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these deaths were due to lung (31%), prostate (10%), and colorectal cancers (10%). Among women, most deaths were from lung (25%), breast (15%), and colorectal cancers (10%), with an additional 1% from cervical cancers. For breast, cervical, and colorectal cancers, routine screening is recommended by the U.S. Preventive Services Task Force (USPSTF) 3 –6 —an independent panel of experts in primary care and prevention that systematically reviews evidence of effectiveness—and by most major medical organizations. 7 Screening recommendations from the USPSTF for breast, cervical, and colorectal cancers are shown in Table 1. A 2003 report from the National Cancer Policy Board 8 noted that screening all eligible people not currently screened with USPSTFrecommended mammography, Pap smears, and colorectal cancer screening tests could prevent an additional 4475 deaths from breast cancer, 3644 deaths from cervical cancer, and 9632 deaths from colorectal cancer per year. At present, the USPSTF does not recommend screening for lung and prostate cancers because no convincing evidence shows that benefits outweigh harms. 3,9

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.

Background. A two dose measles vaccination schedule is recommended routinely for all schoolentry-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 an 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 vaccinalion, or maternal year of birth. However, children of 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 outbreaks by reducing the number of outbreaks.

SummaryIn February 1992, an outbreak of cholera occurred among persons who had flown on a commercial airline flight from South America to Los Angeles. This study was conducted to determine the magnitude and the cause of the outbreak. Passengers were interviewed and laboratory specimens were collected to determine the magnitude of the outbreak. A case-control study was performed to determine the vehicle of infection. Seventy-five of the 336 passengers in the United States had cholera; 10 were hospitalized and one died. Cold seafood salad, served between Lima, Peru and Los Angeles, California, was the vehicle of infection (odds ratio, 11·6; 95% confidence interval, 3·3–44·5). This was the largest airline-associated outbreak of cholera ever reported and demonstrates the potential for airline-associated spread of cholera from epidemic areas to other parts of the world. Physicians should obtain a travel history and consider cholera in patients with diarrhoea who have travelled from cholera-affected countries. This outbreak also highlights the risks associated with eating cold foods prepared in cholera-affected countries.

An outbreak of dermatitis occurred among county jail inmates who removed dead fish from the Sacramento River in California after a spill of metam sodium. The spilled chemical decomposes to methylisothiocyanate (MITC), a known skin irritant. A retrospective cohort study was conducted among the inmates and their crew leaders. Among 42 jail group members, 27 had dermatitis involving the feet and ankles; dermatitis was associated with lower extremity water contact (RR = 3.4, 95% CI 1.0-11.8); the attack rate increased with length of time spent in the water. For comparison, other state and federal employees who worked in the river at the same time were also interviewed. None reported dermatitis. Over three-quarters (24/31) of these other clean-up workers whose feet became wet changed to dry clothing immediately; none of the jail group changed immediately. The river concentration of MITC measured 20-40 ppb at the time of exposure. We speculate that prolonged wetness, occlusive boots, friction, and heat contributed to chemical irritation at this low concentration; the experience of the other clean-up workers suggests that this outbreak could have been prevented.

An outbreak of giardiasis occurred among staff of a job training center after a meeting at a restaurant. Twenty-seven (75%) of 36 attendees became ill compared with 1 (3%) of 31 staff members not attending (relative risk, 23.3; 95% confidence interval, 3.4-161.4). Because most attendees ate all items on a fixed menu, no individual food item could be conclusively associated with illness. Circumstantial evidence suggests, however, that ice contaminated by a food handler may have been the vehicle. The restaurant had multiple sanitary violations, and 2 employees, 1 with asymptomatic giardiasis and the other with a Giardia-infected, diapered child, served ice to the attendees. This outbreak demonstrates the potential for restaurant-based giardiasis outbreaks.

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 casecontrol 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 numarous 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 P 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.

Objectives: To describe an outbreak and to identify risk factors for mumps occurring in a highly vaccinated high school population. (Note: Highly vaccinated means a population in which more than 95% have been vaccinated.) Design and Participants: Survey and cohort study of 307 (97%) of 318 students. Outcome Measures: Mumps was defined as an illness with 2 or more days of parotid swelling. Serologic confirmation of infection was obtained in eight cases, seven of which were evaluated for presence of IgM antibody using immunofluorescent antibodies. Vaccination records were verified for 297 (97%) students. Results: Between October 3 and November 23, 1990, clinical mumps developed in 54 students (attack rate, 18%), 53 of whom had been vaccinated. Most cases (40 [77%] of 52) occurred 12 to 20 days after a school-wide pep rally. Immunofluorescent antibody testing of all seven specimens demonstrated IgM antibody to mumps. Risk factors for clinical mumps identified in multivariate analyses included female gender (odds ratio, 3.0; 95% confidence interval, 1.6 to 5.7) and source of vaccination other than the local public health clinic (students vaccinated by private providers [odds ratio, 3.0; 95% confidence interval, 1.3 to 5.2] or in other districts [odds ratio, 2.4; 95% confidence interval, 1.1 to 5.3]). Conclusions: The overall attack rate is the highest reported to date (and to our knowledge) for a population demonstrating virtually complete mumps vaccine coverage. Even verified documentation of vaccination may not be an accurate indicator of an individual's protection against mumps. Vaccination failure may play an important role in contemporary mumps outbreaks. We found no evidence to indicate that waning immunity (secondary vaccine failure) contributed significantly to this outbreak. A second dose of mumps vaccine, as recommended using measles-mumps-rubella vaccine, could potentially prevent similar outbreaks in secondary school populations in the future. (Arch Pediatr Adolesc Med. 1995;149:774-778)

