Neighborhood Environment and Asthma Exacerbation in Washington, DC.

Approximately one in eight people in the United States have been diagnosed with asthma. Asthma is associated with significant medical expenditure and has been implicated as a leading reason for chronic school absences. Environmental risk factors such as access to green space and exposure to poor air quality are patterned such that some vulnerable populations may be at higher risk. Using data from DC Health, the Washington, DC, department of public health, this study investigated associations between neighborhood social, built, and natural environments and rates of asthma-related healthcare encounters by ZIP code between 2014 and 2017. We found that significant differences in rates exist between ZIP codes and for different subpopulations. Black boys had the highest overall rate, with 58.49 visits per 1,000 population, ranging by ZIP code from 0 to 88.56 visits. We found that the ZIP code Social Vulnerability Index was consistently associated with rates of healthcare encounters, but not access to green/open space or exposure to high traffic. However, we discuss how the ZIP code level may not be an appropriate level at which to investigate such built/natural environment features because of the proportion of variability that is found within rather than between ZIP codes. We end with a short discussion of ways that nurses, in particular school nurses, could help to address neighborhood environmental risk factors.

Investigation of Salmonella Enteritidis Outbreak Associated with Truffle Oil - District of Columbia, 2015.

On September 8, 2015, the District of Columbia Department of Health (DCDOH) received a call from a person who reported experiencing gastrointestinal illness after eating at a District of Columbia (DC) restaurant with multiple locations throughout the United States (restaurant A). Later the same day, a local emergency department notified DCDOH to report four persons with gastrointestinal illness, all of whom had eaten at restaurant A during August 30-September 5. Two patients had laboratory-confirmed Salmonella group D by stool culture. On the evening of September 9, a local newspaper article highlighted a possible outbreak associated with restaurant A. Investigation of the outbreak by DCDOH identified 159 patrons who were residents of 11 states and DC with gastrointestinal illness after eating at restaurant A during July 1-September 10. A case-control study was conducted, which suggested truffle oil-containing food items as a possible source of Salmonella enterica serotype Enteritidis infection. Although several violations were noted during the restaurant inspections, the environmental, laboratory, and traceback investigations did not confirm the contamination source. Because of concern about the outbreak, the restaurant's license was suspended during September 10-15. The collaboration and cooperation of the public, media, health care providers, and local, state, and federal public health officials facilitated recognition of this outbreak involving a pathogen commonly implicated in foodborne illness.

Laboratory Capacity for Antimicrobial Susceptibility Surveillance of Neisseria gonorrhoeae-District of Columbia, 2007-2012.

BACKGROUND: In the District of Columbia (DC), Neisseria gonorrhoeae (gonorrhea) infections accounted for more than 25% of 9321 incident sexually transmitted infections reported in 2011; untreated infections can lead to reproductive complications and a higher risk for HIV transmission. In DC, limited capacity to measure the prevalence of antibiotic-resistant N. gonorrhoeae is available; culture-based antibiotic susceptibility testing (AST) is needed to monitor antimicrobial resistance. We examined the capacity of laboratories that report to the DC Department of Health to perform AST for ongoing surveillance of antibiotic-resistant N. gonorrhoeae and to identify suspected treatment failures. METHODS: We created a survey about diagnostic methods for gonorrhea testing and identified 33 laboratories that reported gonorrhea results to Department of Health in 2007 to 2012. Laboratories were assessed for use of bacterial culture or nucleic acid amplification testing (NAAT) for gonorrhea testing, prevalence of AST on gonorrhea-positive cultures, and types of antibiotics tested during AST. We estimated the prevalence of laboratory practices on the basis of self-report by staff. RESULTS: Nineteen (58%) laboratories completed the survey, representing 92% of the gonorrhea reporting. Seventeen (89%) of 19 laboratories conducted testing by culture; only 6 (35%) performed AST; 79% performed NAAT. Barriers to AST included longer completion times and limited number of provider requests for AST. Commercial laboratories (32%) were more likely to conduct both culture and NAAT, compared with health care facilities (11%). CONCLUSIONS: We report a low prevalence of laboratories performing AST because of multiple barriers. State-specific strategies addressing these barriers are needed to improve detection of antibiotic-resistant gonorrhea stains circulating among the population.

Identifying populations at risk: interdisciplinary environmental climate change tracking.

