Contribution of different HFE genotypes to iron overload disease: a pooled analysis.

PURPOSE: To determine the contribution of the C282Y and H63D mutations in the HFE gene to clinical expression of hereditary hemochromatosis. METHODS: Pooled analysis of 14 case-control studies reporting HFE genotype data, to evaluate the association of different HFE genotypes with iron overload. In addition, we used data from the pooled analysis and published data to estimate the penetrance of the C282Y/C282Y genotype. RESULTS: Homozygosity for the C282Y mutation carried the largest risk for iron overload (OR = 4383, 95% CI 1374 to >10,000) and accounted for the majority of hemochromatosis cases (attributable fraction (AF) = 0.73). Risks for other genotypes were much smaller: OR = 32 for genotype C282Y/H63D (95% CI 18.5 to 55.4, AF = 0.06); OR = 5.7 for H63D/H63D (95% CI 3.2 to 10.1, AF = 0.01); OR = 4.1 for C282Y heterozygosity (95% CI 2.9 to 5.8, with heterogeneity in study results, making this association uncertain); and OR = 1.6 for H63D heterozygosity (95% CI 1 to 2.6, AF = 0.03). Estimates of penetrance for the C282Y/C282Y genotype were highly sensitive to estimates of the prevalence of iron overload disease. At a prevalence of 2.5 per 1000 or less, penetrance of the C282Y/C282Y genotype is unlikely to exceed 50%. Penetrance of other HFE genotypes is much lower. CONCLUSIONS: C282Y homozygosity confers the highest risk for iron overload but the H63D mutation is also associated with increased risk. Our data indicate a gradient of risk associated with different HFE genotypes and thus suggest the presence of other modifiers, either genetic or environmental, that contribute to the clinical expression of hemochromatosis.

Employment for people with psychiatric disabilities: knowledge dissemination utilization experiences.

As attitudes toward vocational activities for individuals with disabilities have changed, the importance of long-term funding support and of planned training have become evident. Continued emphasis is needed on the values underlying the interest in and the empowering nature of employment rights.

A coccidioidomycosis outbreak following the Northridge, Calif, earthquake.

OBJECTIVE: To describe a coccidioidomycosis outbreak in Ventura County following the January 1994 earthquake, centered in Northridge, Calif, and to identify factors that increased the risk for acquiring acute coccidioidomycosis infection. DESIGN: Epidemic investigation, population-based skin test survey, and case-control study. SETTING: Ventura County, California. RESULTS: In Ventura County, between January 24 and March 15, 1994, 203 outbreak-associated coccidioidomycosis cases, including 3 fatalities, were identified (attack rate [AR], 30 cases per 100,000 population). The majority of cases (56%) and the highest AR (114 per 100,000 population) occurred in the town of Simi Valley, a community located at the base of a mountain range that experienced numerous landslides associated with the earthquake. Disease onset for cases peaked 2 weeks after the earthquake. The AR was 2.8 times greater for persons 40 years of age and older than for younger persons (relative risk, 2.8; 95% confidence interval [CI], 2.1-3.7; P<.001). Environmental data indicated that large dust clouds, generated by landslides following the earthquake and strong aftershocks in the Santa Susana Mountains north of Simi Valley, were dispersed into nearby valleys by northeast winds. Simi Valley case-control study data indicated that physically being in a dust cloud (odds ratio, 3.0; 95% CI, 1.6-5.4; P<.001) and time spent in a dust cloud (P<.001) significantly increased the risk for being diagnosed with acute coccidioidomycosis. CONCLUSIONS: Both the location and timing of cases strongly suggest that the coccidioidomycosis outbreak in Ventura County was caused when arthrospores were spread in dust clouds generated by the earthquake. This is the first report of a coccidioidomycosis outbreak following an earthquake. Public and physician awareness, especially in endemic areas following similar dust cloud-generating events, may result in prevention and early recognition of acute coccidioidomycosis.

Transmission of Mycobacterium tuberculosis in a California State Prison, 1991.

