HICNet Medical News Digest      Mon, 08 Aug 1994        Volume 07 : Issue 33

Today's Topics:

  [MMWR 8 July 94] Medical Costs Attributable to Cigarette Smoking
  [MMWR] Risk of Traumatic Injuries from Helicopter Crashes
  [MMWR] Assessment of Vectorborne Diseases during Midwest Floods
  [MMWR] Adult Lead Blood Epidemology
  [MMWR] Availability of EpiInfo Version 6
  [MMWR] Preventing Organic Dust Toxic Syndrome
  [MMWR] 1995 Symposium on Statistical Methods
  [MMWR 29 July 94] Respiratory Illiness Associate with Mushrooms
  [MMWR] Flood related mortalities

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Date: Sun, 07 Aug 94 23:07:17 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR 8 July 94] Medical Costs Attributable to Cigarette Smoking
Message-ID: <uu7Pqc1w165w@stat.com>

Medical-Care Expenditures Attributable to Cigarette Smoking --
United States, 1993

     Cigarette smoking is the most important preventable cause of
morbidity and premature mortality in the United States; however,
approximately 48 million persons aged greater than or equal to 18
years are smokers (1), and approximately 24 billion packages of
cigarettes are purchased annually (2). Each year, approximately
400,000 deaths in the United States are attributed to cigarette
smoking (3) and costs associated with morbidity attributable to
smoking are substantial (4). To provide estimates for 1993 of
smoking-attributable costs for selected categories of direct
medical-care expenditures (i.e., prescription drugs,
hospitalizations, physician care, home-health care, and
nursing-home care), the University of California and CDC analyzed
data from the 1987 National Medical Expenditures Survey (NMES-2)
and from the Health Care Financing Administration (HCFA). This
report summarizes the results of the analysis.
     The NMES-2 is a population-based longitudinal survey of the
civilian, noninstitutionalized U.S. population (5). A cohort of
35,000 persons in 14,000 households was selected for face-to-face
interviews four times during February 1987-May 1988. Respondents
provided data about sociodemographic factors, health insurance
coverage, use of medical care, and medical-care expenditures.
Information also was collected about self-reported health status
and health-risk behaviors including smoking, safety-belt nonuse,
and obesity. The Medical Provider Survey, a supplement to NMES-2,
provided confirmation of self-reported medical-care costs and
supplied information about costs that survey respondents were
unable to report.
     To estimate costs attributable to smoking, respondents were
categorized as never smokers, former smokers with less than 15
years' exposure, former smokers with 15 or more years' exposure,
and current smokers. First, the effect of smoking history on the
presence of smoking-related medical conditions (i.e., heart
disease, emphysema, arteriosclerosis, stroke, and cancer) was
determined. Second, for each of the medical-care expenditure
categories, the probability of having any expenditures and the
level of expenditures were estimated as a function of smoking,
medical conditions, and health status (6). All models controlled
for age, race/ethnicity, poverty status, marital status,
education level, medical insurance status, region of residence,
safety-belt nonuse, and obesity. Data were weighted to project
the estimated costs of smoking-attributable medical care to the
noninstitutionalized U.S. population. These costs were then
adjusted for 1993 by applying the category-specific smoking-
attributable percentages to national health-care expenditure data
for 1993 reported by HCFA (7). Nursing-home costs were estimated
by applying the smoking-attributable percentage of hospital
expenditures for persons aged greater than or equal to 65 years
to total nursing-home expenditures reported by HCFA. Costs of
smoking-attributable medical care also were categorized by source
of payment (i.e., self pay, private insurance, Medicare,
Medicaid, other federal, other state, and other).
     In 1987, the total medical-care expenditures for the five
expense categories reported on NMES-2 was $308.7 billion; of this
total, an estimated $21.9 billion (7.1%) was attributable to
smoking (Table 1). Hospital expenses accounted for most ($11.4
billion) costs attributable to smoking, followed by ambulatory
physician care* ($6.6 billion) and nursing-home care ($2.2
billion). Public funding (i.e., Medicare, Medicaid, and other
federal and state sources) paid for 43.3% of the medical-care
expenditures attributable to smoking (Table 2). The distribution
of expenditures by source of payment varied substantially by age
group. For persons aged greater than or equal to 65 years, public
funding accounted for 60.6% of smoking-attributable costs,
compared with 31.2% for persons aged less than 65 years.
     When the smoking-attributable percentages derived from
NMES-2 were applied to HCFA national health-care expenditure data
(6), estimated smoking-attributable costs for medical care in
1993 were $50.0 billion. Of these costs, $26.9 billion were for
hospital expenditures, $15.5 billion for physician expenditures,
$4.9 billion for nursing-home expenditures, $1.8 billion for
prescription drugs, and $900 million for home-health-care**
expenditures.

Reported by: JC Bartlett, MPH, School of Public Health, LS
Miller, PhD, School of Social Welfare, Univ of California-
Berkeley; DP Rice, ScD, WB Max, PhD, Institute for Health and
Aging, Univ of California-San Francisco. Office on Smoking and
Health, National Center for Chronic Disease Prevention and Health
Promotion; Public Health Practice Program Office, CDC.

Editorial Note: The findings in this report indicate that
cigarette smoking accounts for a substantial and preventable
portion of all medical-care costs in the United States. For each
of the approximately 24 billion packages of cigarettes sold in
1993, approximately $2.06 was spent on medical care attributable
to smoking. Of the $2.06, approximately $0.89 was paid through
public sources.
     From 1987 to 1993, the more than twofold increase in
estimated direct medical-care costs attributable to smoking
primarily reflect the substantial increase in medical-care
expenditures during this period (7). In addition, the 1993 HCFA
estimate of national health-care expenditures included expenses
not covered by NMES-2 (e.g., hospitalization and other
medical-care costs for persons too ill to respond to NMES-2).
     This analysis controlled for potential confounders such as
sociodemographic status, health insurance status, and risk
behaviors other than smoking. Previous estimates assumed the
difference in medical-care use between smokers and nonsmokers was
primarily attributable to smoking and did not account for other
associated risk factors that may result in excessive medical
expenditures (4).
     The smoking-attributable costs described in this report are
underestimated for two reasons. First, the cost estimates do not
include all direct medical costs attributable to cigarette
smoking (e.g., burn care resulting from cigarette-smoking-related
fires, perinatal care for low-birthweight infants of mothers who
smoke, and costs associated with diseases caused by exposure to
environmental tobacco smoke). Second, the indirect costs of
morbidity (e.g., due to work loss and bed-disability days) and
loss in productivity resulting from the premature deaths of
smokers and former smokers were not included in these estimates.
In 1990, estimated indirect losses associated with morbidity and
premature mortality were $6.9 billion and $40.3 billion,
respectively (3); these estimates suggest that the total economic
burden of cigarette smoking is more than twice as high as the
direct medical costs described in this report.

