Biomonitoring of exposure to Great Lakes contaminants among licensed anglers and Burmese refugees in Western New York: Toxic metals and persistent organic pollutants, 2010-2015.

Between 2010 and 2015, the New York State Department of Health (NYSDOH) conducted a biomonitoring program to gather exposure data on Great Lakes contaminants among licensed anglers and Burmese refugees living in western New York who ate locally caught fish. Four hundred and nine adult licensed anglers and 206 adult Burmese refugees participated in this program. Participants provided blood and urine samples and completed a detailed questionnaire. Herein, we present blood metal levels (cadmium, lead, and total mercury) and serum persistent organic pollutant concentrations [polychlorinated biphenyls (PCBs), polybrominated diphenyl ethers (PBDEs), dichlorodiphenyldichloroethylene (DDE), and trans-nonachlor]. Multiple linear regression was applied to investigate the associations between analyte concentrations and indicators of fish consumption (locally caught fish meals, store-bought fish meals, and consuming fish/shellfish in the past week). Licensed anglers consumed a median of 16 locally caught fish meals and 22 store-bought fish meals while Burmese refugees consumed a median of 106 locally caught fish meals and 104 store-bought fish/shellfish meals in the past year. Compared to the general U.S. adult population, licensed anglers had higher blood lead and mercury levels; and Burmese refuges had higher blood cadmium, lead, and mercury, and higher serum DDE levels. Eating more locally caught fish was associated with higher blood lead, blood mercury, and serum ∑PCBs concentrations among licensed anglers. Licensed anglers and Burmese refugees who reported fish/shellfish consumption in the past week had elevated blood mercury levels compared with those who reported no consumption. Among licensed anglers, eating more store-bought fish meals was also associated with higher blood mercury levels. As part of the program, NYSDOH staff provided fish advisory outreach and education to all participants on ways to reduce their exposures, make healthier choices of fish to eat, and waters to fish from. Overall, our findings on exposure levels and fish consumption provide information to support the development and implementation of exposure reduction public health actions.

Biomonitoring of per- and polyfluoroalkyl substances in minority angler communities in central New York State.

Onondaga Lake in central New York State was listed as a Superfund site in 1994 due to industrial disposal of pollutants. A biomonitoring program was conducted to assess exposure to over 70 legacy contaminants and contaminants of emerging concern in populations disproportionately at risk for exposure residing near Onondaga Lake and to educate these communities on how to reduce exposures. The populations of focus were refugees from Burma and Bhutan and low-income, primarily African American, anglers (urban anglers). These communities consume locally caught fish for economic as well as cultural reasons and therefore may be at higher risk of exposure. This study focuses on assessment of exposure to per- and polyfluoroalkyl substances (PFAS) and associations with local fish consumption. Using respondent driven sampling, 311 refugees and 89 urban anglers were enrolled in the study. Following informed consent, study participants provided blood and urine specimens and completed a questionnaire. Percentiles of locally caught fish meals in the past 12 months by race/ethnicity groups showed that the Burmese participants of Karen ethnicity were the highest consumers, with a median of 135 meals compared to 103 meals for the other Burmese participants, 70 meals for the urban anglers, and 44 meals for the Bhutanese participants. Compared to the National Health and Nutrition Examination Survey (NHANES) 2015-16 sample of the general U.S. population, the Karen participants had markedly elevated perfluorooctane sulfonic acid (PFOS) and perfluorodecanoic acid (PFDA) levels with median serum concentrations 9.5 times greater (41.6 ng/mL vs. 4.4 ng/mL) and 26.9 times greater (2.69 ng/mL vs. 0.10 ng/mL), respectively; the other Burmese participants had moderately elevated levels of PFOS and PFDA with median serum concentrations 3.0 times greater (13.3 ng/mL vs. 4.4 ng/mL) and 7.3 greater times greater (0.73 ng/mL vs. 0.10 ng/mL), respectively; and, PFAS levels were not elevated in the Bhutanese or urban angler cohorts. Male gender was consistently the strongest predictor of PFAS exposure among all study cohorts. A positive association between local fish consumption was indicated only for PFOS among urban anglers. An association between local fish consumption and PFAS was not statistically significant among the refugee cohorts, perhaps due to the lack of 'lower-end' exposure or exposure variability. Community events were held by the program staff to present the biomonitoring results and distribute community outreach materials with visual aids specific for the study populations to promote safe fish eating.

