax for paid antismoking advertising campaigns aimed at young persons. References 1. DiFranza FR, Tye JB. Who profits from tobacco sales to children? JAMA 1990;263:2784-7. 2. US Department of Health and Human Services. Preventing tobacco use among young people: a report of the Surgeon General. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1994. 3. Pierce JP, Gilpin E, Burns DM, et al. Does tobacco advertising target young people to start smoking?: evidence from California. JAMA 1991;266:3154-8. 4. Hunter SM, Croft JB, Burke GL, Parker FC, Webber LS, Berenson GS. Longitudinal patterns of cigarette smoking and smokeless tobacco use in youth: the Bogalusa Heart Study. Am J Public Health 1986;76:193-5. 5. Shah BV. Software for Survey Data Analysis (SUDAAN) version 5.30 [Software documentation]. Research Triangle Park, North Carolina: Research Triangle Institute, 1989. 6. CDC. Comparison of the cigarette brand preferences of adult and teenaged smokers--United States, 1989, and 10 U.S. communities, 1988 and 1990. MMWR 1992;41:169-73,179-81. 7. LNA/MediaWatch Multi-Media Service. Ad dollars summary, January- December 1993. New York: Competitive Media Reporting, 1994. 8. Maxwell JC Jr. The Maxwell consumer report: fourth-quarter and year-end 1993 sales estimates for the cigarette industry. Richmond, Virginia: Wheat First Securities/Butcher & Singer, February 10, 1994. 9. LNA/Arbitron Multi-Media Service. Product vs. media report. New York: Competitive Media Reporting, 1993. 10. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives--full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991:152; DHHS publication no. (PHS)91-50212. *TAPS respondents who completed the survey by mail questionnaire were not eligible for the TAPS-II survey. TAPS-II included household interviews of persons who did not respond by telephone. **Adolescents who reported smoking cigarettes on 1 or more of the 30 days preceding the survey. ***The four regions were Northeast (Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont), Midwest (Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin), South (Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia), and West (Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming). ------------------------------ Date: Tue, 23 Aug 94 21:37:33 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR] Effectiveness in Disease Prevention Medical-Care Spending Message-ID: Effectiveness in Disease and Injury Prevention Medical-Care Spending -- United States One aspect of health-care reform is the role of prevention in controlling costs. To evaluate data on medical spending by disease category, the National Public Services Research Institute examined data from the 1987 National Medical Expenditure Survey (NMES-2), with emphasis on the Medical Provider Survey supplement. This report presents the findings of that analysis. The NMES-2 was a population-based longitudinal survey in which data were gathered for the civilian, noninstitutionalized U.S. population for January 1-December 31, 1987 (the most recent year for which complete data were available), about sociodemographic factors; use of medical care; and medical-care expenditures for hospital inpatient, outpatient, and emergency department care; physician and allied health professional services; prescribed medication; emergency transport; and medical supplies and equipment (1). The Medical Provider Survey supplement provided confirmation of self-reported medical-care costs and information about costs that survey respondents were unable to report. The analysis presented in this report was restricted to the household survey sample of the NMES-2, a subset of the data that included face-to-face interviews of approximately 35,000 persons in 14,000 households regarding use of and expenses for health services during 1987. Not included in this analysis were dental costs, mental health services without a medical component, and administrative costs and overhead for insurance claims. All medical expenditure estimates were adjusted to December 1993 dollars using medical-care spending per capita for all medical treatment as the inflator. Cardiovascular disease accounted for $80 billion (14%) of the $572 billion (in 1993 dollars) in medical spending for services other than nursing-home care, dental care, and insurance claims processing (Table 1). Injuries accounted for $69 billion (12%), including spending attributed to longer term musculoskeletal deterioration resulting from injury. Spending for each of these categories exceeded that for cancer and for genitourinary disease (including kidney disease) ($49 billion each). Medical spending for well care, including preventive care, was 3% of the total costs ($17 billion). Excluding live births, injury was the largest contributor to health-care expenditures for persons aged 5-49 years (Figure 1). Injury was the second largest contributor to health-care costs among persons aged less than 5 years and greater than 85 years; cardiovascular disease and cancer were the two largest contributors for those aged 50-85 years. Medical spending on injury treatment averaged $284 per person. Injury costs increased for those aged greater than 65 years, with the highest per capita spending for injury being for those aged greater than or equal to 70 years (Figure 