From <@uga.cc.uga.edu:owner-mednews@ASUACAD.BITNET> Tue Jun 6 14:05:01 1995 with BSMTP id 6610; Tue, 06 Jun 95 12:50:40 EDT UGA.CC.UGA.EDU (LMail V1.2a/1.8a) with BSMTP id 4821; Tue, 6 Jun 1995 11:41:55 -0400 HICNet Medical News Digest Tue, 06 Jun 1995 Volume 08 : Issue 22 Today's Topics: [MMWR - May12] Imported Dengue -- United States, 1993-1994 [MMWR] Carbon Monoxide Poisoning from Use of Gasoline-Fueled Power [MMWR] Eye Injuries to Agricultural Workers [MMWR] National Chronic Disease Prevention and Control Conference [MMWR] Course in Hospital Epidemiology [MMWR May19] World No-Tobacco Day, 1995 [MMWR] Assessment of the Impact of a 100% Smoke-FreeOrdinance on Smoking-Attributable Mortality -- Mexico, 1992 +------------------------------------------------+ ! ! ! 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 *Asia/Pacific: http://biomed.nus.sg/MEDNEWS/welcome.html *Americas: http://lab.xrt.upenn.edu:2000/hicn (good till June 1995) *Europe: http://www.dmu.ac.uk/ln/MEDNEWS/ Compilation Copyright 1995 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 Stephen Cristol, M.D. MPH, 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 ---------------------------------------------------------------------- To: hicnews Imported Dengue -- United States, 1993-1994 Dengue is a mosquito-transmitted acute disease caused by any of four virus serotypes (DEN-1, DEN-2, DEN-3, and DEN-4) and characterized by the sudden onset of fever, headache, myalgia, rash, nausea, and vomiting. The disease is endemic in most tropical areas of the world and has occurred in U.S. residents returning from travel to such areas. This report summarizes information about cases of imported dengue among U.S. residents during 1993 and 1994. Serum samples from 148 U.S. residents who had suspected dengue with onset in 1993 (57 cases) and 1994 (91 cases) were submitted to CDC for diagnostic testing from 33 states (Table 1). Of these, 46 (31%) cases from 17 states were serologically or virologically diagnosed as dengue (1) by isolation of dengue virus, detection of dengue-specific IgM, single high titers of IgG antibodies in acute serum samples, or a fourfold or greater rise in dengue-specific antibodies between acute- and convalescent-phase serum samples. Dengue serotype (DEN-2 and DEN-3) was identified for two cases. Of the 46 persons with laboratory-diagnosed dengue, 25 (54%) were males. Age was reported for 32 and ranged from 1 year to 87 years (median: 27 years). Travel histories were available for 43 persons (Table 1); infections probably were acquired in the Caribbean islands (21 cases), Mexico and Central America (10), and Asia (10). Two patients reported possible exposure in two locations: Australia and Asia, and Asia and Africa. Clinical information was available for 40 of 46 laboratory- confirmed cases. The most commonly reported symptoms were consistent with classic dengue fever (e.g., fever [92%], myalgia [48%], rash [48%], and headache [42%]). Other manifestations included petechiae or purpura (four patients); low white blood cell count (1000- 2700/mm3 [normal: 3200-9800/mm3]) (13 patients); low platelet count (20,000-134,000/mm3 [normal: 150,000-450,000/mm3]) (13 patients); and elevated liver enzymes (seven patients). Six patients were hospitalized. One patient (aged 12 years) with secondary dengue infection developed fever, thrombocytopenia, epistaxis, right pleural effusion, ascites, and hypotension--signs compatible with dengue shock syndrome (DSS). One patient (aged 11 years), who also had a secondary infection, developed mild disseminated intravascular coagulation. One patient (aged 49 years) with an unspecified serologic response had fever, myalgias, thrombocytopenia, leukopenia, elevated liver function test results, and hypotension (blood pressure 90/48 mmHg). Reported by: State and territorial health depts. Dengue Br, Div of Vector-Borne Infectious Diseases, National Center for Infectious Diseases, CDC. Editorial Note: Dengue is not endemic in the United States. However, because the incubation period is 3-14 days, U.S. residents who become infected during travel to tropical areas may have onset of illness after returning to the United States (2). Although most dengue infections are associated with mild illness, the risk for dengue hemorrhagic fever (DHF) is greater in some persons--particularly those with repeat (secondary) infection. DHF is characterized by fever, platelet count less than or equal to 100,000/mm3, hemorrhagic manifestations, and leaky capillary syndrome (hemoconcentration, hypoalbuminemia, or pleural or abdominal effusions). DSS includes DHF and hypotension or narrow pulse pressure (less than or equal to 20 mmHg) (3,4) and is associated with a high fatality rate (5). The incidence of DHF is increasing in the Americas: since 1982, dengue epidemics with associated DHF have occurred in Aruba, Brazil, Colombia, Curacao, Dominican Republic, El Salvador, French Guiana, Honduras, Mexico, Nicaragua, Puerto Rico, St. Lucia, Suriname, and Venezuela. In addition, dengue is endemic in many islands in the Caribbean, in Mexico, and in most countries in Central and South America (6). In 1994, outbreaks of dengue were reported from Brazil, Costa Rica, Dominican Republic, Haiti, Mexico, Nicaragua, Panama, Puerto Rico, and Venezuela. Nicaragua and Panama recently confirmed infections attributable to DEN-3 (7), a serotype that was last isolated in the Americas in 1977 (8). In the Americas, dengue is transmitted by Aedes aegypti mosquitoes. Although nearly eradicated from the region during the 1960s, this species is now present in most tropical areas of the Americas. In the United States, A. aegypti is present year-round in the southernmost Gulf of Mexico coast states from Texas to Florida; a small focus also exists on the island of Molokai in Hawaii. Autochthonous transmission of dengue has not occurred in the United States since 1986 (6); however, introduction of the virus by persons who have acquired infections in other countries could result in local transmission. The 37 laboratory-confirmed cases identified in 1994 represent almost twice the average number of similar cases identified annually during 1987-1993 (n=20) and the highest number of positives identified since 1982 (n=45) (6). However, these totals do not include cases that may have been reported to state health departments but for which specimens were not submitted for testing at CDC. In addition, in 1994, the California Department of Health Services received reports of five cases of suspected dengue that were documented at the state's Viral and Rickettsial Disease Laboratory (9). Compared with previous years, a higher proportion of cases reported in 1994 were characterized by severe disease. The three persons with life-threatening illness underscore the importance of early recognition and treatment of the severe manifestations of dengue infection. The prevention of dengue infection in tropical locations requires avoiding exposure to mosquitoes (10) and includes the continuous use of mosquito repellent and protective clothing. Although the Aedes species that transmits dengue may bite at any time during the day, peak activity occurs during the early morning and late afternoon. Ae. aegypti usually is present in peridomestic settings and is found most often in dark areas such as closets and bathrooms, behind curtains, and under beds. For tourists, the risk for exposure to dengue may be lower in some settings, including beaches, hotels with well-kept grounds, and heavily forested areas and jungles. Health-care providers should consider dengue in the differential diagnosis for all patients who have compatible manifestations and a recent history of travel to tropical areas. When dengue is suspected, patients should be monitored for evidence of hypotension, hemoconcentration, and thrombocytopenia. Because of the anticoagulant properties of acetylsalicylic acid (i.e., aspirin), only acetaminophen products are recommended for management of fever. Acute- and convalescent-phase serum samples should be obtained for viral isolation and serodiagnosis and sent for confirmation through state or territorial health department to CDC's Dengue Branch, Division of Vector-Borne Infectious Diseases, National Center for Infectious Diseases, 2 Calle Casia, San Juan, PR 00921-3200; telephone (809) 766- 5181; fax (809) 766-6596. Serum specimens should be accompanied by a summary of clinical and epidemiologic information, including a detailed travel history with dates and location of travel and dates of onset of illness and blood collection. References 1. CDC. Case definitions for public health surveillance. MMWR 1990;39(no. RR-13):10-1. 2. Benenson AS, ed. Control of communicable diseases in man. 15th ed. Washington, DC: American Public Health Association, 1990:119. 3. Morens DM. Antibody-dependent enhancement of infection and the pathogenesis of viral disease. Clin Infect Dis 1994;19:500-12. 4. Pan American Health Organization. Dengue and dengue hemorrhagic fever: guidelines for prevention and control. Washington, DC: Pan American Health Organization, 1994:12-3. 5. Tassniyom S, Vasanawathana S, Chirawatkul A, Rojanasuphot S. Failure of high-dose methylprednisolone in established dengue shock syndrome: a placebo-controlled, double-blind study. Pediatrics 1993;92:111-5. 6. Rigau-Perez JG, Gubler DJ, Vorndam AV, Clark GG. Dengue surveillance--United States, 1986-1992. In: CDC surveillance summaries, MMWR 1994;43(no. SS-2):7-19. 7. CDC. Dengue type 3 infection--Nicaragua and Panama, October-November 1994. MMWR 1995;44:21-4. 8. Gubler DJ. Dengue and dengue hemorrhagic fever in the Americas. Puerto Rico Health Sciences Journal 1987;6:107-11. 9. Division of Communicable Disease Control. Dengue and dengue hemorrhagic fever--a significant risk for travelers. California Morbidity, January 13, 1995. 10. CDC. Advisory memorandum no. 109--dengue update. Atlanta: US Department of Health and Human Services, Public Health Service, March 10, 1995. ------------------------------ To: hicnews Power Carbon Monoxide Poisoning from Use of Gasoline-Fueled Power Wash= ers in an Underground Parking Garage -- District of Columbia, 1994 On June 17, 1994, five workers in the District of Columbia were = treated in an emergency department for carbon monoxide (CO) poisoning followi= ng exposure to the exhaust from two gasoline-fueled power washers (i.e.,= pressure washers), which they had used in an empty underground parking garage.= These cases were identified by The George Washington University (GWU) Divis= ion of Occupational and Environmental Medicine (DOEM) through ongoing survei= llance for work-related injuries among construction workers treated in the G= WU emergency department (1). This report summarizes the results of an investigation by DOEM of this incident. At 11 p.m. on June 16, four laborers and a foreman (age range: 2= 2-39 years) began preparing to resurface the floor of an underground parki= ng garage that had been closed for business when the crew began work. At approx= imately 12:30 a.m., the workers started two power washers equipped with 8-hor= sepower, gasoline-fueled engines. A pedestal fan used previously in such situa= tions was not operable. In addition, the garage exhaust fan was not in operatio= n, and the main door of the garage (located approximately two levels above t= he work site) was closed. At approximately 3:30 a.m., a worker collapsed. His three co-wor= kers and the foreman assisted him out of the garage and remained outside with = him for a few minutes before they returned to the garage and resumed work. A se= cond worker then collapsed; the co-workers immediately turned off the wash= ers, evacuated the garage, and contacted the District of Columbia Fire Dep= artment. Onsite evaluation by fire department officials indicated that all fiv= e men had acute symptoms including dizziness, confusion, headache, and nervousn= ess. The two workers who had collapsed were transported by ambulance to a loca= l emergency department. At the hospital, carboxyhemoglobin (COHb) level= s, obtained from the workers at 5:10 a.m., were 20% and 17%, respectivel= y (normal: less than or equal to 5%-10% for smokers and less than or eq= ual to 1% for nonsmokers [2]). Carbon monoxide poisoning was diagnosed, and the= y were treated with hyperbaric oxygen and released later that day. The three= other workers were transported to the hospital where their COHb levels, obt= ained at 7:15 a.m., were 10.3%, 13.4%, and 7.9%, respectively. They were admin= istered 100% oxygen and released. At 4:14 a.m., the fire department's hazardous materials team res= ponded to investigate the incident. Based on measurements using a hand-operated= air pump and indicator tube approximately 1 hour after the washers had been tu= rned off, the concentration of CO was 648 parts per million (ppm).