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Objectives. Infections caused by respiratory viruses are associated with recurrent epidemics and widespread morbidity and mortality. Routine surveillance of these pathogens is necessary to determine virus activity, monitor for changes in circulating strains, and plan for public health preparedness. The Southern Nevada Health District in Las Vegas, Nevada, recruited five pediatric medical practices to serve as sentinel sites for the Pediatric Early Warning Sentinel Surveillance (PEWSS) program. Methods. Sentinel staff collected specimens throughout the year from ill children who met the influenza-like illness case definition and submitted specimens to the Southern Nevada Public Health Laboratory for molecular testing for influenza and six non-influenza viruses. Results. Laboratory results were analyzed and reported to the medical and general communities in weekly bulletins year-round. PEWSS data were also used to establish viral respiratory seasonal baselines and in influenza vaccination campaigns. The surveillance program was evaluated using the Centers for Disease Control and Prevention's (CDC's) Updated Guidelines for Evaluating Public Health Surveillance Systems. PEWSS met three of six program usefulness criteria and seven of nine surveillance system attributes, which exceeded the CDC Guidelines evaluation criteria for a useful and complete public health surveillance program. Conclusion. We found that PEWSS is a useful and complete public health surveillance system that is simple, flexible, accessible, and stable.

Ancient human hair specimens can shed light on the extent of pre-historic exposures to methylmercury and provide valuable comparison data with current-day exposures, particularly for Indigenous Peoples who continue to rely upon local traditional food resources. Human hair from ancient Aleutian Island Native remains were tested for total and methylmercury (Hg, MeHg) and were radiocarbon dated. The remains were approximately 500 years old (1450 A.D.). For four adults, the mean and median total hair mercury concentration was 5.8 ppm (SD=0.9). In contrast, MeHg concentrations were lower with a mean of 1.2 ppm (SD=1.8) and a median of 0.54 ppm (0.12–3.86). For the five infants, the mean and median MeHg level was 1.2 ppm (SD=1.8) and 0.20 ppm (0.007–4.61), respectively. Segmental analyses showed variations in MeHg concentrations in 1-cm segments, consistent with fluctuations in naturally occurring exposure to mercury through dietary sources. The levels are comparable to or lower than those found in fish and marine mammal-eating populations today who rely far less on subsistence food than pre-historic humans. The findings are, therefore, compatible with increased anthropogenic release of trace metals during the past several centuries.

background Vibrio parahaemolyticus, the leading cause of seafood-associated gastroenteritis in the United States, typically is associated with the consumption of raw oysters gathered from warm-water estuaries. We describe a recognized outbreak of V. parahaemolyticus infection associated with the consumption of seafood from Alaska. methods After we received reports of the occurrence of gastroenteritis on a cruise ship, we conducted a retrospective cohort study among passengers, as well as active surveillance throughout Alaska to identify additional cases, and an environmental study to identify sources of V. parahaemolyticus and contributors to the outbreak. results Of 189 passengers, 132 (70 percent) were interviewed; 22 of the interviewees (17 percent) met our case definition of gastroenteritis. In our multiple logistic-regression analysis, consumption of raw oysters was the only significant predictor of illness; the attack rate among people who consumed oysters was 29 percent. Active surveillance identified a total of 62 patients with gastroenteritis. V. parahaemolyticus serotype O6:K18 was isolated from the majority of patients tested and from environmental samples of oysters. Patterns on pulsed-field gel electrophoresis were highly related across clinical and oyster isolates. All oysters associated with the outbreak were harvested when mean daily water temperatures exceeded 15.0°C (the theorized threshold for the risk of V. parahaemolyticus illness from the consumption of raw oysters). Since 1997, mean water temperatures in July and August at the implicated oyster farm increased 0.21°C per year (P