OBJECTIVES: An investigation was conducted to determine whether ongoing transmission of Mycobacterium tuberculosis was occurring in a California state prison. METHOD: Prison pharmacy records were used to identify cases of active tuberculosis (TB). RESULTS: Ten of the 18 cases of active TB treated at the facility during 1991 were diagnosed at the prison that same year (an incidence of 184 per 100,000). Three inmates were infectious for a total of 7 months while imprisoned. The prevalence of TB skin test-positivity among inmates was 30%, and the incidence of new infection attributable to incarceration was 5.9 per 100 inmates per year. CONCLUSIONS: Transmission of M. tuberculosis may be occurring in the California prison system.

Blood lead levels in radiator repair workers in Colorado.

A laboratory-based blood lead surveillance system in Colorado identified radiator repair workers as having the highest blood lead levels of all worker groups reported. A survey of 42 radiator repair shops in ten locales throughout Colorado was undertaken to estimate the prevalence of workers with elevated blood lead levels > 25 micrograms/dL. The survey was designed to test the sensitivity of the surveillance system and to assess working conditions and practices in the radiator repair industry in Colorado. Of 63 workers, 39 (62%) had blood lead levels > 25 micrograms/dL. The sensitivity of the surveillance system for detecting radiator repair workers with elevated blood lead levels was estimated at 11%. None of the radiator repair shops had adequate local exhaust ventilation. Work practice and engineering modifications are needed to reduce lead exposure in this industry.

An evaluation of measles revaccination among school-entry-aged children.

BACKGROUND: A two dose measles vaccination schedule is recommended routinely for all school-entry-aged children. We evaluated this recommendation by determining both measles antibody seroprevalence and the response to revaccination in seronegative children in this age group. METHODS: Children 4 to 6 years of age who had received a single dose of measles vaccine between the ages of 15 to 17 months were tested for measles antibody by using enzyme-linked immunosorbent assay (ELISA) microneutralization technique. Seronegative children were revaccinated and again tested for measles antibody (immunoglobulin M [IgM] and neutralizing). RESULTS: Of 679 children tested, 37 (5.4%) were seronegative. Seronegativity was not significantly associated with age, sex, race, age at initial vaccination, time since vaccination, or maternal year of birth. However, children mothers with a college degree were 12 times more likely to be seronegative than children of mothers who never attended college (P < .01). Of the 37 seronegative children, 36 seroconverted after revaccination--33 producing IgM measles antibody, suggestive of a primary immune response. The cost per seroconversion would have been an estimated $415 if all 679 children had been revaccinated. CONCLUSIONS: Revaccination reduces the pool of children who are susceptible to measles. Although the cost per seroconversion is high, a two-dose schedule should reduce the substantial costs of controlling measles out breaks by reducing the number of outbreaks.

Nosocomial outbreak of Candida albicans sternal wound infections following cardiac surgery traced to a scrub nurse.

From August 1988 through October 1989, 15 patients at 1 hospital developed Candida albicans sternal wound infections after cardiac surgery. An investigation found that case-patients were more likely than cardiac surgery patients without sternal wound infections to have surgeries lasting > 165 min (11/15 vs. 20/45; odds ratio [OR], 5.0; 95% confidence interval [CI], 1.5-16.3) or exposure to first scrub nurse A (15/15 vs. 22/45; OR, infinity; 95% CI, 2.5, infinity). Molecular typing of 5 case-patient C. albicans isolates revealed a common strain. Nurse A had a history of recurrent vaginal infections responding to topical antifungal agents; however, cultures of multiple samples from nurse A, beginning 3 weeks after the last infected patient's surgery, failed to yield C. albicans. Following her voluntary transfer from cardiac surgery, no additional infections of case-patients were detected. This study demonstrates the utility of combining epidemiologic methods and molecular typing in investigating C. albicans infection clusters and suggests that a common exogenous source can be responsible for C. albicans surgical wound infections.

Missed opportunities for tuberculosis prevention.

