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HICNet Medical News Digest      Tue, 06 Jun 1995        Volume 08 : 
Issue 22

Today's Topics:

  [MMWR - May12] Imported Dengue -- United States, 1993-1994
  [MMWR] Carbon Monoxide Poisoning from Use of Gasoline-Fueled Power
  [MMWR] Eye Injuries to Agricultural Workers
  [MMWR] National Chronic Disease Prevention and Control Conference
  [MMWR] Course in Hospital Epidemiology
  [MMWR May19] World No-Tobacco Day, 1995
  [MMWR] Assessment of the Impact of a 100% Smoke-FreeOrdinance on
  Smoking-Attributable Mortality -- Mexico, 1992

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To: hicnews

             Imported Dengue -- United States, 1993-1994

     Dengue is a mosquito-transmitted acute disease caused by any of 
four
virus serotypes (DEN-1, DEN-2, DEN-3, and DEN-4) and characterized by 
the
sudden onset of fever, headache, myalgia, rash, nausea, and vomiting. 
The
disease is endemic in most tropical areas of the world and has occurred 
in
U.S. residents returning from travel to such areas. This report 
summarizes
information about cases of imported dengue among U.S. residents during 
1993
and 1994.
     Serum samples from 148 U.S. residents who had suspected dengue with 
onset
in 1993 (57 cases) and 1994 (91 cases) were submitted to CDC for 
diagnostic
testing from 33 states (Table 1). Of these, 46 (31%) cases from 17 
states were
serologically or virologically diagnosed as dengue (1) by isolation of 
dengue
virus, detection of dengue-specific IgM, single high titers of IgG 
antibodies
in acute serum samples, or a fourfold or greater rise in dengue-specific
antibodies between acute- and convalescent-phase serum samples. Dengue
serotype (DEN-2 and DEN-3) was identified for two cases.
     Of the 46 persons with laboratory-diagnosed dengue, 25 (54%) were 
males.
Age was reported for 32 and ranged from 1 year to 87 years (median: 27 
years).
Travel histories were available for 43 persons (Table 1); infections 
probably
were acquired in the Caribbean islands (21 cases), Mexico and Central 
America
(10), and Asia (10). Two patients reported possible exposure in two 
locations:
Australia and Asia, and Asia and Africa.
     Clinical information was available for 40 of 46 laboratory-
confirmed
cases. The most commonly reported symptoms were consistent with classic 
dengue
fever (e.g., fever [92%], myalgia [48%], rash [48%], and headache 
[42%]).
Other manifestations included petechiae or purpura (four patients); low 
white
blood cell count (1000- 2700/mm3 [normal: 3200-9800/mm3]) (13 patients); 
low
platelet count (20,000-134,000/mm3 [normal: 150,000-450,000/mm3]) (13
patients); and elevated liver enzymes (seven patients).
     Six patients were hospitalized. One patient (aged 12 years) with
secondary dengue infection developed fever, thrombocytopenia, epistaxis, 
right
pleural effusion, ascites, and hypotension--signs compatible with dengue 
shock
syndrome (DSS). One patient (aged 11 years), who also had a secondary
infection, developed mild disseminated intravascular coagulation. One 
patient
(aged 49 years) with an unspecified serologic response had fever, 
myalgias,
thrombocytopenia, leukopenia, elevated liver function test results, and
hypotension (blood pressure 90/48 mmHg).

Reported by: State and territorial health depts. Dengue Br, Div of
Vector-Borne Infectious Diseases, National Center for Infectious 
Diseases,
CDC.

Editorial Note: Dengue is not endemic in the United States. However, 
because
the incubation period is 3-14 days, U.S. residents who become infected 
during
travel to tropical areas may have onset of illness after returning to 
the
United States (2). Although most dengue infections are associated with 
mild
illness, the risk for dengue hemorrhagic fever (DHF) is greater in some
persons--particularly those with repeat (secondary) infection. DHF is
characterized by fever, platelet count less than or equal to 
100,000/mm3,
hemorrhagic manifestations, and leaky capillary syndrome 
(hemoconcentration,
hypoalbuminemia, or pleural or abdominal effusions). DSS includes DHF 
and
hypotension or narrow pulse pressure (less than or equal to 20 mmHg) 
(3,4) and
is associated with a high fatality rate (5).
     The incidence of DHF is increasing in the Americas: since 1982, 
dengue
epidemics with associated DHF have occurred in Aruba, Brazil, Colombia,
Curacao, Dominican Republic, El Salvador, French Guiana, Honduras, 
Mexico,
Nicaragua, Puerto Rico, St. Lucia, Suriname, and Venezuela. In addition,
dengue is endemic in many islands in the Caribbean, in Mexico, and in 
most
countries in Central and South America (6). In 1994, outbreaks of dengue 
were
reported from Brazil, Costa Rica, Dominican Republic, Haiti, Mexico,
Nicaragua, Panama, Puerto Rico, and Venezuela. Nicaragua and Panama 
recently
confirmed infections attributable to DEN-3 (7), a serotype that was last
isolated in the Americas in 1977 (8).
     In the Americas, dengue is transmitted by Aedes aegypti mosquitoes.
Although nearly eradicated from the region during the 1960s, this 
species is
now present in most tropical areas of the Americas. In the United 
States, A.
aegypti is present year-round in the southernmost Gulf of Mexico coast 
states
from Texas to Florida; a small focus also exists on the island of 
Molokai in
Hawaii. Autochthonous transmission of dengue has not occurred in the 
United
States since 1986 (6); however, introduction of the virus by persons who 
have
acquired infections in other countries could result in local 
transmission.
     The 37 laboratory-confirmed cases identified in 1994 represent 
almost
twice the average number of similar cases identified annually during 
1987-1993
(n=20) and the highest number of positives identified since 1982 (n=45) 
(6).
However, these totals do not include cases that may have been reported 
to
state health departments but for which specimens were not submitted for
testing at CDC. In addition, in 1994, the California Department of 
Health
Services received reports of five cases of suspected dengue that were
documented at the state's Viral and Rickettsial Disease Laboratory (9).
     Compared with previous years, a higher proportion of cases reported 
in
1994 were characterized by severe disease. The three persons with
life-threatening illness underscore the importance of early recognition 
and
treatment of the severe manifestations of dengue infection.
     The prevention of dengue infection in tropical locations requires
avoiding exposure to mosquitoes (10) and includes the continuous use of
mosquito repellent and protective clothing. Although the Aedes species 
that
transmits dengue may bite at any time during the day, peak activity 
occurs
during the early morning and late afternoon. Ae. aegypti usually is 
present in
peridomestic settings and is found most often in dark areas such as 
closets
and bathrooms, behind curtains, and under beds. For tourists, the risk 
for
exposure to dengue may be lower in some settings, including beaches, 
hotels
with well-kept grounds, and heavily forested areas and jungles.
     Health-care providers should consider dengue in the differential
diagnosis for all patients who have compatible manifestations and a 
recent
history of travel to tropical areas. When dengue is suspected, patients 
should
be monitored for evidence of hypotension, hemoconcentration, and
thrombocytopenia. Because of the anticoagulant properties of 
acetylsalicylic
acid (i.e., aspirin), only acetaminophen products are recommended for
management of fever. Acute- and convalescent-phase serum samples should 
be
obtained for viral isolation and serodiagnosis and sent for confirmation
through state or territorial health department to CDC's Dengue Branch,
Division of Vector-Borne Infectious Diseases, National Center for 
Infectious
Diseases, 2 Calle Casia, San Juan, PR 00921-3200; telephone (809) 766-
5181;
fax (809) 766-6596. Serum specimens should be accompanied by a summary 
of
clinical and epidemiologic information, including a detailed travel 
history
with dates and location of travel and dates of onset of illness and 
blood
collection.