References
1. CDC. Cigarette smoking among adults--United States, 1992, and
changes in the definition of current cigarette smoking. MMWR
1994;43:342-6.
2. US Department of Agriculture. Tobacco situation and outlook
report. Washington, DC: US Department of Agriculture, Economic
Research Service, Commodity Economics Division, June 1994;
publication no. TBS-227.
3. CDC. Cigarette smoking-attributable mortality and years of
potential life lost--United States, 1990. MMWR 1993;42:645-9.
4. Herdman R, Hewitt M, Laschover M. Smoking-related deaths and
financial costs: Office of Technology Assessment Estimates for
1990--OTA testimony before the Senate Special Committee on Aging.
Washington, DC: US Congress, Office of Technology Assessment
Testimony, May 6, 1993.
5. National Center for Health Services Research and Health
Technology Assessment. National Medical Expenditure Survey.
Methods II. Questionnaires and data collection methods for the
household survey and the Survey of American Indians and Alaska
Natives. Rockville, Maryland: US Department of Health and Human
Services, Public Health Service, National Center for Health
Services Research and Health Technology Assessment, September
1989; DHHS publication no. (PHS)89-3450.
6. Duan W, Manning WG, Morris CN, Newhouse JP. A comparison of
alternative models for the demand for medical care. Journal of
Business and Economic Statistics 1983;1:115-26.
7. Burner ST, Waldo DR, McKusick DR. National health
expenditures: projections through 2030. Health Care Financ Rev
1992;14(1).

*Includes hospital-based outpatient and emergency care and care
in physicians' offices.
**In 1993, HCFA excluded all but Medicare- and Medicaid-certified
care in this category.



------------------------------

Date: Sun, 07 Aug 94 23:08:44 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR] Risk of Traumatic Injuries from Helicopter Crashes
Message-ID: <0w7Pqc2w165w@stat.com>

Risk for Traumatic Injuries
From Helicopter Crashes During Logging Operations --
Southeastern Alaska, January 1992-June 1993

     Helicopters are used by logging companies in the Alaska
panhandle to harvest timber in areas that otherwise are
inaccessible and/or unfeasible for conventional logging (because
of rugged terrain, steep mountain slopes, environmental
restrictions, or high cost). The National Transportation Safety
Board (NTSB) investigated six helicopter crashes related to
transport of logs by cable (i.e., long-line logging*) that
occurred in southeastern Alaska during January 1992-June 1993 and
resulted in nine fatalities and 10 nonfatal injuries. This report
presents case investigations of these incidents.

Incident Reports
     Incident 1. On February 23, 1992, a helicopter crashed while
transporting nine loggers. The copilot and five loggers died;
five others were seriously injured. The NTSB investigation
revealed that a long-line attached to the underside of the
helicopter became tangled in the tail rotor during a landing
approach, causing an in-flight separation of the tail section
(1). Passenger flights with long-line and external attachments
are illegal (2) and violate industry safety standards.
     Incident 2. On March 6, 1992, a helicopter crashed while
preparing to pick up a load of logs with a long-line. The pilot
and copilot were seriously injured. According to the pilot and
copilot, the engine failed, and the pilot immediately released
the external log load and attempted autorotation**.
     Incident 3. On November 10, 1992, a helicopter crashed while
attempting to land at a logging site, sustaining substantial
damage. The solo pilot was not injured. NTSB investigation
revealed that the helicopter's long-line had snagged on a tree
stump during the landing and that the company had no documented
training program (1).
     Incident 4. On February 19, 1993, a helicopter crashed from
a 200-foot hover after transporting two logs to a log-drop area.
The pilot and copilot were killed. NTSB investigation revealed
in-flight metal fatigue of a flight-control piston rod.
     Incident 5. On May 2, 1993, a helicopter crashed during an
attempted emergency landing after using a long-line to lift a log
1200 feet above ground level followed by rapid descent to a
75-foot hover. The pilot died, and a logger on the ground was
injured. NTSB investigation revealed an in-flight separation of
the tail rotor and tail rotor gear box from the helicopter. The
company had been using a flight procedure that would have heavily
loaded the helicopter drive train (1).
     Incident 6. On May 8, 1993, a helicopter crashed after
attempting to lift a log from a logging site with a long-line.
The pilot and copilot sustained minor injuries, but the aircraft
was substantially damaged. NTSB investigation found that the
engine failed because machine nuts had come loose from the engine
or its housing and became caught in the engine. The helicopter
crashed when the pilot attempted autorotation.

Investigation Findings
     Statewide occupational injury surveillance in Alaska through
a federal-state collaboration was established in mid-1991, with
1992 being the first full year of comprehensive population-based
occupational fatality surveillance for Alaska. During the time
these incidents occurred, an estimated 25 helicopters in Alaska
were capable of conducting long-line logging operations;
approximately 20 were single-engine models from one manufacturer
(Federal Aviation Administration [FAA], unpublished data, 1993).
Approximately 50 helicopter pilots were employed in long-line
logging operations in southeastern Alaska (FAA and Alaska
Department of Labor, unpublished data, 1993). Using these
denominators, the events in this report are equivalent to an
annual crash rate of 16% (six crashes per 25 helicopters per 18
months), 0.24 deaths per long-line helicopter in service per year
(nine deaths per 25 helicopters per 18 months), and an annual
fatality rate for long-line logging helicopter pilots of
approximately 5000 deaths per 100,000 pilots (four pilot deaths
per 50 pilots per 18 months).*** In comparison, during 1980-1989,
the U.S. fatality rate for all industries was 7.0 per 100,000
workers per year; Alaska had the highest overall occupational
fatality rate of any state (34.8 per 100,000 per year) for the
same period (4).
     According to NTSB investigations to determine probable
cause, all six crashes involved "...improper operational and/or
maintenance practices" that reflected a lack of inspections of
long-line helicopter logging operations (1). In incidents 4, 5,
and 6, investigative evidence also indicated that log loads
routinely exceeded weight and balance limits for the aircraft.
Following increased inspections, no additional logging-related
helicopter crashes were reported through June 30, 1994.