Essential polyunsaturated fatty acids (PUFA) of the omega-3 family are believed to protect against cardiovascular disease. A rich source of omega-3 PUFA is found in fish and marine mammals (seal, walrus, whale), which are a large part of the traditional diet of Alaska Natives (Eskimo, American Indians, Aleuts), a group that has been reported to have a lower mortality rate from cardiovascular disease than non-Natives. An autopsy study using standardized methods to evaluate the extent of atherosclerosis and its risk factors, and analyses of stored triglyceride fatty acids was conducted in a sample of Alaska Native subjects and non-Native subjects living in Alaska. Findings indicate that Alaska Natives had less advanced atherosclerosis in coronary arteries, along with higher proportions of omega-3 and lower proportions of omega-6 PUFA in adipose tissue, than did non-Natives. We conclude that high dietary intake of omega-3 PUFA may account for the lower extent of coronary artery atherosclerosis, contributing to the reported lower heart disease mortality among Alaska Natives.

In their Policy Forum “Ethics and the conduct of public health surveillance” (30 Jan., p. [631][1]), A. L. Fairchild and R. Bayer imply that there is a lack of ethical oversight of public health surveillance. Their implication comes from the notion that because public health surveillance is not

Although guidelines for the ethical review of researchare continuously evolving, there is one point upon whichthere has long been general consensus: that researchprojects involving human subjects require prior review andapproval by an appropriate institutional review board (IRB).The very definition of research, however, involves someambiguities. The collection or manipulation of data involv-ing human subjects may or may not always be consideredresearch per se. Research, as currently defined, occurs whena study is designed to contribute to generalizable knowledge[1–4,4a]. “Non-research” activities generally take the formof patient treatment, public health practice, program evalu-ation, or population surveillance [2,5]. Public laws providefor oversight of the collection of confidential information bypublic health authorities without consent, and confer specialprotection of the information from public disclosure. This isgenerally because many public health efforts essential toprotect the public health involve the routine collection ofhighly confidential and sensitive personal and medical in-formation (e.g., mandatory reporting of communicable dis-eases). In a similar vein, other public health efforts, such asinvestigation of disease outbreaks, must occur quickly toreduce the spread of the disease and find the source asquickly as possible. Activities undertaken to investigatedisease outbreaks involve application of proven publichealth strategies, not research. Although the activities mayinvolve case-control or cohort study designs, formal statis-tical analysis of data, and publication of findings and controlmeasures, the purpose of the work is to apply public healthpractice, not to contribute to generalizable knowledge, as ina research project [2,5]. While these types of public healthactivities are generally not designed to contribute to gener-alizable knowledge, they may often result in publication offindings in the peer-reviewed literature. Thus the distinctionbetween research and non-research is anythingbut distinct.As a consequence, the responsibility for determiningwhen and whether a manuscript submitted for publicationhas had appropriate ethical review (or an appropriate ex-emption to this requirement) all too often falls on the shoul-ders of journal editors. The editors of Preventive Medicine[6] and other journals [7] frequently receive manuscripts forconsideration that do not document whether or not the studyreceived appropriate ethical review. Frankly, checking forethical review at such a late stage defeats the purpose. It isvery difficult for editors to differentiate research from non-research unless the authors provide explicit information tohelp them. Furthermore, it is simply not appropriate for aresearch study involving human subjects to proceed with nooversight from an IRB with only an after-the-fact opinion ofa journal editor as the sole inducement to comply withhuman subjects protections.Why do we need ethical review of human research stud-ies in the first place? Ethical review accomplishes severalpurposes. It provides expert assessment of the safety of anyprocedures used in a study and it ensures that the autonomyof subjects under study is maintained and that the rights ofindividuals with diminished autonomy are likewise pro-tected (i.e., prisoners, children). It allows an evaluation ofrisk vs. benefit to ensure that benefits to subjects are max-imized while harms are minimized. It helps ensure that anyresearch risks are equitably distributed among populationsmost likely to benefit from the results. Finally, it ensuresthat the research design is sound and that those who conductthe research are competent both to conduct the research andto assure the well being of the research subjects, includingobtaining proper informed consent when appropriate.If we proceed first from the tenet that the common goal

