Deaths due to injury in the military.

INTRODUCTION: More military personnel die of injuries each year than any other cause. This paper provides a basic epidemiologic description of injury deaths in the military. METHODS: Using fatality data from the Department of Defense Directorate of Information and Operations Reports and population data from the Defense Manpower Data Center, death rates of men and women in the military services for unintentional injury, suicide, homicide, and illness were calculated for the 1980-1992 period. RESULTS: From 1980 to 1992, injuries (unintentional injuries, suicides, and homicides combined) accounted for 81% of all nonhostile deaths among active duty personnel in the Armed Services. The overall death rate due to unintentional injuries was 62.3 per 100,000 person-years. The suicide rate was 12.5, the homicide rate 5.0, and the death rate due to illness 18.4. From 1980 to 1992 mortality from unintentional injuries declined about 4% per year. The rates for suicide and homicide were stable. Men in the services die from unintentional injuries at about 2.5 times the rate of women and from suicides at about twice the rate of women. Women in the military, however, have a slightly higher homicide rate than men. CONCLUSION: Injuries (unintentional injuries, suicides, and homicides) are the leading cause of death among active duty members of the U.S. Armed Forces, accounting for about four out of five deaths. The downward trend for fatal unintentional injuries indicates the success that can be achieved when attention is focused on preventing injuries. Further reduction in injury mortality would be facilitated if collection and coding of data were standardized across the military services.

Injuries in the military: a review and commentary focused on prevention.

BACKGROUND: In November 1996, the Armed Forces Epidemiological Board (AFEB) Injury Prevention and Control Work Group issued a report that cited injuries as the leading cause of morbidity and mortality among military service members. This article reviews the types and categories of military morbidity and mortality data examined by the AFEB work group and the companion Department of Defense (DoD) Injury Surveillance and Prevention Work Group. This article further uses the injury data reviewed to illustrate the role of surveillance and research in injury prevention. The review provides the context for discussion of the implications of the AFEB work group's findings for the prevention of injuries in the military. METHODS: The AFEB work group consisted of 11 civilian injury epidemiologists, health professionals and scientists from academia, and other non-DoD government agencies, plus six military liaison officers. Injury data from medical databases were provided to the civilian experts on the AFEB work group by the all-military DoD Injury Surveillance and Prevention Work Group. The AFEB work group assessed the value of each database to the process of prevention and made recommendations for improvement and use of each data source. RESULTS: Both work groups found that injuries were the single leading cause of deaths, disabilities, hospitalizations, outpatient visits, and manpower losses among military service members. They also identified numerous data sources useful for determining the causes and risk factors for injuries. Those data sources indicate that training injuries, sports, falls, and motor vehicle crashes are among the most important causes of morbidity for military personnel. CONCLUSIONS: While the work group recommends ways to prevent injuries, they felt the top priority for injury prevention must be the formation of a comprehensive medical surveillance system. Data from this surveillance system must be used routinely to prioritize and monitor injury and disease prevention and research programs. The success of injury prevention will depend not just on use of surveillance but also partnerships among the medical, surveillance, and safety agencies of the military services as well as the military commanders, other decision makers, and service members whose direct actions can prevent injuries and disease.

Fetal alcohol syndrome: a review for Texas physicians.

Fetal alcohol syndrome (FAS) is commonly believed to be the leading known cause of mental retardation in the United States, although surveillance at state and national levels is problematic. The most serious consequence of fetal alcohol exposure is central nervous system (CNS) dysfunction. While the facial features of FAS become more subtle with age, growth deficits and, particularly, the CNS impairment appear to be permanent. Among factors that affect the risk and severity of fetal alcohol damage are the timing of the alcohol exposure, binge drinking that produces high blood alcohol concentrations, polydrug use, and genetic variations. From various studies, the incidence of FAS ranges from 0.2 to 3.0 affected birth per 1000 live births. The methods of measuring FAS occurrence are fraught with difficulties and inaccuracies, as are surveys of alcohol use by women during pregnancy. Still, indirect studies both in Texas and the United States suggest that the occurrence of FAS is increasing. A first, important step to reducing the incidence of FAS and related problems is to increase the awareness of physicians and other health care providers about the issues of FAS diagnosis, prevention, and treatment. Referral and information resources about FAS are provided.

Status of tuberculosis infection control programs at Texas hospitals, 1989 through 1991.