BACKGROUND: With the recent resurgence of tuberculosis in the United States, it is unclear whether existing prevention strategies can successfully control and eliminate the disease. We determined the extent to which opportunities for prevention were missed among patients with tuberculosis. METHODS: For all patients with active tuberculosis reported to the Oregon Health Division, Portland, from July 1991 through June 1992, we determined previous history of tuberculosis therapy, previous tuberculin skin test status, the presence of medical conditions for which skin testing is recommended, and previous health care. We then determined whether they had undergone preventive procedures in accordance with current recommendations of the Advisory Council for the Elimination of Tuberculosis. RESULTS: Of 153 patients with active tuberculosis, 90 (59%) had indications for--but had not previously undergone--recommended procedures. Ten patients (7%) did not complete therapy for previous disease; two (1%) did not complete preventive therapy; 12 (8%) with known previous positive tuberculin skin tests and an indication for preventive therapy never received it; and 66 (43%) with known indications for screening never received a skin test. Indications for skin testing included exposure to active tuberculosis (44%), predisposing medical conditions (83%), previous residence in an institution (24%), and birth in a country with a high prevalence of tuberculosis (29%). CONCLUSIONS: Based on their known effectiveness, a major reduction in tuberculosis morbidity could occur if preventive measures were fully implemented. Appropriate skin testing is a prevention strategy of major importance. Priorities should include working to change provider practice to better ensure that persons with indications routinely receive tuberculin skin tests.

An outbreak of Norwalk virus gastroenteritis associated with eating raw oysters. Implications for maintaining safe oyster beds.

OBJECTIVE: To determine the characteristics and the cause of an outbreak of gastroenteritis associated with eating raw oysters. DESIGN: Survey of groups of persons reporting illness to the health department after eating oysters; survey of convenience sample of oyster harvesters; and tracing of implicated oysters. SETTING: General community. MAIN OUTCOME MEASURES: Relative risk for illness after oyster consumption, source bed of contaminated oysters, presence of antibodies to Norwalk virus in serum, presence of a Norwalk virus in stool by direct electron microscopy and reverse transcription-polymerase chain reaction (RT-PCR), and DNA sequences of RT-PCR products. RESULTS: Seventy (83%) of 84 persons who ate raw oysters became ill vs three (7%) of 43 people who did not eat raw oysters (relative risk, 11.9; 95% confidence interval, 4.0 to 34.2). Eleven (79%) of 14 serum pairs had at least a fourfold increase in antibody to Norwalk virus. All 12 stool samples tested were positive by electron microscopy and/or RT-PCR for Norwalk virus. The RT-PCR products from all seven stool samples tested had identical DNA sequences. Implicated oysters were harvested November 9 through 13, 1993, from a remote oyster bed. Crews from 22 (85%) of 26 oyster harvesting boats working in this area reported routine overboard disposal of sewage. One harvester with a high level of antibodies to Norwalk virus reported having gastroenteritis November 7 through 10 and overboard disposal of feces into the oyster bed. CONCLUSIONS: This outbreak was caused by contamination of oysters in the oyster bed, probably by stool from one or more ill harvesters. Education of oyster harvesters and enforcement of regulations governing waste disposal by oyster harvesting boats might prevent similar outbreaks.

Firearms in New Mexico.

To determine the prevalence of firearm ownership and storage practices in New Mexico, we did a random-digit-dialing survey of New Mexico residents in October 1991. Of 200 households surveyed, 79 (40%) had 1 or more firearms in the home. Rural households were more likely than urban households to have firearms (44% versus 30%), and households with annual incomes of greater than $25,000 were more likely to have a firearm than households with incomes of $25,000 or less (41% versus 33%). Household firearm ownership did not vary with the presence of young (< 15 years old) children (38% with children versus 41% without). Handguns were generally owned for self-protection, and rifles were owned for hunting. Of households with firearms, 24% stored them unsafely (unlocked and loaded or unloaded but with ammunition nearby), including 21% of households with young children. Of the households with handguns only, 40% stored these firearms unsafely compared with 13% of those with rifles only. The prevalence of gun ownership in New Mexico is similar to that reported in national surveys; handguns are stored less safely than rifles; and the presence of young children in the home does not appear to improve firearm storage safety.

Impact of regulation on benzodiazepine prescribing to a low income elderly population, New York State.