Background — Chlamydia pneumoniae has been identified in coronary atheroma, but concomitant serum antibody titers have been inconsistently positive and unavailable before the detection of early or advanced atherosclerotic lesions. Methods and Results —This retrospective investigation was performed on premortem serum specimens and autopsy tissue from 60 indigenous Alaska Natives at low risk for coronary heart disease, selected by the potential availability of their stored specimens. Serum specimens were drawn a mean of 8.8 years (range, 0.7 to 26.2 years) before death, which occurred at a mean age of 34.1 years (range, 15 to 57 years), primarily from noncardiovascular causes (97%). Coronary artery tissues were independently examined histologically and, for C pneumoniae organism and DNA, by immunocytochemistry (ICC) and polymerase chain reaction (PCR) with species-specific monoclonal antibody and primers. Microimmunofluorescence detected species-specific IgG, IgA, and IgM antibody in stored serum. C pneumoniae , frequently within macrophage foam cells, was identified in coronary fibrolipid atheroma (raised lesions, Stary types II through V) in 15 subjects (25%) and early flat lesions in 7 (11%) either by PCR (14, 23%) or ICC (20, 33%). The OR for C pneumoniae in raised atheroma after a level of IgG antibody ≥1:256 >8 years earlier was 6.1 (95% CI, 1.1 to 36.6) and for all coronary tissues after adjustment for multiple potential confounding variables, including tobacco exposure, was 9.4 (95% CI, 2.6 to 33.8). Conclusions —Serological evidence for C pneumoniae infection frequently precedes both the earliest and more advanced lesions of coronary atherosclerosis that harbor this intracellular pathogen, suggesting a chronic infection and developmental role in coronary heart disease.

OBJECTIVES: The prevalence and characteristics of fetal alcohol syndrome cases and the usefulness of various data sources in surveillance were examined in Alaska to guide prevention and future surveillance efforts. METHODS: Sixteen data sources in Alaska were used to identify children with fetal alcohol syndrome. Medical charts were reviewed to verify cases, and records were reviewed to provide descriptive data. RESULTS: Fetal alcohol syndrome rates varied markedly by birth year and race, with the highest prevalence (4.1 per 1000 live births) found among Alaska Natives born between 1985 and 1988. Screening and referral programs to diagnostic clinics identified 70% of all recorded cases. The intervention program for children 0 to 3 years of age detected 29% of age-appropriate cases, and Medicaid data identified 11% of all cases; birth certificates detected only 9% of the age-appropriate cases. CONCLUSIONS: Our findings indicate a high prevalence of fetal alcohol syndrome in Alaska and illustrate that reliance on any one data source would lead to underestimates of the extent of fetal alcohol syndrome in a population.

In November 1992 residents of Fairbanks, Alaska became concerned about the potential health effects of an oxygenated fuel program during which 15% (by volume) methyl tertiary butyl ether (MTBE) was added to gasoline. To address those concerns, we earlier completed a survey of occupational exposure to MTBE. We conducted a follow-up survey of workers' exposure to benzene from gasoline in Fairbanks.Cross-sectional exposure survey.We examined blood concentrations of benzene from a convenience sample of workers taken in December 1992 during the oxygenated fuel program and from another convenience sample of workers taken in February 1993 after the program was suspended.In December, the median blood benzene concentration of samples taken from four mechanics after their workshift (postshift) was 1.32 micrograms/l (range, 0.84-2.61 micrograms/l), and seven nonmechanics (drivers and other garage workers) had a median postshift blood benzene concentration of 0.27 microgram/l (range, 0.09-0.45 microgram/l). In February, nine mechanics had a median postshift blood benzene concentration of 1.99 micrograms/l (range, 0.92-3.23 micrograms/l), and nine nonmechanics had a median postshift blood benzene concentration of 0.26 microgram/l (range, 0.2-0.46 microgram/l).Mechanics had higher blood benzene concentrations than did nonmechanics, but further study is needed to determine the impact of the oxygenated fuel program on exposure to benzene.