Reported by: G Bledsoe, Occupational Injury Prevention Program,
Section of Epidemiology, Div of Public Health, JP Middaugh, State
Epidemiologist, Alaska Dept of Health and Social Svcs; D Study,
Labor Standards and Safety Div, Occupational Safety and Health,
Alaska Dept of Labor. National Transportation Safety Board,
Anchorage, Alaska. Alaska Activity, Div of Safety Research,
National Institute for Occupational Safety and Health, CDC.

Editorial Note: The incidents in this report demonstrate that
long-line helicopter logging is a technology application with an
unusually high risk for occupational fatalities. General aviation
regulations restrict the number of hours pilots can fly during
given time periods; however, long-line helicopter logging
involves carrying loads outside the rotorcraft, and there are no
legal limitations on crew flight hours. Although flight-crew work
schedules and daily flight hours vary greatly by logging company,
flight-crew duty periods can exceed 10 hours per day for 10
consecutive days.
     Helicopter logging operations often place heavy demands on
helicopter machinery and associated equipment. The highly
repetitive lift/transport/drop cycles are frequently conducted at
or beyond maximum aircraft capacity in remote areas, where rugged
terrain, extremely steep mountain slopes (as great as 70
degrees), and adverse weather conditions prevail. Complex
operations under such circumstances may increase the likelihood
of both human error and machine failure (5). In addition,
conditions are unfavorable for successful autorotation during
most helicopter long-line logging operations.
     Regardless of where helicopter logging operations are
conducted, the jurisdictional responsibility for inspection rests
with the FAA office nearest the main or registered corporate
office for the helicopter company (in all of the cases in this
report, these offices were in the contiguous United States). This
necessitates travel of great distances to conduct helicopter
logging inspections, and remote operations may escape or evade
inspection for long periods. The NTSB has recommended that
operational and maintenance oversight responsibilities for remote
sites be assigned to the nearest FAA office (1).
     In response to these incidents, the Alaska Federal-State
Interagency Collaborative Working Group on the Prevention of
Occupational Traumatic Injuries**** met in a special session on
July 8, 1993, to discuss approaches for reducing the number of
such crashes and ameliorating the outcome of crash injuries.
Based on these and other findings, the working group made the
following recommendations (6):

-- All helicopter logging pilots and ground crews should receive
specific training in long-line operations.
-- Companies should follow all manufacturers' recommendations for
more frequent helicopter maintenance (because of intensity of
use) and for limits on maximum allowable loads.
-- Companies should establish and observe appropriate limits on
helicopter-crew flight time and duty periods.
-- Companies should consider using multi-engine rotorcraft.
-- Specific industrywide operating standards and procedures
should be developed.
-- Companies should provide training in on-site emergency medical
care for helicopter logging crews at all work locations.
-- State, regional, and local agencies involved in emergency
medical services education should make low-cost emergency medical
training available to persons likely to work in a helicopter
logging environment.
-- All flights over water should include appropriate survival
equipment for all crew and passengers, who should wear personal
flotation devices at all times during flights over water.

References
1. National Transportation Safety Board. NTSB safety
recommendation A-93-78 through -80. Washington, DC: National
Transportation Safety Board, June 17, 1993.
2. Office of the Federal Register. Code of Federal Regulations,
Vol 14, part 133. Washington, DC: US Department of
Transportation, Federal Aviation Administration, January, 1992.
3. Roland HE Jr, Detwiler JF. Fundamentals of fixed and rotary
wing aerodynamics. Los Angeles: University of Southern
California, November 1967.
4. Jenkins EL, Kisner SM, Fosbroke DE, et al. Fatal injuries to
workers in the United States, 1980-1989: a decade of
surveillance. Atlanta: US Department of Health and Human
Services, Public Health Service, CDC, NIOSH, 1993.
5. Aircraft accident investigation manual. Los Angeles:
University of Southern California, Institute of Safety and
Systems Management, December 1992.
6. Helicopter logging: Alaska's most dangerous occupation? State
of Alaska Epidemiology Bulletin, August 16, 1993; bulletin no.
32.

*A typical long-line logging helicopter carries an approximately
200-foot load cable (i.e., long-line), which is attached by a
hook to the underside of the helicopter. A second hook is fixed
to the free end of the cable, where a choker cable (an apparatus
designed to cinch or =FEchoke=FE around suspended logs) is connected
to one to four logs per load.
**Autorotation allows a helicopter to make an unpowered descent
by maximizing on the windmilling effect and orientation of the
main rotor=FEforward airspeed and altitude can be converted to
rotor energy to reduce the rate of descent. Successful
autorotation depends on helicopter airspeed and altitude when the
maneuver is attempted (3). Most helicopters conduct long-line
logging operations with minimal or no forward airspeed at less
than 400 feet above ground level, while optimal conditions for
autorotation require an altitude of at least 500 feet above
ground level and airspeed of more than 60 knots per hour.
***These rates refer to the period of intense collaborative
investigation and may not represent incidence over a longer
period of time; however, they accurately reflect the high risk of
helicopter long-line logging during that interval.
****Representatives from the Alaska Department of Health and
Social Services, Alaska Department of Labor, FAA, CDC's National
Institute for Occupational Safety and Health, NTSB, Occupational
Safety and Health Administration, U.S. Coast Guard, and the U.S.
Forest Service.