References
1. CDC. Case definitions for public health surveillance. MMWR 
1990;39(no.
RR-13):10-1.
2. Benenson AS, ed. Control of communicable diseases in man. 15th ed.
Washington, DC: American Public Health Association, 1990:119.
3. Morens DM. Antibody-dependent enhancement of infection and the 
pathogenesis
of viral disease. Clin Infect Dis 1994;19:500-12.
4. Pan American Health Organization. Dengue and dengue hemorrhagic 
fever:
guidelines for prevention and control. Washington, DC: Pan American 
Health
Organization, 1994:12-3.
5. Tassniyom S, Vasanawathana S, Chirawatkul A, Rojanasuphot S. Failure 
of
high-dose methylprednisolone in established dengue shock syndrome: a
placebo-controlled, double-blind study. Pediatrics 1993;92:111-5.
6. Rigau-Perez JG, Gubler DJ, Vorndam AV, Clark GG. Dengue
surveillance--United States, 1986-1992. In: CDC surveillance summaries, 
MMWR
1994;43(no.
SS-2):7-19.
7. CDC. Dengue type 3 infection--Nicaragua and Panama, October-November 
1994.
MMWR 1995;44:21-4.
8. Gubler DJ. Dengue and dengue hemorrhagic fever in the Americas. 
Puerto Rico
Health Sciences Journal 1987;6:107-11.
9. Division of Communicable Disease Control. Dengue and dengue 
hemorrhagic
fever--a significant risk for travelers. California Morbidity, January 
13,
1995.
10. CDC. Advisory memorandum no. 109--dengue update. Atlanta: US 
Department of
Health and Human Services, Public Health Service, March 10, 1995.


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

To: hicnews
Power

     Carbon Monoxide Poisoning from Use of Gasoline-Fueled Power Wash=
ers
       in an Underground Parking Garage -- District of Columbia, 1994

     On June 17, 1994, five workers in the District of Columbia were =
treated
in an emergency department for carbon monoxide (CO) poisoning followi=
ng
exposure to the exhaust from two gasoline-fueled power washers (i.e.,=
 pressure
washers), which they had used in an empty underground parking garage.=
 These
cases were identified by The George Washington University (GWU) Divis=
ion of
Occupational and Environmental Medicine (DOEM) through ongoing survei=
llance
for work-related injuries among construction workers treated in the G=
WU
emergency department (1). This report summarizes the results of an
investigation by DOEM of this incident.
     At 11 p.m. on June 16, four laborers and a foreman (age range: 2=
2-39
years) began preparing to resurface the floor of an underground parki=
ng garage
that had been closed for business when the crew began work. At approx=
imately
12:30 a.m., the workers started two power washers equipped with 8-hor=
sepower,
gasoline-fueled engines. A pedestal fan used previously in such situa=
tions was
not operable. In addition, the garage exhaust fan was not in operatio=
n, and
the main door of the garage (located approximately two levels above t=
he work
site) was closed.
     At approximately 3:30 a.m., a worker collapsed. His three co-wor=
kers and
the foreman assisted him out of the garage and remained outside with =
him for a
few minutes before they returned to the garage and resumed work. A se=
cond
worker then collapsed; the co-workers immediately turned off the wash=
ers,
evacuated the garage, and contacted the District of Columbia Fire Dep=
artment.
Onsite evaluation by fire department officials indicated that all fiv=
e men had
acute symptoms including dizziness, confusion, headache, and nervousn=
ess. The
two workers who had collapsed were transported by ambulance to a loca=
l
emergency department. At the hospital, carboxyhemoglobin (COHb) level=
s,
obtained from the workers at 5:10 a.m., were 20% and 17%, respectivel=
y
(normal: less than or equal to 5%-10% for smokers and less than or eq=
ual to 1%
for nonsmokers [2]). Carbon monoxide poisoning was diagnosed, and the=
y were
treated with hyperbaric oxygen and released later that day. The three=
 other
workers were transported to the hospital where their COHb levels, obt=
ained at
7:15 a.m., were 10.3%, 13.4%, and 7.9%, respectively. They were admin=
istered
100% oxygen and released.
     At 4:14 a.m., the fire department's hazardous materials team res=
ponded to
investigate the incident. Based on measurements using a hand-operated=
 air pump
and indicator tube approximately 1 hour after the washers had been tu=
rned off,
the concentration of CO was 648 parts per million (ppm).* The only id=
entified
source of CO was the exhaust from the gasoline-powered washers.

