HICNet Medical News Digest      Tue, 23 Aug 1994        Volume 07 : Issue 38

Today's Topics:

  [MMWR 12 Aug 94] Cryptosporidium Infections Associated Swimming Pools
  [MMWR] Lyme Disease
  [MMWR] Undervaccinated Children after Mass Vaccination Campaign
  [MMWR] Legionaire's Disease Breakout Associated with Cruise Ship
  [MMWR 19 Aug 94] Cigarette Brand Preferences Adolescent Smokers
  [MMWR] Effectiveness in Disease Prevention Medical-Care Spending
  [MMWR] Occupational Injury Deaths of Postal Workers

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Date: Tue, 23 Aug 94 21:18:38 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR 12 Aug 94] Cryptosporidium Infections Associated Swimming Pools
Message-ID: <RHoJRc1w165w@stat.com>

             Cryptosporidium Infections Associated
      with Swimming Pools -- Dane County, Wisconsin, 1993

     In March and April 1993, an outbreak of cryptosporidiosis in
Milwaukee resulted in diarrheal illness in an estimated 403,000
persons (1). Following that outbreak, testing for Cryptosporidium
in persons with diarrhea increased substantially in some areas of
Wisconsin; by August 1, 1993, three of six clinical laboratories in
Dane County were testing routinely for Cryptosporidium as part of
ova and parasite examinations. In late August 1993, the Madison
Department of Public Health and the Dane County Public Health
Division identified two clusters of persons with
laboratory-confirmed Cryptosporidium infection in Dane County
(approximately 80 miles west of Milwaukee). This report summarizes
the outbreak investigations.
     On August 23, a parent reported to the Madison Department of
Public Health that her daughter was ill with laboratory-confirmed
Cryptosporidium infection and that other members of her daughter's
swim team had had severe diarrhea. On August 26, public health
officials inspected the pool where the team practiced (pool A) and
interviewed a convenience sample of patrons at the pool. Seventeen
(55%) of 31 pool patrons interviewed reported having had watery
diarrhea for 2 or more days with onset during July or August. Eight
(47%) of the 17 had had watery diarrhea longer than 5 days. Four
persons who reported seeking medical care had stool specimens
positive for Cryptosporidium.
     On August 31, public health nurses at the Dane County Public
Health Division identified a second cluster of nine persons with
laboratory-confirmed Cryptosporidium infection while following up
case-reports voluntarily submitted by physicians. Seven of the nine
ill persons reported swimming at one large outdoor pool (pool B).
Because of the potential for disease transmission in multiple
settings, a community-based matched case-control study was
initiated on September 3 to identify risk factors for
Cryptosporidium infection among Dane County residents.
     Laboratory-based surveillance was used for case finding. A
case was defined as Cryptosporidium infection that was
laboratory-confirmed during August 1-September 11, 1993, in a Dane
County resident who was also the first person in a household to
have signs or symptoms (i.e., watery diarrhea of 2 or more days'
duration). During the study interval, 85 Dane County residents with
stool specimens positive for Cryptosporidium were identified.
Sixty-five (77%) persons were interviewed; 36 (55%) had illnesses
meeting the case definition. Systematic digit-dialing was used to
select 45 controls, who were matched with 34 case-patients by age
group and telephone exchange. All study participants were
interviewed by telephone using a standardized questionnaire to
obtain information on demographics, signs and symptoms,
recreational water use, child-care attendance, drinking water
sources, and presence of diarrheal illness in household members.
     The median age of ill persons was 4 years (range: 1-40 years).
Reported signs and symptoms included watery diarrhea (94%), stomach
cramps (93%), and vomiting (53%). Median duration of diarrhea was
14 days (range: 1-30 days). Swimming in a pool or lake during the
2 weeks preceding onset of illness was reported by 82% of
case-patients and 50% of controls (matched odds ratio [MOR]=6.0;
95% confidence interval [CI]=1.4-25.3). Twenty-one percent of
case-patients and 2% of controls (MOR=7.3; 95% CI=0.9-59.3)
reported swimming in pool A. Fifteen percent of case-patients and
2% of controls (MOR=undefined [6/0]; p=0.02, paired sample sign
test) reported swimming in pool B. When persons reporting pool A or
B use were excluded from the analysis, the association with
recreational water use was not statistically significant (MOR=3.4,
95% CI=0.8-15.7). Child-care attendance was reported for 74% of
case-patients aged less than 6 years and 44% of controls (MOR=2.9;
95% CI=0.8-10.7). Two case-patients reported child-care attendance
and use of pool A or pool B. No case-patients reported travel to
the Milwaukee area during the March-April outbreak, and no
associations were found between illness and drinking water sources.
     To limit transmission of Cryptosporidium in Dane County pools,
state and local public health officials implemented the following
recommendations: 1) closing the pools that were epidemiologically
linked to infection and hyperchlorinating those pools to achieve a
disinfection (CT*) value of 9600; 2) advising all area pool
managers of the increased potential for waterborne transmission of
Cryptosporidium; 3) posting signs at all area pools stating that
persons who have diarrhea or have had diarrhea during the previous
14 days should not enter the pool; 4) notifying area physicians of
the increased potential for cryptosporidiosis in the community and
requesting that patients with watery diarrhea be tested for
Cryptosporidium; and 5) maintaining laboratory-based surveillance
in the community to determine whether transmission was occurring at
other sites (e.g., child-care centers and other pools).
     On August 27, pool A was closed and hyperchlorinated for 18
hours; on September 3, pool B closed early for the season. Because
many control measures were initiated less than 1 week before many
pools closed for the season (after September 5), their impact on
transmission could not be evaluated adequately.

Reported by: J Bongard, MS, Dane County Public Health Div, Madison;
R Savage, MS, Madison Dept of Public Health; R Dern, MS, St. Mary's
Medical Center, Madison; H Bostrum, J Kazmierczak, DVM, S Keifer,
H Anderson, MD, State Epidemiologist for Occupation and
Environmental Health, JP Davis, MD, State Epidemiologist for
Communicable Diseases, Bur of Public Health, Wisconsin Div of
Health. Div of Parasitic Diseases, National Center for Infectious
Diseases; Div of Field Epidemiology, Epidemiology Program Office,
CDC.

