Tuberculosis in a correctional facility.

BACKGROUND: After the identification of five suspected cases of tuberculosis (TB) in a Nassau County (New York) jail during a 3-week period, an epidemiologic investigation was begun to document the number of cases of TB infection and disease associated with the jail, the characteristics of current or former inmates with TB disease, and the factors contributing to TB transmission in the jail. METHODS: The county TB register was matched against the inmate files of the jail. Medical records from hospitals, the health department, and the jail were then reviewed. All inmates in the jail were skin tested during a mass screening. RESULTS: From January 1, 1988, through March 16, 1990, of 205 TB cases in the county, 49 (24%) were associated with the jail. Forty of the cases occurred among current or former inmates, one in a corrections officer, and eight among community contacts of inmates. The 40 inmates with TB were predominantly nonwhite (75%), unmarried (80%) men (90%), with a median age of 32 years. Twenty-three (58%) had a history of injecting drug use, and 14 (35%) were known to be seropositive for the human immunodeficiency virus. Thirty (75%) of the inmates had culture-confirmed pulmonary TB. Five (29%) of 17 Mycobacterium tuberculosis isolates had the same phage type and DNA fingerprint, which was consistent with transmission of infection within the jail. The mass screening revealed that 374 (20%) of 1855 inmates were tuberculin positive. CONCLUSIONS: Without an effective program of TB control, jails can act as reservoirs of disease for inmates and staff, and for the community into which the inmates are released.

Pediatric head injuries and deaths from bicycling in the United States.

OBJECTIVE: To estimate the potential benefit of increasing bicycle helmet use among children and adolescents in the United States. DESIGN: All bicycle-related deaths (Multiple Cause-of-Death Public Use Data Tapes, 1989 through 1992) and bicycle-related injuries treated in sampled emergency departments (National Electronic Injury Surveillance System, 1989 through 1993) were used to calculate traumatic brain injury-associated death and head injury rates per 1,000,000 US residents. Preventable injuries and deaths were estimated by calculating the population-attributable risk of head injury due to nonuse of bicycle helmets. PATIENTS: US residents aged 0 through 19 years who were injured or who died as a result of a bicycle crash. RESULTS: An average of 247 traumatic brain injury deaths and 140,000 head injuries among children and adolescents younger than 20 years were related to bicycle crashes each year in the United States. As many as 184 deaths and 116,000 head injuries might have been prevented annually if these riders had worn helmets. An additional 19,000 mouth and chin injuries were treated each year. The youngest age groups had the highest proportions of both head and mouth injuries. CONCLUSION: There continues to be a need to advocate for greater use of bicycle helmets, particularly among young children. Helmet design changes should be considered to prevent mouth injuries.

Changing epidemiology of mumps and its impact on university campuses.

The reported incidence of mumps has declined dramatically since licensure of the live attenuated mumps vaccine in the United States in 1967, particularly in young children. Because administration of the vaccine was not widely practiced during the first decade it was available, there is now a cohort of teenagers and young adults who are relatively underimmunized. Reported mumps cases in this cohort increased substantially during 1986 to 1987. Mumps outbreaks at three Illinois universities, from which 123 clinical cases were reported between September 1986 and May 1987, were investigated. Meningeal involvement was reported in 17% of case-patients, orchitis occurred in 19% of 64 men, 6% of patients were hospitalized, and direct health care costs were estimated at $264 per case and more than $32,000 for the three outbreaks combined. The risk of mumps illness was greater for students less than 20 years of age (relative risk [RR] = 2.1, 95% confidence interval [CI] = 1.4, 3.1); students residing in dormitories (RR = 2.7, 95% CI = 1.6, 4.6); and out-of-state students (RR = 1.8, 95% CI = 1.0, 3.0). Because the available data suggest that mumps in college-aged persons is due chiefly to a failure to vaccinate susceptible persons, colleges and universities should become one major focus of mumps prevention activities to reduce susceptibility in this high-risk population.

Boilerbaisse: an outbreak of methemoglobinemia in New Jersey in 1992.