Biomonitoring of toxic metals, organochlorine pesticides, and polybrominated biphenyl 153 in Michigan urban anglers.

The 32-mile Detroit River and surrounding tributaries have been designated as a Great Lakes Area of Concern due to pollution from decades of municipal and industrial discharges, sewer overflows and urban development. The Agency for Toxic Substances and Disease Registry and the Michigan Department of Health and Human Services conducted a biomonitoring study to assess exposures to persistent toxic substances in Detroit urban shoreline anglers who may be at high exposure risk due to consumption of locally caught fish. Using a modified venue-based sampling approach, 287 adult shoreline anglers along the Detroit River were recruited and participated in the program. Study participants provided blood and urine specimens and completed a questionnaire interview. In this report, we examine percentile estimates for blood lead, blood manganese, urine arsenic, urine mercury, urine cadmium, organochlorine pesticides in serum (mirex, hexachlorobenzene, chlordane), and serum polybrominated biphenyl 153 (PBB 153) concentrations among study participants. Multiple linear regression was used to identify predictors of contaminant concentrations. The Detroit urban anglers' blood lead concentrations were 2 times higher than the general adult U.S. population (median (95% CI): 2.9 µg/dL (1.8-2.3) vs. 0.94 µg/dL (0.90-0.98)). PBB 153 levels were 1.8 times higher than the general adult U.S. population at the 95th percentile (95th percentile, 95% CI: 62.7 ng/g of lipid, 53.2-75.2 vs. 34.6 ng/g of lipid, 12.8-66.8). Percentile estimates of the other study pollutants were similar to background levels found in the general U.S. population. Eating more locally caught fish was not associated with increased body burdens for any of the contaminants examined in this report. Higher blood lead was associated with increased age, male sex, current smoking, residing in a home built before 1960, an annual income less than $25,000, and a work history of lead paint removal. Evidence of PBB exposure in our study cohort likely reflects the continued effect of a widespread contamination of livestock feed in 1973 among Michigan's lower peninsula population. These study results help determine if the pollutants examined warrant further consideration in subsequent population-based biomonitoring of frequent consumers of fish from the Detroit River and surrounding waterways. The biomonitoring data from this study also served to inform public health officials regarding the potential need for environmental public health actions to reduce harmful exposures.

Assessing exposures to per- and polyfluoroalkyl substances in two populations of Great Lakes Basin fish consumers in Western New York State.

BACKGROUND: Fish and other seafood are an important dietary source of per- and polyfluoroalkyl substances (PFAS) exposure in many areas of the world, and PFAS were found to be pervasive in fish from the Great Lakes area. Few studies, however, have examined the associations between Great Lakes Basin fish consumption and PFAS exposure. Many licensed anglers and Burmese refugees and immigrants residing in western New York State consume fish caught from the Great Lakes and surrounding waters, raising their risk of exposure to environmental contaminants including PFAS. The aims of this study were to: 1) present the PFAS exposure profile of the licensed anglers and Burmese refugees and 2) examine the associations between serum PFAS levels and local fish consumption. METHODS: Licensed anglers (n = 397) and Burmese participants (n = 199) provided blood samples and completed a detailed questionnaire in 2013. We measured 12 PFAS in serum. Multiple linear regression was used to assess associations between serum PFAS concentrations and self-reported consumption of fish from Great Lakes waters. RESULTS: Licensed anglers and Burmese participants reported consuming a median of 16 (IQR: 6-36) and 88 (IQR: 44-132) meals of locally caught fish in the year before sample collection, respectively (data for Burmese group restricted to 10 months of the year). Five PFAS were detected in almost all study participants (PFOS, PFOA, PFHxS, PFNA and PFDA; 97.5-100%). PFOS had the highest median serum concentration in licensed anglers (11.6 ng/mL) and the Burmese (35.6 ng/mL), approximately two and six times that of the U.S. general population, respectively. Serum levels of other PFAS in both groups were generally low and comparable to those in the general U.S. POPULATION: Among licensed anglers, Great Lakes Basin fish meals over the past year were positively associated with serum PFOS (P < 0.0001), PFDA (P < 0.0001), PFHxS (P = 0.01), and PFNA (P = 0.02) and the number of years consuming locally caught fish was positively associated with serum PFOS (P = 0.01) and PFDA (P = 0.01) levels. In the Burmese group, consuming Great Lakes Basin fish more than three times a week in the past summer was positively associated with serum PFOS (P = 0.004) and PFDA (P = 0.02) among the Burmese of non-Karen ethnicity, but not among those of Karen ethnicity, suggesting potential ethnic differences in PFAS exposure. CONCLUSIONS: Great Lakes Basin fish consumption was associated with an increase in blood concentrations of some PFAS, and especially of PFOS, among licensed anglers and Burmese refugees and immigrants in western New York State. In the Burmese population, there may be other important PFAS exposure routes related to residential history and ethnicity. Continued outreach efforts to increase fish advisory awareness and reduce exposure to contaminants are needed among these populations.