------------------------------

Date: Sun, 07 Aug 94 23:11:41 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR] Assessment of Vectorborne Diseases during Midwest Floods
Message-ID: <727Pqc3w165w@stat.com>

Rapid Assessment of Vectorborne Diseases
During the Midwest Flood -- United States, 1993

     Heavy spring and summer rainfall during 1993 caused the most
extensive flash and riverine flooding ever recorded in the upper
midwestern United States. In portions of the flood region,*
standing water provided large expanses of habitat capable of
producing large populations of the mosquitoes Culex pipiens and
Cx. tarsalis. These species can rapidly amplify transmission of
the arboviruses that cause St. Louis encephalitis (SLE) and
western equine encephalitis (WEE). Although information from
state health departments in the disaster area indicated minimal
SLE or WEE activity in the region before the flooding, large
vector populations in certain areas following the flooding
increased the potential for exposure of residents and emergency
workers to arboviral infection. To determine the risk for
arboviral disease in the disaster area, CDC, in collaboration
with state and local health departments, conducted surveillance
during August-September 1993. This report summarizes the results
of the surveillance activity.
     The risk for SLE or WEE amplification was low in the
northern part of the flood region because flooding occurred
during late summer, vector population densities were moderate,
and nighttime temperatures were below 50 F (10 C). To verify the
low risk, mosquito-based surveillance was conducted in Iowa,
Minnesota, Nebraska, North Dakota, and South Dakota during August
2-7. Because larger mosquito populations and higher average
temperatures (that may facilitate virus amplification) were
observed in the southern part of the flood region, intensive
surveillance for SLE and WEE was conducted in Illinois, Iowa,
Kansas, and Missouri from August 1 through September 21.
Mosquitoes were collected in carbon dioxide-baited light traps
and sorted by species. Known vector species were grouped into
pools of up to 100 mosquitoes and tested for the presence of SLE
antigen (using an antigen-capture enzyme-linked immunosorbent
assay) and/or WEE virus (using a Vero cell culture plaque assay).
     WEE virus was detected in one pool of Cx. tarsalis collected
in Deuel County, South Dakota; no evidence of SLE activity was
detected in any of the 186,501 mosquitoes tested from throughout
the region (Table 1). In Iowa, state-based sentinel chicken
surveillance revealed no evidence of SLE or WEE activity. In
Illinois, state-based wild bird surveillance identified SLE virus
in one of 2073 birds tested. Two human cases of SLE were reported
from the nine-state area; one occurred within the disaster area.
Sporadic cases of SLE frequently occur in the Midwest; these
cases were not related to flooding in 1993. Because surveillance
data indicated minimal risk for arboviral disease above
background levels in the disaster area, contingency plans for
large-scale mosquito adulticiding were not implemented.

Reported by: J Anders, Div of Microbiology, LA Shireley, MPH,
State Epidemiogist, North Dakota State Dept of Health and
Consolidated Laboratories. L Volmer, Office of Communicable
Disease Prevention and Control, K Forsch, State Epidemiologist,
South Dakota State Dept of Health. MT Osterholm, PhD, State
Epidemiologist, Minnesota Dept of Health. WL Schell, JP Davis,
MD, State Epidemiologist, Div of Health, Wisconsin Dept of Health
and Social Svcs. WA Rowley, Dept of Entomology, Iowa State Univ;
R Currier, LA Wintermeyer, MD, State Epidemiologist, Iowa Dept of
Public Health. WL Kramer, TJ Safranek, MD, State Epidemiologist,
Nebraska Dept of Health. D Alfano, Bur of Disease Control, Kansas
Dept of Health and Environment. LD Haramis, Vector Surveillance
and Control, Illinois Dept of Public Health. W Kottkamp, St.
Louis County Dept of Health-Vector Control, St. Louis; CL
Frazier, Southeast Missouri State Univ, Cape Girardeau; FT
Satalowich, Vector Control, Missouri Dept of Health. US Navy
Disease Vector Ecology and Control Center, Naval Air Station,
Jacksonville, Florida; US Navy Disease Vector Ecology and Control
Center, Alameda, California; US Navy Environmental and Preventive
Medicine Unit No. 2, Norfolk, Virginia. US Air Force Reserve 910
AG/DOS. Emergency Response Coordination Group, Vienna, Ohio.
National Center for Environmental Health; Medical
Entomology/Ecology Br, Div of Vector-Borne Infectious Diseases,
National Center for Infectious Diseases, CDC.

Editorial Note: Although natural disasters that result in
flooding often are followed by a proliferation of mosquitoes, in
the United States such disasters are rarely followed immediately
by epidemics of arboviral disease. Surveillance data in this
report confirmed that, in 1993, flood-related risk for epidemic
mosquitoborne arboviral infections was low in the upper
midwestern United States.
     Despite the presumed low risk for mosquitoborne arboviral
disease after flood-related natural disasters, surveillance for
arboviruses can assist in determining prevalence in large vector
populations and the need for mosquito control. Because the 1993
Midwest flood was more widespread than previous floods in the
region, the risk for arboviral disease was unknown. Surveillance
provided an accurate determination of the risk for transmission
of arboviral infection and obviated the expense of large-scale
mosquito control. For example, the total allocation for arbovirus
surveillance in the disaster area was approximately $390,000
(range: $32,275 [Illinois] to $150,000 [Missouri]). If
surveillance had not been implemented in the area, prophylactic
mosquito control most likely would have been conducted. The
estimated cost of mosquito control for the St. Louis metropolitan
area alone was $1.6 million. If other metropolitan areas in the
flood region also were treated, the total estimated cost of
prophylactic mosquito control would have exceeded $10 million.
These findings suggest that arbo- virus surveillance programs to
determine public health risk can prevent unnecessary expenditures
associated with application of insecticides.
     In addition to large-scale application of insecticides, the
primary public health interventions to prevent mosquitoborne
arboviral outbreaks include community alerts that warn residents
to avoid mosquito exposure during twilight hours by staying
inside screened or air-conditioned buildings or by using
repellents or other personal protection measures. The decision to
use large-scale application of insecticides to reduce vector
population densities is complex and depends on many factors,
including detection of early-season arbovirus transmission,
indicating increased risk for human infection. Timely
intervention, however, requires an active program of mosquito and
avian surveillance and appropriate mosquito-control measures.
     Reasons also may exist for emergency control of mosquitoes
that are not related to disease transmission after a disaster.
Pest (i.e., nonvector) mosquito species may cause severe nuisance
problems that compromise emergency-response operations. CDC
recommends control of pest mosquitoes when 1) emergency-response
or reconstruction efforts are substantially hampered by large
populations of mosquitoes, 2) normal civil services (e.g. police,
fire, emergency medical services, power, and water and sewage
services) in the disaster area are substantially disrupted, or 3)
large nuisance mosquito populations place additional stress on
the human population (1). Surveillance protocols and control
methods vary by the mosquito species. Decisions to control pest
mosquitoes are based on criteria that differ from those to
control vector mosquitoes. No large-scale emergency control of
pest mosquitoes was conducted in the 1993 flood disaster.
     In the disaster area, the risk for epidemic transmission of
arboviruses during 1994 is being monitored by human, bird, and
mosquito surveillance. Winter snows and spring rains contributed
to flooding and standing water in some areas of the midwestern
United States that experienced flooding in 1993. As a result,
mosquitoes in these localities may be more abundant than usual
during the 1994 arbovirus transmission season.