Editorial Note: Person-to-person, waterborne, and zoonotic
transmission of Cryptosporidium has been well documented (2). A
marked seasonality has been reported, with peaks occurring in North
America during late summer and early fall (3,4). Cryptosporidiosis
associated with use of swimming pools has been reported previously
(5-7) but is probably underrecognized. Infection with
Cryptosporidium resulting from recreational water use may
contribute to the observed seasonal distribution.
     The March-April 1993 Milwaukee waterborne outbreak stimulated
increased testing for Cryptosporidium in Dane County, increasing
the likelihood of outbreak detection. However, the number of cases
described in this report was not sufficient to conduct a stratified
matched analysis. Confounding of the associations found for
child-care attendance and pool use is possible, although child-care
attendance was reported in only one case for each implicated pool.
     Cryptosporidium oocysts are small (4-6 u), are resistant to
chlorine, and have a high infectivity. The chlorine CT of 9600
needed to kill Cryptosporidium oocysts is approximately 640 times
greater than required for Giardia cysts (8). The ability of pool
sand-filtration systems to remove oocysts under field conditions
has not been well documented, but would not be expected to be
effective. Results of an infectivity study suggest that the
infective dose among humans for Cryptosporidium is low (H. DuPont,
University of Texas Medical School at Houston, personal
communication, 1994). Because of the large number of oocysts
probably shed by symptomatic persons, even limited fecal
contamination could result in sufficient oocyst concentrations in
localized areas of a pool to cause additional human infections.
     This investigation underscores the potential for transmission
of Cryptosporidium in swimming pools. Health-care providers should
consider requesting Cryptosporidium testing of stool specimens from
persons with watery diarrhea, and public health departments should
consider establishing surveillance for Cryptosporidium to
facilitate prompt recognition of outbreaks. Maintaining the high
levels of chlorine necessary to kill Cryptosporidium in swimming
pools is not feasible; therefore, such recreational water use
should be recognized as a potential increased risk for
cryptosporidiosis in immumocompromised persons, including those
with human immunodeficiency virus infection, in whom this infection
may cause lifelong, debilitating illness (9).

References
1. Mac Kenzie WR, Hoxie NJ, Proctor ME, et al. A massive outbreak
in Milwaukee of Cryptosporidium infection transmitted through the
public water supply. N Engl J Med 1994;331:161-7.
2. Casemore DP. Epidemiologic aspects of human cryptosporidiosis.
Epidemiol Infect 1990;104:1-28.
3. Wolfson JS, Richter JM, Waldron WA, Weber DJ, McCarthy DM,
Hopkins CC. Cryptosporidiosis in immunocompetent patients. N Engl
J Med 1985;312:1278-82.
4. Skeels MR, Sokolow R, Hubbard CV, Andrus JK, Baisch J.
Cryptosporidium infection in Oregon public health clinic patients,
1985-1988: the value of statewide laboratory surveillance. Am J
Public Health 1990;80:305-8.
5. Sorvillo FJ, Fujioka K, Nahlen B, et al. Swimming-associated
cryptosporidiosis. Am J Public Health 1992;82:742-4.
6. Bell A, Guasparini R, Meeds D, et al. A swimming pool-associated
outbreak of cryptosporidiosis in British Columbia. Can J Public
Health 1993;84:334-7.
7. CDC. Surveillance for waterborne disease outbreaks--United
States, 1991-1992. MMWR 1993;42(no. SS-5):1-22.
8. Current WL, Garcia LS. Cryptosporidiosis. Clin Microbiol Rev
1991;4:305-8.
9. Navin TR, Juranek DD. Cryptosporidiosis: clinical,
epidemiologic, and parasitologic review. Rev Infect Dis 1984;6:313-
27.

*CT=pool chlorine concentration (in parts per million) multiplied
by time (in minutes).



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

Date: Tue, 23 Aug 94 21:19:17 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR] Lyme Disease
Message-ID: <uioJRc2w165w@stat.com>

               Lyme Disease -- United States, 1993

     In 1982, CDC initiated surveillance for Lyme disease (LD), and
in 1990, the Council of State and Territorial Epidemiologists
adopted a resolution making LD a nationally notifiable disease.
This report summarizes surveillance data for LD in the United
States during 1993.
     LD is defined as the presence of an erythema migrans rash or
at least one objective sign of musculoskeletal, neurologic, or
cardiovascular disease and laboratory confirmation of infection
(1). In 1993, 8185 cases of LD were reported to CDC by 44 state
health departments, 1492 (15%) fewer cases than were reported in
1992 (9677) (Figure 1). Most cases were reported from the
northeastern, mid-Atlantic, north-central, and Pacific coastal
regions (Figure 2). Six states (Alaska, Arizona, Colorado,
Mississippi, Montana, and South Dakota) reported no LD cases. The
overall incidence rate was 3.3 per 100,000 population. Eight states
in established LD-endemic northeastern and upper north-central
regions reported rates of more than 3.3 per 100,000 (Connecticut,
41.3; Rhode Island, 27.3; Delaware, 21.0; New York, 15.5; New
Jersey, 10.1; Pennsylvania, 8.9; Wisconsin, 8.2; and Maryland,
3.8); these states accounted for 6962 (85%) of the cases reported
nationally. Of the total cases, 6132 (75%) were reported from 81
counties that had at least five cases and had rates of at least 10
per 100,000 population.
     Most (83%) of the decrease in 1993 resulted from reductions in
the numbers of case reports from four states in which LD is endemic
(California, Connecticut, New York, and Wisconsin). New York, which
reported 34% of the U.S. cases in 1993, accounted for 41% of the
decrease (609 cases), and Connecticut accounted for 27% of the
decrease (410 cases). Thirteen states reported small increases in
the number of cases. New Jersey had the largest increase (786
cases, compared with 681 in 1992).
     The age distribution of persons reported with LD was bimodal,
with peaks occurring for children aged 5-14 years (1098 cases) and
adults aged 30-49 years (2298 cases). Males (51%) and females were
nearly equally affected.

Reported by: State health departments. Bacterial Zoonoses Br, Div
of Vector-Borne Infectious Diseases, National Center for Infectious
Diseases, CDC.