* The only id= entified source of CO was the exhaust from the gasoline-powered washers. Reported by: L Nessel-Stephens, MSS, LS Welch, MD, JL Weeks, ScD, KL = Hunting, PhD, J C=85rdenas-Amaya, MD, Div of Occupational and Environmental Me= dicine, The George Washington Univ, Washington, DC. Div of Surveillance, Hazard Evaluations, and Field Studies, National Institute for Occupational S= afety and Health, CDC. Editorial Note: CO is a potentially lethal gas with nonspecific warni= ng properties. Levels of CO uptake vary among persons and are a function= of air concentration, level of exertion and ventilatory rate, and duration o= f exposure. For example, among workers engaged in light work and who we= re exposed to a CO concentration of 700 ppm, COHb levels were 20% after = 35 minutes and 40% after approximately 1 hour (4). In general, COHb leve= ls greater than 20% are associated with symptoms; dizziness and unsteady= gait may result from levels greater than 30% (5). Based on estimates of the Bureau of Labor Statistics (BLS), in 1= 992 CO exposure accounted for 867 nonfatal work-related CO poisonings in pri= vate industry in the United States that resulted in days away from work (B= LS, Survey of Occupational Injuries and Illnesses, unpublished data, 1992= ) and for 32 fatal work-related CO poisonings (BLS, Census of Fatal Occupationa= l Injuries, unpublished data, 1992). The occurrence of nonfatal work-re= lated CO poisonings probably is underestimated because workers with mild sympt= oms may not seek treatment, medical providers may not recognize nonspecific s= ymptoms as manifestations of CO poisoning, and some correctly diagnosed cases= may not be reported as work-related. Since November 1990, DOEM has identified four other cases of CO = poisoning among construction workers; all required emergency medical treatment = (1). Two cases involved use of gasoline-powered forklifts in an enclosed wareh= ouse, and two involved use of gasoline-fueled saws. Similar incidents have been= reported among workers in other industries, including farmers using gasoline-f= ueled pressure washers to clean structures housing animals (6; NIOSH, unpub= lished data, 1993) and workers using liquid propane-powered floor burnishers= to clean floors in a retail establishment (7). During January 1985-February 19= 95, the Colorado Department of Public Health and Environment (CDPHE) received= reports of 147 cases of occupational CO poisoning related to the use of gasoline-powered equipment; of these, 13 (9%) were associated with us= e of pressure washers (CDPHE, unpublished data, 1995). The investigation described in this report and other incidents i= ndicate that many workers may not be aware of the risks of CO poisoning assoc= iated with gasoline-fueled engines and may not be able to assess accurately= whether ventilation is adequate for their safe use. For example, in 1993, to characterize risk awareness and behavior related to the indoor use of= small engines, NIOSH surveyed 416 persons involved in flood-cleanup activit= ies in Missouri. Of those who had ever used a gasoline-powered pressure wash= er, 38% reported bringing the engine component of the washer inside a buildin= g (NIOSH, unpublished data, 1993). For many construction projects, CO exposure cannot be consistent= ly ·_ controlled because of the involvement of multiple contractors. The em= ployer of the laborers involved in the incident described in this report has discontinued use of the gasoline-powered pressure washers in undergro= und parking garages and now uses electric- or diesel-powered washers. How= ever, other contractors routinely use gasoline-powered equipment in maintai= ning and resurfacing parking garage floors--often without additional ventilati= on. Alternatives to gasoline-powered equipment (i.e., electric and diesel equipment) are associated with other potential hazards (e.g., imprope= r use of electric equipment can result in electrocution, and unfiltered diesel= exhaust contains hazardous particulates). Even though diesel equipment and well-maintained gasoline-fueled equipment that are fitted with cataly= tic converters emit less CO, the reduced levels may be too high for safe = indoor use. The risk for CO exposure to workers can be reduced through impro= ved ventilation. In addition, however, risk-reduction efforts must includ= e air monitoring for CO levels. Reliable air monitoring includes the requir= ement for persons who have been trained to perform the monitoring and for equip= ment that has been properly calibrated and maintained. Training and warning lab= els can increase awareness among contractors and workers about the risks asso= ciated with use of gasoline-fueled equipment in enclosed spaces. References 1. Hunting KL, Nessel-Stephens L, Sandford SM, Shesser R, Welch LS. Surveillance of construction worker injuries through an urban emergen= cy department. J Occup Med 1994;36:356-64. 2. Smith R. Systemic toxicology. In: Amdur MO, Doull J, Klassen CD, e= ds. Casarett and Doull's toxicology: the basic science of poisons. 4th ed= . New York: Pergamon Press, 1991:264-8. 3. NIOSH. Pocket guide to chemicals. Cincinnati: US Department of Hea= lth and Human Services, Public Health Service, CDC, 1990; DHHS publication no= . (NIOSH)90-117. 4. Forbes WH, Sargent F, Foughton FJW. The rate of CO uptake by norma= l man. Am J Physiol 1945;143:594-608. 5. Seger DL, Welch L. Carbon monoxide. In: Sullivan JB, Krieger GR. H= azardous materials toxicology: clinical principles of environmental health. Ba= ltimore: Williams and Wilkins, 1992: 1160-4. 6. CDC. Unintentional carbon monoxide poisoning from indoor use of pr= essure washers--Iowa, January 1992-January 1993. MMWR 1993;42:777-9,785. 