BACKGROUND: Climate change, experienced as extreme weather events such as heat waves can lead to poorer air quality and underscores the critical need to consider the consequences of these environmental changes on health. Changes are occurring at a rate that exceeds what the world has experienced over the last 650,000 years, yet little attention has been focused on the potentially catastrophic public health effects of climate change. METHODS: This study instituted a two-phase approach. In building capacity for an Environmental Public Health Tracking Network, the District of Columbia Department of Health first examined the availability of climate change and health data. These data were then used to assess vulnerabilities and disease burden associated with heat, air quality, and hospitalizations for asthma (N = 5,921) and acute myocardial infarction (AMI) (N = 2,773) during 2007-2010. A Poisson regression analysis was applied to the time series of daily counts for hospitalizations for selected age, race, and gender groups. RESULTS: Although no significant associations were found for PM2.5, PM10, or ozone with asthma-related or AMI-related hospitalizations with seasonal changes, surveillance data found disparities in hospitalizations particularly in female, African American residents for both asthma and AMI. CONCLUSIONS: Tracking Networks are critical for assessing community environmental health vulnerabilities.

Infectious disease burden and vaccination needs among asylees versus refugees, district of columbia.

BACKGROUND: Unlike US-bound refugees, asylum seekers (asylees) apply for asylum while residing in the United States and are not provided a medical screening. Infectious disease burden and vaccination needs have not been described among US asylees. METHODS: We conducted a retrospective cohort study of 630 asylees and 151 refugees referred to the District of Columbia (DC) Department of Health screening program for an initial US medical screening during September 2003-August 2007. We assessed the prevalence of latent tuberculosis infection (tuberculin skin test reactivity ≥10 mm), human immunodeficiency virus (HIV) and hepatitis B seropositivity, intestinal parasite test positivity, need for vaccinations, and time from date of US arrival to receipt of screening. RESULTS: Asylees in DC had a similar prevalence as refugees of latent tuberculosis infection (39% vs 38%, respectively, P = .83), pathogenic intestinal parasites (4% vs 2%, P = .36), and need for adult vaccinations (80% vs 80%, P = .95). Asylees were screened significantly later after US arrival compared with refugees (55 weeks vs 1 week, P < .001). Asylees had higher prevalence of latent tuberculosis infection, hepatitis B and HIV seropositivity, and child and adult vaccination needs than the US population (P < .001). CONCLUSIONS: This study of the infectious disease concerns of a US asylee population suggests that in DC, asylees have similar infectious disease burden and prevention needs as refugees and should be screened with the same urgency. Because applicants for US asylum are not linked to prompt medical screenings, DC asylees are typically screened much later, placing them and US communities at risk.

Vascular access hemorrhages contribute to deaths among hemodialysis patients.

In 2007 the Maryland Medical Examiner noted a potential cluster of fatal vascular access hemorrhages among hemodialysis patients, many of whom died outside of a health-care setting. To examine the epidemiology of fatal vascular access hemorrhages, we conducted a retrospective case review in District of Columbia, Maryland, and Virginia from January 2000 to July 2007 and a case-control study. Records from the Medical Examiner and Centers for Medicare and Medicaid Services were reviewed, from which 88 patients were identified as fatal vascular access hemorrhage cases. To assess risk factors, a subset of 20 cases from Maryland was compared to 38 controls randomly selected among hemodialysis patients who died from non-vascular access hemorrhage causes at the same Maryland facilities. Of the 88 confirmed cases, 55% hemorrhaged from arteriovenous grafts, 24% from arteriovenous fistulas, and 21% from central venous catheters. Of 82 case-patients with known location of hemorrhage, 78% occurred at home or in a nursing home. In the case-control analysis, statistically significant risk factors included the presence of an arteriovenous graft, access-related complications within 6 months of death, and hypertension; presence of a central venous catheter was significantly protective. Psychosocial factors and anticoagulant medications were not significant risk factors. Effective strategies to control vascular access hemorrhage in the home and further delineation of warning signs are needed.

Exchange Sex Among High School Students-Washington, DC, 2017.