Editorial Note: LD, the most commonly reported vectorborne
infectious disease in the United States (2), is caused by the
spirochete Borrelia burgdorferi and is transmitted by the bite of
an infected Ixodes tick. In the northeastern and upper
north-central regions of the United States, the principal tick
vector is Ixodes scapularis (black-legged tick), and in Pacific
coast states, the principal vector is Ixodes pacificus (western
black-legged tick).
     LD risks are geographically limited; rates vary substantially
by town or other geopolitical area within counties (3,4), and the
distribution of vector ticks varies greatly, even within individual
residential properties (5). LD can be prevented by avoiding contact
with the tick vector or by applying insect repellents and
acaricides as directed, wearing long pants and long-sleeved shirts,
tucking pants into socks, checking regularly for ticks, and
promptly removing attached ticks.
     The decrease in reported cases in 1993 may reflect a
combination of three factors: decreased reporting by physicians,
decreased case detection (6), and a true decrease in the number of
cases. In Connecticut and New York, vector surveillance data
suggest that I. scapularis population densities were lower in 1993
than in previous years. The decrease in New York also may be
attributed to limitations in staffing and decreased reporting by
physicians (D. White, Bureau of Communicable Diseases, New York
State Department of Health, personal communication, 1994). The
increase in New Jersey was attributed to an increase in reported
cases from Hunterdon County as a result of improved reporting by
physicians and a true increase in disease incidence (CDC,
unpublished data, 1993). The actual incidence of LD in the United
States is unknown, and estimates are subject to the influences of
underreporting, misclassification, and overdiagnosis.
     Accurate surveillance data are needed to target populations
for LD prevention strategies (e.g., vaccination). In 1993, two U.S.
manufacturers received Food and Drug Administration approval to
conduct field trials of LD vaccines in humans. One manufacturer is
conducting Phase III efficacy trials involving approximately 10,000
participants from endemic areas of the north central, mid-Atlantic,
and New England states. The second manufacturer is conducting Phase
II safety and immunogenicity trials involving approximately 400
persons residing in New England. Results of Phase I trials
conducted in the United States have been published (7), and
preliminary results of Phase II safety and efficacy trials (8,9)
suggest the vaccine is safe and immunogenic. Both candidate
vaccines use a recombinant outer-surface protein as the immunogen.
The candidate vaccines stimulate production of antibodies that
target B. burgdorferi in the midguts of infected ticks while they
extract blood from a vaccinated animal (10).
     Reliable identification of risks is required for targeting
individually applied interventions for LD. LD surveillance data
will be needed to determine the effectiveness of control and
prevention efforts.

References
1. CDC. Case definitions for public health surveillance. MMWR
1990;39(no. RR-13):19-21.
2. Dennis DT. Epidemiology. In: Coyle PK, ed. Lyme disease. St.
Louis: Mosby-Year Book, 1993:27-37.
3. Cartter ML, Mshar P, Hadler JL. The epidemiology of Lyme disease
in Connecticut. Conn Med 1989;53:320-3.
4. White DJ, Chang H-G, Benach JL, et al. The geographic spread and
temporal increase of the Lyme disease epidemic. JAMA 1991;266:1230-
6.
5. Maupin GO, Fish D, Zultowsky J, Campos EG, Piesman J. Landscape
ecology of Lyme disease in a residential area of Westchester
County, New York. Am J Epidemiol 1991;133:1105-13.
6. CDC. Lyme disease--United States, 1991-1992. MMWR 1993;42:345-8.
7. Keller D, Koster FT, Marks DH, Hosbach P, Erdile LF, Mays JP.
Safety and immunogenicity of a recombinant outer surface protein A
Lyme vaccine. JAMA 1994;271:1764-8.
8. Hoecke CV, De Grave D, Hauser P, Lebacq E. Evaluation of three
formulations of a candidate vaccine against Lyme disease in healthy
adult volunteers. In: Proceedings of the VI International Congress
on Lyme Borreliosis. Bologna, Italy: International Congress on Lyme
Borreliosis, 1994:123-6.
9. Hosbach P, Koster F, Wormser G, et al. Clinical studies in
humans of outer surface protein A (Osp A) vaccine for Lyme disease
[Abstract]. In: Proceedings of the VI International Congress on
Lyme Borreliosis. Bologna, Italy: International Congress on Lyme
Borreliosis, 1994.
10. Fikrig E, Telford SR, Barthold SW, Kantor FS, Spielman A,
Flavell RA. Elimination of Borrelia burgdorferi from vector ticks
feeding on Osp A-immunized mice. Proc Natl Acad Sci 1992;89:5418-
21.



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

Date: Tue, 23 Aug 94 21:20:13 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR] Undervaccinated Children after Mass Vaccination Campaign
Message-ID: <ekoJRc3w165w@stat.com>

         Assessment of Undervaccinated Children Following
           a Mass Vaccination Campaign -- Kansas, 1993

     A 1992 retrospective survey by the Kansas Department of Health
and Environment (KDHE) of children entering school in Kansas
indicated that 52% were completely vaccinated by 24 months of age
(i.e., received four doses of diphtheria and tetanus toxoids and
pertussis vaccine [DTP], three doses of poliomyelitis vaccine, and
one dose of measles-mumps-rubella vaccine [MMR]). In response to
this low vaccination coverage rate, the KDHE set a goal for 1995 of
completely vaccinating 90% of children by age 24 months. A major
new initiative--Operation Immunize (OI)--undertaken to accomplish
this goal consisted of three statewide vaccination campaigns on
weekends during 1993-1994. This report summarizes the results of an
assessment of the short-term impact of OI on children who remained
undervaccinated following the first campaign.
     OI was designed to reach children, particularly those aged
less than 24 months, who were not up-to-date with their
vaccinations. An extensive promotional effort was made throughout
the state to encourage participation in OI. Vaccinations were
available free or at reduced cost at 192 sites in the state during
the campaigns.
     During the first campaign (April 24-25, 1993), 7120 children
were vaccinated; 2616 (37%) were aged less than 24 months. Of the
children aged less than 24 months, 71% were not up-to-date with
their vaccinations; 29% were due for their next series of
vaccinations but were not yet considered behind schedule. OI
reached 6% of the estimated 31,498 children (based on the 1992
retrospective survey) aged less than 24 months in Kansas who were
not up-to-date.
     A follow-up study begun in November 1993 assessed the
vaccination status of children aged less than 24 months who were
vaccinated during the April campaign but who needed additional
vaccinations to be brought up-to-date during the next 6 months. OI
records were available for 331 of these children. Each child's
vaccination status was determined as of October 25, 1993 (6 months
after the first OI campaign), using the recommendations of the
Advisory Committee on Immunization Practices for DTP, polio, and
MMR (1). Information on vaccinations was obtained from local health
departments, parents, and physicians.
     Children were considered up-to-date if they were within 1
month of being age-appropriately vaccinated by October 25, 1993. If
the local health department had no record of vaccinations given
since April 24-25, 1993, and the child's parents could not be
contacted by phone and did not respond to two written requests for
information, the child was considered lost to follow-up. As of
October 25, 1993, 102 (31%) children were up-to-date; 35 (11%) had
received additional vaccinations but remained behind schedule; 102
(31%) had received no additional vaccinations; and 92 (28%) were
lost to follow-up.

Reported by: S Dismuke, MD, Univ of Kansas Medical Center, Kansas
City; N McWilliams, Johnson County Health Dept, Mission; S Bowden,
M Burt, J Hansen, M Miller, L Perry, A Pelletier, MD, Acting State
Epidemiologist, Bur of Disease Control, Kansas Dept of Health and
Environment. Div of Field Epidemiology, Epidemiology Program
Office, CDC.