Biomonitoring of populations in Western New York at risk for exposure to Great Lakes contaminants.

The New York State Department of Health conducted the Healthy Fishing Communities Program in collaboration with the Agency for Toxic Substances and Disease Registry to assess human exposure to contaminants common to Lake Ontario, Lake Erie and surrounding rivers and waterways among populations in western New York State who eat locally caught fish. The program enrolled licensed anglers and Burmese refugees and immigrants, living near four designated Great Lakes Areas of Concern: Buffalo River, Niagara River, Eighteenmile Creek, and the Rochester Embayment. These target populations were sampled and enrolled independently into the program between February and October of 2013. A core set of contaminants were measured in blood and urine of 409 licensed anglers and 206 Burmese refugees and immigrants which included lead, cadmium, mercury, PCBs, PBDEs, organochlorine pesticides (hexachlorobenzene, mirex, DDT, DDE, and chlordane and its metabolites oxychlordane and trans-Nonachlor), and PFOS and PFOA. Biomonitoring results showed that both groups had higher geometric means for blood lead, total blood mercury, and serum PFOS compared to the 2013-2014 NHANES reference levels. The Burmese refugee group also showed higher geometric means for creatinine-adjusted urine mercury and lipid-adjusted serum DDE compared to national levels. Licensed angler participants reported eating a median of 16 locally caught fish meals in the past year. Burmese participants consumed local fish throughout the year, and most frequently in the summer (median 39 fish meals or 3 times a week). The study results provide valuable information on populations at high risk of exposure to contaminants in the Great Lakes Basin of western New York. The results provide the foundation for developing and implementing public health actions to reduce potential exposures to Great Lakes pollutants.

Biomonitoring of mercury and persistent organic pollutants in Michigan urban anglers and association with fish consumption.

The 32-mile Detroit River and surrounding tributaries have been designated as a Great Lakes Area of Concern due to pollution from decades of municipal and industrial discharges, sewer overflows and urban development. Key pollutants in fish samples from the Detroit River include mercury, polychlorinated biphenyls (PCBs), dichlorodiphenyldichloroethylene (DDE), dioxins and furans. A biomonitoring study was conducted to assess exposures to these persistent toxic substances in Detroit urban shoreline anglers who may be at high exposure risk due to consumption of locally caught fish. Using a modified venue-based sampling approach, 287 adult shoreline anglers along the Detroit River were recruited and participated in the program. Study participants provided blood and urine specimens and completed a questionnaire following informed consent. We examined percentile estimates for total blood mercury, PCBs, DDE, and dioxin-like total toxic equivalency (TEQ) concentrations among study participants. Multiple linear regression was used to identify important predictors of contaminant concentrations. Participants consumed a median of 64 Detroit River caught fish meals in the past year. The Detroit urban anglers' median total blood mercury concentrations was 3.2 times higher than that for the general adult U.S. population. PCB concentrations among the Detroit anglers aged 18-39 years were higher than the U.S. population of the same race/ethnicity. Elevated levels of DDE and total TEQ concentrations were not observed in the cohort. Eating more locally caught fish was associated with higher total blood mercury and serum PCB concentrations. The biomonitoring data served to inform public health officials and help guide environmental public health actions to reduce harmful exposures.

Biomonitoring programs in Michigan, Minnesota and New York to assess human exposure to Great Lakes contaminants.