We document an echovirus 18 meningitis outbreak occurring at a remote overnight children's camp in Alaska. The outbreak involved 26% of 113 camp residents, was associated with building overcrowding and occurred in a camp with a contaminated drinking water source. Lack of specific children's camp regulations and failure to implement and enforce existing regulations may have contributed to the outbreak.

Outbreaks of paralytic shellfish poisoning have occurred worldwide. The authors reviewed records at the Alaska Division of Public Health to determine the epidemiologic characteristics of this disease. To assess risk factors for illness, the authors conducted a case-control study. A case was defined as illness compatible with paralytic shellfish poisoning within 12 hours of the consumption of shellfish, and a control was defined as a non-ill participant at a meal in which at least one case occurred. The authors documented 54 outbreaks of paralytic shellfish poisoning involving 117 ill persons from 1973 to 1992. One person died, four (3%) required intubation, and 29 (25%) required an emergency flight to a hospital. Outbreaks occurred with multiple shellfish species, during all four seasons, and at many locations. During the case-control study, illness was not associated with the shellfish toxin level, method of preparation, dose, race, sex, or age; alcohol consumption was associated with a reduced risk of illness (odds ratio = 0.05; p = 0.03). Although paralytic shellfish poisoning causes significant illness, the authors could not identify risk factors with clear implications for prevention strategies. This suggests that shellfish from uncertified beaches should not be eaten. Alcohol may protect against the adverse effects of paralytic shellfish poison.

Arterial, liver, and serum specimens were collected from 130 Alaska Natives who underwent forensic necropsy (mean age, 36.9 years; age range, 9-85 years; 38 females and 92 males). Based upon the observed frequencies of the six common apo E genotypes, the estimates of the relative frequencies of the corresponding alleles in the population are 0.020 +/- 0.009 for E2, 0.787 +/- 0.026 for E3 and 0.193 +/- 0.025 for E4. Analysis showed significant differences, by apo E genotype, in the extent of total surface lesion involvement in both the right and left coronary arteries. In all but the abdominal aorta, the pattern of lesion involvement by genotype is consistent with a decrease in lesions for genotypes with the E2 allele and an increase in lesions for the genotypes with the E4 allele, relative to the E3 homozygotes. After adjustment for low + very low density lipoprotein cholesterol (LDL + VLDL-C), the differences fell below statistically significant levels. Analysis by genotype of total serum cholesterol, high density lipoprotein cholesterol (HDL-C) and LDL + VLDL-C showed no statistically significant differences in analyte levels among genotypes. However, evidence is seen of a pattern in which total cholesterol and VLDL + LDL-C is less in genotypes with the E2 allele and greater in those with the E4 allele. We conclude that there does appear to be an effect by apo E genotype upon extent of atherosclerosis in the coronary arteries of Alaska Natives and this effect is likely due to the previously reported effect of apo E polymorphisms on serum cholesterol, particularly LDL + VLDL-C.

Background Foodborne botulism resulting from consumption of uncooked aquatic game foods has been an endemic hazard among Alaska Native populations for centuries. Our review was conducted to help target botulism prevention and response activities. Methods Records of Alaska botulism investigations for the period 1947-2007 were reviewed. We used the Centers for Disease Control and Prevention case definitions for foodborne botulism and linear regression to evaluate incidence trends and χ(2) or Fisher's Exact tests to evaluate categorical data. Results A total of 317 patients (61% of whom were female) and 159 outbreaks were reported. Overall mean annual incidence was 6.9 cases per 100,000 Alaska Native persons; mean incidence was lower in 2000 (5.7 cases per 100,000 Alaska Native persons) than in any period since 1965-1969 (0.8 cases per 100,000 Alaska Native persons). Age-specific incidence was highest (26.6 cases per 100,000 Alaska Native persons) among persons aged ≥60 years. The overall case-fatality rate was 8.2%, and the case-fatality rate was ≤4.0% since 1980. Misdiagnosis was associated with a higher case-fatality rate and delayed antitoxin administration. Conclusions Foodborne botulism remains a public health problem in Alaska. Incidence might be decreasing, but it remains >800 times the overall US rate (0.0068 cases per 100,000 persons). Prevention messages should highlight the additional risk to female individuals and older persons. Early diagnosis is critical for timely access to antitoxin and supportive care.