On 1 January 1989, in an effort to reduce diversion of benzodiazepines for illicit use and reduce inappropriate prescribing, a regulation was implemented requiring the reporting of all benzodiazepine prescriptions to the New York State Department of Health. To assess the impact of the regulation on prescribing practices to the elderly, we followed the number of benzodiazepines and other central nervous system medications prescribed to a cohort of participants in an elderly pharmaceutical insurance program. Benzodiazepines were prescribed for 4652 (22%) of the 20,944 patients studied. By the last quarter of 1989, benzodiazepines were prescribed for 3120 (15%) patients, a decrease of 33%. The number of prescriptions of benzodiazepines decreased by 5010 (45%), from 11,123 to 6113. Decreases in the number of prescriptions were similar across benzodiazepine brands (range 40-56%). Statistically significant (p < 0.05) decreases were seen in all sex, age, race and marital status groups. Increases in number (and percent increases) of prescriptions for miscellaneous anxiolytics (i.e. hydroxyzine (399, 69%), meprobamate (299, 149%), buspirone (263, 111%), chloral hydrate (138, 265%), antidepressants (658, 19%), barbiturates (150, 29%), and tranquilizers (198, 19%), some of which may be more toxic or less effective, were noted. New York State's reporting regulation was effective in reducing both the number of patients being prescribed benzodiazepines and the number of prescriptions given to those who remain on benzodiazepines in the elderly population studies.

Age as a risk factor for burn injury requiring hospitalization during early childhood.

OBJECTIVE: To examine the variation by age in the rates and causes of burn injury requiring hospitalization during early childhood. DESIGN AND SETTING: Hospital discharge data and a burn unit admission log were used to identify all children in the Denver (Colo) metropolitan area younger than 5 years who sustained burn injuries and were hospitalized in 1989 and 1990. Patients' medical records were reviewed. RESULTS: One hundred twenty-two children were identified with burn injuries that required hospitalization, an annual incidence of 40.5 per 100,000 children younger than 5 years. Children aged 6 months through 2 years accounted for 88% of all cases and were seven times more likely to be hospitalized for a burn injury than were children outside this age range. Scalding and contact with hot objects accounted for 64% and 20% of cases, respectively, and occurred primarily in the 6-month through 2-year age group. CONCLUSIONS: The findings underscore the importance of developmental stage as a determinant of risk and type of burn injury. Children aged 6 months through 2 years are at increased risk of severe burn injury and should be targeted for prevention efforts.

A description of nonfatal spinal cord injury using a hospital-based registry.

To formulate an epidemiologic description of West Virginia spinal cord injury (SCI) resulting in hospitalization, we used data collected during the West Virginia Spinal Cord Injury Registry's first three years of operation, July 1985 through June 1988, supplemented by data from registries in neighboring states. The West Virginia registry was established to detect newly injured persons potentially in need of rehabilitation services. Because reporting is hospital based, the registry records only injured patients surviving until hospitalization. The overall incidence of hospitalized SCI patients was 25 per million per year; the sex-specific rate among men was 4.6 times the rate among women. Age-specific rates peaked in the 15-24 years age group and declined with increasing age. Motor vehicle crashes accounted for 69% of all hospitalized SCI; falls, for 21%; and sports, falling objects, and violence, for less than 10% each. Most cause-specific incidence rates were highest for young males; however, falls were more common for the elderly. At least 25% of victims used drugs or alcohol shortly before injury, and none injured in auto or truck crashes reported wearing seat belts. Quadriplegia resulted for 56% of recorded SCI patients, whereas paraplegia resulted for the remaining 44%. SCI was more common in the summer months, on weekends, and during late afternoon hours. Both neurologic deficit and time of occurrence varied by cause. Although limitations exist, registry data has proved useful in describing spinal cord injury in West Virginia and has potential public health use in guiding prevention programs.

Measles in pregnancy: a descriptive study of 58 cases.