Editorial Note: Mass vaccination campaigns have been successful in
developing countries (2-4); however, during the past decade, mass
campaigns have not been used widely in the United States. Mass
campaigns such as OI can focus public attention on the control of
vaccine-preventable diseases and increase support for vaccination
programs. However, mass campaigns are resource-intensive, and in
some cases, increases in vaccination coverage rates have been
difficult to sustain (5,6).
     Options for the evaluation of OI were limited by the low
incidence in Kansas of the vaccine-preventable diseases targeted by
OI and the lack of current data on the vaccination status of Kansas
children. The only population-based vaccination data available in
Kansas are from retrospective surveys of children entering school.
When collected, these data are 3-4 years old and therefore are not
useful for evaluating the immediate impact of a mass vaccination
campaign.
     Calculating the limited percentage of the target population
reached by OI provided one measure of the campaign's effectiveness;
the study also sought to assess the ongoing impact of the campaign
on children's vaccination status. This study indicated that many
children reached by OI did not maintain up-to-date vaccination
status during the 6 months after the campaign.
     The experience with OI demonstrates that reaching
undervaccinated children with mass campaigns can be difficult, even
when the level of effort and commitment are high, as in Kansas.
When used, mass campaigns should be an adjunct to ongoing,
comprehensive vaccination programs (as outlined in the Childhood
Immunization Initiative [7]), which are designed to meet local
needs. Such programs for routine vaccination should include efforts
to reduce barriers to vaccination, establish vaccination record
information systems, improve surveillance, and use vaccination
coverage assessments to monitor program performance.

References
1. ACIP. General recommendations on immunization. MMWR 1989;38:205-
14,219-27.
2. CDC. Update: eradication of paralytic poliomyelitis in the
Americas. MMWR 1992;41:681-3.
3. CDC. National Immunization Days and status of poliomyelitis
eradication--Philippines, 1993. MMWR 1994;43:6-7,13.
4. Expanded Program on Immunization. Planning principles for
accelerated immunization activities. Geneva: World Health
Organization, 1985.
5. Jorgenson DM, Zenker P, Quinlisk MP. Effectiveness of a one-day
vaccination campaign-- Oklahoma [Abstract]. In: Abstracts of the
41st Annual Conference of the Epidemic Intelligence Service,
Atlanta, April 6-10, 1992. Atlanta: US Department of Health and
Human Services, Public Health Service, CDC, 1992.
6. Abdool Karim SS, Abdool Karim Q, Dilraj A, Chamane M.
Unsustainability of a measles immunisation campaign--rise in
measles incidence within 2 years of the campaign. S Afr Med J
1993;83:322-3.
7. CDC. Reported vaccine-preventable diseases--United States, 1993,
and the Childhood Immunization Initiative. MMWR 1994;43:57-60.



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

Date: Tue, 23 Aug 94 21:21:34 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR] Legionaire's Disease Breakout Associated with Cruise Ship
Message-ID: <NmoJRc4w165w@stat.com>

        Update: Outbreak of Legionnaires' Disease Associated
                      with a Cruise Ship, 1994

     On July 15, 1994, CDC was notified by the New Jersey State
Department of Health of six persons with pneumonia who had recently
traveled to Bermuda on the cruise ship Horizon (1). In conjunction
with local and state health departments, an investigation was
initiated; as of August 10, a total of 14 passengers had
Legionnaires' disease (LD) confirmed by either sputum culture (one
patient), detection of antigens of Legionella pneumophila serogroup
1 (Lp1) in urine by radioimmunoassay (seven patients) (2), or
fourfold rise in titer of antibodies to Lp1 between acute- and
convalescent-phase serum specimens (six patients). Possible cases
in 28 other passengers with pneumonia that occurred within 2 weeks
after sailing aboard the Horizon are under investigation. Cases
have occurred from nine separate week-long cruises during April 30-
July 9, 1994.
     To identify the source of Legionella sp., a case-control study
was conducted, and environmental sampling of the ship's water
system was performed. Exposure to the whirlpool baths was strongly
associated with illness (odds ratio=16.4; 95% confidence
interval=3.7-72.3). Cultures taken from a sand filter used for
recirculation of whirlpool water yielded an isolate of Lp1; this
isolate and the clinical isolate had matching monoclonal antibody
subtyping patterns (3).
     A variety of interventions were completed, including
hyperchlorination of the ship's potable water supply, removal of
the whirlpool filters, and discontinuation of the whirlpool baths.
Following completion of these interventions, on July 30 the Horizon
resumed its weekly sailing schedule from New York City to Bermuda.

Reported by: I Guerrero, MD, Community Medical Center, Toms River;
C Genese, MJ Hung, S Paul, MD, H Ragazzoni, DVM, J Brook, MD, L
Finelli, PhD, KC Spitalny, MD, State Epidemiologist, New Jersey
State Dept of Health. BA Mojica, MD, KJ Mahoney, MSW, RT Heffernan,
MPH, Div of Disease Intervention, New York City Dept of Health; SF
Kondracki, DL Morse, MD, State Epidemiologist, New York State Dept
of Health. ML Cartter, MD, J Hadler, MD, State Epidemiologist,
Connecticut Dept of Public Health and Addiction Svcs. JT Rankin,
Jr, DVM, State Epidemiologist, Pennsylvania Dept of Health. C
Groves, MS, Maryland State Dept of Health and Mental Hygiene. Div
of Quarantine, National Center for Prevention Svcs; Office of the
Director, National Center for Environmental Health; Div of Field
Epidemiology, Epidemiology Program Office; Childhood and
Respiratory Diseases Br, Div of Bacterial and Mycotic Diseases,
National Center for Infectious Diseases, CDC.

Editorial Note: This outbreak represents the first documented
instance of LD aboard a cruise ship docking in U.S. ports.
Whirlpool spas previously have been associated with transmission of
Legionella (4,5); hyperchlorination of water systems and
replacement of filter devices have successfully terminated
outbreaks of LD linked to whirlpool spas. CDC recommends
post-intervention environmental sampling of whirlpool circulation
systems in conjunction with ongoing surveillance for cases of
pneumonia to ensure the efficacy of these interventions. Suspected
cases of LD among Horizon passengers should be reported to CDC
through state and local health departments.
     Additional recommendations to reduce the transmission of
Legionella sp. from whirlpool baths and aboard cruise ships will be
the subject of a special meeting of public health officials, LD
experts, and members of the whirlpool and cruise line industries;
the meeting is tentatively scheduled for the fall of 1994 in
Atlanta. Additional information about the meeting is available from
CDC's Office of the Director, National Center for Environmental
Health, telephone (404) 488-7093.