PURPOSE: Exchange sex, the exchange of money or nonmonetary items for sex, is associated with sexually transmitted diseases and HIV. We sought to identify prevalence and characteristics associated with exchange sex among District of Columbia (DC) high school students. METHODS: We used the 2017 DC Youth Risk Behavior Survey, a cross-sectional survey of students in grades 9-12 (n = 8,578). We performed multivariable logistic regression to examine associations between exchange sex and demographic, home environment, and substance use measures. RESULTS: In 2017, a total of 7.4% (95% confidence interval [CI]: 6.6-8.2) of students reported ever having engaged in exchange sex. Odds of exchange sex were higher among males (adjusted odds ratio [AOR]: 2.5; 95% CI: 1.6-4.0) and students who had sexual contact with partners of both sexes (AOR: 2.4; 95% CI: 1.2-4.9), compared with students having sexual contact with partners of opposite sex only. Exchange sex was also associated with having been kicked out, run away, or abandoned during the past 30 days (AOR: 10.7; 95% CI: 7.0-16.3]); going hungry during the past 30 days (AOR: 2.2; 95% CI: 1.1-4.5); and ever using synthetic marijuana (AOR: 2.6; 95% CI: 1.3-5.0) or cocaine, heroin, methamphetamines, or ecstasy (AOR: 2.9; 95% CI: 1.6-5.3]), compared with those who had not. CONCLUSIONS: Approximately one in 14 DC high school students engaged in exchange sex. Programs providing services to youth with unstable housing, food insecurity, or who use drugs should incorporate sexual health services to address exchange sex practices.

Enhanced One Health Surveillance during the 58th Presidential Inauguration-District of Columbia, January 2017.

OBJECTIVE: In January 2017, Washington, DC, hosted the 58th United States presidential inauguration. The DC Department of Health leveraged multiple health surveillance approaches, including syndromic surveillance (human and animal) and medical aid station-based patient tracking, to detect disease and injury associated with this mass gathering. METHODS: Patient data were collected from a regional syndromic surveillance system, medical aid stations, and an internet-based emergency department reporting system. Animal health data were collected from DC veterinary facilities. RESULTS: Of 174 703 chief complaints from human syndromic data, there were 6 inauguration-related alerts. Inauguration attendees who visited aid stations (n = 162) and emergency departments (n = 180) most commonly reported feeling faint/dizzy (n = 29; 17.9%) and pain/cramps (n = 34;18.9%). In animals, of 533 clinical signs reported, most were gastrointestinal (n = 237; 44.5%) and occurred in canines (n = 374; 70.2%). Ten animals that presented dead on arrival were investigated; no significant threats were identified. CONCLUSION: Use of multiple surveillance systems allowed for near-real-time detection and monitoring of disease and injury syndromes in humans and domestic animals potentially associated with inaugural events and in local health care systems.

Early detection of influenza outbreaks using the DC Department of Health's syndromic surveillance system.

BACKGROUND: Since 2001, the District of Columbia Department of Health has been using an emergency room syndromic surveillance system to identify possible disease outbreaks. Data are received from a number of local hospital emergency rooms and analyzed daily using a variety of statistical detection algorithms. The aims of this paper are to characterize the performance of these statistical detection algorithms in rigorous yet practical terms in order to identify the optimal parameters for each and to compare the ability of two syndrome definition criteria and data from a children's hospital versus vs. other hospitals to determine the onset of seasonal influenza. METHODS: We first used a fine-tuning approach to improve the sensitivity of each algorithm to detecting simulated outbreaks and to identifying previously known outbreaks. Subsequently, using the fine-tuned algorithms, we examined (i) the ability of unspecified infection and respiratory syndrome categories to detect the start of the flu season and (ii) how well data from Children's National Medical Center (CNMC) did versus all the other hospitals when using unspecified infection, respiratory, and both categories together. RESULTS: Simulation studies using the data showed that over a range of situations, the multivariate CUSUM algorithm performed more effectively than the other algorithms tested. In addition, the parameters that yielded optimal performance varied for each algorithm, especially with the number of cases in the data stream. In terms of detecting the onset of seasonal influenza, only "unspecified infection," especially the counts from CNMC, clearly delineated influenza outbreaks out of the eight available syndromic classifications. In three of five years, CNMC consistently flags earlier (from 2 days up to 2 weeks earlier) than a multivariate analysis of all other DC hospitals. CONCLUSIONS: When practitioners apply statistical detection algorithms to their own data, fine tuning of parameters is necessary to improve overall sensitivity. With fined tuned algorithms, our results suggest that emergency room based syndromic surveillance focusing on unspecified infection cases in children is an effective way to determine the beginning of the influenza outbreak and could serve as a trigger for more intensive surveillance efforts and initiate infection control measures in the community.

Medicaid patient asthma-related acute care visits and their associations with ozone and particulates in Washington, DC, from 1994-2005.