BACKGROUND: On October 20, 1992, > 40 children from one elementary school visited the school nurse due to the acute onset of blue lips and hands, vomiting, and headache during and after the school lunch periods. Forty-nine children were seen by physicians that day and 14 were hospitalized. Laboratory analysis revealed methemoglobinemia in many of the children. All recovered in 36 hours. OBJECTIVE: A case-control study was supplemented by environmental and laboratory investigations to determine the outbreak source. METHODS: Cases were selected based on the laboratory diagnosis of methemoglobinemia (methemoglobin level > 2%). Children whose methemoglobin levels were missing or < 2% were excluded from analysis. Controls were obtained by selecting every third name from a school roster. The parents of 29 students who met the case definition and 52 controls were interviewed. RESULTS: All 29 cases and 33% (17/52) of the controls ate soup during the school lunch (odds ratio undefined, lower 95% confidence limit 16.1). Two pots of soup were prepared from ready-to-serve cans, which were diluted with water and enriched with a commercially prepared flavor enhancer. The school's boiler, dormant during the previous 5 months, was restarted on the morning of the outbreak. The boiler also served as a tankless hot water heater. Laboratory analysis of the soup identified abnormally high quantities of nitrite (459 ppm) and sodium metaborate, major components of the boiler water treatment solution. Undiluted soup from the same lot had 2.0 ppm nitrites; the flavor enhancer had 2.2 ppm nitrites. Nitrites were present in the hot potable water system (4 to 10 ppm) and absent in the cold potable water system. CONCLUSIONS: This outbreak of methemoglobinemia due to nitrite poisoning was traced to soup contaminated by nitrites in a boiler additive. Nitrites are ubiquitous and potentially hazardous inorganic ions. Extreme caution should be used when the possibility for toxic human exposure to nitrites exists.

Reviews of evidence regarding interventions to increase use of child safety seats.

BACKGROUND: In 1998, nearly 600 child occupants of motor vehicles aged younger than 4 years died in motor vehicle crashes. Yet approximately 29% of children aged 4 years and younger do not ride in appropriate child safety seat restraints, which, when correctly installed and used, reduce the need for hospitalization in this age group by 69% and the risk of death by approximately 70% for infants and by 47% to 54% for toddlers (aged 1 to 4 years). METHODS: The systematic review development team reviewed the scientific evidence of effectiveness for five interventions to increase child safety seat use. For each intervention, changes in the use of child safety seats or injury rates were the outcome measures evaluated to determine the success of the intervention. Database searching was concluded in March 1998. More than 3500 citations were screened; of these citations, 72 met the inclusion criteria for the reviews. RESULTS: The systematic review process identified strong evidence of effectiveness for child safety seat laws and distribution plus education programs. In addition, community-wide information plus enhanced enforcement campaigns and incentive plus education programs had sufficient evidence of effectiveness. Insufficient evidence was identified for education-only programs aimed at parents, young children, healthcare professionals, or law enforcement personnel. CONCLUSIONS: Evidence is available about the effectiveness of four of the five interventions we reviewed. This scientific evidence, along with the accompanying recommendations of the Task Force elsewhere in this supplement, can be a powerful tool for securing the resources and commitment required to implement these strategies.

Reviews of evidence regarding interventions to increase the use of safety belts.

BACKGROUND: The use of safety belts is the single most effective means of reducing fatal and nonfatal injuries in motor vehicle crashes. If all motor vehicle occupants consistently wore safety belts, an estimated 9553 deaths would have been prevented in 1999 alone. METHODS: The Guide to Community Preventive Services's methods for systematic reviews were used to evaluate the effectiveness of three interventions to increase safety belt use. Effectiveness was assessed on the basis of changes in safety belt use and number of crash-related injuries. RESULTS: Strong evidence was found for the effectiveness of safety belt laws in general and for the incremental effectiveness of primary safety belt laws relative to secondary laws. Strong evidence for the effectiveness of enhanced enforcement programs for safety belt laws was also found. Additional information is provided about the applicability, other effects, and barriers to implementation of these interventions. CONCLUSIONS: These reviews form the basis of the recommendations by the Task Force on Community Preventive Services presented elsewhere in this supplement. They can help decision makers identify and implement effective interventions that fit within an overall strategy to increase safety belt use.

Methods for conducting systematic reviews of the evidence of effectiveness and economic efficiency of interventions to reduce injuries to motor vehicle occupants.