2). However, increases in spending for cardiovascular disease and cancer for those age groups were higher than those for injury. Inpatient hospital costs were the largest component of medical spending ($329 billion [57%]), with ambulatory-care visits contributing $90 billion (16%) and hospital outpatient services, $66 billion (11%). Prescriptions were the fourth largest component ($38 billion [7%]). Home-health-care ($20 billion), emergency department ($15 billion), and other medical ($15 billion) costs each contributed approximately 3%. By type of care, cardiovascular disease accounted for 15% of the hospital costs; cancer, 11%; and injury, 10% (Table 2). Cardiovascular disease also contributed the most in prescription costs (27%) and home-health-care costs (27%) (Table 2). Injury costs were the largest component of spending for emergency department visits (46%), hospital outpatient visits (16%), and ambulatory care (16%). Of the ambulatory-care visit costs, 14% were for well care. Reported by: TR Miller, PhD, DC Lestina, MS Galbraith, Children's Safety Network Economics and Insurance Resource Center, National Public Svcs Research Institute, Landover, Maryland. DC Viano, PhD, Biomedical Science Dept, General Motors Research Laboratories, Warren, Michigan. Div of Unintentional Injury Prevention, National Center for Injury Prevention and Control, CDC. Editorial Note: The findings in this report indicate that the largest source of health-care spending in the U.S. population is cardiovascular disease. This reflects the high prevalence of coronary or ischemic heart disease, which is the leading cause of death in the United States. However, the influences and risk factors for cardiovascular disease potentially can be modified through public policy and preventive practice (e.g., smoking and diet). Injury, the leading cause of death for persons in all age groups from 1 year through 44 years (2), is also a large contributor to health-care costs. The data in this report corroborate the finding that medical-care payments for injury are the second leading source of direct medical costs in the noninstitutionalized U.S. population (3). In addition, the cost burden for injuries is spread across all age groups (4). Because direct medical costs do not include the reduced or lost productivity in the working-age population, this analysis does not adequately present the total economic burden attributable to injury. This study is subject to at least four limitations. First, the data underestimate total direct medical costs because institutionalized persons, military members and their families, and homeless persons were excluded. Second, nursing home costs-- approximately $60 billion annually across all disease categories (5)--also were omitted from this analysis. Third, the unitary, systems-based categorization of each illness or injury used in this analysis masks the potential importance of some categories, such as infectious diseases. Infectious diseases were subsumed under the injury or system category that they affect; for example, pulmonary infections tended to be classified in the respiratory category, urinary tract infections in the genitourinary category, and human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) in the categories of affected systems or as miscellaneous. Similarly, spending for outpatient visits for complications of diabetes mellitus may appear as cardiovascular disease costs. Fourth, the direct costs related to infectious diseases are underestimated because the incidence of HIV infection and AIDS resulted in substantially increased spending after 1987 (6). Numerous prevention measures reduce direct medical costs while saving lives. For example, approximately $2 are saved in medical-care costs for every $1 spent on child-safety seats (7); from 1982 through 1990, child-safety seats and safety belts saved the lives of approximately 1300 infants and toddlers in the United States (8). The data in this report underscore the impact of different disease categories and the need to evaluate the relative effectiveness and the cost-effectiveness of interventions that prevent and control the effects of disease; such data can assist in making decisions regarding treatment and prevention programs (9). References 1. Edwards WS, Berlin M. Questionnaires and data collection methods for the household survey and the survey of American Indians and Alaskan Natives. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, National Center for Health Services Research and Health Care Technology Assessment, 1989; DHHS publication no. (PHS)89-3450. (National Medical Expenditure Survey Methods 2.) 2. NCHS. Health, United States, 1992. Washington, DC: US Department of Health and Human Services, Public Health Service, CDC, 1993; DHHS publication no. (PHS)93-1232. 3. Harlan LC, Harlan WR, Parsons PE. The economic impact of injuries: a major source of medical costs. Am J Public Health 1990;80:453-9. 4. Max W, Rice DP, MacKenzie EJ. The lifetime cost of injury. Inquiry 1990;27:332-43. 5. Bureau of the Census. Statistical abstract of the United States, 1993. Washington, DC: US Department of Commerce, Bureau of the Census, 1993. 6. Mann JM, Tarantola DJM, Netter TW, eds. AIDS in the world. Cambridge, Massachusetts: Harvard University Press, 1992:316. 