Reported by: L Nessel-Stephens, MSS, LS Welch, MD, JL Weeks, ScD, KL =
Hunting,
PhD, J C=85rdenas-Amaya, MD, Div of Occupational and Environmental Me=
dicine, The
George Washington Univ, Washington, DC. Div of Surveillance, Hazard
Evaluations, and Field Studies, National Institute for Occupational S=
afety and
Health, CDC.

Editorial Note: CO is a potentially lethal gas with nonspecific warni=
ng
properties. Levels of CO uptake vary among persons and are a function=
 of air
concentration, level of exertion and ventilatory rate, and duration o=
f
exposure. For example, among workers engaged in light work and who we=
re
exposed to a CO concentration of 700 ppm, COHb levels were 20% after =
35
minutes and 40% after approximately 1 hour (4). In general, COHb leve=
ls
greater than 20% are associated with symptoms; dizziness and unsteady=
 gait may
result from levels greater than 30% (5).
     Based on estimates of the Bureau of Labor Statistics (BLS), in 1=
992 CO
exposure accounted for 867 nonfatal work-related CO poisonings in pri=
vate
industry in the United States that resulted in days away from work (B=
LS,
Survey of Occupational Injuries and Illnesses, unpublished data, 1992=
) and for
32 fatal work-related CO poisonings (BLS, Census of Fatal Occupationa=
l
Injuries, unpublished data, 1992). The occurrence of nonfatal work-re=
lated CO
poisonings probably is underestimated because workers with mild sympt=
oms may
not seek treatment, medical providers may not recognize nonspecific s=
ymptoms
as manifestations of CO poisoning, and some correctly diagnosed cases=
 may not
be reported as work-related.
     Since November 1990, DOEM has identified four other cases of CO =
poisoning
among construction workers; all required emergency medical treatment =
(1). Two
cases involved use of gasoline-powered forklifts in an enclosed wareh=
ouse, and
two involved use of gasoline-fueled saws. Similar incidents have been=
 reported
among workers in other industries, including farmers using gasoline-f=
ueled
pressure washers to clean structures housing animals (6; NIOSH, unpub=
lished
data, 1993) and workers using liquid propane-powered floor burnishers=
 to clean
floors in a retail establishment (7). During January 1985-February 19=
95, the
Colorado Department of Public Health and Environment (CDPHE) received=
 reports
of 147 cases of occupational CO poisoning related to the use of
gasoline-powered equipment; of these, 13 (9%) were associated with us=
e of
pressure washers (CDPHE, unpublished data, 1995).
     The investigation described in this report and other incidents i=
ndicate
that many workers may not be aware of the risks of CO poisoning assoc=
iated
with gasoline-fueled engines and may not be able to assess accurately=
 whether
ventilation is adequate for their safe use. For example, in 1993, to
characterize risk awareness and behavior related to the indoor use of=
 small
engines, NIOSH surveyed 416 persons involved in flood-cleanup activit=
ies in
Missouri. Of those who had ever used a gasoline-powered pressure wash=
er, 38%
reported bringing the engine component of the washer inside a buildin=
g (NIOSH,
unpublished data, 1993).
     For many construction projects, CO exposure cannot be consistent=
ly

_
                                                                                                                   

controlled because of the involvement of multiple contractors. The em=
ployer of
the laborers involved in the incident described in this report has
discontinued use of the gasoline-powered pressure washers in undergro=
und
parking garages and now uses electric- or diesel-powered washers. How=
ever,
other contractors routinely use gasoline-powered equipment in maintai=
ning and
resurfacing parking garage floors--often without additional ventilati=
on.
Alternatives to gasoline-powered equipment (i.e., electric and diesel
equipment) are associated with other potential hazards (e.g., imprope=
r use of
electric equipment can result in electrocution, and unfiltered diesel=
 exhaust
contains hazardous particulates). Even though diesel equipment and
well-maintained gasoline-fueled equipment that are fitted with cataly=
tic
converters emit less CO, the reduced levels may be too high for safe =
indoor
use.
     The risk for CO exposure to workers can be reduced through impro=
ved
ventilation. In addition, however, risk-reduction efforts must includ=
e air
monitoring for CO levels. Reliable air monitoring includes the requir=
ement for
persons who have been trained to perform the monitoring and for equip=
ment that
has been properly calibrated and maintained. Training and warning lab=
els can
increase awareness among contractors and workers about the risks asso=
ciated
with use of gasoline-fueled equipment in enclosed spaces.