BACKGROUND: Paralleling the resurgence of tuberculosis (TB) in the United States, the reported number of persons with TB in Texas increased by 33% during 1985 through 1992, the third largest rise among all the states. This increase prompted us to survey hospitals in Texas to determine their degree of compliance with recommendations in the Centers for Disease Control and Prevention TB guidelines. METHODS: In April 1992, we mailed a voluntary questionnaire about TB infection control practices, health care worker tuberculin skin testing procedures, and Mycobacterium tuberculosis laboratory methods to a convenience sample of hospitals in Texas. RESULTS: Of 180 hospitals surveyed, 151 (83%) returned completed questionnaires. Of these, 90 (60%) were nonteaching community hospitals; 28 (19%) were teaching community hospitals; 13 (9%) were university-affiliated hospitals; and 20 (13%) were other hospitals. The number of hospitals to which patients with TB were admitted increased from 98 (65%) in 1989 to 122 (81%) in 1991. Respondent hospitals had a mean of 183 acute care beds (median 100, range 5 to 999), 6 acid-fast bacillus isolation rooms (median 2, range 0 to 57) and 7.5 admissions/year of patients with TB (median 2, range 0 to 202). Of hospitals responding to specific questions, 20% (27/137) admitted patients with multidrug-resistant TB, 18% (25/140) reported not having any acid-fast bacillus isolation rooms, and 28% (35/125) had no rooms meeting all of the Centers for Disease Control and Prevention criteria for acid-fast bacillus isolation (negative air pressure, > or = 6 air changes per hour, and air directly vented to the outside). The tuberculin skin test conversions among health care workers rose from 246 (0.6%) in 1989 to 547 (0.9%) in 1991. CONCLUSION: Although the number of Texas hospitals admitting patients with TB increased during 1989 through 1991, many facilities still did not have infection control practices consistent with the 1992 Centers for Disease Control and Prevention TB guidelines.

Surveillance for silicosis, 1993--Illinois, Michigan, New Jersey, North Carolina, Ohio, Texas, and Wisconsin.

PROBLEM/CONDITION: Silicosis is an occupational respiratory disease caused by the inhalation of respirable dust containing crystalline silica. Public health surveillance programs to identify workers at risk for silicosis and target workplace-specific and other prevention efforts are currently being field-tested in seven U.S. states. REPORTING PERIOD COVERED: Confirmed cases ascertained by state health departments during the period January 1, 1993, through December 31, 1993; the cases and associated workplaces were followed through December 1994. DESCRIPTION OF SYSTEMS: As part of the Sentinel Event Notification System for Occupational Risks (SENSOR) program initiated by CDC's National Institute for Occupational Safety and Health (NIOSH), development of state-based surveillance and intervention programs for silicosis was initiated in 1987 in Michigan, New Jersey, Ohio, and Wisconsin and in 1992 in Illinois, North Carolina, and Texas. RESULTS: From January 1, 1993, through December 2, 1994, the SENSOR silicosis programs in Illinois, Michigan, New Jersey, North Carolina, Ohio, Texas, and Wisconsin confirmed 256 cases of silicosis that were initially ascertained in 1993. Overall, 185 (72%) were initially identified through review of hospital discharge data or through hospital reports of silicosis diagnoses; 188 (73%) were associated with silica exposure in manufacturing industries (e.g., foundries; stone, clay, glass, and concrete manufacturers; and industrial and commercial machinery manufacture). Overall, 42 (16%) cases were associated with silica exposure from sandblasting operations. Among the 193 confirmed cases for which information was available about duration of employment in jobs with potential exposure to silica, 37 (19%) were employed < or = 10 years in such jobs and 156 (81%) were employed > or = 11 years. A total of 192 primary workplaces associated with potentially hazardous silica exposures were identified for the 256 confirmed silicosis cases. Of these, nine (5%) workplaces were inspected by state health department (SHD) industrial hygienists, 19 (10%) were referred to the Occupational Safety and Health Administration (OSHA) for follow-up, and seven (4%) were routinely monitored by the Mine Safety and Health Administration. Of the 157 (82%) remaining workplaces, follow-up activities determined that 82 were no longer in operation, eight were no longer using silica, 18 were assigned a lower priority for follow-up, six were associated with building trades and could not be inspected because of the transient nature of work in the construction industry, and 43 workplaces were not inspected for other reasons. Fourteen (7%) of the 192 workplaces were inspected. At 10 of the 14 workplaces, airborne levels of crystalline silica were measured; in nine, silica levels exceeded the NIOSH-recommended exposure level of 0.05 mg/m, and in six, airborne silica levels also exceeded federal permissible exposure limits. ACTIONS TAKEN: Employee-specific and other preventive interventions have been initiated in response to reported cases. In addition, special silicosis prevention projects have been initiated in Michigan, New Jersey, North Carolina, Ohio, Texas, and Wisconsin. To facilitate the implementation of silicosis surveillance by other states, efforts are ongoing to identify and standardize core data needed by surveillance programs to describe cases and the workplaces where exposure occurred. These core variables will be incorporated into a user-friendly software system that states can use for data collection and reporting.

