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To the Editor.— DiGuiseppi et al1note that "bicycling injuries to children account for 300 000 emergency department visits and 500 to 600 deaths each year in the United States." Yet, despite an extensive bicycle helmet campaign in Seattle, Wash, the level of bicycle helmet use by children is only 15.7%. In the control city, Portland, Ore, it was 2.9%. The effect of the campaign was meritorious, but fell far short of levels needed to make much of an impression on bicycle-related head injuries among children. More dramatic action is needed if helmet use is not to flounder at the same level as that found with automobile seat restraints prior to recent stronger measures. We need to make bicycle helmet use by younger children an expected group norm that they and their parents will recognize as sensible and accept as a routine practice. Education by physicians, police, schools

To the Editor.— In "Vaccination and Disease Prevention for Adults" (1982; 248:1607), Goodman et al note in the Table thatinactivatedpoliovirus vaccine (IPV) is contraindicated during pregnancy on theoretical grounds. I question use of that rather standard phraseology with regard to either IPV or the oral live-virus vaccine (OPV). During the mid-1950s, when IPV first became available, among those with highest priority for immunization were pregnant women. They were not noted to suffer untoward effects nor did their offspring suffer birth defects. In the case of OPV, it is well known that the vaccine virus often spreads to other family members after being given to children within the family. Consequently, many susceptible pregnant mothers have been "immunized" along with their children. There is no evidence that they or their pregnancy outcomes have been adversely affected as a result. In short, I see no reason to withhold either IPV or

To the Editor.— The recommendations for vaccine injury compensation published in the Dec 7 issue ofThe Journal 1 are both necessary and generally sound. All claims of injury should first be funneled through a no-fault federal compensation program. However, when the claimant finds the disposition of his claim by the program to be unsatisfactory, there probably deserves to be a limited appeals process involving petition for a rehearing or appeal to a federal court, where a contention as to fact could be heard by a judge without jury. This is most apt to be needed when a claim is turned down. In addition, health insurers should not be permitted to exclude these injuries from medical care coverage, and compensation should be limited to cases of serious injury only to the extent that a family's health insurance does not provide such coverage. Pain and suffering compensation should be excluded. In

To the Editor.— In their COMMENTARY "Facilitating the Transitions of Adolescence," Hamburg et al 1 state "one in ten girls becomes pregnant during adolescence, and most of the pregnancies are not intended." Although one in ten is bad enough, that figure is in fact much too low. When abortions are considered along with childbirths, the true figure comes closer to 25% to 30%. Only about half of all teenage pregnancies go to term, and these number about 500 000 newborns annually.

To the Editor.— In their response to my letter on polio vaccination during pregnancy, Goodman et al 1 state, "Use of the number of doses distributed gives a measure of the overall risk of vaccine-associated poliomyelitis and gives a prospective OPV [oral polio vaccine] recipient or contact of a recipient the overall odds of becoming a vaccine-associated case." The courts of the state of Washington have held that this statement was inadequate and misleading and, therefore, awarded judgment to the vaccine-associated polio victim against the vaccine manufacturer. Other parties to the litigation settled out of court, in part because that statement on the signed informed consent was regarded as indefensible. The vast majority of OPV recipients are newborns who are slated to receive four doses of OPV (five in past years) by the time they enter school. Consequently, estimation of "one case of paralytic poliomyelitis in recipients or contacts for

To the Editor.— Dr Schwartz 1 in the article entitled "The Inevitable Failure of Current Cost-Containment Strategies: Why They Can Provide Only Temporary Relief" nicely provides documentary support for "Baumol's disease," a condition that has been used in the past to explain the high cost of hamburgers in New York ( Forbes , Aug 15, 1983, p 92; Forbes , Sept 15, 1977, p 166). William Baumol, an economist at New York University and Princeton (NJ) University, notes that "any service that is inherently labor-intensive will tend to rise in cost faster than the general rate of inflation." He explains that a person can provide only so many units of a labor-intensive service during a day. Since each person must eat and partake of the other basic goods and services of society, each will demand sufficient compensation to permit this. He claims that investment in capital goods, education, and technology is required to