The primary objective of this ecologic and contextual study is to determine statistically significant short-term associations between air quality (daily ozone and particulate concentrations) and Medicaid patient general acute care daily visits for asthma exacerbations over 11 years for Washington, DC residents, and to identify regions and populations that may experience increased asthma exacerbations related to air quality. After removing long-term trends and day-of-week effects in the Medicaid data, Poisson regression was applied to daily time series data. Significant associations were found between asthma-related general acute care visits and ozone concentrations. Significant associations with both ozone and PM2.5 concentrations were observed for 5- to 12-year-olds. While poor air quality was closely associated with asthma exacerbations observed in acute care visits in areas where Medicaid enrollment was high, the strongest associations between asthma-related visits and air quality were not always for the areas with the highest Medicaid enrollment.

Assessing rabies knowledge gaps in human and animal healthcare professionals practicing in Washington, DC-A one health approach.

Once a person is exposed to the rabies virus, it is universally fatal unless postexposure prophylaxis (PEP) is administered promptly. In the United States, determining whether PEP recommeded is often a collaborative effort where health departments work with both animal and human healthcare professionals to enact animal quarantines (or rabies testing), recommending PEP when appropriate. A failure in the knowledge base of either profession can result in incorrect PEP recommendations and an increased risk of adverse outcomes. To assess rabies knowledge in licensed physicians and veterinarians practicing in Washington, DC, we conducted a survey from December 2, 2016, to January 2, 2017, assessing their knowledge of the clinical signs, epidemiology and the primary vectors of rabies. These responses were compared between the two groups. Physician-specific or veterinary-specific questions regarding the correct PEP schedule and administration site or animal quarantine recommendations, respectively, were also included. Nine hundred and fifty-two physicians and 125 veterinarians responded. Veterinarians were more likely to select the correct vectors and clinical signs in animals than physicians. Physicians more likely selected the correct transmission routes. Less than half of physicians identified the correct PEP schedule (39.4%) and administration site (49.0%). Half of veterinarians (50.0%) correctly identified quarantine length for wildlife-exposed vaccinated dogs compared to only 19.4% for unvaccinated dogs. Several knowledge gaps were identified amongst physicians and veterinarians. Due to the fatal nature of rabies, it is important that all healthcare providers have an understanding of current recommendations. Health departments can work to correct these gaps and serve as a bridge between human and animal healthcare professionals.

Elevated lead in drinking water in Washington, DC, 2003-2004: the public health response.

BACKGROUND: In 2003, residents of the District of Columbia (DC) experienced an abrupt rise in lead levels in drinking water, which followed a change in water-disinfection treatment in 2001 and which was attributed to consequent changes in water chemistry and corrosivity. OBJECTIVES: To evaluate the public health implications of the exceedance, the DC Department of Health expanded the scope of its monitoring programs for blood lead levels in children. METHODS: From 3 February 2004 to 31 July 2004, 6,834 DC residents were screened to determine their blood lead levels. RESULTS: Children from 6 months to 6 years of age constituted 2,342 of those tested; 65 had blood lead levels > 10 microg/dL (the "level of concern" defined by the Centers for Disease Control and Prevention), the highest with a level of 68 microg/dL. Investigation of their homes identified environmental sources of lead exposure other than tap water as the source, when the source was identified. Most of the children with elevated blood lead levels (n = 46; 70.8%) lived in homes without lead drinking-water service lines, which is the principal source of lead in drinking water in older cities. Although residents of houses with lead service lines had higher blood lead levels on average than those in houses that did not, this relationship is confounded. Older houses that retain lead service lines usually have not been rehabilitated and are more likely to be associated with other sources of exposure, particularly lead paint. None of 96 pregnant women tested showed blood lead levels > 10 microg/dL, but two nursing mothers had blood lead levels > 10 microg/dL. Among two data sets of 107 and 71 children for whom paired blood and water lead levels could be obtained, there was no correlation (r(2) = -0.03142 for the 107). CONCLUSIONS: The expanded screening program developed in response to increased lead levels in water uncovered the true dimensions of a continuing problem with sources of lead in homes, specifically lead paint. This study cannot be used to correlate lead in drinking water with blood lead levels directly because it is based on an ecologic rather than individualized exposure assessment; the protocol for measuring lead was based on regulatory requirements rather than estimating individual intake; numerous interventions were introduced to mitigate the effect; exposure from drinking water is confounded with other sources of lead in older houses; and the period of potential exposure was limited and variable.