7. CDC. Carbon monoxide poisoning associated with a propane-powered f= loor burnisher-- Vermont, 1992. MMWR 1993;42:726-8. * The NIOSH recommended exposure limit for CO is 35 ppm (as an 8-hour time-weighted average), and the recommended ceiling limit is 200 ppm = (3). ------------------------------ To: hicnews Eye Injuries to Agricultural Workers -- Minnesota, 1992-1993 During 1993, U.S. farm workers incurred an estimated 13,500 eye injuries that resulted in lost work time (1); many of these injuries could have been prevented. To determine the incidence of eye injuries and use of eye protection among farm workers, the Minnesota Occupational Health Nurses in Agricultural Communities (OHNAC)* examined data from the Minnesota Farming Health Survey (MFHS) conducted during January-April 1992 and December 1992-April 1993. This report summarizes the results of this analysis. Occupational health nurses administered questionnaires during on- farm visits. Square-mile sections of land in three agricultural regions of the state were sampled at a sampling rate of 3.5%. All farms on any portion of the sampled land were selected. Farms were considered eligible for the survey if farm operators reported that they actively farmed, that they sold greater than or equal to $1000 of farm produce annually, and that their farm income accounted for at least half of their total household income. Overall, 1359 farm household members living on 372 (68.5%) of 543 eligible farms were included in the survey; respondents were farm operators and selected adult household members. Farm injuries were defined as self-reported events related to farm operation that resulted in restricted activities for at least four hours, loss of consciousness, or seeking of medical care. Respondents reported 106 farm injuries during the two periods** (annual rate: 78.0 injuries per 1000 farm household members [95% confidence interval (CI)=63.7-92.2]). Ten persons sustained 11 farm-related eye injuries (10% of all injuries and 8.1 eye injuries per 1000 farm household members [95% CI=3.3-12.9]). Of the 11 farm-related eye injuries, four were caused by chemicals and seven by foreign bodies. Chemical-related eye injuries involved splashes of liquid agricultural chemicals (two cases) and fungicidal dust (one case); the fourth incident involved discovery of an eye injury in a child who had exited a chemical storage shed, although the details of the injury could not be ascertained. Foreign body-related injuries were sustained in association with activities including working with hand and power tools, welding, grinding, cutting metal, and augering grain. The injured person was reported to have been using eye protection in only one of these incidents. Medical care was sought for nine (82%) of the 11 injuries; seven required immediate medical attention. However, no residual problems or restrictions were reported by respondents; three of the 10 injuries to adults resulted in lost work time. Farm operators also were asked about their use of protective equipment and/or procedures while performing specific work tasks involving potential dermal exposures to agricultural chemicals (Table 1). For mixing or loading agricultural chemicals or for sprayer maintenance, 50% reported never wearing eye protection (e.g., goggles or safety glasses), and 9% reported never using protective gloves. Of the 207 respondents who worked with anhydrous ammonia (an extremely caustic alkali that is stored under pressure and applied as a liquid fertilizer), 73 (35%) reported that they never or sometimes wore goggles, and 92 (44%) reported that they never or sometimes checked the water supply in their field emergency water tank.*** Reported by: C Lexau, MPH, D Bishop, PhD, Div of Family Health, Minnesota Dept of Health. Div of Safety Research, and Div of Surveillance, Hazard Evaluations, and Field Studies, National Institute for Occupational Safety and Health, CDC. Editorial Note: The MFHS findings document the occurrence of eye injuries in a specific production-agriculture worker group--farmers and household members living on family-operated farms--and are consistent with other recent reports. For example, the Regional Rural Injury Study, a population-based survey in five midwestern states, documented an annual rate of 58.3 farm injury events per 1000 household members--farm-related eye injuries accounted for 8.2% of all farm injuries (2).**** Based on the Traumatic Injury Surveillance of Farmers survey during 1993, the estimated 13,500 eye injuries among farm workers in the United States that resulted in lost time from work accounted for approximately 6.7% of all lost-time injuries estimated for farming operations (1). Although the survey participation rate was relatively low, MFHS data for selected characteristics of farm operators and farm operations were consistent with data from the 1992 Census of Agriculture. Based on the incident descriptions obtained by MFHS, each of the 10 eye injuries to adults would most likely have been prevented if appropriate and well-fitting eye protection had been worn while those persons engaged in work with agricultural chemicals, power and hand tools, and grain- or seed- moving equipment. Personal protective equipment traditionally has not been considered a primary strategy for hazard control. The preferred strategies have included hazard substitution (i.e., replacing a hazardous chemical with a less hazardous one) and hazard isolation or use of engineering controls (3). Although these strategies are applicable in agricultural settings (e.g., use of closed pesticide-handling systems), use of eye protection provides a practical and cost-effective method of preventing eye injuries among farm workers. Goggles are recommended for chemical splash protection, and safety glasses with side shields can provide adequate protection (except in dusty environments) against flying particles or objects (4,5). In Minnesota, OHNAC is working with individual agricultural chemical dealers to promote the use of eye protection among their clients. Concurrent with educational programs and media promotions by Minnesota OHNAC staff, the chemical