References
1. Hunting KL, Nessel-Stephens L, Sandford SM, Shesser R, Welch LS.
Surveillance of construction worker injuries through an urban emergen=
cy
department. J Occup Med 1994;36:356-64.
2. Smith R. Systemic toxicology. In: Amdur MO, Doull J, Klassen CD, e=
ds.
Casarett and Doull's toxicology: the basic science of poisons. 4th ed=
. New
York: Pergamon Press, 1991:264-8.
3. NIOSH. Pocket guide to chemicals. Cincinnati: US Department of Hea=
lth and
Human Services, Public Health Service, CDC, 1990; DHHS publication no=
.
(NIOSH)90-117.
4. Forbes WH, Sargent F, Foughton FJW. The rate of CO uptake by norma=
l man. Am
J Physiol 1945;143:594-608.
5. Seger DL, Welch L. Carbon monoxide. In: Sullivan JB, Krieger GR. H=
azardous
materials toxicology: clinical principles of environmental health. Ba=
ltimore:
Williams and Wilkins, 1992: 1160-4.
6. CDC. Unintentional carbon monoxide poisoning from indoor use of pr=
essure
washers--Iowa, January 1992-January 1993. MMWR 1993;42:777-9,785.
7. CDC. Carbon monoxide poisoning associated with a propane-powered f=
loor
burnisher-- Vermont, 1992. MMWR 1993;42:726-8.

* The NIOSH recommended exposure limit for CO is 35 ppm (as an 8-hour
time-weighted average), and the recommended ceiling limit is 200 ppm =
(3).



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

To: hicnews

       Eye Injuries to Agricultural Workers -- Minnesota, 1992-1993

     During 1993, U.S. farm workers incurred an estimated 13,500 eye 
injuries
that resulted in lost work time (1); many of these injuries could have 
been
prevented. To determine the incidence of eye injuries and use of eye
protection
among farm workers, the Minnesota Occupational Health Nurses in 
Agricultural
Communities (OHNAC)* examined data from the Minnesota Farming Health 
Survey
(MFHS) conducted during January-April 1992 and December 1992-April 1993. 
This
report summarizes the results of this analysis.
     Occupational health nurses administered questionnaires during on-
farm
visits. Square-mile sections of land in three agricultural regions of 
the
state were sampled at a sampling rate of 3.5%. All farms on any portion 
of the
sampled land were selected. Farms were considered eligible for the 
survey if
farm operators reported that they actively farmed, that they sold 
greater than
or equal to $1000 of farm produce annually, and that their farm income
accounted for at least half of their total household income. Overall, 
1359
farm household members living on 372 (68.5%) of 543 eligible farms were
included in the survey; respondents were farm operators and selected 
adult
household members. Farm injuries were defined as self-reported events 
related
to farm operation that resulted in restricted activities for at least 
four
hours, loss of consciousness, or seeking of medical care.
     Respondents reported 106 farm injuries during the two periods** 
(annual
rate: 78.0 injuries per 1000 farm household members [95% confidence 
interval
(CI)=63.7-92.2]). Ten persons sustained 11 farm-related eye injuries 
(10% of
all injuries and 8.1 eye injuries per 1000 farm household members [95%
CI=3.3-12.9]).
     Of the 11 farm-related eye injuries, four were caused by chemicals 
and
seven by foreign bodies. Chemical-related eye injuries involved splashes 
of
liquid agricultural chemicals (two cases) and fungicidal dust (one 
case); the
fourth incident involved discovery of an eye injury in a child who had 
exited
a chemical storage shed, although the details of the injury could not be
ascertained. Foreign body-related injuries were sustained in association 
with
activities including working with hand and power tools, welding, 
grinding,
cutting metal, and augering grain. The injured person was reported to 
have
been using eye protection in only one of these incidents. Medical care 
was
sought for nine (82%) of the 11 injuries; seven required immediate 
medical
attention. However, no residual problems or restrictions were reported 
by
respondents; three of the 10 injuries to adults resulted in lost work 
time.
     Farm operators also were asked about their use of protective 
equipment
and/or procedures while performing specific work tasks involving 
potential
dermal exposures to agricultural chemicals (Table 1). For mixing or 
loading
agricultural chemicals or for sprayer maintenance, 50% reported never 
wearing
eye protection (e.g., goggles or safety glasses), and 9% reported never 
using
protective gloves.
     Of the 207 respondents who worked with anhydrous ammonia (an 
extremely
caustic alkali that is stored under pressure and applied as a liquid
fertilizer), 73 (35%) reported that they never or sometimes wore 
goggles, and
92 (44%) reported that they never or sometimes checked the water supply 
in
their field emergency water tank.***

Reported by: C Lexau, MPH, D Bishop, PhD, Div of Family Health, 
Minnesota Dept
of Health. Div of Safety Research, and Div of Surveillance, Hazard
Evaluations, and Field Studies, National Institute for Occupational 
Safety and
Health, CDC.

Editorial Note: The MFHS findings document the occurrence of eye 
injuries in a
specific production-agriculture worker group--farmers and household 
members
living on family-operated farms--and are consistent with other recent 
reports.
For example, the Regional Rural Injury Study, a population-based survey 
in
five midwestern states, documented an annual rate of 58.3 farm injury 
events
per 1000 household members--farm-related eye injuries accounted for 8.2% 
of
all farm injuries (2).**** Based on the Traumatic Injury Surveillance of
Farmers survey during 1993, the estimated 13,500 eye injuries among farm
workers in the United States that resulted in lost time from work 
accounted
for approximately 6.7% of all lost-time injuries estimated for farming
operations (1). Although the survey participation rate was relatively 
low,
MFHS data for selected characteristics of farm operators and farm 
operations
were consistent with data from the 1992 Census of Agriculture.
     Based on the incident descriptions obtained by MFHS, each of the 10 
eye
injuries to adults would most likely have been prevented if appropriate 
and
well-fitting eye protection had been worn while those persons engaged in 
work
with agricultural chemicals, power and hand tools, and grain- or seed-
moving
equipment. Personal protective equipment traditionally has not been 
considered
a primary strategy for hazard control. The preferred strategies have 
included
hazard substitution (i.e., replacing a hazardous chemical with a less
hazardous one) and hazard isolation or use of engineering controls (3).
Although these strategies are applicable in agricultural settings (e.g., 
use
of closed pesticide-handling systems), use of eye protection provides a
practical and cost-effective method of preventing eye injuries among 
farm
workers. Goggles are recommended for chemical splash protection, and 
safety
glasses with side shields can provide adequate protection (except in 
dusty
environments) against flying particles or objects (4,5).
     In Minnesota, OHNAC is working with individual agricultural 
chemical
dealers to promote the use of eye protection among their clients. 
Concurrent
with educational programs and media promotions by Minnesota OHNAC staff, 
the
chemical dealers have agreed to sell eye protection devices at a 
discount
during the spring and early summer. Minnesota OHNAC has successfully 
used a
similar approach with operators of local grain elevators to increase the
availability of respiratory protection (6).
     Chemical-related eye injuries are a focus for prevention efforts in
Minnesota because they accounted for many of the eye injuries reported 
in the
MFHS and represented most (67%) of the reported chemical injuries. The
recently implemented U.S. Environmental Protection Agency Worker 
Protection
Standard (7) requires farm operators (including family farmers) to adopt
preventive measures when working with pesticides. This standard includes
requirements that all workers comply with personal protective equipment
recommendations detailed on pesticide labels, that decontamination
sites--including an emergency water supply--be furnished for employees, 
and
that eye
protection be used when closed pesticide-handling systems are operated 
under
pressure.