Reference
1. CDC. Emergency mosquito control associated with Hurricane
Andrew--Florida and Louisiana, 1992. MMWR 1993;42:240-2.

*Illinois, Iowa, Kansas, Minnesota, Missouri, Nebraska, North
Dakota, South Dakota, and Wisconsin.



------------------------------

Date: Sun, 07 Aug 94 23:13:00 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR] Adult Lead Blood Epidemology
Message-ID: <D57Pqc4w165w@stat.com>

Adult Blood Lead Epidemiology and Surveillance --
United States, 1992-1994

     CDC's National Institute for Occupational Safety and Health
Adult Blood Lead Epidemiology and Surveillance program (ABLES)
monitors elevated blood lead levels (BLLs) among adults in the
United States (1). Twenty-two states currently report
surveillance results to ABLES. Beginning in 1993, ABLES began
detecting both new cases and persons with multiple reports over
time. In this report, ABLES provides data for the first quarter
of 1994 and compares annual data for 1993 and 1992.
     During January 1-March 31, 1994, the number of reports of
elevated BLLs increased over those reported for the same period
in both 1992 and 1993 in all reporting categories (Table 1); this
increase is consistent with the increase from 1992 to 1993 in
total annual BLL reports (2). The number of reports of adults
with elevated BLLs reflects monitoring practices by employers.
Variation in national quarterly reporting totals, especially
first-quarter totals, may result from 1) changes in the number of
participating states; 2) timing of receipt of laboratory BLL
reports by state-based surveillance programs; and 3) interstate
differences in worker BLL testing by lead-using industries.
     The reported number of adults with elevated BLLs increased
from 8886 in 1992 to 11,240 in 1993 (Table 2); this increase
resulted in part from a net gain of two reporting states (three
additions and one deletion) to ABLES in 1993. A total of 6584 new
case reports* accounted for 59% of the total cases (11,240)
reported during 1993.
     Fifty-two percent of persons reported in 1992 were reported
again to the system during 1993. Reasons for repeat reports of
elevated BLLs include 1) recurring exposure resulting from lack
of existing control measures and inapropriate worker-protection
practices; 2) routine tracking of elevated employee BLLs below
the medical removal limits; and 3) increased employer monitoring
during medical removal. Increased testing of workers in
construction trades--as new workplace medical-monitoring programs
are established to comply with new Occupational Safety and Health
Administration regulations (3)--also may partially explain
increases in reports of elevated BLLs.
     These data suggest that work-related lead exposure is an
ongoing occupational health problem in the United States. By
expanding the number of participating states, reducing
variability in reporting, and distinguishing between new and
recurring elevated BLLs in adults, ABLES can enhance surveillance
for this preventable condition.

Reported by: NH Chowdhury, MBBS, Alabama Dept of Public Health. C
Fowler, MS, Arizona Dept of Health Svcs. FJ Mycroft, PhD,
Occupational Health Br, California Dept of Health Svcs. BC Jung,
MPH, Connecticut Dept of Public Health and Addiction Svcs. M
Lehnherr, Occupational Disease Registry, Div of Epidemiologic
Studies, Illinois Dept of Public Health. R Gergely, Iowa Dept of
Public Health. E Keyvan-Larijani, MD, Lead Poisoning Prevention
Program, Maryland Dept of the Environment. R Rabin, MSPH, Div of
Occupational Hygiene, Massachusetts Dept of Labor and Industries.
A Carr, MBA, Bur of Child and Family Svcs, Michigan Dept of
Public Health. D Solet, PhD, Div of Public Health Svcs, New
Hampshire State Dept of Health and Human Svcs. B Gerwel, MD,
Occupational Disease Prevention Project, New Jersey Dept of
Health. R Stone, PhD, New York State Dept of Health. S Randolph,
MSN, North Carolina Dept of Environment, Health, and Natural
Resources. E Rhoades, MD, Oklahoma State Dept of Health. M
Barnett, MS, State Health Div, Oregon Dept of Human Resources. J
Gostin, MS, Occupational Health Program, Div of Environmental
Health, Pennsylvania Dept of Health. R Marino, MD, Div of Health
Hazard Evaluations, South Carolina Dept of Health and
Environmental Control. D Perrotta, PhD, Bur of Epidemiology,
Texas Dept of Health. D Beaudoin, MD, Bur of Epidemiology, Utah
Dept of Health. L Toof, Div of Epidemiology and Health Promotion,
Vermont Dept of Health. J Kaufman, MD, Washington State Dept of
Labor and Industries. D Higgins, Wisconsin Dept of Health and
Social Svcs. Div of Surveillance, Hazard Evaluations, and Field
Studies, National Institute for Occupational Safety and Health,
CDC.

References
1. CDC. Surveillance of elevated blood lead levels among adults--
United States, 1992. MMWR 1992;41:285-8.
2. CDC. Adult blood lead epidemiology and surveillance--United
States, fourth quarter, 1993. MMWR 1994;43:246-7.
3. Office of the Federal Register. Code of federal regulations:
occupational safety and health standards. Subpart Z: toxic and
hazardous substances--lead. Washington DC: Office of the Federal
Register, National Archives and Records Administration, 1993. (29
CFR section 1926, part II).

*At least one report of an adult with an elevated BLL ( greater
than or equal to 25 ug/dL) who had not been reported previously
in 1992. Of the newly reported cases in 1993, 257 (4%) were
reported by new ABLES states (for which all cases are considered
new).