dealers have agreed to sell eye protection devices at a discount during the spring and early summer. Minnesota OHNAC has successfully used a similar approach with operators of local grain elevators to increase the availability of respiratory protection (6). Chemical-related eye injuries are a focus for prevention efforts in Minnesota because they accounted for many of the eye injuries reported in the MFHS and represented most (67%) of the reported chemical injuries. The recently implemented U.S. Environmental Protection Agency Worker Protection Standard (7) requires farm operators (including family farmers) to adopt preventive measures when working with pesticides. This standard includes requirements that all workers comply with personal protective equipment recommendations detailed on pesticide labels, that decontamination sites--including an emergency water supply--be furnished for employees, and that eye protection be used when closed pesticide-handling systems are operated under pressure. References 1. NIOSH. Traumatic Injury Surveillance of Farmers, 1993: statistical abstract. Cincinnati: US Department of Health and Human Services, Public Health Service, CDC (in press). 2. Gerberich SG, Gibson RW, French LR, et al. The Regional Rural Injury Study-I (RRIS-I): a population-based effort--a report to the CDC, 1993. Minneapolis: University of Minnesota, Regional Injury Prevention Research Center, 1993. 3. Olishifski JB. Methods of control. In: Plog BA, ed. Fundamentals of industrial hygiene. 3rd ed. Chicago: National Safety Council, 1988. 4. Vinger PF, Sliney DH. Eye disorders. In: Levy BS, Wegman DH, eds. Occupational health: recognizing and preventing work-related disease. Boston/Toronto: Little, Brown, and Company, 1988. 5. American National Standards Institute. American National Standard practice for occupational and educational eye and face protection. New York: American National Standards Institute, 1989; publication no. (ANSI)Z87.1-1989. 6. Lexau CA. Evaluation results: Minnesota Farming Health Project grain elevator health promotion program. Minneapolis: Minnesota Department of Health, 1994. 7. US Environmental Protection Agency. The worker protection standard for agricultural pesticides: how to comply--what employers need to know. Washington, DC: US Environmental Protection Agency, 1993. * OHNAC is a national surveillance program conducted by CDC's National Institute for Occupational Safety and Health, which has placed public health nurses in rural communities and hospitals in 10 states (California, Georgia, Iowa, Kentucky, Maine, Minnesota, New York, North Carolina, North Dakota, and Ohio) to conduct surveillance for agriculture-related illnesses and injuries that occur among farmers and their family members. These surveillance data are used to assist in reducing the risk for occupational illness and injury in agricultural populations. ** The reporting period for the winter 1992 survey was January 1991- December 1991; the period for the winter 1993 survey was November 1991-October 1992. *** Keeping an emergency water supply in the field is a standard safety precaution; immediate flushing of skin or eyes following contact with anhydrous ammonia is necessary to mitigate the severe burns that will otherwise result. **** The questionnaire for farm injuries used on the MFHS was adapted from the Regional Rural Injury Study, but the population eligible for inclusion in the MFHS included more full-time farmers. ------------------------------ To: hicnews Conference National Chronic Disease Prevention and Control Conference CDC is soliciting abstracts for the Tenth National Conference on Chronic Disease Prevention and Control to be held in Atlanta, December 6-8, 1995. The 12 topic areas are: forming coalitions with nontraditional partners; the changing nature of leadership and advocacy; moving from a service provision model to a population-based model; social marketing; system changes to incorporate or implement prevention; program institutionalization with communities; new research paradigms--broadening chronic disease epidemiology; measuring chronic diseases, behaviors, and other risks; translating science into reasonable policy and effective implementation; critical points in the life cycle for behavior change; trends in the chronic disease burden-- the changing priorities of chronic disease; and use of technology to improve the prevention of chronic disease. The deadline for submission of abstracts is June 23, 1995. Additional information and abstract forms are available from Dr. Philip Huang, Chief, Bureau of Disease Prevention, Texas Department of Health, 1100 West 49th St., Austin, TX 78756-3199; telephone (512) 458-7200; fax (512) 459-7618. ------------------------------ To: hicnews Course in Hospital Epidemiology CDC, the Society for Healthcare Epidemiology of America (SHEA), and the American Hospital Association will cosponsor a hospital epidemiology training course October 14-17, 1995, in Miami, Florida. The course, designed for infectious disease fellows, new hospital epidemiologists, and infection-control practitioners, provides hands-on exercises to improve skills in detection, investigation, and control of epidemiologic problems encountered in the hospital setting and lectures and seminars on fundamental aspects of hospital epidemiology. Additional information is available from SHEA Meetings Department, Suite 200, 875 Kings Highway, Woodbury, NJ 08095-3172; telephone (609) 845- 1720; fax (609) 853-0411. ------------------------------ To: hicnews World No-Tobacco Day, 1995 The increase in cigarette smoking worldwide since 1950 has been particularly dramatic in developing countries and has been associated with substantial morbidity, mortality, and economic costs (1,2). Each year, tobacco use accounts for at least 3 million deaths worldwide (1-3). Based on current smoking trends, in 30-40 years, tobacco use is projected to cause 10 million deaths annually, of which 70% will occur among persons in developing countries (1). The global health-care costs resulting from tobacco use exceed $200 billion per year--more than twice the current health budgets of all developing countries combined (4). To increase global awareness of tobacco-attributable morbidity, mortality, and economic costs, the theme of the eighth World No-Tobacco Day, to be held May 31, 1995, is "Tobacco Costs More Than You Think." Additional information about World No-Tobacco Day 1995 is available from the Regional Office for the Americas, World Health Organization (telephone [202] 861-3200), or from CDC's Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion (telephone [404] 488-5705). References 1. Peto R, Lopez AD, Boreham J, Thun M, Heath C. Mortality from smoking in developed countries, 1950-2000. Oxford, England: Oxford University Press, 1994. 