Pediatric patient asthma-related emergency department visits and admissions in Washington, DC, from 2001-2004, and associations with air quality, socio-economic status and age group.

BACKGROUND: The District of Columbia (DC) Department of Health, under a grant from the US Centers for Disease Control and Prevention, established an Environmental Public Health Tracking Program. As part of this program, the goals of this contextual pilot study are to quantify short-term associations between daily pediatric emergency department (ED) visits and admissions for asthma exacerbations with ozone and particulate concentrations, and broader associations with socio-economic status and age group. METHODS: Data included daily counts of de-identified asthma-related pediatric ED visits for DC residents and daily ozone and particulate concentrations during 2001-2004. Daily temperature, mold, and pollen measurements were also obtained. After a cubic spline was applied to control for long-term seasonal trends in the ED data, a Poisson regression analysis was applied to the time series of daily counts for selected age groups. RESULTS: Associations between pediatric asthma ED visits and outdoor ozone concentrations were significant and strongest for the 5-12 year-old age group, for which a 0.01-ppm increase in ozone concentration indicated a mean 3.2% increase in daily ED visits and a mean 8.3% increase in daily ED admissions. However, the 1-4 yr old age group had the highest rate of asthma-related ED visits. For 1-17 yr olds, the rates of both asthma-related ED visits and admissions increased logarithmically with the percentage of children living below the poverty threshold, slowing when this percentage exceeded 30%. CONCLUSION: Significant associations were found between ozone concentrations and asthma-related ED visits, especially for 5-12 year olds. The result that the most significant ozone associations were not seen in the age group (1-4 yrs) with the highest rate of asthma-related ED visits may be related to the clinical difficulty in accurately diagnosing asthma among this age group. We observed real increases in relative risk of asthma ED visits for children living in higher poverty zip codes versus other zip codes, as well as similar logarithmic relationships for visits and admissions, which implies ED over-utilization may not be a factor. These results could suggest designs for future epidemiological studies that include more information on individual exposures and other risk factors.

Expanding veterinary biosurveillance in Washington, DC: The creation and utilization of an electronic-based online veterinary surveillance system.

OBJECTIVES: To enhance the early detection of emerging infectious diseases and bioterrorism events using companion animal-based surveillance. METHODS: Washington, DC, small animal veterinary facilities (n=17) were surveyed to determine interest in conducting infectious disease surveillance. Using these results, an electronic-based online reporting system was developed and launched in August 2015 to monitor rates of canine influenza, canine leptospirosis, antibiotic resistant infections, canine parvovirus, and syndromic disease trends. RESULTS: Nine of the 10 facilities that responded expressed interest conducting surveillance. In September 2015, 17 canine parvovirus cases were reported. In response, a campaign encouraging regular veterinary preventative care was launched and featured on local media platforms. Additionally, during the system's first year of operation it detected 5 canine leptospirosis cases and 2 antibiotic resistant infections. No canine influenza cases were reported and syndromic surveillance compliance varied, peaking during National Special Security Events. CONCLUSIONS: Small animal veterinarians and the general public are interested in companion animal disease surveillance. The system described can serve as a model for establishing similar systems to monitor disease trends of public health importance in pet populations and enhance biosurveillance capabilities.

Detecting Suicide-Related Emergency Department Visits Among Adults Using the District of Columbia Syndromic Surveillance System.

OBJECTIVES: Limited studies have examined the usefulness of syndromic surveillance to monitor emergency department (ED) visits involving suicidal ideation or attempt. The objectives of this study were to (1) examine whether syndromic surveillance of chief complaint data can detect suicide-related ED visits among adults and (2) assess the added value of using hospital ED data on discharge diagnoses to detect suicide-related visits. METHODS: The study data came from the District of Columbia electronic syndromic surveillance system, which provides daily information on ED visits at 8 hospitals in Washington, DC. We detected suicide-related visits by searching for terms in the chief complaints and discharge diagnoses of 248 939 ED visits for which data were available for October 1, 2015, to September 30, 2016. We examined whether detection of suicide-related visits according to chief complaint data, discharge diagnosis data, or both varied by patient sex, age, or hospital. RESULTS: The syndromic surveillance system detected 1540 suicide-related ED visits, 950 (62%) of which were detected through chief complaint data and 590 (38%) from discharge diagnosis data. The source of detection for suicide-related ED visits did not vary by patient sex or age. However, whether the suicide-related terms were mentioned in the chief complaint or discharge diagnosis differed across hospitals. CONCLUSIONS: ED syndromic surveillance systems based on chief complaint data alone would underestimate the number of suicide-related ED visits. Incorporating the discharge diagnosis into the case definition could help improve detection.