References
1. NIOSH. Traumatic Injury Surveillance of Farmers, 1993: statistical
abstract. Cincinnati: US Department of Health and Human Services, Public
Health Service, CDC (in press).
2. Gerberich SG, Gibson RW, French LR, et al. The Regional Rural Injury
Study-I (RRIS-I): a population-based effort--a report to the CDC, 1993.
Minneapolis: University of Minnesota, Regional Injury Prevention 
Research
Center, 1993.
3. Olishifski JB. Methods of control. In: Plog BA, ed. Fundamentals of
industrial hygiene. 3rd ed. Chicago: National Safety Council, 1988.
4. Vinger PF, Sliney DH. Eye disorders. In: Levy BS, Wegman DH, eds.
Occupational health: recognizing and preventing work-related disease.
Boston/Toronto: Little, Brown, and Company, 1988.
5. American National Standards Institute. American National Standard 
practice
for occupational and educational eye and face protection. New York: 
American
National Standards Institute, 1989; publication no. (ANSI)Z87.1-1989.
6. Lexau CA. Evaluation results: Minnesota Farming Health Project grain
elevator health promotion program. Minneapolis: Minnesota Department of
Health, 1994.
7. US Environmental Protection Agency. The worker protection standard 
for
agricultural pesticides: how to comply--what employers need to know.
Washington, DC: US Environmental Protection Agency, 1993.

* OHNAC is a national surveillance program conducted by CDC's National
Institute for Occupational Safety and Health, which has placed public 
health
nurses in rural communities and hospitals in 10 states (California, 
Georgia,
Iowa, Kentucky, Maine, Minnesota, New York, North Carolina, North 
Dakota, and
Ohio) to conduct surveillance for agriculture-related illnesses and 
injuries
that occur among farmers and their family members. These surveillance 
data are
used to assist in reducing the risk for occupational illness and injury 
in
agricultural populations.
** The reporting period for the winter 1992 survey was January 1991-
December
1991; the period for the winter 1993 survey was November 1991-October 
1992.
*** Keeping an emergency water supply in the field is a standard safety
precaution; immediate flushing of skin or eyes following contact with
anhydrous ammonia is necessary to mitigate the severe burns that will
otherwise result.
**** The questionnaire for farm injuries used on the MFHS was adapted 
from the
Regional Rural Injury Study, but the population eligible for inclusion 
in the
MFHS included more full-time farmers.


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To: hicnews
Conference

        National Chronic Disease Prevention and Control Conference

     CDC is soliciting abstracts for the Tenth National Conference on 
Chronic
Disease Prevention and Control to be held in Atlanta, December 6-8, 
1995. The
12 topic areas are: forming coalitions with nontraditional partners; the
changing nature of leadership and advocacy; moving from a service 
provision
model to a population-based model; social marketing; system changes to
incorporate or implement prevention; program institutionalization with
communities; new research paradigms--broadening chronic disease 
epidemiology;
measuring chronic diseases, behaviors, and other risks; translating 
science
into reasonable policy and effective implementation; critical points in 
the
life cycle for behavior change; trends in the chronic disease burden--
the
changing priorities of chronic disease; and use of technology to improve 
the
prevention of chronic disease. The deadline for submission of abstracts 
is
June 23, 1995.
     Additional information and abstract forms are available from Dr. 
Philip
Huang, Chief, Bureau of Disease Prevention, Texas Department of Health, 
1100
West 49th St., Austin, TX 78756-3199; telephone (512) 458-7200; fax 
(512)
459-7618.


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To: hicnews

                  Course in Hospital Epidemiology

     CDC, the Society for Healthcare Epidemiology of America (SHEA), and 
the
American Hospital Association will cosponsor a hospital epidemiology 
training
course October 14-17, 1995, in Miami, Florida. The course, designed for
infectious disease fellows, new hospital epidemiologists, and
infection-control practitioners, provides hands-on exercises to improve 
skills
in detection, investigation, and control of epidemiologic problems 
encountered
in the hospital setting and lectures and seminars on fundamental aspects 
of
hospital epidemiology.
     Additional information is available from SHEA Meetings Department, 
Suite
200, 875 Kings Highway, Woodbury, NJ 08095-3172; telephone (609) 845-
1720; fax
(609) 853-0411.