OBJECTIVE: To describe the effects of measles in pregnancy using a large case series. METHODS: Pregnant women with measles were identified by county health department records, and their hospital and clinic records were reviewed. When available, records for the infants of case patients were also reviewed. RESULTS: Fifty-eight pregnant women with measles were identified. Thirty-five (60%) were hospitalized for measles, 15 (26%) were diagnosed with pneumonia, and two (3%) died of measles complications. Excluding three induced abortions, 18 pregnancies (31%) ended prematurely; five were spontaneous abortions and 13 were preterm deliveries. All but two of the 18 pregnancies that terminated early did so within 14 days of rash onset. Two term infants were born with minor congenital anomalies, but their mothers had measles late in the third trimester. No newborns were diagnosed with congenital measles. CONCLUSIONS: The incidence of death and other complications from measles during pregnancy may be higher than expected for age-comparable, nonpregnant women. Measles in pregnancy may lead to high rates of fetal loss and prematurity, especially in the first 2 weeks after the onset of rash.

Vertical transmission of hepatitis A resulting in an outbreak in a neonatal intensive care unit.

Vertical transmission of hepatitis A virus (HAV) has not been reported. From 25 October to 15 November 1989, 10 cases of symptomatic HAV infection occurred among neonatal intensive care unit (NICU) staff. Testing of other NICU staff and patients identified 4 infected infants. Hepatitis A among staff was associated with caring for 1 of these infants, infant A (relative risk [RR], undefined; P = .05). Risk of illness was greater for staff who did not routinely wash their hands after treating infant A for apnea and bradycardia (RR = 4.9; P = .02). Staff, infants, visitors, and transfused blood products could not be implicated as a source of infant A's infection. Infant A's mother, however, was diagnosed with hepatitis A 10 days after premature labor and delivery. Evidence suggests that infant A was infected by his mother before or during birth. HAV then spread within the NICU because of breaks in infection control precautions. To prevent future outbreaks, NICU staff should adhere rigorously to body substance isolation measures.

Female employee participation in a worksite mammography screening program.

We conducted a survey of 1,184 women 35 years of age or older who were employees of a company in Los Angeles County, California, to determine why some women participated in a worksite mammography screening program whereas others did not. Of the 111 who accepted a mammogram, 90 responded to the survey; of the 1,073 who declined mammography, 620 responded. The women were predominantly white, were well educated, and had health insurance. Of the 111 women who received mammograms, one was diagnosed with carcinoma. Seventy-three percent of the respondents to the survey 40 years of age or older who declined mammograms had already fulfilled American Cancer Society (ACS) guidelines for mammography screening at the time of the program. Women who accepted a mammogram were more likely to have had at least one previous mammogram than were women who had not met ACS guidelines yet who declined screening. We conclude that many female employees who are white, are well educated, and have health insurance may not participate in a worksite mammography screening program because they have been screened elsewhere. Companies providing worksite mammography screening should target education to women who have not met ACS guidelines, especially those who have never had a mammogram.

Symptomatic La Crosse virus infections of the central nervous system: a study of risk factors in an endemic area.

In most years, La Crosse virus is the most common cause of reported mosquito-borne illness in the United States. The authors conducted a case-control study to determine if behavioral and environmental factors influenced the risk of La Crosse virus illness. Data were gathered on 31 serologically confirmed cases and 60 age-, sex-, and geography-matched controls in West Virginia in 1987 and 1988. Univariate analysis revealed minimal elevation of disease risk (odds ratios (ORs) less than 2.0) with increased time outdoors, non-use of insect repellent, non-use of air conditioning, lack of screened windows, and not wearing protective clothing. Univariate and multivariate analysis indicated that the presence of tree holes significantly increased disease risk (OR = 8.5 for greater than or equal to 1 tree hole vs. 0 tree holes). The following factors may also increase disease risk, although the findings were not statistically significant: discarded tires (OR = 3.2 for greater than or equal to 10 tires vs. 0-9 tires); non-tire artificial containers (OR = 4.1 for greater than or equal to 6 containers vs. 0-5 containers); and close proximity of the house to the forest edge (OR = 3.2 for 0-49 ft (0-14.9 m) vs. greater than or equal to 50 ft (greater than or equal to 14.9 m)). The authors conclude that the presence of natural breeding sites (tree holes) is an important risk factor for La Crosse virus illness. These results may be important in guiding future efforts aimed at preventing infection with La Crosse virus.