References
1. CDC. Outbreak of pneumonia associated with a cruise ship, 1994.
MMWR 1994;43:521.
2. Kohler RB, Zimmerman SE, Wilson E, et al. Rapid radioimmunoassay
diagnosis of Legionnaires' disease: detection and partial
characterization of urinary antigen. Ann Intern Med 1981;94:601-5.
3. Joly JR, McKinney RM, Tobin JO, Bibb WF, Watkins ID, Ramsay D.
Development of a standardized subgrouping scheme for Legionella
pneumophila serogroup 1 using monoclonal antibodies. J Clin
Microbiol 1986;23:768-71.
4. Vogt RL , Hudson PJ, Orciari L, Heun EM, Woods TC. Legionnaires'
disease and a whirlpool spa [Letter]. Ann Intern Med 1987;107:596.
5. Spitalny KC, Vogt RL, Orciari LA, Witherell LE, Etkind P, Novick
LF. Pontiac fever associated with a whirlpool spa. Am J Epidemiol
1984;120:809-16.



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

Date: Tue, 23 Aug 94 21:36:29 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR 19 Aug 94] Cigarette Brand Preferences Adolescent Smokers
Message-ID: <iBPJRc1w165w@stat.com>

          Changes in the Cigarette Brand Preferences
      of Adolescent Smokers -- United States, 1989-1993

     Approximately three million U.S. adolescents are smokers, and
they smoke nearly one billion packs of cigarettes each year (1).
The average age at which smokers try their first cigarette is 14-
1/2 years, and approximately 70% of smokers become regular smokers
by age 18 years (2). Evaluating the changes in the brand
preferences of young smokers can help identify factors that
influence adolescents' brand choice and may suggest
smoking-prevention strategies (3,4). This report examines changes
in the brand preferences of teenaged smokers from 1989 to 1993
using data from CDC's 1993 Teenage Attitudes and Practices Survey
(TAPS-II) and comparing them with data from the 1989 TAPS.
     For TAPS, data on knowledge, attitudes, and practices
regarding tobacco use were collected from a national household
sample of adolescents (aged 12-18 years) by telephone interviews.
For TAPS-II, interviews were conducted during February-May 1993. Of
the 9135 respondents to the 1989 TAPS, 7960 (87.1%) participated in
TAPS-II (respondents were aged 15-22 years when TAPS-II was
conducted).* In addition, 4992 (89.3%) persons from a new
probability sample (n=5590 persons aged 10-15 years) participated
in TAPS-II. Data for the 12-18-year-olds in each survey were
analyzed (n=9135 for TAPS; n=7311 for TAPS-II). Because numbers for
other racial groups were too small for meaningful analysis, data
are presented for black, white, and Hispanic adolescents only. Data
were weighted to provide national estimates, and confidence
intervals (CIs) were calculated by using the standard errors
estimated by SUDAAN (5). Adolescent current smokers** were asked if
they usually bought their own cigarettes, and if so, which brand
they usually bought.
     Of the 1031 current smokers aged 12-18 years interviewed in
1993, 724 (70%) reported that they usually bought their own
cigarettes; the brand they usually bought was ascertained for 702
(97%). Marlboro, Camel, and Newport were the most frequently
purchased brands for 86% of the adolescents (Table 1). Marlboro was
the most commonly purchased brand for both male (59% [95% CI= plus
or minus 6.0%]) and female (61% [95% CI= plus or minus 5.8%])
adolescents; the second most commonly purchased brand among males
was Camel (16% [95% CI= plus or minus 5.0%]) and among females was
Newport (15% [95% CI= plus or minus 3.9%]). Marlboro was the most
commonly purchased brand among white (64% [95% CI= plus or minus
4.3%]) and Hispanic (45% [95% CI= plus or minus 14.9%])
adolescents; black adolescents most frequently purchased Newport
(70% [95% CI= plus or minus 14.1%]). Younger smokers (aged 12-15
years) were more likely than older smokers (aged 16-18 years) to
buy Newport and less likely to buy Marlboro; purchasing frequency
for Camel cigarettes was similar among all adolescents.
     Among adolescents nationwide, Marlboro was the most commonly
purchased brand (Table 1). However, by region***, Camel was most
commonly purchased in the West (27% [95% CI= plus or minus 10.8%]),
and Newport, in the Northeast (30% [95% CI= plus or minus 8.8%]).
     From 1989 to 1993, substantial changes in brand preference
occurred among adolescents (Table 2). The percentage of adolescents
purchasing Marlboro cigarettes decreased 8.7 percentage points (13%
decrease), the percentage of adolescents purchasing Camel
cigarettes increased 5.2 percentage points (64% increase), and the
percentage purchasing Newport cigarettes increased 4.5 percentage
points (55% increase). These changes did not completely correlate
with changes in overall cigarette market share during 1989-1993.
During this period, the overall market share for Camel and Newport
remained nearly unchanged, but the overall market share for
Marlboro decreased by 2.8 percentage points (11% decrease).
     For Marlboro cigarettes, the decreases in brand preference
were greatest among white adolescents, younger smokers, and
adolescents residing in the Northeast, Midwest, and West (Table 1)
(6). Increases in brand preference for Camel cigarettes were
greatest among white adolescents and adolescents residing in the
Midwest and West, and increases for Newport cigarettes were
greatest among younger smokers and adolescents residing in the
Northeast.

Reported by: D Barker, MHS, Robert Wood Johnson Foundation,
Princeton, New Jersey. Office on Smoking and Health, National
Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note: Because cigarette sales to adolescents constitute
a small percentage of the total market, overall market share can
only be used to estimate the brand preferences of adults. TAPS and
TAPS-II indicate that brand preference is more tightly concentrated
among adolescents than among adults. In both surveys, at least 85%
of adolescent current smokers purchased one of three brands (i.e.,
Marlboro, Camel, or Newport); however, the three most commonly
purchased brands among all smokers accounted for only 35% of the
overall market share in 1993.
     The three most commonly purchased brands among adolescent
smokers were the three most heavily advertised brands in 1993 (7),
suggesting that cigarette advertising influences adolescents' brand
preference. In 1993, Marlboro, Camel, and Newport ranked first,
second, and third (7), respectively, in advertising expenditures.
However, Camel and Newport ranked seventh and fifth, respectively,
in overall market share (8 ).
     Similarly, the increases in adolescents' brand preference for
Camel cigarettes and the decrease in preference for Marlboro
cigarettes from 1989 to 1993 are not explained by changes in
overall market share for these brands. These changes reflect
variability in brand-specific advertising expenditures: from 1989
to 1993, Marlboro advertising decreased from $102 million to $75
million (7,9), while Camel advertising increased from $27 million
to $43 million (7,9). In contrast, the increased preference for
Newport cigarettes does not reflect the decrease in Newport
advertising expenditures from $49 million to $35 million from 1989
to 1993 (7,9). The regional differences in brand preference of
adolescents and changes in those preferences during 1989-1993
suggest that analysis of the relation between regional advertising
expenditures and brand preferences may help to clarify the role of
cigarette advertising in influencing adolescents' brand preference.
     The findings that black adolescents most commonly purchased
mentholated brands (i.e., Newport and Kool) and that Hispanic
adolescents most commonly purchased Marlboro are consistent with a
previous report (6). Racial/ethnic differences in brand preferences
of adolescents may be influenced by differences in socioeconomic
status and by social and cultural phenomena that require further
explanation.
     The findings of TAPS-II are subject to at least two
limitations. First, the potential exists for nonresponse bias in
the follow-up of TAPS respondents. For example, smoking prevalence
estimates derived from TAPS-II are lower than those based on other
national surveys; TAPS respondents who were successfully followed
up in TAPS-II were less likely to be smokers in 1989 than those who
could not be reinterviewed (Office on Smoking and Health,
unpublished data, 1994). Second, the small number of black and
Hispanic adolescents in TAPS-II lessens the reliability of the
brand preference estimates for these subgroups.
     Because cigarette advertising may influence brand choice of
adolescents (an important component of smoking behavior),
legislation may be needed to restrict cigarette advertising to
which young persons are likely to be exposed (10). In addition,
antitobacco advertising may be an effective public health strategy
to prevent smoking initiation and encourage smoking cessation among
adolescents. Understanding the influence of advertising on
adolescent smoking behavior may assist in clarifying the potential
role of antismoking advertisements. At least two states (California
and Massachusetts) have allocated resources derived from state
excise cigarette tax for paid antismoking advertising campaigns
aimed at young persons.