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To: hicnews

             World No-Tobacco Day, 1995

     The increase in cigarette smoking worldwide since 1950
has been particularly dramatic in developing countries and
has been associated with substantial morbidity, mortality,
and economic costs (1,2). Each year, tobacco use accounts
for at least 3 million deaths worldwide (1-3). Based on
current smoking trends, in 30-40 years, tobacco use is
projected to cause 10 million deaths annually, of which 70%
will occur among persons in developing countries (1). The
global health-care costs resulting from tobacco use exceed
$200 billion per year--more than twice the current health
budgets of all developing countries combined (4).
     To increase global awareness of tobacco-attributable
morbidity, mortality, and economic costs, the theme of the
eighth World No-Tobacco Day, to be held May 31, 1995, is
"Tobacco Costs More Than You Think." Additional information
about World No-Tobacco Day 1995 is available from the
Regional Office for the Americas, World Health Organization
(telephone [202] 861-3200), or from CDC's Office on Smoking
and Health, National Center for Chronic Disease Prevention
and Health Promotion (telephone [404] 488-5705).

References
1. Peto R, Lopez AD, Boreham J, Thun M, Heath C. Mortality
from smoking in developed countries, 1950-2000. Oxford,
England: Oxford University Press, 1994.
2. World Health Organization. World No-Tobacco Day, 31 May
1995 [Advisory kit]. Geneva: World Health Organization,
1995.
3. World Health Organization. World No-Tobacco Day, 31 May
1995 [Press kit]. Geneva: World Health Organization, 1995.
4. Barnum H. The economic burden of the global trade in
tobacco. Tobacco Control 1994;3:358-61.


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To: hicnews
on

        Assessment of the Impact of a 100% Smoke-Free Ordinance
        on Restaurant Sales -- West Lake Hills, Texas, 1992-1994

     Exposure to environmental tobacco smoke (ETS), which is
associated with adverse health effects among nonsmokers (1),
is a health hazard of particular concern for patrons and
employees in restaurants (2). To protect nonsmokers, many
local governments have enacted ordinances requiring
restaurants to be smoke-free. However, the potential
economic impact of these laws on restaurants is an important
concern for restaurant owners. On June 1, 1993, the city of
West Lake Hills (a suburb of Austin), Texas (1995
population: 3000), implemented an ordinance requiring a 100%
smoke-free environment in all commercial establishments to
which the public has access, including all restaurants and
restaurants with bar areas. This report summarizes an
assessment of sales in restaurants during June 1993-December
1994 compared with January 1992-May 1993.
     Restaurants in West Lake Hills had a variety of menus
and food-pricing scales. Restaurant sales data for West Lake
Hills were obtained from the Texas State Comptroller's
office. Aggregate monthly sales data* from January 1992
through December 1994 were obtained for the eight
restaurants in West Lake Hills that had indoor dining areas
and were in operation during all of 1992 and until the
ordinance went into effect in June 1993 (one of these
restaurants closed in April 1994 because its lease expired).
These sales data included the 17-month period preceding
implementation of the ordinance (January 1992-May 1993) and
the 19-month period following implementation (June 1993-December 1994).
Restaurants that opened during the
assessment period were not included in the analysis because
the purpose of the study was to assess the impact of the
ordinance on a consistent panel of restaurants (five
restaurants opened during September 1992-July 1994).
     Data were analyzed using a linear regression model (3)
that examined the relation between total restaurant sales
and the presence of a smoke-free ordinance and that
incorporated seasonal variations in sales and temporal
economic trends. For each factor examined (i.e., time [year
and month], quarter of the year, and presence of the
implemented ordinance), a corresponding regression
coefficient was calculated to measure the effect of that
factor on total restaurant sales. A positive regression
coefficient suggests that the factor was associated with
increased total restaurant sales, and a negative value
suggests that the factor was associated with decreased total
restaurant sales. To test for multicollinearity, variance
inflation factors were computed for each independent
variable in the model. The Durbin-Watson statistic was
computed (4) to test for first-order autocorrelation
(correlation of the residuals [error terms] for adjacent
observations over time).
     Total monthly sales for the restaurants during 1992-1994 varied by
season. Sales peaked during the second
quarter of each year.

_
                                                                                     

     In the initial regression model, the variance inflation
factors for the ordinance variable and the year variable
were above four, indicating multicollinear involvement
between these variables. To address the multicollinearity,
the time variable was removed: although reanalysis did not
change the regression coefficient for the ordinance
variable, the standard error was substantially decreased.
The variance inflation factors for this final model
indicated that multicollinearity was no longer present, and
the Durbin-Watson statistic indicated that significant
first-order autocorrelation was not present (Table 1).
     The regression coefficient for the second quarter of
the year was positive, suggesting that restaurant sales were
greater in the second quarter of each year than in the first
quarter (Table 1). The regression coefficient for the
ordinance variable was positive, suggesting that the total
sales of the restaurants did not decrease after
implementation of the ordinance.

Reported by: P Huang, MD, Bur of Chronic Disease Prevention
and Control; S Tobias, S Kohout, M Harris, D Satterwhite,
Office of Smoking and Health; DM Simpson, MD, State
Epidemiologist, Texas Dept of Health; L Winn, City of West
Lake Hills; J Foehner, L Pedro, Office of the Texas
Comptroller of Public Accounts. Office on Smoking and
Health, National Center for Chronic Disease Prevention and
Health Promotion, CDC.