Over the past century, industrialization and urban practices have resulted in the contamination of the Great Lakes ecosystem-the world's largest surface freshwater system-that provides drinking water and recreation to more than 40 million residents. In 2010, the Great Lakes Restoration Initiative was launched to accelerate efforts to protect and restore the Great Lakes and surrounding areas. Funded by GLRI, the Agency for Toxic Substances and Disease Registry initiated the Biomonitoring of Great Lakes Populations (BGLP) program. The objective of the program is to assess human exposure to legacy and emerging contaminants in the Great Lakes by measuring the body burden of contaminants in potentially susceptible populations. The BGLP program consists of a series of cross-sectional studies carried out collaboratively with states that are funded through ATSDR. The first BGLP Program (BGLP-I) began in 2010 and was completed in September 2015 through cooperative agreements with state health departments in Michigan, Minnesota, and New York. The three state programs targeted susceptible adult populations living in designated areas of contamination. Contaminants measured in all populations include mercury, lead, mirex, hexachlorobenzene, dichlorodiphenyltrichloroethane, and selected polychlorinated biphenyl congeners. In addition, some chemicals of emerging concern, such as per- and polyfluoroalkyl substances, were measured in several populations. The biomonitoring results helped guide public health actions to mitigate chemical exposures in these vulnerable Great Lakes populations. We provide an overview of the BGLP-I program's study populations, designs, and general methods. This overview provides a lead-in for subsequent manuscripts that present human biomonitoring data for legacy and emerging contaminants in culturally diverse susceptible populations-i.e., shoreline anglers, sport anglers, American Indians, and Burmese immigrants-residing in seven areas of concern.

Regional Variation in Human Exposure to Persistent Organic Pollutants in the United States, NHANES.

We examined serum levels of persistent organic pollutants (POPs) among geographical regions of the United States as defined by the US Census Bureau. National Health and Nutrition Examination Survey (NHANES) data for adults aged 20 years and older are presented for selected survey periods between 1999 and 2010. From NHANES 1999 through 2004, dichlorodiphenyldichloroethylene (DDE) concentration levels were consistently higher among people living in the West than in the Midwest, Northeast, or South. In 2003-2010, perfluorinated compound concentrations tended to be highest in the South. The sum of 35 polychlorinated biphenyls (PCBs) congeners was significantly higher in the Northeast [GM: 189; 95% CI: 173-204 ng/g lipid] than the remaining regions. The regional differences in higher body burdens of exposure to particular POPs could be attributed to a variety of activities, including region-specific patterns of land use and industrial and agricultural chemical applications, as well as different levels of regulatory activity.

Communities near toluene diisocyanate sources: an investigation of exposure and health.

Toluene diisocyanate (TDI) is a well-known cause of occupational asthma, but we know little about the potential for exposure and health effects among residents who live near facilities that release TDI. In the mid-1990's, the North Carolina Department of Health and Human Services and the Agency for Toxic Substances and Disease Registry investigated exposures to TDI and health outcomes in one community, which left some unanswered questions. This cross-sectional study evaluated the potential associations between living near a TDI source and the prevalence of three variables: asthma or asthma-like respiratory symptoms, antibodies specific to TDI, and verifiable levels of TDI in residential air. Results among North Carolina residents living near such facilities (five target communities) were compared with the results from residents living further away (five comparison communities). Overall, the prevalence of reporting either asthma or asthma-like respiratory symptoms was higher (odds ratio = 1.60; 95% confidence interval = 0.97-2.54) among residents in target communities than those in comparison communities. However, this difference was not statistically significant. Symptom prevalence varied greatly among the community populations. The prevalence of respiratory symptoms was higher near facilities with historically higher TDI emissions. Among the 351 participants who provided blood samples, only one had immunoglobulin G specific antibodies to TDI. This participant lived in a target area and may have had non-occupational exposure. TDI was detected at an extremely low level (1 ppt) in one of the 45 air samples from target communities. One ppt is one-tenth the EPA reference concentration. Overall, air sample and antibody test results are not consistent with recent or ongoing exposure to TDI.

State programs to reduce uncontrolled ammonia releases and associated injury using the hazardous substances emergency events surveillance system.