2. World Health Organization. World No-Tobacco Day, 31 May 1995 [Advisory kit]. Geneva: World Health Organization, 1995. 3. World Health Organization. World No-Tobacco Day, 31 May 1995 [Press kit]. Geneva: World Health Organization, 1995. 4. Barnum H. The economic burden of the global trade in tobacco. Tobacco Control 1994;3:358-61. ------------------------------ To: hicnews on Assessment of the Impact of a 100% Smoke-Free Ordinance on Restaurant Sales -- West Lake Hills, Texas, 1992-1994 Exposure to environmental tobacco smoke (ETS), which is associated with adverse health effects among nonsmokers (1), is a health hazard of particular concern for patrons and employees in restaurants (2). To protect nonsmokers, many local governments have enacted ordinances requiring restaurants to be smoke-free. However, the potential economic impact of these laws on restaurants is an important concern for restaurant owners. On June 1, 1993, the city of West Lake Hills (a suburb of Austin), Texas (1995 population: 3000), implemented an ordinance requiring a 100% smoke-free environment in all commercial establishments to which the public has access, including all restaurants and restaurants with bar areas. This report summarizes an assessment of sales in restaurants during June 1993-December 1994 compared with January 1992-May 1993. Restaurants in West Lake Hills had a variety of menus and food-pricing scales. Restaurant sales data for West Lake Hills were obtained from the Texas State Comptroller's office. Aggregate monthly sales data* from January 1992 through December 1994 were obtained for the eight restaurants in West Lake Hills that had indoor dining areas and were in operation during all of 1992 and until the ordinance went into effect in June 1993 (one of these restaurants closed in April 1994 because its lease expired). These sales data included the 17-month period preceding implementation of the ordinance (January 1992-May 1993) and the 19-month period following implementation (June 1993-December 1994). Restaurants that opened during the assessment period were not included in the analysis because the purpose of the study was to assess the impact of the ordinance on a consistent panel of restaurants (five restaurants opened during September 1992-July 1994). Data were analyzed using a linear regression model (3) that examined the relation between total restaurant sales and the presence of a smoke-free ordinance and that incorporated seasonal variations in sales and temporal economic trends. For each factor examined (i.e., time [year and month], quarter of the year, and presence of the implemented ordinance), a corresponding regression coefficient was calculated to measure the effect of that factor on total restaurant sales. A positive regression coefficient suggests that the factor was associated with increased total restaurant sales, and a negative value suggests that the factor was associated with decreased total restaurant sales. To test for multicollinearity, variance inflation factors were computed for each independent variable in the model. The Durbin-Watson statistic was computed (4) to test for first-order autocorrelation (correlation of the residuals [error terms] for adjacent observations over time). Total monthly sales for the restaurants during 1992-1994 varied by season. Sales peaked during the second quarter of each year. ·_ In the initial regression model, the variance inflation factors for the ordinance variable and the year variable were above four, indicating multicollinear involvement between these variables. To address the multicollinearity, the time variable was removed: although reanalysis did not change the regression coefficient for the ordinance variable, the standard error was substantially decreased. The variance inflation factors for this final model indicated that multicollinearity was no longer present, and the Durbin-Watson statistic indicated that significant first-order autocorrelation was not present (Table 1). The regression coefficient for the second quarter of the year was positive, suggesting that restaurant sales were greater in the second quarter of each year than in the first quarter (Table 1). The regression coefficient for the ordinance variable was positive, suggesting that the total sales of the restaurants did not decrease after implementation of the ordinance. Reported by: P Huang, MD, Bur of Chronic Disease Prevention and Control; S Tobias, S Kohout, M Harris, D Satterwhite, Office of Smoking and Health; DM Simpson, MD, State Epidemiologist, Texas Dept of Health; L Winn, City of West Lake Hills; J Foehner, L Pedro, Office of the Texas Comptroller of Public Accounts. Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. Editorial Note: The findings in this report are consistent with assessments using similar methods in other locations that have reported that the implementation of smoke-free ordinances has not been associated with adverse economic effects on restaurants (3,5,6). Previous reports of decreases in restaurant sales following the enactment of clean indoor air ordinances have been based on anecdotal information (7-10), on studies that used restaurant owners' self-reports of the impact on their business instead of validated sales data (7,8), and on studies that used tax data to measure restaurant sales but collected data for only one or two quarters following implementation of ordinances (9,10). In comparison, the assessment in West Lake Hills was based on sales data that were validated by tax revenue reported by the State Comptroller's office, included data for periods of time sufficient for statistical analysis, and employed multiple linear regression techniques to account for temporal trends and seasonal variations in sales. The findings in this assessment are subject to at least three limitations. First, because of limitations in data, an ordinary least squares regression model--which assumes no autocorrelation--was used in place of a more specific time series model; however, the Durbin-Watson statistic indicated that significant autocorrelation was not present. Second, the model only explained 33% of the variation in total restaurant sales; future studies may benefit from the inclusion of other variables that can affect restaurant sales. Third, because the assessment focused on a consistent panel of restaurants and excluded restaurants that opened during the assessment period, the findings cannot be generalized to all restaurants in West Lake Hills. The economic impact of smoke-free ordinances is an important consideration for policymakers concerned about the ETS exposure of nonsmokers; assessment of the potential economic impact of these laws should be based on the most objective, scientific evidence available. The findings from the assessment in West Lake Hills has provided policymakers in that community with a scientific appraisal of the impact of public health measures to reduce exposure to tobacco smoke. In addition, the assessment in West Lake Hills provides a model for other local and state public agencies to consider when evaluating tobacco-control programs. References 1. US Environmental Protection Agency. Respiratory health effects of passive smoking: lung cancer and other disorders. Washington, DC: US Environmental Protection Agency, Office of Health and Environmental Assessment, Office of Atmospheric and Indoor Air Programs, 1992; publication no. EPA-600/6-90/006F. 2. Siegel M. Involuntary smoking in the restaurant workplace: a review of employee exposure and health effects. JAMA 1993;270:490-3. 3. Glantz SA, Smith LR. The effect of ordinances requiring smoke-free restaurants on restaurant sales. Am J Public Health 1994;84:1081-5. 4. Durbin J, Watson GS. Testing for serial correlation in least squares regression. Biometrika 1951;37:409-28. 5. Maroney N, Sherwood D, Stubblebine WC. The impact of tobacco control ordinances on restaurant revenues in California. Claremont, California: The Claremont Graduate School, The Claremont Institute for Economic Policy Studies, 1994. 6. Taylor Consulting Group. The San Luis Obispo ordinance: a study of the economic impacts on San Luis Obispo restaurants and bars. San Luis Obispo, California: Taylor Consulting Group, 1993. 7. Gambee P. Economic impacts of smoking ban in Bellflower, California: analysis of survey data, February-May, 1991. Bellflower, California: California Business and Restaurant Alliance, 1991. 8. Charlton Research Company. Pacific Dining Car Restaurant and Southern California Business Association, December 11, 1993-January 15, 1994. San Francisco, California: Charlton Research Company, 1994. 9. Laventhol & Horwath, Certified Public Accountants. Preliminary analysis of the impact of the proposed Los Angeles ban on smoking in restaurants. Los Angeles, California: Laventhol & Horwath, Certified Public Accountants, 1990. 10. Masotti LH, Creticos PA. The effects of a ban on smoking in public places in San Luis Obispo, California. Evanston, Illinois: Creticos & Associates, Inc, 1992. * To protect confidentiality, individual restaurant sales data are not released by the Comptroller's office . ------------------------------ To: hicnews Smoking-Attributable Mortality -- Mexico, 1992 Cigarette smoking causes neoplastic, respiratory, and cardiovascular diseases that contribute substantially to disability, death, and medical-care expenditures (1). In the United States, cigarette smoking is the leading preventable cause of premature death (1). Although the prevalence of cigarette smoking in Mexico (26% in 1993 [2]) is similar to that in the United States, smoking-attributable mortality has not been recently estimated for Mexico or most other developing countries that are experiencing increases in chronic diseases. To assist in the development of programs for preventing tobacco use, the Ministry of Health of Mexico used a modified version of the software program Smoking-Attributable Mortality, Morbidity, and Economic Costs (SAMMEC) to estimate smoking-related mortality (3). This report summarizes trends in the occurrence of smoking-related diseases in Mexico and estimates smoking-attributable mortality and years of potential life lost before age 65 years (YPLL-65) in 1992. Data from the Ministry of Health for 1970, 1980, and 1990 were used to calculate age-adjusted death rates per 100,000 persons for lung cancer, coronary heart disease, cerebrovascular disease, chronic obstructive pulmonary disease, and other smoking-related cancers (e.g., mouth, esophagus, larynx, cervix, bladder, and kidney) (4); rates were directly adjusted to the 1992 population (5). SAMMEC uses smoking prevalence and relative risks for smoking-related diseases to calculate smoking-attributable fractions (the proportions of deaths attributable to cigarette smoking). Because relative risks for smoking-related diseases were unavailable for Mexico, smoking-attributable fractions were estimated (5,6) by using an index based on lung cancer death rates in the United States and Mexico (cigarette smoking accounts for most lung cancer deaths [6]; therefore, the lung cancer death rate in Mexico was used as an overall measure of risk for disease). The lung cancer index was calculated separately for men and women. For men, the lung cancer rate among women was used as the baseline because the prevalence of smoking among women in Mexico has been low until recently, and the prevalence of other risk factors for lung cancer has been similar among men and women in Mexico. For women, the lung cancer rate among U.S. never smokers was used as the baseline (6,7). The index was multiplied by SAMMEC disease-specific smoking-attributable fractions to obtain adjusted disease-specific smoking-attributable fractions