Editorial Note: The findings in this report are consistent
with assessments using similar methods in other locations
that have reported that the implementation of smoke-free
ordinances has not been associated with adverse economic
effects on restaurants (3,5,6).
     Previous reports of decreases in restaurant sales
following the enactment of clean indoor air ordinances have
been based on anecdotal information (7-10), on studies that
used restaurant owners' self-reports of the impact on their
business instead of validated sales data (7,8), and on
studies that used tax data to measure restaurant sales but
collected data for only one or two quarters following
implementation of ordinances (9,10). In comparison, the
assessment in West Lake Hills was based on sales data that
were validated by tax revenue reported by the State
Comptroller's office, included data for periods of time
sufficient for statistical analysis, and employed multiple
linear regression techniques to account for temporal trends
and seasonal variations in sales.
     The findings in this assessment are subject to at least
three limitations. First, because of limitations in data, an
ordinary least squares regression model--which assumes no
autocorrelation--was used in place of a more specific time
series model; however, the Durbin-Watson statistic indicated
that significant autocorrelation was not present. Second,
the model only explained 33% of the variation in total
restaurant sales; future studies may benefit from the
inclusion of other variables that can affect restaurant
sales. Third, because the assessment focused on a consistent
panel of restaurants and excluded restaurants that opened
during the assessment period, the findings cannot be
generalized to all restaurants in West Lake Hills.
     The economic impact of smoke-free ordinances is an
important consideration for policymakers concerned about the
ETS exposure of nonsmokers; assessment of the potential
economic impact of these laws should be based on the most
objective, scientific evidence available. The findings from
the assessment in West Lake Hills has provided policymakers
in that community with a scientific appraisal of the impact
of public health measures to reduce exposure to tobacco
smoke. In addition, the assessment in West Lake Hills
provides a model for other local and state public agencies
to consider when evaluating tobacco-control programs.

References
1. US Environmental Protection Agency. Respiratory health
effects of passive smoking: lung cancer and other disorders.
Washington, DC: US Environmental Protection Agency, Office
of Health and Environmental Assessment, Office of
Atmospheric and Indoor Air Programs, 1992; publication no.
EPA-600/6-90/006F.
2. Siegel M. Involuntary smoking in the restaurant
workplace: a review of employee exposure and health effects.
JAMA 1993;270:490-3.
3. Glantz SA, Smith LR. The effect of ordinances requiring
smoke-free restaurants on restaurant sales. Am J Public
Health 1994;84:1081-5.
4. Durbin J, Watson GS. Testing for serial correlation in
least squares regression. Biometrika 1951;37:409-28.
5. Maroney N, Sherwood D, Stubblebine WC. The impact of
tobacco control ordinances on restaurant revenues in
California. Claremont, California: The Claremont Graduate
School, The Claremont Institute for Economic Policy Studies,
1994.
6. Taylor Consulting Group. The San Luis Obispo ordinance: a
study of the economic impacts on San Luis Obispo restaurants
and bars. San Luis Obispo, California: Taylor Consulting
Group, 1993.
7. Gambee P. Economic impacts of smoking ban in Bellflower,
California: analysis of survey data, February-May, 1991.
Bellflower, California: California Business and Restaurant
Alliance, 1991.
8. Charlton Research Company. Pacific Dining Car Restaurant
and Southern California Business Association, December 11,
1993-January 15, 1994. San Francisco, California: Charlton
Research Company, 1994.
9. Laventhol & Horwath, Certified Public Accountants.
Preliminary analysis of the impact of the proposed Los
Angeles ban on smoking in restaurants. Los Angeles,
California: Laventhol & Horwath, Certified Public
Accountants, 1990.
10. Masotti LH, Creticos PA. The effects of a ban on smoking
in public places in San Luis Obispo, California. Evanston,
Illinois: Creticos & Associates, Inc, 1992.

* To protect confidentiality, individual restaurant sales
data are not released by the Comptroller's office .


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To: hicnews

       Smoking-Attributable Mortality -- Mexico, 1992

     Cigarette smoking causes neoplastic, respiratory, and
cardiovascular diseases that contribute substantially to
disability, death, and medical-care expenditures (1). In the
United States, cigarette smoking is the leading preventable
cause of premature death (1). Although the prevalence of
cigarette smoking in Mexico (26% in 1993 [2]) is similar to
that in the United States, smoking-attributable mortality
has not been recently estimated for Mexico or most other
developing countries that are experiencing increases in
chronic diseases. To assist in the development of programs
for preventing tobacco use, the Ministry of Health of Mexico
used a modified version of the software program
Smoking-Attributable Mortality, Morbidity, and Economic
Costs (SAMMEC) to estimate smoking-related mortality (3).
This report summarizes trends in the occurrence of
smoking-related diseases in Mexico and estimates
smoking-attributable mortality and years of potential life
lost before age 65 years (YPLL-65) in 1992.
     Data from the Ministry of Health for 1970, 1980, and
1990 were used to calculate age-adjusted death rates per
100,000 persons for lung cancer, coronary heart disease,
cerebrovascular disease, chronic obstructive pulmonary
disease, and other smoking-related cancers (e.g., mouth,
esophagus, larynx, cervix, bladder, and kidney) (4); rates
were directly adjusted to the 1992 population (5). SAMMEC
uses smoking prevalence and relative risks for
smoking-related diseases to calculate smoking-attributable
fractions (the proportions of deaths attributable to
cigarette smoking). Because relative risks for
smoking-related diseases were unavailable for Mexico,
smoking-attributable fractions were estimated (5,6) by using
an index based on lung cancer death rates in the United
States and Mexico (cigarette smoking accounts for most lung
cancer deaths [6]; therefore, the lung cancer death rate in
Mexico was used as an overall measure of risk for disease).
     The lung cancer index was calculated separately for men
and women. For men, the lung cancer rate among women was
used as the baseline because the prevalence of smoking among
women in Mexico has been low until recently, and the
prevalence of other risk factors for lung cancer has been
similar among men and women in Mexico. For women, the lung
cancer rate among U.S. never smokers was used as the
baseline (6,7). The index was multiplied by SAMMEC
disease-specific smoking-attributable fractions to obtain
adjusted disease-specific smoking-attributable fractions for
Mexico. The number of deaths from each smoking-related
disease in 1992 was multiplied by the respective adjusted
smoking-attributable fraction to estimate the
smoking-attributable mortality for Mexico and was used to
estimate YPLL-65 associated with cigarette smoking.
     During 1970-1990, death rates for all major
smoking-related diseases in Mexico increased substantially,
ranging from a 60% increase in the death rate for
cerebrovascular disease to a 220% increase in the death rate
for lung cancer (Table 1, page 379).
     When the lung cancer rate among women was used to
estimate the baseline risk for men, the numbers of
smoking-attributable deaths and YPLL-65 among men in 1992
were 6875 and 25,172, respectively (Table 2, page 379). When
the lung cancer rate among U.S. never smokers was used to
estimate the baseline risk among women in Mexico, the
numbers of smoking-attributable deaths and YPLL-65 among
women in Mexico in 1992 were 3378 and 14,996, respectively.
The total numbers of smoking-attributable deaths and YPLL-65
in Mexico in 1992 were 10,253 and 40,168, respectively. Most
smoking-attributable deaths and YPLL-65 among men and women
were associated with cardiovascular diseases, chronic
obstructive pulmonary disease, and lung cancer.