Postoperative infections traced to contamination of an intravenous anesthetic, propofol.

BACKGROUND: Between June 1990 and February 1993, the Centers for Disease Control and Prevention conducted investigations at seven hospitals because of unusual outbreaks of bloodstream infections, surgical-site infections, and acute febrile episodes after surgical procedures. METHODS: We conducted case-control or cohort studies, or both, to identify risk factors. A case patient was defined as any patient who had an organism-specific infection or acute febrile episode after a surgical procedure during the study period in that hospital. The investigations also included reviews of procedures, cultures, and microbiologic studies of infecting, contaminating, and colonizing strains. RESULTS: Sixty-two case patients were identified, 49 (79 percent) of whom underwent surgery during an epidemic period. Postoperative complications were more frequent during the epidemic period than before it. Only exposure to propofol, a lipid-based anesthetic agent, was significantly associated with the postoperative complications at all seven hospitals. In six of the outbreaks, an etiologic agent (Staphylococcus aureus, Candida albicans, Moraxella osloensis, Enterobacter agglomerans, or Serratia marcescens) was identified, and the same strains were isolated from the case patients. Although cultures of unopened containers of propofol were negative, at two hospitals cultures of propofol from syringes currently in use were positive. At one hospital, the recovered organism was identical to the organism isolated from the case patients. Interviews with and observation of anesthesiology personnel documented a wide variety of lapses in aseptic techniques. CONCLUSIONS: With the increasing use of lipid-based medications, which support rapid bacterial growth at room temperature, strict aseptic techniques are essential during the handling of these agents to prevent extrinsic contamination and dangerous infectious complications.

Acute health effects in a community after a release of hydrofluoric acid.

Approximately 3,000 persons were evacuated from a Texas community after 24,036 kg (53,000 lb) of caustic hydrofluoric acid (HF) were released from a nearby petrochemical plant. Emergency room and hospital records of 939 persons who were seen at two area hospitals were reviewed. Most persons who presented at the emergency rooms were female (56%) or black (60%), and their mean age was 33.9 y. The most frequently reported symptoms were eye irritation (41.5%), burning throat (21%), headache (20.6%), and shortness of breath (19.4%). Physical examination results were normal for 49% of the cases; however, irritation of the eyes, nose, throat, skin, and lungs were noted on other exams. Decreased pulmonary function was demonstrated by pulmonary function tests (forced expiratory volume in the first second, less than 80% of predicted value, 42.3%); hypoxemia (pO2 less than 80 mm Hg, 17.4%) and hypocalcemia (less than 8.5 mg/dl, 16.3%) were also noted. Ninety-four (10%) of the cases were hospitalized, and more than 83% of all cases were discharged with a primary diagnosis of "HF exposure." There are several reports of individuals who are acutely and chronically exposed to HF; however, we are unaware of other published reports that describe exposure of a community to HF. This incident represented a unique opportunity to study the immediate health impact on a community of residents who were exposed to a hazardous materials release. Results of this analysis suggest that (a) initial health problems should be followed up, (b) any long-term health effects of HF exposure must be assessed, and (c) the health impact on the population at risk should be determined.

Asbestos-associated disease: a review.

Asbestos and its potential for adversely affecting health remain a source of concern to several sectors of society. Since it rarely occurs in the absence of occupational exposure to asbestos, and because it is potentially preventable, asbestosis was recently defined as a reportable occupational disease in Texas. An overview of the cardinal characteristics of the asbestos minerals and their associated health effects is presented. The role of the primary physician in diagnosis and counseling of individuals with asbestos-associated diseases is addressed.