Challenges exist in comparing foodborne disease outbreaks (FBDOs) across states due to important differences in reporting practices and investigations. Variables such as FBDO size, population size, number of tourists, and suspected etiology are important to consider when interpreting FBDO data. Analysis of eFORS data can be valuable in improving state FBDO investigations. From 2000 to 2005, Florida reported a greater proportion of FBDOs, with two cases per outbreak, than the U.S. as a whole (40.4% in Florida vs. 17.2% in the U.S.). Reporting a higher rate of small FBDOs provided more opportunities for public health interventions but contributed to a lower agent confirmation rate (17.0% in Florida vs. 42.2% in the U.S.). While the Electronic Foodborne Outbreak Reporting System's (eFORS) database brought great improvements in national FBDO surveillance, as with any complex surveillance system, considerable knowledge and specialized expertise is required to properly analyze and interpret the data, especially because there is a large variation in state reports to eFORS.

Gonorrhea case reports to the Alaska Department of Health and Social Services were used to study the contribution of reinfection to rates of gonorrhea infection in Alaska. The case reports of 13,910 infections among 11,132 persons who had laboratory-proven gonorrhea between 1983 and 1987 were examined. Among 1,886 persons who had multiple infections, the average number of infections per person was 2.5 (range = 2-11). These persons accounted for 33.5% of all infections and 16.9% of all patients with gonorrhea from 1983 to 1987. Compared to persons with one infection, those having multiple infections were more likely to be Alaska Natives (relative risk = 1.8, 95% confidence interval = 1.6-1.9) and less than 21 years of age (relative risk = 1.3, 95% confidence interval = 1.2-1.4). There was no difference in risk between men and women. Two thirds of the reinfections occurred within 12 months of the initial infection. If gonorrhea incidence were calculated based on the number of people infected rather than as a "case rate," the mean annual rate (per 100,000) from 1983 to 1987 decreased from 1,644 to 1,228 (a 25.3% decrease) for Alaska Natives and from 316 to 267 (a 15.5% decrease) for non-Natives. Reporting gonorrhea incidence rates by number of persons infected rather than by total number of cases more accurately measures gonorrhea morbidity in a population and will allow prevention efforts to be directed to those persons who contribute the most to perpetuating the disease.

Persistence of circulating toxin in patients with foodborne botulism is not well characterized. Recommendations for administration of botulinum antitoxin are ambiguous for patients with late-presenting disease, such as a Florida woman with toxin-positive serum 12 days after toxin ingestion. We reviewed Alaska records of foodborne outbreaks of botulism that occurred during 1959-2007 to examine the period after ingestion during which toxin was detected. Of 64 cases with toxin-positive serum, toxin was detected up to 11 days after ingestion. The findings from Alaska and Florida support administration of antitoxin up to 12 days after toxin ingestion but do not indicate when circulating toxin should no longer be present.

National fish consumption advisories that are based solely on assessment of risk of exposure to contaminants without consideration of consumption benefits result in overly restrictive advice that discourages eating fish even in areas where such advice is unwarranted. In fact, generic fish advisories may have adverse public health consequences because of decreased fish consumption and substitution of foods that are less healthy.Public health is on the threshold of a new era for determining actual exposures to environmental contaminants, owing to technological advances in analytical chemistry. It is now possible to target fish consumption advice to specific at-risk populations by evaluating individual contaminant exposures and health risk factors. Because of the current epidemic of nutritionally linked disease, such as obesity, diabetes, and cardiovascular disease, general recommendations for limiting fish consumption are ill conceived and potentially dangerous.