Reported by: R Tapia Conyer, MD, P Kuri Morales, MD, F
Meneses Gonzales, MD, Ministry of Health, Mexico City,
Mexico. Epidemiology Br, Office on Smoking and Health,
National Center for Chronic Disease Prevention and Health
Promotion; Data for Decision Making Project, Epidemiology
Program Office, CDC.

Editorial Note: The findings in this report document the
substantial impact of cigarette smoking on premature
mortality in adults in Mexico. Death rates from the leading
causes of smoking-related deaths have nearly tripled since
1970 in Mexico. Based on this analysis, the proportion of
deaths attributable to smoking in Mexico is 9%, compared
with 32% in the United States for the same categories of
deaths considered in this report. These differences may be
attributable to lower cigarette consumption in Mexico
compared with the United States. However, as the population
of Mexico ages and the average duration of smoking
increases, the number of smoking-attributable deaths
probably will increase.
     The estimates of the total number of
smoking-attributable deaths and YPLL-65 in Mexico during
1992 probably are low for at least three reasons. First,
baseline lung cancer rates for U.S. never smokers probably
reflect effects of occupational or environmental exposures
and, therefore, may have produced lower estimates of excess
risk in Mexico. Second, estimates of smoking-attributable
mortality in Mexico do not include deaths from burns,
stillbirths, and sudden infant death syndrome or deaths
occurring during the perinatal period because these risks
are unknown and could not be extrapolated from known risks
in the United States. Third, smoking-attributable mortality
estimates for 1992 reflect the lower prevalences of smoking
in previous decades and may not fully capture increases in
mortality resulting from recent changes in smoking patterns.
In addition, because this study used adjusted
smoking-attributable fractions, the association between
smoking-related behaviors (i.e., duration and amount of
smoking, depth of inhalation, or use of filtered-tip
cigarettes) and smoking-related diseases could not be
examined. Ongoing examination of the relation between
smoking and disease in Mexico will improve the accuracy of
future estimates.
     In Mexico, because chronic diseases (including
neoplasms and cardiovascular disease) are emerging as
leading causes of death (4), the prevention of tobacco use
is a major priority. The findings in this report will assist
in refining policies to reduce the prevalence of cigarette
smoking and risks for associated diseases and to counter the
impact of increased tobacco advertising and other marketing
strategies (8). Priority measures may include preventing the
initiation of cigarette smoking among children and
adolescents, increasing smoking cessation among adult
smokers, developing health education programs, and
establishing legislative policies (e.g., regulating and
restricting the advertisement and promotion of tobacco
products, restricting or banning tobacco sales to minors,
and increasing tobacco taxes and prices [9]).

References
1. CDC. Reducing the health consequences of smoking: 25
years of progress--a report of the Surgeon General.
Rockville, Maryland: US Department of Health and Human
Services, Public Health Service, CDC, 1989; DHHS publication
no. (CDC)89-8411.
2. General Office for Epidemiology. National Addiction
Survey, 1993 [Spanish]. Mexico DF: Ministry of Health, 1993.
3. Shultz JM, Novotny TE, Rice DP. Smoking-Attributable
Mortality, Morbidity, and Economic Cost (SAMMEC) version 2.1
[Software and documentation]. Atlanta: US Department of
Health and Human Services, Public Health Service, CDC, 1992.
4. National Institutes for Statistics, Geography, and
Informatics. Total deaths by cause, sex, and age--United
States of Mexico, 1970, 1980, 1990: population by age, 1992.
Mexico DF: Ministry of Health, General Office for
Statistics, National Institutes for Statistics, Geography,
and Informatics, 1993; publication no. (IFDN)968-811-239-9.
5. Rothman KJ. Modern epidemiology. Boston: Little, Brown,
and Company, 1986.
6. CDC. Smoking and health in the Americas: a 1992 report of
the Surgeon General, in collaboration with the Pan American
Health Organization. Atlanta: US Department of Health and
Human Services, Public Health Service, CDC, 1992; DHHS
publication no. (CDC)92-8419.
7. Peto R, Lopez AD, Boreham J, Thun M, Heath C Jr.
Mortality from tobacco in developed countries: indirect
estimation from national vital statistics. Lancet
1992;339:1268-78.
8. Stebbins R. Making a killing south of the border:
transnational cigarette companies in Mexico and Guatemala.
Soc Sci Med 1994;38:105-15.
9. Roemer R. Development and implementation of a policy on
tobacco control. In: Legislative action to combat the world
tobacco epidemic. 2nd ed. Geneva: World Health Organization
1993:155-80.


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

End of HICNet Medical News Digest V08 Issue #22
***********************************************


---
Editor, HICNet Medical Newsletter
Internet: david@stat.com                 FAX: +1 (602) 451-6135

                                               