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. (Arch Intern Med. 1995;155:713-716)

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. (JAMA. 1995;273:466-471)

An outbreak of gastrointestinal illness in which headache, low grade fever and myalgia were common symptoms occurred among persons who visited a recreational park in Macomb County, Michigan, on July 13-16, 1979. The temporal clustering of onsets of 121 persons who were the first in their households to become ill suggested an incubation period ranging from 4-77 hours. A history of swimming in the park's lake was elicited with significantly greater frequency from these persons than from park visitors who were not ill (age standardized odds ratio = 4.8; 95% confidence interval, 1.8-12.7). One hundred twenty-six park visitors who became ill were household contacts of index patients who had swum in the lake; at least 62 of these 126 cases were probably due to secondary transmission. A secondary attack rate of 19% was observed in household contacts who had not visited the park. Serologic studies identified Norwalk virus as the etiologic agent. The source of the contamination of the lake could not be determined. Although some water samples collected just before and after the epidemic period had high coliform counts, the geometric mean coliform density of all samples collected on those days was within the limits established by the Environmental Protection Agency as acceptable for recreational contact water.

Three patients with severe pneumonia at a community hospital in Columbus, Ohio, were found to have Legionnaires' disease in late August 1977. A subsequent serologic survey of patients with pneumonia at this hospital identified three additional cases. Among patients with pneumonia, hospital exposure in the 2 weeks before onset of illness was significantly associated with Legionnaires' disease (P = 0.003). Serosurveys of hospital employees with a recent history of upper respiratory illness, healthy employees, and workers at the hospital construction site showed that one of 101, one of 107, and none of 114, respectively, has a single reciprocal titer of greater than or equal to 256 to the Legionnaires' disease (LD) bacterium. Serosurveys of patients with pneumonia at three control hospitals identified five additional patients with Legionnaires' disease, three of them with pneumonia that was apparently hospital acquired in a single renal transplant unit. A fourth patient from that unit without clinical illness had a fourfold rise in titer to LD bacterium.

In the period April 1981 through June 1982, there was an unusual increase in the number of deaths and cardiopulmonary arrests in the pediatric intensive care unit at a large medical center hospital in San Antonio, Texas. During this period, 34 of 42 deaths (81 per cent) occurred in the evening work shift, as compared with 36 of 106 (34 per cent) during the previous four years (P less than 0.0001). Reviews of records of patients revealed no association between death in this 15-month epidemic period and a variety of demographic, historical, medical, and admission characteristics; medical or surgical procedures; or the severity of illness. The findings of a blinded clinical consultant support the conclusion that the increase in deaths and cardiopulmonary arrests could not be explained on the basis of the clinical status of the patients, and the consultant concluded that during the epidemic period, there were more deaths and cardiopulmonary arrests that were either unexpected in timing or inconsistent with the previous clinical course. The presence of one nurse was associated with the increased numbers of deaths (relative risk, 10.7; 95 per cent confidence limits, 6.4 to 17.9), cardiopulmonary arrests (relative risk = 25.5, confidence limits = 16.8 to 38.6), and unexpected clinical events, (relative risk, infinite; confidence limits, 33.7 to infinity). Although the cause of the epidemic remains unclear, the findings illustrate that surveillance of deaths and cardiopulmonary resuscitation may allow early recognition of similar problems in other hospitals.

Outbreaks of Norwalk gastroenteritis, which may involve persons of all ages, occur during all seasons and in various locations. Waterborne, foodborne, and person-to-person modes of transmission have been described, and secondary person-to-person transmission is common. Outbreaks generally end in about 1 week; longer outbreaks occur only when new groups of susceptible persons are introduced, usually in the setting of a persistent common source of infection. The illness is generally mild and characterized by nausea, vomiting, diarrhea, and abdominal cramps. Vomiting is the predominant symptom among children, whereas diarrhea is commoner among adults. Forty-two percent of 74 outbreaks of acute nonbacterial gastroenteritis investigated by the Centers for Disease Control from 1976 to 1980 were attributed to the Norwalk virus. The rest resembled Norwalk outbreaks clinically and epidemiologically and were probably caused by 27-nm viral agents similar to the Norwalk virus.