------------------------------

Date: Sun, 07 Aug 94 23:14:08 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR] Availability of EpiInfo Version 6
Message-ID: <067Pqc5w165w@stat.com>

Availability of Version 6 of Epi Info

     The Epi Info computer programs produced by CDC and the World
Health Organization provide public-domain software for word
processing, database management, and statistics work in public
health; more than 40,000 documented copies of Version 5 are in
use in 117 countries. Version 6 of Epi Info was released in June
1994.
     Version 6 features a configurable pull-down menu, facilities
for producing and using hypertext (active text), additional
statistics, and many programming improvements. As with previous
versions, it runs on IBM*-compatible computers under DOS and
requires 640 K of memory (RAM), although use of a hard disk is
recommended.
     A 600-page manual is included on the disks and is available
in printed form. Copies of Epi Info and a companion program for
geographic mapping (Epi Map) are available from USD, Inc., 2075A
West Park Place, Stone Mountain, GA 30087; telephone (404)
469-4098; fax (404) 469-0681. There are charges for Epi Info and
Epi Map.
     Epi Info and Epi Map are available on the worldwide Internet
using the following access information: Site: FTP.CDC.GOV; User
ID: anonymous; Directory for Epi Info: /PUB/EPI/EPIINFO;
Directory for Epi Map: /PUB/EPI/EPIMAP. The compressed files
occupy 3-4 megabytes for each product.

*Use of trade names and commercial sources is for identification
only and does not imply endorsement by the Public Health Service
or the U.S. Department of Health and Human Services.



------------------------------

Date: Sun, 07 Aug 94 23:15:46 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR] Preventing Organic Dust Toxic Syndrome
Message-ID: <Z97Pqc6w165w@stat.com>

NIOSH Alert: Request for Assistance
in Preventing Organic Dust Toxic Syndrome

     CDC's National Institute for Occupational Safety and Health
(NIOSH) periodically issues alerts on workplace hazards that have
caused death, serious injury, or illness to workers. One such
alert, Request for Assistance in Preventing Organic Dust Toxic
Syndrome (1), was recently published and is available to the
public.*
     This alert warns agricultural workers who inhale
contaminated organic dust that they can develop serious
respiratory illness. One of the most common illnesses is organic
dust toxic syndrome (ODTS), a respiratory and systemic illness
that can follow exposures to heavy concentrations of organic
dusts contaminated with microorganisms. An estimated 30%-40% of
workers exposed to such organic dusts will develop ODTS. The
alert describes four incidents in which 29 agricultural workers
developed ODTS. Also described are the various medical conditions
that ODTS includes and the health effects associated with the
syndrome. The alert provides recommendations for minimizing the
risk for exposure to organic dusts and for the use of
respirators.

Reference
1. NIOSH. Request for assistance in preventing organic dust toxic
syndrome. Cincinnati: US Department of Health and Human Services,
Public Health Service, CDC, 1994; DHHS publication no.
(NIOSH)94-102.

*Single copies of this document are available without charge from
the Publications Office, Division of Standards Development and
Technology Transfer, NIOSH, CDC, Mailstop C-13, 4676 Columbia
Parkway, Cincinnati, OH 45226-1998; telephone (800) 356-4674
([513] 533-8328 for persons outside the United States); fax (513)
533-8573.



------------------------------

Date: Sun, 07 Aug 94 23:16:40 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR] 1995 Symposium on Statistical Methods
Message-ID: <Ha8Pqc7w165w@stat.com>

1995 Symposium on Statistical Methods

     CDC and the Agency for Toxic Substances and Disease
Registry; the Atlanta chapter of the American Statistical
Association; the Biostatistics Division, Emory University School
of Public Health; and the Department of Statistics, University of
Georgia, will cosponsor a statistical methods symposium entitled
"Small Area Statistics in Public Health: Design, Analysis,
Graphic and Spatial Methods" January 25-26, 1995, in Atlanta. A
short course, "Geographic Information Systems: Concepts and
Perspectives for Small Area Analysis in Public Health," will be
offered January 24, 1995, in conjunction with the symposium.
     The symposium will include invited plenary presentations and
contributed papers. Abstracts will be accepted in the following
areas: "borrowed strength" methods for small-area estimation; use
of small-area statistics in environmental health issues;
small-area statistics and ethnic subpopulations; estimation and
forecasting from small samples; detection of temporal and spatial
trends in disease patterns; geographic information systems;
mapping and graphic methods for public health research; and
confidentiality and data-accessibility issues. Abstracts should
be postmarked no later than August 1, 1994.
     Abstract, registration, and cost information is available
from CDC's Division of Surveillance and Epidemiology,
Epidemiology Program Office, Mailstop C-08, 1600 Clifton Road,
NE, Atlanta, GA 30333; telephone (404) 639-0080. Additional
information regarding scientific content of the symposium is
available from the Chair, 1995 CDC and ATSDR Symposium on
Statistical Methods, telephone (404) 488-4300 (Internet:
SJS1@CEHEHL1.EM.CDC.GOV).



------------------------------

Date: Sun, 07 Aug 94 23:18:28 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR 29 July 94] Respiratory Illiness Associate with Mushrooms
Message-ID: <HD8Pqc8w165w@stat.com>

         Respiratory Illness Associated with Inhalation
           of Mushroom Spores -- Wisconsin, 1994

     During April 8-14, 1994, eight persons aged 16-19 years from
southeastern Wisconsin visited physicians for respiratory illness
associated with inhalation of Lycoperdon perlatum (i.e., puffball
mushrooms). On April 19, the Bureau of Public Health, Wisconsin
Division of Health, was notified of these cases. This report
summarizes the case investigations.
     On April 3, the adolescents attended a party during which they
inhaled and chewed puffball mushrooms. It was unknown whether other
persons at the party participated in this activity. No illicit
drugs were reportedly used at the party. Three persons reported
nausea and vomiting within 6-12 hours after exposure. Within 3-7
days after exposure, all patients developed cough, fever
(temperature up to 103 F [39.4 C]), shortness of breath, myalgia,
and fatigue.
     Five persons required hospitalization; two were intubated. Two
patients had a history of asthma and were using steroid inhalers.
Chest radiographs on all hospitalized patients indicated bilateral
reticulonodular infiltrates. Two patients underwent transbronchial
lung biopsy, and one had an open lung biopsy. Histopathologic
examination of the lung biopsy specimens revealed an inflammatory
process and the presence of yeast-like structures consistent with
Lycoperdon spores. Fungal cultures of the lung biopsy tissue were
negative.
     All hospitalized patients received corticosteroids, and four
received antifungal therapy with either amphotericin B or azole
drugs. All patients recovered within 1-4 weeks with no apparent
sequelae.