OBJECTIVE: To describe how the Hazardous Substances Emergency Events Surveillance (HSEES) program identifies leading causes of uncontrolled ammonia releases and targets activities aimed at reducing the frequency of these incidents. METHODS: Ammonia incidents reported to HSEES nationally were examined. HSEES programs in state health departments conducted and evaluated data-driven prevention outreach. RESULTS: The primary targeted ammonia incidents in the three HSEES states that are presented include food manufacturing, agriculture, and events related to the production of illicit methamphetamine. Key to these prevention activities was using state-specific HSEES data to identify problems and evaluate the prevention activity, and developing partnerships with other stakeholders. CONCLUSION: HSEES data is used to identify determinants of chemical incidents and their outcomes and to help guide strategies to reduce such occurrences. Surveillance of chemical incidents elucidates the causes and consequences of these events and helps identify problems and measure the effectiveness of prevention programs.

Acute hazardous substance releases resulting in adverse health consequences in children: Hazardous Substances Emergency Events Surveillance system, 1996-2003.

Because of their small size and ongoing organ development, children may be more susceptible than adults to the harmful effects of toxic chemicals. The objective of the study reported here was to identify frequent locations, released substances, and factors contributing to short-term chemical exposures associated with adverse health consequences experienced by children. The study examined the Hazardous Substances Emergency Events Surveillance (HSEES) system data from 1996-2003. Eligible events involved the acute release of a hazardous substance associated with at least one child being injured. The study found that injured children were predominantly at school, home, or a recreational center when events took place. School-related events were associated with the accidental release of acids and the release of pepper spray by pranksters. Carbon monoxide poisonings occurring in the home, retail stores, entertainment facilities, and hotels were responsible for about 10 percent of events involving child victims. Chlorine was one of the top chemicals harmful to children, particularly at public swimming pools. Although human error contributed to the majority of releases involving child victims, equipment failure was responsible for most chlorine and ammonia releases. The authors conclude that chemical releases resulting in injury to children occur mostly in schools, homes, and recreational areas. Surveillance of acute hazardous chemical releases helped identify contributing causes and can guide the development of prevention outreach activities. Chemical accidents cannot be entirely prevented, but efforts can be taken to provide safer environments in which children can live, learn, and play. Wide dissemination of safety recommendations and education programs is required to protect children from needless environmental dangers.

Healthy and safe school environment, Part II, Physical school environment: results from the School Health Policies and Programs Study 2006.

BACKGROUND: As society continues to focus on the importance of academic achievement, the physical environment of schools should be addressed as 1 of the critical factors that influence academic outcomes. The School Health Policies and Programs Study (SHPPS) 2006 provides, for the first time, a comprehensive look at the extent to which schools have health-promoting physical school environment policies and programs. METHODS: The Centers for Disease Control and Prevention conducts the SHPPS every 6 years. In 2006, computer-assisted telephone interviews or self-administered mail questionnaires were completed by state education agency personnel in all 50 states and the District of Columbia and among a nationally representative sample of school districts (n=424). Computer-assisted personal interviews were conducted with personnel in a nationally representative sample of elementary, middle, and high schools (n=992). RESULTS: One third (35.4%) of districts and 51.4% of schools had an indoor air quality management program; 35.3% of districts had a school bus engine-idling reduction program; most districts and schools had a policy or plan for how to use, label, store, dispose of, and reduce the use of hazardous materials; 24.5% of states required districts or schools to follow an integrated pest management program; and 13.4% of districts had a policy to include green design when building new school buildings or renovating existing buildings. CONCLUSIONS: SHPPS 2006 results can guide education and health agency actions in developing and implementing evidence-based tools, policies, programs, and interventions to ensure a safe and healthy physical school environment.

Surveillance of hazardous substance emergency events: identifying areas for public health prevention.

