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In Reply. —Dr Cunningham agrees that there is a need for a more targeted approach to lead screening. Certainly a tenet of public health is that our preventive efforts are most effective when we focus on those who are most at risk. However, how can we target in the absence of supportive data? In 1991, the CDC concluded that it would not be possible to predict which communities are at low enough risk of childhood lead exposure that screening would not be required. 1 The NHANES III data 2 would indicate that surveillance of lead exposure and reassessment of the CDC guidelines may well result in screening being more targeted in the future. In the meanwhile, unless there are data and methods available to determine which areas are of low risk, it is sound public policy for legislatures to follow the CDC guidelines. Dr Schoen is certainly entitled to his

Lead poisoning is one of the worst environmental threats to children in the United States and is also entirely preventable. 1 An increased understanding of the adverse effects of lead poisoning—neurological, endocrinological, hematological, reproductive, and growth—resulted in the Centers for Disease Control and Prevention lowering the acceptable blood lead level three times in the last 20 years. 2 The article by Pirkle et al 3 documents the dramatic decrease in blood lead levels from 0.62 to 0.14 μmol/L (12.8 to 2.8 μg/dL) between 1976 to 1980 and 1988 to 1991. Most significantly, the percentage of US children aged 1 to 5 years with blood lead levels 0.48 μmol/L (10 μg/dL) or greater decreased from 88.2% to 8.9%. Decreases in blood lead levels occurred for all age and income groups. This is surely one of the most remarkable public health achievements of the decade and is undoubtedly the result of government

Objective: To determine if the severity of subacute symptoms in eosinophilia-myalgia syndrome (EMS) was affected by medical history or use of nutritional supplements other than tryptophan before illness. Design and Study Population: A case-control study was conducted of EMS cases systematically sampled from all those reported to a statewide surveillance system in California in 1989. Excluding two previous EMS-related deaths, interviews were completed in 73% (57/78) of the eligible case patients sampled. Main Outcome Measures: The severity of any myalgia(s), dyspnea, or walking impairment during each of the first 3 months of EMS was quantified by means of self-reported integer scores ranging from 0 (asymptomatic) to 10 (severe symptoms). Case patients in the top tercile of combined, unweighted monthly scores were defined as having severe symptoms. Results: All interviewees (57 of 57) had consumed supplemental tryptophan before illness; 89% (51/57) were female. The odds of severe symptoms were not significantly associated with gender, age, previous antidepressant use, or cumulative amounts of supplemental tryptophan consumed before or after EMS onset ( P >.1). Previous consumption of any multivitamin(s), however, was associated with significantly lower odds of severe symptoms (adjusted odds ratio, 0.05; 95% confidence limits, 0.007, 0.4; P =.006). Conclusions: The consumption of multivitamincontaining supplements before EMS appears to have modified the severity of subacute symptoms in this sample of cases from California. (Arch Intern Med. 1993;153:2368-2373)

In Reply.— Drs Witt and Wagner express concern that our report suggests that aldicarb-related illness could result from food residues below the level of laboratory detection. Their arguments are based on a small study of corporate executives and on experimental data. A further description of the illnesses would be useful in clarifying our assertions in the earlier article. Report of a Case.— On the morning of July 4,1985, one of the index cases in this outbreak, a 62-year-old woman receiving digoxin therapy, was seen with lacrimation, salivation, diaphoresis, vomiting, diarrhea, and muscle twitching. She was in shock, with a heart rate of 31 beats per minute and atrial fibrillation. Two other family members who had shared a watermelon with her were also severely ill. Before there had been any publicity about contaminated melons, the physician diagnosed cholinesterase-inhibitor poisoning. Treatment with atropine resulted in resolution of the symptoms. Based on the