Reported by: TA Taft, MD, RC Cardillo, MD, D Letzer, DO, CT
Kaufman, DO, Milwaukee; JJ Kazmierczak, DVM, JP Davis, MD,
Communicable Disease Epidemiologist, Bur of Public Health,
Wisconsin Div of Health. Div of Respiratory Disease Studies,
National Institute for Occupational Safety and Health; Div of
Bacterial and Mycotic Diseases, National Center for Infectious
Diseases, CDC.

Editorial Note: Lycoperdonosis is a rare respiratory illness caused
by inhalation of spores of the mushroom Lycoperdon. Puffballs,
which are found worldwide, grow in the autumn and can be edible
then. In the spring, they desiccate and form spores that can be
easily released by agitating the mushroom (1). One puffball species
(L. marginatum) can produce psychoactive effects (2).
     Only three cases of lycoperdonosis have been reported
previously (1,3)--two in children and one in an adolescent. These
three patients had inhaled large quantities of puffball spores, one
unintentionally and two deliberately (as a folk remedy to control
nosebleed). All patients had evidence of bilateral infiltrates on
chest radiographs. Whether the pulmonary process results from a
hypersensitivity reaction, an actual infection by the spores, or
both is unknown.
     The efficacy of using antifungal agents to treat
lycoperdonosis is unknown. Physicians should be aware of this
illness, especially in children and young adults presenting with a
compatible clinical history and progressive respiratory symptoms.

References
1. Strand RD, Neuhauser EBD, Sornberger CF. Lycoperdonosis. N Engl
J Med 1967;277:89-91.
2. Lincoff G, Mitchel DH. Toxic and hallucinogenic mushroom
poisoning. Williams WK, ed. New York: Van Nostrand Reinhold
Company, 1977.
3. Henriksen NT. Lycoperdonosis. Acta Paediatr Scand 1976;65:643-5.



------------------------------

Date: Sun, 07 Aug 94 23:19:38 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR] Flood related mortalities
Message-ID: <FF8Pqc9w165w@stat.com>

                Epidemiologic Notes and Reports
           Flood-Related Mortality -- Georgia, July 4-14, 1994

     On July 3, 1994, tropical storm Alberto struck the Florida
panhandle with maximum sustained winds of 60 miles per hour. On
July 4, as the center of the storm deteriorated over Columbus,
Georgia, a cold front pushed through Alabama and southwestern
Georgia from the northwest, producing warm, moist air and unstable
weather resulting in heavy, prolonged thunderstorms. Rainfall
totals in some areas of south central Georgia were 12-15 inches
during a 24-hour period; Americus, Georgia, recorded 24 inches on
July 6 (W. Zaleski, National Weather Service, personal
communication, 1994). Several rivers, cresting up to 20 feet above
flood stage, inundated major portions of the state. Flood waters
forced closure of 175 roads in 30 counties, and more than 100 dams
and recreational watersheds were either damaged or destroyed.
Forty-three (27%) of Georgia's 159 counties were declared federal
disaster areas, and seven additional counties were declared state
disaster areas. This report summarizes preliminary findings of
surveillance for deaths associated with the floods.
     To assess mortality associated with flooding, CDC obtained
epidemiologic information from medical examiners and coroners
(ME/Cs) in 48 of the 50 counties declared disaster areas and in two
counties adjacent to disaster areas. ME/Cs were asked about the
number of deaths in their counties attributable to flooding during
July 4-14 and for information about the circumstances of each
death. A flood-related death was defined as a death that resulted
from the floods during July 4-14, as determined by the ME/C in each
county.
     From July 4 through July 14, ME/Cs classified 30 deaths as
flood related. Two deaths were excluded from further analyses
because they involved motor-vehicle crashes not directly related to
flooding. Of the 28 remaining deaths, 27 occurred in 10 of the
federally declared disaster counties; one occurred in an adjacent
county (Figure 1). Fifteen deaths occurred in Sumter County; local
officials attributed approximately 50% of these deaths to the
rupture of seven to nine small earthen dams in the county. Waters
from the dams inundated surrounding creeks, sweeping away many of
the persons who died.
     Decedents ranged in age from 2 to 84 years (mean: 31 years;
median: 28 years); 20 were male (Table 1). Eighteen deaths occurred
on July 6*. For 27 of 28 decedents, drowning was reported as the
cause of death and "accident"** as the manner of death; the cause
and manner of one flood-related death are unknown. Of the 27
drownings, 20 were motor-vehicle-related (e.g., victims drove into
low-lying areas, across washed-out bridges, or off the road into
deep water).