References
1. DiFranza FR, Tye JB. Who profits from tobacco sales to children?
JAMA 1990;263:2784-7.
2. US Department of Health and Human Services. Preventing tobacco
use among young people: a report of the Surgeon General. Atlanta:
US Department of Health and Human Services, Public Health Service,
CDC, National Center for Chronic Disease Prevention and Health
Promotion, Office on Smoking and Health, 1994.
3. Pierce JP, Gilpin E, Burns DM, et al. Does tobacco advertising
target young people to start smoking?: evidence from California.
JAMA 1991;266:3154-8.
4. Hunter SM, Croft JB, Burke GL, Parker FC, Webber LS, Berenson
GS. Longitudinal patterns of cigarette smoking and smokeless
tobacco use in youth: the Bogalusa Heart Study. Am J Public Health
1986;76:193-5.
5. Shah BV. Software for Survey Data Analysis (SUDAAN) version 5.30
[Software documentation]. Research Triangle Park, North Carolina:
Research Triangle Institute, 1989.
6. CDC. Comparison of the cigarette brand preferences of adult and
teenaged smokers--United States, 1989, and 10 U.S. communities,
1988 and 1990. MMWR 1992;41:169-73,179-81.
7. LNA/MediaWatch Multi-Media Service. Ad dollars summary, January-
December 1993. New York: Competitive Media Reporting, 1994.
8. Maxwell JC Jr. The Maxwell consumer report: fourth-quarter and
year-end 1993 sales estimates for the cigarette industry. Richmond,
Virginia: Wheat First Securities/Butcher & Singer, February 10,
1994.
9. LNA/Arbitron Multi-Media Service. Product vs. media report. New
York: Competitive Media Reporting, 1993.
10. Public Health Service. Healthy people 2000: national health
promotion and disease prevention objectives--full report, with
commentary. Washington, DC: US Department of Health and Human
Services, Public Health Service, 1991:152; DHHS publication no.
(PHS)91-50212.

*TAPS respondents who completed the survey by mail questionnaire
were not eligible for the TAPS-II survey. TAPS-II included
household interviews of persons who did not respond by telephone.
**Adolescents who reported smoking cigarettes on 1 or more of the
30 days preceding the survey.
***The four regions were Northeast (Connecticut, Maine,
Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania,
Rhode Island, and Vermont), Midwest (Illinois, Indiana, Iowa,
Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota,
Ohio, South Dakota, and Wisconsin), South (Alabama, Arkansas,
Delaware, District of Columbia, Florida, Georgia, Kentucky,
Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South
Carolina, Tennessee, Texas, Virginia, and West Virginia), and West
(Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana,
Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming).



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

Date: Tue, 23 Aug 94 21:37:33 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR] Effectiveness in Disease Prevention Medical-Care Spending
Message-ID: <aDPJRc2w165w@stat.com>

         Effectiveness in Disease and Injury Prevention
            Medical-Care Spending -- United States

     One aspect of health-care reform is the role of prevention in
controlling costs. To evaluate data on medical spending by disease
category, the National Public Services Research Institute examined
data from the 1987 National Medical Expenditure Survey (NMES-2),
with emphasis on the Medical Provider Survey supplement. This
report presents the findings of that analysis.
     The NMES-2 was a population-based longitudinal survey in which
data were gathered for the civilian, noninstitutionalized U.S.
population for January 1-December 31, 1987 (the most recent year
for which complete data were available), about sociodemographic
factors; use of medical care; and medical-care expenditures for
hospital inpatient, outpatient, and emergency department care;
physician and allied health professional services; prescribed
medication; emergency transport; and medical supplies and equipment
(1). The Medical Provider Survey supplement provided confirmation
of self-reported medical-care costs and information about costs
that survey respondents were unable to report. The analysis
presented in this report was restricted to the household survey
sample of the NMES-2, a subset of the data that included
face-to-face interviews of approximately 35,000 persons in 14,000
households regarding use of and expenses for health services during
1987. Not included in this analysis were dental costs, mental
health services without a medical component, and administrative
costs and overhead for insurance claims. All medical expenditure
estimates were adjusted to December 1993 dollars using medical-care
spending per capita for all medical treatment as the inflator.
     Cardiovascular disease accounted for $80 billion (14%) of the
$572 billion (in 1993 dollars) in medical spending for services
other than nursing-home care, dental care, and insurance claims
processing (Table 1). Injuries accounted for $69 billion (12%),
including spending attributed to longer term musculoskeletal
deterioration resulting from injury. Spending for each of these
categories exceeded that for cancer and for genitourinary disease
(including kidney disease) ($49 billion each). Medical spending for
well care, including preventive care, was 3% of the total costs
($17 billion).
     Excluding live births, injury was the largest contributor to
health-care expenditures for persons aged 5-49 years (Figure 1).
Injury was the second largest contributor to health-care costs
among persons aged less than 5 years and greater than 85 years;
cardiovascular disease and cancer were the two largest contributors
for those aged 50-85 years.
     Medical spending on injury treatment averaged $284 per person.
Injury costs increased for those aged greater than 65 years, with
the highest per capita spending for injury being for those aged
greater than or equal to 70 years (Figure 2). However, increases in
spending for cardiovascular disease and cancer for those age groups
were higher than those for injury.
     Inpatient hospital costs were the largest component of medical
spending ($329 billion [57%]), with ambulatory-care visits
contributing $90 billion (16%) and hospital outpatient services,
$66 billion (11%). Prescriptions were the fourth largest component
($38 billion [7%]). Home-health-care ($20 billion), emergency
department ($15 billion), and other medical ($15 billion) costs
each contributed approximately 3%.
     By type of care, cardiovascular disease accounted for 15% of
the hospital costs; cancer, 11%; and injury, 10% (Table 2).
Cardiovascular disease also contributed the most in prescription
costs (27%) and home-health-care costs (27%) (Table 2). Injury
costs were the largest component of spending for emergency
department visits (46%), hospital outpatient visits (16%), and
ambulatory care (16%). Of the ambulatory-care visit costs, 14% were
for well care.