7. Miller TR, Demes JC, Bovbjerg RR. Child seats: how large are the benefits and who should pay? In: Child occupant protection [Monograph]. Warrendale, Pennsylvania: Society of Automotive Engineers 1993:81-9; publication no. SP-986. 8. National Highway Traffic Safety Administration. Occupant protection facts. Washington, DC: US Department of Transportation, National Highway Traffic Safety Administration, 1990. 9. Public Health Service/Battelle. For a healthy nation: returns on investment in public health. Atlanta: US Department of Health and Human Services, Public Health Service, Office of Disease Prevention and Health Promotion and CDC/Battelle, Center for Public Health Research and Evaluation, 1994. ------------------------------ Date: Tue, 23 Aug 94 21:38:25 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR] Occupational Injury Deaths of Postal Workers Message-ID: Occupational Injury Deaths of Postal Workers -- United States, 1980-1989 Extensive media coverage of work-related homicides at U.S. Postal Service facilities raised the concern about whether postal workers are at increased risk for work-related homicide, particularly from those committed by disgruntled coworkers. Based on national surveillance data, neither the Postal Service industry nor postal occupations are among the groups at increased risk for work-related homicide (1,2). To further assess this concern and to determine the relative magnitude of occupational injury deaths in the Postal Service, CDC's National Institute for Occupational Safety and Health (NIOSH) used data from its National Traumatic Occupational Fatalities (NTOF) surveillance system* to examine occupational injury deaths in the Postal Service and compare Postal Service fatality rates with overall rates for all U.S. industries. This report summarizes the results of that analysis. NTOF data for 1980 through 1989 (the most recent year for which complete data are available) were analyzed. Employment data for the calculation of rates were derived from the Current Population Survey (4). Rates were calculated only for 1983-1989 because reporting of Postal Service employment data changed in 1983. NTOF recorded 169 occupational injury deaths among U.S. Postal Service workers during 1980-1989. During 1983-1989, the average annual rate of occupational injury death in the Postal Service was 2.1 per 100,000 workers, less than half the rate of 5.4 per 100,000 workers for all industries combined. Men accounted for 130 (77%) of the occupational injury deaths in the Postal Service and had a higher rate of fatal injury than did women (2.3 per 100,000 workers, compared with 1.8). A total of 98 (58%) of the decedents were aged greater than 45 years. Motor-vehicle-related events (n=72) were the leading cause of fatal occupational injury, followed by homicide (n=40) (Figure 1, page 593). Cause-specific rates for Postal Service employees were consistently lower than rates for all industries, with the largest differential in the category of machine-related deaths (Figure 2, page 593). Collisions between motor vehicles caused 43 (60%) of the motor-vehicle-related deaths among Postal Service workers. Three (4%) deaths occurred to pedestrians on the job who were struck by motor vehicles. Fifty-one (71%) deaths occurred among mail carriers and eight (11%) among drivers. Among homicide victims, 26 (65%) were men. The homicide rate for men was 0.5 per 100,000, compared to 0.6 for women. Firearms were used in 34 (85%) of the homicides. Seventeen (43%) of the victims were mail carriers; nine (23%), postal clerks; five (13%), postmasters and mail superintendents; and three (8%), other specified occupations. Occupation was unknown or not specified for six (15%) of the victims. Reported by: Div of Safety Research, National Institute for Occupational Safety and Health, CDC. Editorial Note: The findings in this report indicate that the occupational fatality rate for U.S. Postal Service workers is approximately 2.5 times lower than that for all workers combined. Motor-vehicle-related events and homicides combined accounted for 66% of occupational injury deaths in the Postal Service. This analysis indicated an occupational homicide rate among Postal Service workers that did not exceed the rate for all U.S. workers. Media attention to violence in Postal Service facilities resulted in press reports that enumerated violent incidents over a defined period (1983 through 1993). By comparing a newspaper review of occupational violence in the Postal Service (5) with cases reported in NTOF, NIOSH identified five work-related homicides not included in the NTOF database. Incorporating these five cases into the calculation of a work-related homicide rate for the Postal Service increased the rate to 0.63 per 100,000 workers, nearly equal to the average overall national rate (0.64) for the same period. However, it was not practical to similarly identify work-related homicides that were not included in NTOF for other industries; such an enumeration of missed cases would probably increase the average annual all-industries rate. Although the occupational homicide rate for the Postal Service industry is similar to the national rate for all industries, coworkers appear to be disproportionately responsible for homicides that occur in the Postal Service. During 1992, 82% of