The Hazardous Substances Emergency Events Surveillance (HSEES) system is a comprehensive, state-based surveillance system of hazardous substance releases and public health consequences. Maintained by the Agency for Toxic Substances and Disease Registry (ATSDR) since 1990, the system captures information on acute releases of hazardous substances that need to be cleaned up or neutralized according to federal, state, or local law. Information about threatened releases that result in public health action such as evacuation is also included. Of the 39,766 events reported to HSEES for 1996--2001, 8% resulted in deaths or injuries. Funded through a competitive program announcement, 15 states currently participate in HSEES. State coordinators actively collect data from multiple sources after an eligible event occurs and enter data about the event into a standardized ATSDR-provided web-based system. The information in HSEES describes the distribution and characteristics of hazardous substances emergencies and the morbidity and mortality experienced by employees, responders, and the general public as the result of hazardous substances releases. Analysis of HSEES data helps identify risk factors associated with hazardous substances releases. For example, although events in which chlorine was released account for only 1.6% of all events, they were 3.52 times more likely to result in injuries. Knowledge of these factors is useful in planning public safety interventions and can impact the formulation of guidelines and policies to help reduce the number of events (primary prevention) and the morbidity and mortality associated with these events (secondary prevention). Utilizing state-specific analyses of HSEES data, participating states have been able to develop prevention outreach activities such as awareness training of first responders, primary prevention of spills, and secondary prevention of related injuries and deaths caused by ammonia, chlorine, and mercury. Specific examples involving ammonia, chlorine, and mercury releases will be presented in detail.

Releases from improper chemical mixing, Hazardous Substances Emergency Events Surveillance system, 1996-2001.

OBJECTIVE: To examine the public health consequences of acute hazardous substance releases resulting from the improper mixing of chemicals. METHODS: Data from the Agency for Toxic Substances and Disease Registry's Hazardous Substances Emergency Events Surveillance system for 1996-2001 events were analyzed. RESULTS: "Private households" was the most frequent industry classification among improper mixing events, and chlorine was associated with a greater prevalence of improper mixing events. Releases from improper mixing were considerably more likely to involve fire, explosion, and fire-explosion combined; were markedly more likely to result in personal injury (48% for improper mixing events vs. 7% other events); and had a significantly greater percentage of victims with traumatic injury (PR = 3.07, 95% CI = 2.55-3.71). CONCLUSIONS: Improper chemical mixing can cause dangerous, harmful reactions and are preventable. Consumers should be educated to avoid mixing noncompatible products.

Trends in hypertension-related death in the United States: 1980-1998.

Trends in hypertension-related mortality for groups by race/ethnicity, sex, and age have not been examined previously. National multiple-cause mortality files for 1980-1998 were analyzed for adult decedents with hypertension listed as one of 20 conditions causing death. Racial/ethnic comparisons of hypertension-related death were performed using age-standardized and age-specific rates in years (per 100,000). Age-standardized rate increased from 183.1 in 1980 to 243.7 in 1998, a relative increase of 33% and an average annual increase of 1.5% (p<0.0001). From 1981 to 1998, age-specific death rates increased for persons > or =85 years (average annual increase of 10.4% for blacks, 7.9% for whites), 75-84 years (5.9% for blacks, 3.6% for whites), and 65-74 years (3.2% for blacks, 1.4% for whites). By 1997-1998, blacks had greater death rates compared with whites at all ages. Over the past two decades, there has been a step-by-step increase in hypertension-related mortality, which has continued to show a male over female and black over white predominance. Prevention and control of hypertension must continue to be pursued as a strategy to reduce cardiovascular disease morbidity and mortality.

Risk factors for acute chemical releases with public health consequences: Hazardous Substances Emergency Events Surveillance in the U.S., 1996-2001.

BACKGROUND: Releases of hazardous materials can cause substantial morbidity and mortality. To reduce and prevent the public health consequences (victims or evacuations) from uncontrolled or illegally released hazardous substances, a more comprehensive analysis is needed to determine risk factors for hazardous materials incidents. METHODS: Hazardous Substances Emergency Events Surveillance (HSEES) data from 1996 through 2001 were analyzed using bivariate and multiple logistic regression. Fixed-facility and transportation-related events were analyzed separately. RESULTS: For fixed-facility events, 2,327 (8%) resulted in at least one victim and 2,844 (10%) involved ordered evacuations. For transportation-related events, 759 (8%) resulted in at least one victim, and 405 (4%) caused evacuation orders. Fire and/or explosion were the strongest risk factors for events involving either victims or evacuations. Stratified analysis of fixed-facility events involving victims showed a strong association for acid releases in the agriculture, forestry, and fisheries industry. Chlorine releases in fixed-facility events resulted in victims and evacuations in more industry categories than any other substance. CONCLUSIONS: Outreach efforts should focus on preventing and preparing for fires and explosions, acid releases in the agricultural industry, and chlorine releases in fixed facilities.