BACKGROUND: Motor vehicle occupant injury prevention is included in the Guide to Community Preventive Services because of the enormous health impact of these largely preventable injuries. This article describes the methods for conducting systematic literature reviews of interventions for three key injury prevention strategies: increasing child safety seat use, increasing safety belt use, and decreasing alcohol-impaired driving. METHODS: Systematic review methods follow those established for the Guide to Community Preventive Services and include: (1) recruiting a systematic review development team, (2) developing a conceptual approach for selecting interventions and for selecting outcomes that define the success of the interventions, (3) defining and conducting a search for evidence of effectiveness, (4) evaluating and summarizing the body of evidence of effectiveness, (5) evaluating other potential beneficial and harmful effects of the interventions, (6) evaluating economic efficiency, (7) identifying implementation barriers, (8) translating the strength of the evidence into recommendations, and (9) identifying and summarizing research gaps. RESULTS: The systematic review development team evaluated 13 interventions for the three strategic areas. More than 10,000 titles and abstracts were identified and screened; of these, 277 met the a priori systematic review inclusion criteria. Systematic review findings for each of the 13 interventions are provided in the accompanying articles in this supplement. CONCLUSION: The general methods established for conducting systematic reviews for the Guide to Community Preventive Services were successfully applied to interventions to reduce injuries to motor vehicle occupants.

Reviews of evidence regarding interventions to reduce alcohol-impaired driving.

BACKGROUND: Alcohol-related motor vehicle crashes are a major public health problem, resulting in 15,786 deaths and more than 300,000 injuries in 1999. This report presents the results of systematic reviews of the effectiveness and economic efficiency of selected population-based interventions to reduce alcohol-impaired driving. METHODS: The Guide to Community Preventive Services's methods for systematic reviews were used to evaluate the effectiveness of five interventions to decrease alcohol-impaired driving, using changes in alcohol-related crashes as the primary outcome measure. RESULTS: Strong evidence was found for the effectiveness of .08 blood alcohol concentration laws, minimum legal drinking age laws, and sobriety checkpoints. Sufficient evidence was found for the effectiveness of lower blood alcohol concentration laws for young and inexperienced drivers and of intervention training programs for servers of alcoholic beverages. Additional information is provided about the applicability, other effects, and barriers to implementation of these interventions. CONCLUSION: These reviews form the basis of the recommendations by the Task Force on Community Preventive Services presented elsewhere in this supplement. They can help decision makers identify and implement effective interventions that fit within an overall strategy to prevent impaired driving.

Data collection instrument and procedure for systematic reviews in the Guide to Community Preventive Services. Task Force on Community Preventive Services.

INTRODUCTION: A standardized abstraction form and procedure was developed to provide consistency, reduce bias, and improve validity and reliability in the Guide to Community Preventive Services: Systematic Reviews and Evidence-Based Recommendations (the Guide). DATA COLLECTION INSTRUMENT: The content of the abstraction form was based on methodologies used in other systematic reviews; reporting standards established by major health and social science journals; the evaluation, statistical and meta-analytic literature; expert opinion and review; and pilot-testing. The form is used to classify and describe key characteristics of the intervention and evaluation (26 questions) and assess the quality of the study's execution (23 questions). Study procedures and results are collected and specific threats to the validity of the study are assessed across six categories (intervention and study descriptions, sampling, measurement, analysis, interpretation of results and other execution issues). DATA COLLECTION PROCEDURES: Each study is abstracted by two independent reviewers and reconciled by the chapter development team. Reviewers are trained and provided with feedback. DISCUSSION: What to abstract and how to summarize the data are discretionary choices that influence conclusions drawn on the quality of execution of the study and its effectiveness. The form balances flexibility for the evaluation of papers with different study designs and intervention types with the need to ask specific questions to maximize validity and reliability. It provides a structured format that researchers and others can use to review the content and quality of papers, conduct systematic reviews, or develop manuscripts. A systematic approach to developing and evaluating manuscripts will help to promote overall improvement of the scientific literature.

Fighting as a marker for multiple problem behaviors in adolescents.

PURPOSE: Behaviors that put adolescents at risk frequently occur together. To help identify high-risk adolescents, we analyzed a national, self-reported behavior survey of high school students to assess the suitability of fighting as a marker for students with multiple problem behaviors. METHODS: A cross-sectional cluster survey of 11,631 U.S. high school students in 1990 was used to compare the prevalence of recent problem behaviors among all students and those who fight. RESULTS: One (8%) of every 12 students was in a fight during the 30 days before the survey. Reported problem behaviors were prevalent among fighters: during the previous 12 months, 24% attempted suicide; during the previous 30 days, 26% carried a firearm, 13% used cocaine, and 39% drove a motor vehicle while intoxicated; during the previous 3 months 41% had two or more sex partners; and 45% had sexual intercourse and did not use a condom the last time they had sex. Of all students, fighters accounted for 22% of those who reported attempting suicide, 49% carrying a firearm, 46% using cocaine, 18% driving while intoxicated, 25% having sex with multiple partners, and 11% not using condoms. Three or more of these six problem behaviors were reported by 26% of the fighters. The problem behaviors were all positively correlated, and the first principal component accounted for 35% of the total variation among the individual variables.