To the Editor.— In "Fatal Occupational Injuries" (1982;248:692), Baker et al analyzed deaths related to work injuries during 1978 in Maryland. Of the 148 deaths, 25% involved road vehicles, 16% involved nonroad vehicles, 11% involved boats, and 5% involved aircraft. Firearms accounted for another 11% of injuries. A similar fatal injury pattern was seen in Oregon during 1980 and 1981, when there were 163 occupational fatalities. Here, deaths occurred as follows: 28.2%, traffic accidents; 4.3%, industrial vehicles; 7.4%, aircraft accidents; and 2.4%, homicides. It is surprising that fatal truck accidents are not more frequent. In Oregon, during 1980, about half of all trucks inspected by the State Police failed to pass routine safety inspections. Many of these vehicles lacked adequate brakes and posed a serious hazard to their drivers. They also represented a danger to the general public because of some of the hazardous cargos carried. This underscores the point

To the Editor.— In discussing "Health Effects of Urban Air Pollution," Mitchell et al (242:1163, 1979) seem to take the view that current national ambient air quality standards, as adopted by the Environmental Protection Agency, for carbon monoxide (CO) are justified for sea level, but that an eight-hour CO standard of 6 ppm should be substituted in high-altitude areas. Adjustment of the basic CO standard to accommodate for high-altitude effects is reasonable, but, for sea level areas, the present 9 ppm, eight-hour CO standard, which may be exceeded only once a year, is already more stringent than can be justified by cost-benefit analysis. The difference between using a 15 ppm, eight-hour CO standard and a 9 ppm, eight-hour CO standard is an increase of 1% in COHb concentration. Can one truly argue that this makes any real difference to a person's health if it happens five to ten times a year

To the Editor.— The points made by Hickman and Barness in their commentary "Immunization Program for Adults" (237:129, 1977) are well taken but deserve some amplification. First, physicians considering administration of tetanus toxoid as part of wound prophylaxis would be well advised in most cases to use tetanusdiphtheria toxoids (adult). No tetanus booster is needed following most wounds where the last booster was given less than five years previously. Thus, since diphtheria toxoid alone is not generally available and most adults never receive any boosters unless they are confronted with this need after a wound, updating against diphtheria at that time is also in order and will not cause excessive reaction to the diphtheria component. Second, when an adult has never been immunized against diphtheria, physicians should regard the booster dose of adult diphtheria-tetanus toxoids as an integral part of the immunization series and establish a reminder system to get

To the Editor.— In "The Changing American Health Scene" (237:1710-1714, 1977), Rogers and Blendon indicate that nationally age-adjusted death rates, infant and maternal mortality, and death rates from coronary artery disease have fallen substantially in recent years. This is also true for Seattle-King County. However, in Seattle-King County coronary heart disease mortality reached its highest rates by the late 1940s. The peak age-adjusted rates (US standard million, 1940) were 270.3 deaths per 100,000 men in 1949 and 91.9 to 93.9 deaths per 100,000 women on several occasions between 1949 and 1965. An international coding change for deaths has made distortions in comparison of coronary heart disease mortality since 1968, causing rates to be only about 87% of what they would be with prior coding. Nevertheless, adjusting for this, Seattle-King County rates declined by about 20% from peak rates. The decline for those under 60 years of age is more striking.

To the Editor.— In "Do Economic Slumps Increase Illness?" (242:1241, 1979), a correlation between ischemic heart disease and economic conditions is suggested. Between 1968 and the end of 1971, the Seattle area's largest employer reduced its work force from more than 100,000 to fewer than 40,000 employees, costing the community a huge proportion of its basic industry jobs. Few communities since the Depression have experienced such severe unemployment so quickly, and many employees with 15 to 20 years' seniority were stunned to find themselves laid off and without any job prospects. Rahe et al 1 and Petrich and Holmes 2 have shown that life crises such as loss of employment are associated with illness development, yet it is surprising how little (if any) effect the Seattle-area recession had on heart disease mortality in men aged 55 to 64 years (Table). Also, in contrast to the Australia experience, coronary heart disease