Increasing trends in hospitalization for atrial fibrillation in the United States, 1985 through 1999: implications for primary prevention.

BACKGROUND: Atrial fibrillation, the most common sustained disturbance of heart rhythm, is associated with a 5-fold increase in the incidence of ischemic stroke. METHODS AND RESULTS: The National Hospital Discharge Survey was used to estimate the annual number and prevalence of hospitalizations with atrial fibrillation among men and women 35 years of age or older. From 1985 through 1999, hospitalizations increased from 154 086 to 376 487 for a first-listed diagnosis and from 787 750 to 2 283 673 for any diagnosis. Prevalence was higher among successive age groups. Age-standardized prevalence was consistently higher among men than women. In 1999, essential hypertension, ischemic heart disease, congestive heart failure, and diabetes were prominent coexisting conditions. The number of male patients discharged home decreased from 77% to 63%, whereas the number of discharges to long-term care increased from 9% to 15%; the corresponding values for women were 72% to 56% and 15% to 23%. A slight increase in discharges to short-term care was indicated, whereas no trends were noted for in-hospital mortality. CONCLUSIONS: Hospitalizations for atrial fibrillation have increased dramatically (2- to 3-fold) in recent years. The public health burden of atrial fibrillation is enormous and expected to continue to increase over the next decades. Primary prevention of atrial fibrillation must be recognized and pursued as a complementary management strategy for reducing cardiovascular morbidity and mortality.

Establishing data elements for the Paul Coverdell National Acute Stroke Registry: Part 1: proceedings of an expert panel.

BACKGROUND AND PURPOSE: Stroke is the third-leading cause of death and a leading cause of disability in adults in the United States. In recent years, leaders in the stroke care community identified a national registry as a critical tool to monitor the practice of evidence-based medicine for acute stroke patients and to target areas for continuous quality of care improvements. An expert panel was convened by the Centers for Disease Control and Prevention to recommend a standard list of data elements to be considered during development of prototypes of the Paul Coverdell National Acute Stroke Registry. METHODS: A multidisciplinary panel of representatives of the Brain Attack Coalition, professional associations, nonprofit stroke organizations, and federal health agencies convened in February 2001 to recommend key data elements. Agreement was reached among all participants before an element was added to the list. RESULTS: The recommended elements included patient-level data to track the process of delivering stroke care from symptom onset through transport to the hospital, emergency department diagnostic evaluation, use of thrombolytic therapy when indicated, other aspects of acute care, referral to rehabilitation services, and 90-day follow-up. Hospital-level measures pertaining to stroke center guidelines were also recommended to augment patient-level data. CONCLUSIONS: Routine monitoring of the suggested parameters could promote community awareness campaigns, support quality improvement interventions for stroke care and stroke prevention in each state, and guide professional education in hospital and emergency system settings. Such efforts would reduce disability and death among stroke patients.

Increased atrial fibrillation mortality: United States, 1980-1998.

The authors used death certificate data to evaluate national trends in the reporting of atrial fibrillation as an underlying or contributory cause of death for groups defined by age (45 years or older), sex, and race (Black vs. White) and to examine comorbidity. The multiple-causes mortality files from 1980 through 1998 were analyzed for decedents, with atrial fibrillation (International Classification of Diseases, Ninth Revision, code 427.3) listed as one of up to 20 conditions causing death. The number of decedents with atrial fibrillation increased from 18,947 in 1980 to 61,946 in 1998, and the proportion with atrial fibrillation reported as the underlying cause of death rose from 8.3% in 1980 to 11.6% in 1998. Age-standardized death rates from 1980 to 1998 were consistently highest among White men, followed (in descending order) by White women, Black men, and Black women. Overall, the age-standardized rate (per 100,000) increased from 27.6 in 1980 to 69.8 in 1998 (an average annual increase of 5.4%, p < 0.0001). Ischemic heart disease was the most frequent underlying cause of death among decedents with atrial fibrillation (26.8%). These findings emphasize the need for increased application of proven prevention and control measures to decrease associated cardiovascular morbidity and mortality.