An outbreak of furunculosis among high school athletes.

Furuncles (boils) are common among teenagers; however, few outbreaks have been documented. We investigated an outbreak of furuncles that occurred among male athletes of a Kentucky high school during the 1986 to 1987 school year. The overall attack rate was 25% (31/124). The risk of developing a furuncle increased two to three times in those who had skin injury. Athletes who sustained abrasions more than twice per week (P less than 0.01), who had a cut that required bandaging (P = 0.01), or had an unspecified injury causing a missed practice or game (P = 0.04) were at increased risk. The risk of developing furunculosis did not appear to be related to contact with formites, but rather, to contact with furuncles. Although athletes shared common areas (showers, locker rooms, practice areas, the attack rates for varsity football (36%) and varsity basketball (33%) were four times greater than for nonvarsity teams (P less than 0.01). Players who had a friend with a furuncle were more than twice as likely to also have had a furuncle (P less than 0.01). Exposure to furuncles appeared to increase the risk of furunculosis independently of reported skin injury. Control and prevention should, therefore, focus on both reducing skin injury and reducing exposure to furuncles, rather than attempting to sterilize inanimate objects.

Causes of nonfatal injuries in the United States, 1986.

During the 1986 National Health Interview Survey (NHIS), data on injuries resulting in a doctor visit or restricted activity for at least a half day were collected and assigned E-codes. Based on 603 injuries, the estimated number of nonfatal injuries for civilian, noninstitutionalized U.S. residents in 1986 was 60,212,000. The most frequent cause of injury was a fall (11,547,000), followed by motor vehicle traffic crashes (4,361,000) and adverse effects of drugs and biologics (3,363,000). While cause-specific detail was limited by small numbers of injuries in the sample, the NHIS can provide a valuable snapshot of the causes of nonfatal injuries.

Vaccine-preventable diseases on college campuses: the emergence of mumps.

Because of the adverse health impact of vaccine-preventable diseases, particularly measles and rubella, on college campuses, the American College Health Association (ACHA) Committee on Immunization and the House of Delegates issued position statements in 1983 and 1984 stating that colleges and universities should institute prematriculation immunity requirements. Since then, many colleges have implemented requirements and some states have passed comprehensive college laws requiring proof of immunity at the time of matriculation. No college rubella outbreaks have been reported to the Centers for Disease Control (CDC) since 1985. Measles outbreaks, however, have continued to be reported. In 1986-1987, 315 college measles cases were reported from 15 states, comprising over 3% of the total cases reported to CDC. Thirty-six percent of college measles cases could have been prevented through full implementation of prematriculation immunity requirements. Outbreaks of mumps were reported among students attending 16 colleges and universities in 3 states where active surveillance was undertaken during the 1986-1987 academic year. These mumps outbreaks, the first reported in colleges since vaccine licensure in 1967, were responsible for considerable health impact and disruption of activities. The outbreaks paralleled the increase in mumps reported nationally, which was largely a result of illness among unvaccinated adolescents and young adults not previously exposed to mumps. A lack of routine mumps vaccination in the past has allowed accumulation of susceptible unvaccinated persons in middle schools, high schools, and colleges. Outbreaks are likely to occur in those colleges that draw students who attended primary and secondary school in states without comprehensive laws requiring mumps vaccination.(ABSTRACT TRUNCATED AT 250 WORDS)

The epidemiology of Lyme disease in Kentucky, 1985-1990.

Lyme Disease has become the most common vector-borne disease in the United States. To assess the extent of the disease in Kentucky, all case reports were reviewed for 1985-1990. A total of 51 cases met the current case definition. Epidemiologic features were similar to those reported nationally. Although the recognized tick vectors for Lyme Disease have still not been identified in Kentucky, physicians should educate their patients on the risk of Lyme Disease and measures to prevent tick bites. Reporting cases of Lyme Disease will continue to be important so that trends in the disease's occurrence in Kentucky can be monitored.

Exposure to environmental tobacco smoke among Missouri children.