work-related homicides were associated with robberies or miscellaneous crimes; only 4% were committed by coworkers or former coworkers (6). By comparison, the NTOF data in this report, supplemented with information from the newspaper review (5), indicated that 57% (20/35) of work-related homicides of postal workers from 1983 through 1989 were committed by coworkers or former coworkers. However, 14 of the 20 coworker homicides occurred in a single incident. The remaining 15 postal worker homicides were presumed to have been committed by persons who were not Postal Service employees. The findings in this report are subject to at least three limitations (3). First, because the NTOF surveillance system is based only on data from death certificates, occupational injury deaths are undercounted; on average, death certificate-based surveillance systems capture approximately 81% of occupational injury deaths (7). Second, previous studies have demonstrated 60%- 76% agreement between industry and occupation information listed on death certificates and actual employment status at the time of death (3), which could be a source of misclassification. Third, death certificates provide only limited data about the circumstances of traumatic fatalities. Although postal workers do not appear to be at increased risk for occupational homicide, homicide was the third leading cause of occupational injury death in the United States from 1980 through 1989 (1,3). Developing strategies for the prevention of work-related homicide will require examination of the circumstances (e.g., location and working conditions) in which violence has previously occurred. Factors that may increase the risk for homicide among mail carriers are working alone in a community setting, carrying currency and other valuables, and working in high-crime areas (1,2). Enhanced security measures and devices may be appropriate to reduce assaults occurring within Postal Service facilities. Determining the risk factors for coworker violence will require assessing individual incidents to determine whether there úÿ (continued next message) ------------------------------------------------------------------------ Date: 08-24-94 Msg # 509141 To: ELIOT GELWAN Conf: (700) EMAIL From: David Dodell Stat: Private Subj: HICN738 Medical News Read: No ------------------------------------------------------------------------ ÿ@FROM :david@STAT.COM úÿ(Continued from last message) were preceding indications of impending violence (e.g., threats) and evaluating work conditions and management practices that could reduce the risk for violence. As part of such an effort, additional study is needed of behavioral factors that can lead to violence between coworkers and improved surveillance of nonfatal occupational injuries incurred through violence. In addition to addressing occupational injury deaths resulting from violence, the NTOF data reported here highlight a need to continue to address the risk for motor-vehicle-related injuries. Postal Service employees drive approximately 1.5 billion miles on the job each year (J. Jones, Office of Safety and Health, U.S. Postal Service, personal communication, 1994). Use of safety belts, maintaining mechanical integrity of the fleet (both Postal Service and personal vehicles used in the performance of duties), and training should be evaluated to identify means by which the Postal Service can reduce the risk for motor-vehicle-related fatalities. References 1. NIOSH. NIOSH alert: request for assistance in preventing homicide in the workplace. Cincinnati: US Department of Health and Human Service, Public Health Service, CDC, 1993; DHHS publication no. (NIOSH)93-109. 2. Castillo DN, Jenkins EL. Industries and occupations at high risk for work-related homicide. J Occup Med 1994;36:125-32. 3. NIOSH. Fatal injuries to workers in the United States, 1980- 1989: a decade of surveillance--national profile. Cincinnati: US Department of Health and Human Services, Public Health Service, CDC, 1993; DHHS publication no. (NIOSH)93-108. 4. US Department of Labor. Employment and earnings. Vols 31-37 (issue no. 1 for each year). Washington, DC: US Department of Labor, Bureau of Labor Statistics, 1984-1990. 5. Barringer F. Anger in the post office: killings raise questions. New York Times, 1993 May 7: 1(col 3), 6(col 1). 6. Windau J, Toscano G. Workplace homicides in 1992. In: US Department of Labor, ed. Compensation and working conditions, 1994. Vol 46, issue 2. Washington, DC: US Department of Labor, Bureau of Labor Statistics, 1994. 7. Stout NA, Bell C. Effectiveness of source documents for identifying fatal occupational injuries: a synthesis of studies. Am J Public Health 1991;81:725-8. *NTOF is based on death certificates compiled from all 52 vital statistics reporting units in the United States that meet three criteria: the decedent was greater than or equal to 16 years of age, the cause of death was an injury or poisoning according to the International Classification of Diseases, Ninth Revision, and the certifier responded positively to the "Injury at Work?" question (3). ------------------------------ End of HICNet Medical News Digest V07 Issue #38 *********************************************** --- Editor, HICNet Medical Newsletter Internet: david@stat.com FAX: +1 (602) 451-1165 Bitnet : ATW1H@ASUACAD