Survey of underlying conditions of persons hospitalized with acute respiratory disease during influenza epidemics in Houston, 1978-1981.

The peak occurrence of hospitalizations of persons with acute respiratory disease (ARD), usually pneumonia, has coincided with the peak of influenza virus activity each year. The purpose of this study was to examine the diagnoses other than ARD on the discharge record of patients hospitalized with ARD. We were particularly interested in determining the frequency of high-risk conditions for which influenza vaccine is currently recommended. The risk for ARD hospitalization was 19.7 per ten thousand for persons with high-risk conditions and only 9.3 for persons without. Chronic pulmonary disorders were the most common underlying conditions identified, and persons with pulmonary conditions had the greatest risk for ARD hospitalization. The highest rate occurred among persons older than 65 yr of age with pulmonary conditions (87.5 per ten thousand), and the rate was 27.5 for persons 45 to 64 yr of age. Cardiac conditions were the second most frequent group of underlying disorders of patients hospitalized with ARD. Only for persons younger than 20 yr of age was the risk of ARD hospitalization greater for persons with cardiac conditions than for those with pulmonary conditions (22.9 and 14.9 per ten thousand, respectively). Death, however, was more frequent among persons with underlying heart disease. Intensified effort is needed to fully implement recommendations for prophylaxis of influenza in order to reduce these risks.

Acute respiratory disease hospitalizations as a measure of impact of epidemic influenza.

Current measures of the health impact of epidemic influenza focus on analyses of death certificate data which may underestimate the true health effect. Previous investigations of influenza-related morbidity either have lacked virologic confirmation of influenza virus activity in the community or were not population-based. Community virologic surveillance in Houston, Texas has demonstrated that influenza viruses have produced epidemics each year since 1974. This study examined the relationship of hospitalizations with acute respiratory disease to the occurrence of influenza epidemics. Discharge records of 13,297 acute respiratory disease hospitalizations that occurred between July 1978 and June 1981 were obtained from 11 hospitals with 48.4% of hospital beds available in Harris County (metropolitan Houston). The correlation of adult acute respiratory disease hospitalizations with established indices of community acute respiratory disease morbidity was strong (r = 0.74) and indicated that the peak of adult acute respiratory disease hospitalizations followed the peak of influenza virus isolations by one week. Only 23.2% of persons hospitalized were 65 years of age or older, compared to 60-70% of persons who die during influenza epidemics. Although the highest rates of acute respiratory disease hospitalizations occurred among infants and persons aged 65 years or older, the rates for adults 45-64 years and preschool children aged 1-4 years were greater than 1 per 1,000 persons. Surveillance of acute respiratory disease hospitalizations can improve the measurement of serious morbidity associated with epidemic influenza, and can better define the characteristics of persons at risk for development of illness requiring hospitalization.

Cell-free varicella-zoster virus in cultured human melanoma cells.

Varicella-zoster virus (VZV) has been isolated and serially propagated in a continuous cell line derived from a human malignant melanoma tumour. Human melanoma cells (HMC) have been further evaluated as a substrate for the production of cell-free virus and compare favourably with human embryo cells. Within 60 h after inoculation with VZV-infected cells, HMC monolayers incubated at 32 degrees C exhibited advanced syncytial cytopathic effect, and the overlying culture medium contained greater than 10(2) p.f.u./ml. The cell pellet from a mechanically dispersed 150 cm2 monolayer yielded 10(5) p.f.u. after sonic disruption, while the medium ('scraping medium') in which the cells had been harvested contained up to one log more infectious virus than was found in the cells from the same monolayer. When infected cells were subjected to Dounce homogenization, most of the infectivity was found in the nuclear fraction. The concentration and purification of cell-free virus were also investigated. Concentration was carried out by three methods: ultracentrifugation, dialysis against hydrophilic compounds and liquid polymer phase separation. The first two procedures caused considerable loss of biological activity, whereas precipitation with 8% polyethylene glycol resulted in a 50-fold increase in titre. Purification of cell-free virus with retention of infectivity was achieved by rate zonal centrifugation in linear potassium tartrate gradients. Infectious virus was also recovered after sedimentation in combination equilibrium-viscosity gradients of potassium tartrate and glycerol, but not after centrifugation to equilibrium in caesium chloride gradients.