To the Editor. — In his commentary "A Prescription for the Rising Cost of Medical Care" (237:2383, 1977), Vernon Mark, MD, suggests the abandonment of Medicaid in favor of a municipal, county, and state hospital system, which he feels could provide the services needed by the medically indigent more cheaply, without sacrifice in quality of services, and with less fraud. He implied that the problem of the old government hospital system related to physical facilities, not to inadequate medical care. I do not agree. Seattle-King County has had a better county hospital than most in the country. Hospital care provided there in the past and currently has technically been good, often excellent. Today it still sees many Medicaid patients as part of the medical care mainstream (as it should be). The patient has freedom of choice to the extent that the private sector is willing to participate in Medicaid. During the

To the Editor.— In response to the question as to what action should be taken after accidental needle-stick exposure when the contact patient is not known to have hepatitis (240:2325, 1978), the Seattle-King County Health Department's viral hepatitis case survey results may be helpful. All patients whose cases were reported were contacted by a nurse and asked about possible exposure sources. These sources included work in the health professions and needle exposures. During a two-year period, only one patient recalled an accidental needle-stick exposure. It had occurred eight months before her illness, and she was given standard immune serum globulin at the time. Her hepatitis was not type B. Although only an estimated 40% to 50% of hepatitis cases were reported in the metropolitan Seattle area (1.2 million people) during that period, it seems safe to infer that while needle-stick exposures to serum from persons with unknown hepatitis antigen status

To the Editor.— In the QUESTIONS AND ANSWERS section (1982;248:593), the association between sudden infant death syndrome (SIDS) and elevated triiodothyronine (T 3 ) levels found at autopsy was discussed. The answer indicated that there was no proved causative association between elevated T 3 levels and the later development of SIDS. It might be worth noting that all of 30 consecutive Oregon SIDS infants had essentially normal thyroxine levels at the time of newborn screening for congenital hypothyroidism. In addition, none of 66 infants found to have congenital hypothyroidism at the time of newborn screening subsequently died of SIDS.

To the Editor.— I concur with the general findings of King and Young (239:2674, 1978) related to prisoners and their seizure disorders. Based on my limited experience, the prevalence of prisoners receiving anticonvulsants in Seattle is undoubtedly equivalent to that in Illinois. However, two points must be recognized. There is a tendency for prisoners to be overmedicated. Many prisoners who take anticonvulsants are probably not suffering from epilepsy. They continue to receive these drugs because no one has the inclination to reassess the need for them. In this day of frequent prisoner complaints about their medical care and common lawsuits related to "violations" of prisoners' rights, the jail physician is often subjected to abuse if he tries to readjust a prisoner's medications. A high proportion (often more than half) of prisoners are alcoholics or addicts. It is my impression that most prisoners who take anticonvulsants are among this

SEATTLE-KING County has experienced an outbreak of diphtheria since 1972. 1 It has been characterized mainly by cutaneous diphtheria among alcohol-using indigent adults in Seattle's Skid Road area. During this period, 749 cases and carriers of diphtheria were identified, and one, described here, was an unusual case of chronic intermittent cutaneous diphtheria. Methods For three years the patient was often seen at one of five health facilities: Harborview Medical Center (HMC), Seattle-King County Health Department Communicable Disease Control Clinic, Seattle City Jail, Seattle Indian Health Clinic, and Pioneer Square Neighborhood Health Center. There, the patient's skin lesions were swabbed with a sterile cotton-tipped applicator, and the material was either directly inoculated onto blood agar, tellurite, and Loeffler's blood culture media, or, in several of the facilities, Amies transport medium without charcoal was used initially. Nasopharyngeal and throat cultures were also obtained when the patient was examined at the Health Department.

In Reply.— Dr Raring is correct that JAMA erroneously printed " The data provided by Capps et al is an interesting expansion of information on this subject. Unfortunately, the small and heterogeneous nonwhite Oregon population precluded meaningful similar stratification by race and age.