Reported by: TR Miller, PhD, DC Lestina, MS Galbraith, Children's
Safety Network Economics and Insurance Resource Center, National
Public Svcs Research Institute, Landover, Maryland. DC Viano, PhD,
Biomedical Science Dept, General Motors Research Laboratories,
Warren, Michigan. Div of Unintentional Injury Prevention, National
Center for Injury Prevention and Control, CDC.

Editorial Note: The findings in this report indicate that the
largest source of health-care spending in the U.S. population is
cardiovascular disease. This reflects the high prevalence of
coronary or ischemic heart disease, which is the leading cause of
death in the United States. However, the influences and risk
factors for cardiovascular disease potentially can be modified
through public policy and preventive practice (e.g., smoking and
diet).
     Injury, the leading cause of death for persons in all age
groups from 1 year through 44 years (2), is also a large
contributor to health-care costs. The data in this report
corroborate the finding that medical-care payments for injury are
the second leading source of direct medical costs in the
noninstitutionalized U.S. population (3). In addition, the cost
burden for injuries is spread across all age groups (4). Because
direct medical costs do not include the reduced or lost
productivity in the working-age population, this analysis does not
adequately present the total economic burden attributable to
injury.
     This study is subject to at least four limitations. First, the
data underestimate total direct medical costs because
institutionalized persons, military members and their families, and
homeless persons were excluded. Second, nursing home costs--
approximately $60 billion annually across all disease categories
(5)--also were omitted from this analysis. Third, the unitary,
systems-based categorization of each illness or injury used in this
analysis masks the potential importance of some categories, such as
infectious diseases. Infectious diseases were subsumed under the
injury or system category that they affect; for example, pulmonary
infections tended to be classified in the respiratory category,
urinary tract infections in the genitourinary category, and human
immunodeficiency virus (HIV) infection and acquired
immunodeficiency syndrome (AIDS) in the categories of affected
systems or as miscellaneous. Similarly, spending for outpatient
visits for complications of diabetes mellitus may appear as
cardiovascular disease costs. Fourth, the direct costs related to
infectious diseases are underestimated because the incidence of HIV
infection and AIDS resulted in substantially increased spending
after 1987 (6).
     Numerous prevention measures reduce direct medical costs while
saving lives. For example, approximately $2 are saved in
medical-care costs for every $1 spent on child-safety seats (7);
from 1982 through 1990, child-safety seats and safety belts saved
the lives of approximately 1300 infants and toddlers in the United
States (8). The data in this report underscore the impact of
different disease categories and the need to evaluate the relative
effectiveness and the cost-effectiveness of interventions that
prevent and control the effects of disease; such data can assist in
making decisions regarding treatment and prevention programs (9).

References
1. Edwards WS, Berlin M. Questionnaires and data collection methods
for the household survey and the survey of American Indians and
Alaskan Natives. Rockville, Maryland: US Department of Health and
Human Services, Public Health Service, National Center for Health
Services Research and Health Care Technology Assessment, 1989; DHHS
publication no. (PHS)89-3450. (National Medical Expenditure Survey
Methods 2.)
2. NCHS. Health, United States, 1992. Washington, DC: US Department
of Health and Human Services, Public Health Service, CDC, 1993;
DHHS publication no. (PHS)93-1232.
3. Harlan LC, Harlan WR, Parsons PE. The economic impact of
injuries: a major source of medical costs. Am J Public Health
1990;80:453-9.
4. Max W, Rice DP, MacKenzie EJ. The lifetime cost of injury.
Inquiry 1990;27:332-43.
5. Bureau of the Census. Statistical abstract of the United States,
1993. Washington, DC: US Department of Commerce, Bureau of the
Census, 1993.
6. Mann JM, Tarantola DJM, Netter TW, eds. AIDS in the world.
Cambridge, Massachusetts: Harvard University Press, 1992:316.
7. Miller TR, Demes JC, Bovbjerg RR. Child seats: how large are the
benefits and who should pay? In: Child occupant protection
[Monograph]. Warrendale, Pennsylvania: Society of Automotive
Engineers 1993:81-9; publication no. SP-986.
8. National Highway Traffic Safety Administration. Occupant
protection facts. Washington, DC: US Department of Transportation,
National Highway Traffic Safety Administration, 1990.
9. Public Health Service/Battelle. For a healthy nation: returns on
investment in public health. Atlanta: US Department of Health and
Human Services, Public Health Service, Office of Disease Prevention
and Health Promotion and CDC/Battelle, Center for Public Health
Research and Evaluation, 1994.



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

Date: Tue, 23 Aug 94 21:38:25 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR] Occupational Injury Deaths of Postal Workers
Message-ID: <qePJRc3w165w@stat.com>

            Occupational Injury Deaths of Postal Workers --
                       United States, 1980-1989

     Extensive media coverage of work-related homicides at U.S.
Postal Service facilities raised the concern about whether postal
workers are at increased risk for work-related homicide,
particularly from those committed by disgruntled coworkers. Based
on national surveillance data, neither the Postal Service industry
nor postal occupations are among the groups at increased risk for
work-related homicide (1,2). To further assess this concern and to
determine the relative magnitude of occupational injury deaths in
the Postal Service, CDC's National Institute for Occupational
Safety and Health (NIOSH) used data from its National Traumatic
Occupational Fatalities (NTOF) surveillance system* to examine
occupational injury deaths in the Postal Service and compare Postal
Service fatality rates with overall rates for all U.S. industries.
This report summarizes the results of that analysis.
     NTOF data for 1980 through 1989 (the most recent year for
which complete data are available) were analyzed. Employment data
for the calculation of rates were derived from the Current
Population Survey (4). Rates were calculated only for 1983-1989
because reporting of Postal Service employment data changed in
1983.
     NTOF recorded 169 occupational injury deaths among U.S. Postal
Service workers during 1980-1989. During 1983-1989, the average
annual rate of occupational injury death in the Postal Service was
2.1 per 100,000 workers, less than half the rate of 5.4 per 100,000
workers for all industries combined. Men accounted for 130 (77%) of
the occupational injury deaths in the Postal Service and had a
higher rate of fatal injury than did women (2.3 per 100,000
workers, compared with 1.8). A total of 98 (58%) of the decedents
were aged greater than 45 years.
     Motor-vehicle-related events (n=72) were the leading cause of
fatal occupational injury, followed by homicide (n=40) (Figure 1,
page 593). Cause-specific rates for Postal Service employees were
consistently lower than rates for all industries, with the largest
differential in the category of machine-related deaths (Figure 2,
page 593).
     Collisions between motor vehicles caused 43 (60%) of the
motor-vehicle-related deaths among Postal Service workers. Three
(4%) deaths occurred to pedestrians on the job who were struck by
motor vehicles. Fifty-one (71%) deaths occurred among mail carriers
and eight (11%) among drivers.
     Among homicide victims, 26 (65%) were men. The homicide rate
for men was 0.5 per 100,000, compared to 0.6 for women. Firearms
were used in 34 (85%) of the homicides. Seventeen (43%) of the
victims were mail carriers; nine (23%), postal clerks; five (13%),
postmasters and mail superintendents; and three (8%), other
specified occupations. Occupation was unknown or not specified for
six (15%) of the victims.