for Mexico. The number of deaths from each smoking-related disease in 1992 was multiplied by the respective adjusted smoking-attributable fraction to estimate the smoking-attributable mortality for Mexico and was used to estimate YPLL-65 associated with cigarette smoking. During 1970-1990, death rates for all major smoking-related diseases in Mexico increased substantially, ranging from a 60% increase in the death rate for cerebrovascular disease to a 220% increase in the death rate for lung cancer (Table 1, page 379). When the lung cancer rate among women was used to estimate the baseline risk for men, the numbers of smoking-attributable deaths and YPLL-65 among men in 1992 were 6875 and 25,172, respectively (Table 2, page 379). When the lung cancer rate among U.S. never smokers was used to estimate the baseline risk among women in Mexico, the numbers of smoking-attributable deaths and YPLL-65 among women in Mexico in 1992 were 3378 and 14,996, respectively. The total numbers of smoking-attributable deaths and YPLL-65 in Mexico in 1992 were 10,253 and 40,168, respectively. Most smoking-attributable deaths and YPLL-65 among men and women were associated with cardiovascular diseases, chronic obstructive pulmonary disease, and lung cancer. Reported by: R Tapia Conyer, MD, P Kuri Morales, MD, F Meneses Gonzales, MD, Ministry of Health, Mexico City, Mexico. Epidemiology Br, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion; Data for Decision Making Project, Epidemiology Program Office, CDC. Editorial Note: The findings in this report document the substantial impact of cigarette smoking on premature mortality in adults in Mexico. Death rates from the leading causes of smoking-related deaths have nearly tripled since 1970 in Mexico. Based on this analysis, the proportion of deaths attributable to smoking in Mexico is 9%, compared with 32% in the United States for the same categories of deaths considered in this report. These differences may be attributable to lower cigarette consumption in Mexico compared with the United States. However, as the population of Mexico ages and the average duration of smoking increases, the number of smoking-attributable deaths probably will increase. The estimates of the total number of smoking-attributable deaths and YPLL-65 in Mexico during 1992 probably are low for at least three reasons. First, baseline lung cancer rates for U.S. never smokers probably reflect effects of occupational or environmental exposures and, therefore, may have produced lower estimates of excess risk in Mexico. Second, estimates of smoking-attributable mortality in Mexico do not include deaths from burns, stillbirths, and sudden infant death syndrome or deaths occurring during the perinatal period because these risks are unknown and could not be extrapolated from known risks in the United States. Third, smoking-attributable mortality estimates for 1992 reflect the lower prevalences of smoking in previous decades and may not fully capture increases in mortality resulting from recent changes in smoking patterns. In addition, because this study used adjusted smoking-attributable fractions, the association between smoking-related behaviors (i.e., duration and amount of smoking, depth of inhalation, or use of filtered-tip cigarettes) and smoking-related diseases could not be examined. Ongoing examination of the relation between smoking and disease in Mexico will improve the accuracy of future estimates. In Mexico, because chronic diseases (including neoplasms and cardiovascular disease) are emerging as leading causes of death (4), the prevention of tobacco use is a major priority. The findings in this report will assist in refining policies to reduce the prevalence of cigarette smoking and risks for associated diseases and to counter the impact of increased tobacco advertising and other marketing strategies (8). Priority measures may include preventing the initiation of cigarette smoking among children and adolescents, increasing smoking cessation among adult smokers, developing health education programs, and establishing legislative policies (e.g., regulating and restricting the advertisement and promotion of tobacco products, restricting or banning tobacco sales to minors, and increasing tobacco taxes and prices [9]). References 1. CDC. Reducing the health consequences of smoking: 25 years of progress--a report of the Surgeon General. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1989; DHHS publication no. (CDC)89-8411. 2. General Office for Epidemiology. National Addiction Survey, 1993 [Spanish]. Mexico DF: Ministry of Health, 1993. 3. Shultz JM, Novotny TE, Rice DP. Smoking-Attributable Mortality, Morbidity, and Economic Cost (SAMMEC) version 2.1 [Software and documentation]. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1992. 4. National Institutes for Statistics, Geography, and Informatics. Total deaths by cause, sex, and age--United States of Mexico, 1970, 1980, 1990: population by age, 1992. Mexico DF: Ministry of Health, General Office for Statistics, National Institutes for Statistics, Geography, and Informatics, 1993; publication no. (IFDN)968-811-239-9. 5. Rothman KJ. Modern epidemiology. Boston: Little, Brown, and Company, 1986. 6. CDC. Smoking and health in the Americas: a 1992 report of the Surgeon General, in collaboration with the Pan American Health Organization. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1992; DHHS publication no. (CDC)92-8419. 7. Peto R, Lopez AD, Boreham J, Thun M, Heath C Jr. Mortality from tobacco in developed countries: indirect estimation from national vital statistics. Lancet 1992;339:1268-78. 8. Stebbins R. Making a killing south of the border: transnational cigarette companies in Mexico and Guatemala. Soc Sci Med 1994;38:105-15. 9. Roemer R. Development and implementation of a policy on tobacco control. In: Legislative action to combat the world tobacco epidemic. 2nd ed. Geneva: World Health Organization 1993:155-80. ------------------------------ End of HICNet Medical News Digest V08 Issue #22 *********************************************** --- Editor, HICNet Medical Newsletter Internet: david@stat.com FAX: +1 (602) 451-6135