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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

Sir .—I have several comments on the discussion of polio immunization policy for children presented by Marcuse 1 and Katz 2 in the September 1989 issue of AJDC . In the past, the real risk of oral polio virus vaccine (OPV)–related polio has probably been closer to 1 case per 100000 persons immunized. The state of Washington had about 1 case annually for many years. The rate may be lower nationally, but that is most likely a problem of lack of recognition and/or reporting. Additionally, OPV can cause nonparalytic illness, which usually goes unrecognized unless the vaccine virus is picked up inadvertently when spinal fluid is cultured and the patient is then asked about possible OPV exposures (Bruce G. Weniger, MD, MPH; David Remis, MD; Mark Heerema, MD; et al, unpublished case, October 1982). Perhaps the type III component in vaccine is now less apt to revert to neurotoxicity, but can

Sir. —Dr Fulginiti 1 made some good points in his editorial in the May issue of AJDC on standards. Having sat on several committees that grappled with establishing standards, I feel that it also is important to recognize some of the inherent biases of such committees. First, they tend to agree there is a problem requiring the establishment of a standard. Second, they are biased toward a "safe rather than sorry" viewpoint. Third, they do not reflect the universe of those who deal with the problem. Rather, they tend to reflect those who see the worst aspects of the problem and omit those who see the other end of the spectrum

Sir.—Dr Helfer's1 response to Dr Comerci's letter on primary care and pediatrics was not very helpful. First, there are very few tasks in medicine or any other profession that cannot be broken down so that average nonprofessional persons can learn and perform them. I am certain that some of the ladies from the International Ladies Garment Union could learn to perform many cosmetic surgery tasks, and some could learn to do excellent cataract surgery. I know of a nurse's aide who was extremely facile in performing a wide assortment of urologic procedures and could easily have been taught to do cardiac catheterizations. What distinguishes a physician is not his ability to perform various specialized tasks competently but rather his wide knowledge base and his ability to use it to keep people well and to diagnose and treat illness. It is a common act of gross arrogance on the part

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.— 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

Sir .—I appreciate that medical researchers, other scientists, and some medical specialists will find conversion to SI units useful. 1 Certain of these units might even be adopted with little complaint from the average physician. However, it seems arbitrary to foist all these units off on the general public when 99.9% of the people will obtain no benefit and merely become confused. Calorie is a term that has become a part of our everyday language. Why substitute joule? The general public thinks that a joule is a gem. To avoid confusion, let the scientists adapt rather than vice versa. The same applies to gram and milligram , which the public has finally begun to understand and use to a limited extent. To introduce mole for mass measurement will cause confusion. The public thinks a mole is a nuisance that makes a mess of front lawns. There is no public benefit from

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

Sir .—In the May 1988 issue of AJDC , Cochi et al 1 described the problem of mumps resurgence in the United States, due to a relatively underimmunized cohort of children born between 1967 and 1977. This cohort has been developing mumps at an older median age than children in the prevaccine days. It is regrettable that this problem was allowed to develop, because it was predictable and could have been attacked at less expense when the children were much younger and easily identifiable as being susceptible. 2,3 Mumps is a disease subject to eradication. It is not highly contagious and has no animal reservoir. Mumps vaccine should have been provided by Centers for Disease Control, Atlanta, through its vaccine assistance program for low-income children in the early 1970s when it became apparent that the vaccine was being used widely by private health care providers for their patients and that this

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.