Reported by: Div of Safety Research, National Institute for
Occupational Safety and Health, CDC.

Editorial Note: The findings in this report indicate that the
occupational fatality rate for U.S. Postal Service workers is
approximately 2.5 times lower than that for all workers combined.
Motor-vehicle-related events and homicides combined accounted for
66% of occupational injury deaths in the Postal Service. This
analysis indicated an occupational homicide rate among Postal
Service workers that did not exceed the rate for all U.S. workers.
     Media attention to violence in Postal Service facilities
resulted in press reports that enumerated violent incidents over a
defined period (1983 through 1993). By comparing a newspaper review
of occupational violence in the Postal Service (5) with cases
reported in NTOF, NIOSH identified five work-related homicides not
included in the NTOF database. Incorporating these five cases into
the calculation of a work-related homicide rate for the Postal
Service increased the rate to 0.63 per 100,000 workers, nearly
equal to the average overall national rate (0.64) for the same
period. However, it was not practical to similarly identify
work-related homicides that were not included in NTOF for other
industries; such an enumeration of missed cases would probably
increase the average annual all-industries rate.
     Although the occupational homicide rate for the Postal Service
industry is similar to the national rate for all industries,
coworkers appear to be disproportionately responsible for homicides
that occur in the Postal Service. During 1992, 82% of work-related
homicides were associated with robberies or miscellaneous crimes;
only 4% were committed by coworkers or former coworkers (6). By
comparison, the NTOF data in this report, supplemented with
information from the newspaper review (5), indicated that 57%
(20/35) of work-related homicides of postal workers from 1983
through 1989 were committed by coworkers or former coworkers.
However, 14 of the 20 coworker homicides occurred in a single
incident. The remaining 15 postal worker homicides were presumed to
have been committed by persons who were not Postal Service
employees.
     The findings in this report are subject to at least three
limitations (3). First, because the NTOF surveillance system is
based only on data from death certificates, occupational injury
deaths are undercounted; on average, death certificate-based
surveillance systems capture approximately 81% of occupational
injury deaths (7). Second, previous studies have demonstrated 60%-
76% agreement between industry and occupation information listed on
death certificates and actual employment status at the time of
death (3), which could be a source of misclassification. Third,
death certificates provide only limited data about the
circumstances of traumatic fatalities.
     Although postal workers do not appear to be at increased risk
for occupational homicide, homicide was the third leading cause of
occupational injury death in the United States from 1980 through
1989 (1,3). Developing strategies for the prevention of
work-related homicide will require examination of the circumstances
(e.g., location and working conditions) in which violence has
previously occurred. Factors that may increase the risk for
homicide among mail carriers are working alone in a community
setting, carrying currency and other valuables, and working in
high-crime areas (1,2). Enhanced security measures and devices may
be appropriate to reduce assaults occurring within Postal Service
facilities. Determining the risk factors for coworker violence will
require assessing individual incidents to determine whether there


(continued next message)

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Date: 08-24-94                         Msg # 509141 
  To: ELIOT GELWAN                     Conf: (700) EMAIL
From: David Dodell                     Stat: Private
Subj: HICN738 Medical News             Read: No
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@FROM   :david@STAT.COM                                               
(Continued from last message)
were preceding indications of impending violence (e.g., threats)
and evaluating work conditions and management practices that could
reduce the risk for violence. As part of such an effort, additional
study is needed of behavioral factors that can lead to violence
between coworkers and improved surveillance of nonfatal
occupational injuries incurred through violence.
     In addition to addressing occupational injury deaths resulting
from violence, the NTOF data reported here highlight a need to
continue to address the risk for motor-vehicle-related injuries.
Postal Service employees drive approximately 1.5 billion miles on
the job each year (J. Jones, Office of Safety and Health, U.S.
Postal Service, personal communication, 1994). Use of safety belts,
maintaining mechanical integrity of the fleet (both Postal Service
and personal vehicles used in the performance of duties), and
training should be evaluated to identify means by which the Postal
Service can reduce the risk for motor-vehicle-related fatalities.

References
1. NIOSH. NIOSH alert: request for assistance in preventing
homicide in the workplace. Cincinnati: US Department of Health and
Human Service, Public Health Service, CDC, 1993; DHHS publication
no. (NIOSH)93-109.
2. Castillo DN, Jenkins EL. Industries and occupations at high risk
for work-related homicide. J Occup Med 1994;36:125-32.
3. NIOSH. Fatal injuries to workers in the United States, 1980-
1989: a decade of surveillance--national profile. Cincinnati: US
Department of Health and Human Services, Public Health Service,
CDC, 1993; DHHS publication no. (NIOSH)93-108.
4. US Department of Labor. Employment and earnings. Vols 31-37
(issue no. 1 for each year). Washington, DC: US Department of
Labor, Bureau of Labor Statistics, 1984-1990.
5. Barringer F. Anger in the post office: killings raise questions.
New York Times, 1993 May 7: 1(col 3), 6(col 1).
6. Windau J, Toscano G. Workplace homicides in 1992. In: US
Department of Labor, ed. Compensation and working conditions, 1994.
Vol 46, issue 2. Washington, DC: US Department of Labor, Bureau of
Labor Statistics, 1994.
7. Stout NA, Bell C. Effectiveness of source documents for
identifying fatal occupational injuries: a synthesis of studies. Am
J Public Health 1991;81:725-8.

*NTOF is based on death certificates compiled from all 52 vital
statistics reporting units in the United States that meet three
criteria: the decedent was greater than or equal to 16 years of
age, the cause of death was an injury or poisoning according to the
International Classification of Diseases, Ninth Revision, and the
certifier responded positively to the "Injury at Work?" question
(3).



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

End of HICNet Medical News Digest V07 Issue #38
***********************************************


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