Reported by: C Duke, Coroner, Baker County, Newton; E Bon, Coroner,
Bibb County, Macon; J Reeves, Deputy Coroner, Butts County,
Jackson; B Miller, Coroner, Calhoun County, Morgan; B Chancellor,
Coroner, Chattahoochee County, Cusseta; M Griffin, Coroner, Clay
County, Fort Gaines; P Dickson, Coroner, Clayton County, Jonesboro;
D Millians, Coroner, Coweta County, Newnan; G O'Neal, Coroner,
Crawford County, Knoxville; A Posey, Deputy Coroner, Crisp County,
Cordele; B Cooper, Coroner, Decatur County, Bainbridge; J Burton,
MD, Medical Examiner, DeKalb County, Decatur; R Bowen, Coroner,
Dooly County, Cordele; S Mackey, Deputy Coroner, Doughtery County,
Albany; S Manry, Deputy Coroner, Early County, Blakely; C Mowell,
Coroner, Fayette County, Fayetteville; D McGowan, Chief
Investigator, Fulton County Medical Examiner's Office, Atlanta; J
Kennebrew, Coroner, Harris County, Hamilton; R Stewart, Coroner,
Henry County, McDonough; D Galpin, Coroner, Houston County, Warner
Robins; J Bridge, Coroner, Jones County, Gray; J Smith, Coroner,
Lamar County, Barnesville; S Braden, Sheriff, Lee County,
Smithville; J Swank, Chief Investigator, Macon County, Montezuma;
J Tante, Coroner, Marion County, Buena Vista; J Worley, Coroner,
Meriweather County, Alvaton; T Toole, Coroner, Miller County,
Colquitt; A Dillon, Coroner, Monroe County, Forsyth; V Novak,
Deputy Coroner, Muscogee County, Columbus; B Johnson, Coroner,
Newton County, Covington; K Rookes, Acting Coroner, Peach County,
Fort Valley; B Hudson, Coroner, Pike County, Meansville; C Young,
Coroner, Pulaski County, Hawkinsville; I Bellflower, Coroner,
Quitman County, Georgetown; D Crozier, Deputy Coroner, Randolph
County, Cuthbert; H Ellison, MD, Coroner, Rockdale County, Conyers;
J Wall, Coroner, Schley County, Ellaville; G Skipper, Coroner,
Seminole County, Donaldsonville; R Buchanan, Coroner, Spaulding
County, Griffin; L McClung, Coroner, S Moreno, Fire Chief, Sumter
County, Americus; L Stone, Coroner, Stewart County, Lumpkin; J
Cosby, Coroner, Talbot County, Talbotton; B Goddard, Coroner,
Taylor County, Reynolds; E Jenkins, Coroner, Terrell County,
Dawson; E Lucas, Deputy Coroner, Troup County, West Point; T
Cochran, Upson County, Thomaston; S Potter, Coroner, Webster
County, Preston; R Coker, Coroner, Wilcox County, Pitts; J Banks,
Coroner, Worth County, Sylvester; K Toomey, MD, State
Epidemiologist, J Drinnon, Div of Public Health, Georgia Dept of
Human Resources. K Davis, Federal Emergency Management Agency; M
Johnson, Southeast Regional Climatological Center, Columbia, South
Carolina. W Zaleski, National Weather Svc, Peachtree City, Georgia.
Surveillance and Programs Br; Disaster Assessment and Epidemiology
Section, Health Studies Br, Div of Environmental Hazards and Health
Effects, Emergency Response Coordination Group, National Center for
Environmental Health, CDC.

Editorial Note: Floods account for an estimated 40% of natural
disasters worldwide (1). In the United States, floods cause an
average of 146 deaths per year. Most flood-related deaths are
attributed to flash floods (2) (i.e., flooding that occurs within
a few hours of heavy or excessive rain, when a dam or levee fails,
or following a sudden release of water impounded by an ice jam
[1]). Most flash floods occur during July-September (3) and are
usually caused by slow-moving or localized and heavy thunderstorm
activity. When these conditions exist, tributary streams can crest
their banks in hours, or even minutes, after the onset of heavy
rain (1).
     The rapid onset of high-rising waters often makes effective
warning and escape difficult and increases the risk for death (4).
The leading cause of death from flash floods is drowning, and more
than 50% of drownings in flash floods are associated with motor
vehicles (5). Victims are often unwilling to abandon their cars,
trucks, or boats and can be trapped inside. In Georgia, drowning
was the cause of 96% of flood-related deaths, and 74% of these were
motor-vehicle related.
     Surveillance data from ME/Cs have provided timely information
on mortality associated with natural disasters (6,7). Data from
ME/Cs in past disasters have been used to develop recommendations
for preventing flood- and other disaster-related deaths (7). During
the 1993 midwestern floods, ME/C surveillance data were used to
monitor flood-related mortality and to develop prevention
strategies, including disseminating information about flood and
postflood hazards to groups at increased risk and identifying water
tributaries that posed hazards for flooding. Similarly, the
surveillance findings from Georgia suggest that deaths from floods
may be prevented by identifying flood- and flash-flood-prone areas
and then advising persons to take appropriate actions when the
potential exists for a flash flood. For example, motorists should
be warned not to drive through areas in imminent danger of flash
floods or onto roads and bridges covered by rapidly moving water
(8). If vehicles are necessary to evacuate a community,
particularly a mobile home community, safe evacuation routes should
be identified in advance. In addition, deaths may be prevented by
inspecting and requiring safety certification of dams located in
flood-prone areas.

References
1. French JG. Floods. In: Gregg MB, ed. The public health
consequences of disasters. Atlanta: US Department of Health and
Human Services, Public Health Service, CDC, 1989:39-49.
2. Federal Emergency Management Agency. A report to US Senate
Committee on Appropriation. Washington, DC: Federal Emergency
Management Agency, 1992.
3. French J, Ing R, Von Allmen S, Wood R. Mortality from flash
floods: a review of National Weather Service reports, 1969-81.
Public Health Rep 1983;6:584-8.
4. National Weather Service/American Red Cross/Federal Emergency
Management Agency. Flash floods and floods...the awesome power!: a
preparedness guide. Washington, DC: US Department of Commerce,
National Oceanic and Atmospheric Administration, National Weather
Service/American Red Cross, 1992; report no. NOAA/PA 92050, ARC
4493.
5. Frazier K. The violent face of nature: severe phenomena and
natural disasters. New York: William Morrow and Company Inc, 1979.
6. CDC. Medical examiner/coroner reports of deaths associated with
Hurricane Hugo--South Carolina. MMWR 1989;38:754,759-62.
7. CDC. Flood-related mortality--Missouri, 1993. MMWR 1993;42:941-
3.
8. CDC. Beyond the flood: a prevention guide for personal health
and safety. Atlanta: US Department of Health and Human Services,
Public Health Service, CDC, 1993.
 *Because some decedents were not found until after high waters
subsided, it was sometimes difficult to verify exact date and time
of death; therefore, all dates reflect the day on which the
decedent was found.
**"Manner of death" and "accident" are medicolegal terms used on
death certificates and refer to the circumstances under which a
death occurs; "cause of death" refers to the injury or illness
responsible for the death. When a death occurs under "accidental"
circumstances, the preferred term within the public health
community for the cause of death is "unintentional injury".



------------------------------

End of HICNet Medical News Digest V07 Issue #33
***********************************************


---
Editor, HICNet Medical Newsletter
Internet: david@stat.com                 FAX: +1 (602) 451-1165
Bitnet  : ATW1H@ASUACAD