Psychological responses to the sniper attacks: Washington DC area, October 2002.

BACKGROUND: This study assessed the psychological and behavioral responses of residents of the Washington DC metropolitan area to the October 2002 sniper shootings, as well as the association between measures of exposure to the shootings and elevated traumatic stress symptoms. METHODS: Random-digit-dial telephone survey of 1205 adults living in Washington DC and two surrounding counties during the shootings, conducted May 2003. Main outcome measures included self-reports regarding traumatic stress symptoms, perceptions of safety, behavioral responses, and exposures to incidents. RESULTS: Forty-five percent of residents reported going to public spaces such as parks and shopping centers less than usual, and 5.5% reported missing at least 1 day of work because of the sniper attacks. Women who reported living within 5 miles of any shooting incident were significantly more likely to report elevated traumatic stress symptoms-consistent with a probable diagnosis of post-traumatic stress disorder-than women who reported living farther from incidents (odds ratio = 4.2, 95% confidence interval = 1.9-9.3). Among men, there was no significant association between reported residential proximity and elevated traumatic stress symptoms. CONCLUSIONS: These results suggest the substantial behavioral and psychological impact that traumatic events such as these sniper shootings can have on communities. They support the importance of clinicians and community leaders addressing psychological functioning in the setting of such events that threaten a population. The results further suggest that women who report residing closest to such incidents are at greatest risk for experiencing elevated symptoms of traumatic stress, and perhaps warrant special attention.

Priorities of low-income urban residents for interventions to address the socio-economic determinants of health.

OBJECTIVES: To determine the priorities of low-income urban residents for interventions that address the socio-economic determinants of health. METHODS: We selected and estimated the cost of 16 interventions related to education, housing, nutrition, employment, health care, healthy behavior, neighborhood improvement, and transportation. Low-income residents of Washington, D.C. (N=431) participated in decision exercises to prioritize these interventions. RESULTS: Given a budget valued at approximately twice an estimated cost of medical and dental care ($885), the interventions ultimately prioritized by the greatest percentage of individuals were: health insurance (95%), housing vouchers (82%) dental care (82%), job training (72%), adult education (63%), counseling (68%), healthy behavior incentives (68%), and job placement (67%). The percentages of respondents who received support for housing, adult education, and job training and placement were far less than the percentage who prioritized these interventions. CONCLUSIONS: Poor and low-income residents' priorities may usefully inform allocation of social services that affect health.

Demographics and tumor characteristics of colorectal cancers in the United States, 1998-2001.

BACKGROUND: Descriptions of population characteristics for intestinal cancers frequently combine colon and rectal sites. However, some studies suggest that cancers of subsites in the intestinal tract may differ both by demographics and biology. Examination of colon and rectal cancers' characteristics separately could identify different risk profiles for these sites. METHODS: Data from combined National Program of Cancer Registries (NPCR) and Surveillance, Epidemiology, and End Results (SEER) databases were examined for risk characteristics by age, race, sex, and ethnicity, as well as for SEER-reported trends over 27 years. RESULTS: Males had higher incidences of both colon and rectal cancers, but this predominance was greater for rectal cancers. Colon cancer rates were higher for blacks than for whites but rectal cancer rates were slightly higher for whites than for blacks. The change in incidence rates by race occurred abruptly at sites in the lower colon. Asians had low rates of colon cancer, but their rectal cancer rates were similar to those of blacks. Trends for both sites showed declines in incidence rates in whites, but slight to no change in blacks. Mortality in blacks increased until about 10 years ago. CONCLUSIONS: Colon and rectal cancer sites should be studied independently because of major differences in their characteristics. Age-specific incidence rates differ by race and site. Any effect from screening is difficult to demonstrate because of changes in procedures over time, resulting in different levels of effective detection in the intestinal tract, and because of slow acceptance of screening by the public.

The National Capitol Region's Emergency Department syndromic surveillance system: do chief complaint and discharge diagnosis yield different results?

We compared syndromic categorization of chief complaint and discharge diagnosis for 3,919 emergency department visits to two hospitals in the U.S. National Capitol Region. Agreement between chief complaint and discharge diagnosis was good overall (kappa=0.639), but neurologic and sepsis syndromes had markedly lower agreement than other syndromes (kappa statistics 0.085 and 0.105, respectively).