Childhood exposure to environmental tobacco smoke (ETS) increases the risk of lower respiratory infections (e.g., bronchitis and pneumonia), exacerbates childhood asthma, and increases the prevalence of fluid in the middle ear. Using self-reported telephone survey data, we examined the attitudes and practices of Missouri residents related to ETS exposure of children. Ninety-five percent of all respondents believed that ETS exposure is harmful to children and the percentage was similar for households with children (96%) and without children (94%). ETS was present in 42% of households and the percentage was similar for households with children (41%) and without children (44%). Childhood exposure to ETS remains a problem in Missouri, despite widespread awareness of the hazards. More active intervention is needed to reduce ETS exposure in the home.

Motorcycle helmet-use laws and head injury prevention.

OBJECTIVE: To rebut criticism of a previous study of motorcycle helmet-use laws through reanalysis with improved measures of exposure, stratification for regional differences in crash risk, and addressing of total motorcycle-related mortality and the grounds for targeting motorcyclists for helmet-use laws. DESIGN: Death certificate-based correlational study of motorcycle-related deaths and motorcycle helmet-use laws. POPULATION STUDIED: United States resident deaths from 1979 through 1986. RESULTS: Regardless of the denominator used (resident population, motorcycle registrations, or motorcycle crashes), states with full helmet-use laws had consistently lower head injury-associated death rates than states without such laws, even when stratified by region. Total motorcycle-related mortality, however, was similar between law groups. On a registration or crash basis, motorcyclists who died in crashes had a fivefold to sixfold higher risk of head injury than those who died using any other type of motor vehicle. CONCLUSION: Full helmet-use laws were consistently associated with lower rates of head injury-associated death. While disagreement remains on the acceptability of the legislative approach, the scientific basis for motorcycle helmet-use laws as a head injury prevention tool appears sound.

Head injury--associated deaths from motorcycle crashes. Relationship to helmet-use laws.

A review of US mortality data from 1979 to 1986 identified 15,194 deaths and nearly 600,000 years of potential life lost before age 65 years that were associated with head injuries from motorcycle crashes. White males from 15 to 34 years of age accounted for 69% of the deaths. The rate of motorcycle-related deaths associated with head injury declined modestly between 1979 and 1986 (19% using rates based on resident population and 8% based on motorcycle registrations). Population-based rates adjusted for age, sex, and race in states with partial or no motorcycle helmet-use laws were almost twice those in states with comprehensive helmet-use laws. Two states that weakened their helmet-use laws from comprehensive to partial during the study period had increases in motorcycle-related head injury death rates (184% and 73%), and one state that strengthened its law from partial to comprehensive had a decline in its death rate (44%). Head injury death rates based on motorcycle registrations were also lowest in states with comprehensive helmet-use laws. Since helmets reduce the severity of nonfatal head injuries in addition to lowering the rate of fatal injuries, we urge the adoption and enforcement of comprehensive motorcycle helmet-use legislation.

Shigellosis in Kentucky, 1986 through 1989.

A marked increase in the number of cases of shigellosis was reported in Kentucky in 1988. To examine reasons for this increase, we reviewed the 389 cases of shigellosis reported from 1986 through 1989. Ninety-three percent (285/305) of cases due to known species were due to Shigella sonnei. Sixty-two percent (243/389) of cases occurred in children less than 10 years of age. The annual incidence for blacks (6.8 cases per 100,000) was nearly four times that for whites (1.8 per 100,000). The increased number of cases in 1988 was due to outbreaks in five areas of the state, which accounted for 85% (200/234) of the cases. Three of the five outbreaks involved day-care centers. The primary mode of transmission appeared to be person-to-person; there was no evidence of a common source of infection from food or water. To prevent future outbreaks, cases of shigellosis need to be reported promptly to ensure appropriate investigation and control by local health departments.

The Will Rogers phenomenon. Stage migration and new diagnostic techniques as a source of misleading statistics for survival in cancer.

We found that a cohort of patients with lung cancer first treated in 1977 had higher six-month survival rates for the total group and for subgroups in each of the three main TNM stages (tumor, nodes, and metastases) than a cohort treated between 1953 and 1964 at the same institutions. The more recent cohort, however, had undergone many new diagnostic imaging procedures. According to the "old" diagnostic data for both cohorts, the recent cohort had a prognostically favorable "zero-time shift." In addition, by demonstrating metastases that had formerly been silent and unidentified, the new technological data resulted in a stage migration. Many patients who previously would have been classified in a "good" stage were assigned to a "bad" stage. Because the prognosis of those who migrated, although worse than that for other members of the good-stage group, was better than that for other members of the bad-stage group, survival rates rose in each group without any change in individual outcomes. When classified according to symptom stages that would be unaltered by changes in diagnostic techniques, the two cohorts had similar survival rates.