A measles outbreak occurred among a highly vaccinated population in Alaska during 1998, providing an opportunity to determine the incremental efficacy of >or=2 doses of measles-containing vaccine (MCV) compared with 1 dose. Of 33 confirmed case patients identified, 31 had been vaccinated with 1 dose of MCV, 1 had received 2 doses, and vaccination status was unknown in 1 case. Seventy percent of cases were school-associated; 58% of cases occurred in 2 high schools. Of 3679 students attending the 2 schools, 50.4% and 45.5% had received >or=2 doses of MCV before measles introduction at the schools. The relative risk of developing measles among persons vaccinated with >or=2 doses of MCV compared with 1 dose was 0.06 (95% confidence interval, 0.01-0.44; P

The results of liver function tests allowed local and state public health professionals in Alaska to accurately predict the magnitude of an outbreak of hepatitis A.

OBJECTIVE: To characterize the nature and burden of snowmobile injuries in Alaska by examining injury deaths and hospitalizations associated with snowmobiles and comparing these with injury deaths and hospitalizations associated with on-road motor vehicles. METHODS: The authors used vital statistics, medical examiner, Department of Public Safety, and Department of Transportation records to identify snowmobile injury deaths, and used vital statistics mortality files to identify on-road motor vehicle injury deaths. The Alaska Trauma Registry provided data on hospitalizations. The number of vehicles in use in 1993-1994 was estimated from snowmobile sales and on-road motor vehicle registrations. RESULTS: For 1993-1994, injury death and hospitalization rates were greater for snowmobiles than for on-road motor vehicles. In northern Alaska, snowmobile injuries outnumbered on-road motor vehicle injuries. A total of 26 snowmobile injury deaths were reported; 7 decedents drowned after breaking through ice and 8 were ejected from vehicles. More than half (58%) of the snowmobile injury deaths involved a natural object such as a boulder, ravine, or river. Of the 17 decedents for whom blood alcohol concentrations were available, 11 (65%) had blood alcohol concentrations > or = 100 mg/dL. CONCLUSIONS: Natural obstacles and alcohol intoxication contribute to the high risk of injury death associated with snowmobile use. Injury control strategies, including trail development and improvement, should be evaluated.

Risk assessments relying on the U.S. EPA reference dose (RfD) for methylmercury exposure have led to restrictive fish consumption advisories in many states. These advisories fail to account for the benefits associated with fish consumption. Although the use of an RfD is valuable in efforts to regulate industrial emissions, food consumption advice should occur within a broader context that includes consideration of both risks and benefits.

Although most people are thought to receive their highest acute exposures to gasoline while refueling, relatively little is actually known about personal, nonoccupational exposures to gasoline during refueling activities. This study was designed to measure exposures associated with the use of an oxygenated fuel under cold conditions in Fairbanks, Alaska. We compared concentrations of gasoline components in the blood and in the personal breathing zone (PBZ) of people who pumped regular unleaded gasoline (referred to as regular gasoline) with concentrations in the blood of those who pumped an oxygenated fuel that was 10% ethanol (E-10). A subset of participants in a wintertime engine performance study provided blood samples before and after pumping gasoline (30 using regular gasoline and 30 using E-10). The biological and environmental samples were analyzed for selected aromatic volatile organic compounds (VOCs) found in gasoline (benzene, ethylbenzene, toluene, m-/p-xylene, and o-xylene); the biological samples were also analyzed for three chemicals not found in gasoline (1,4-dichlorobenzene, chloroform, and styrene). People in our study had significantly higher levels of gasoline components in their blood after pumping gasoline than they had before pumping gasoline. The changes in VOC levels in blood were similar whether the individuals pumped regular gasoline or the E-10 blend. The analysis of PBZ samples indicated that there were also measurable levels of gasoline components in the air during refueling. The VOC levels in PBZ air were similar for the two groups. In this study, we demonstrate that people are briefly exposed to low (ppm and sub-ppm) levels of known carcinogens and other potentially toxic compounds while pumping gasoline, regardless of the type of gasoline used. Images Figure 1. Figure 2. Figure 3.

To the Editor: Between June 1 and November 1, 1994, as part of an investigation of an outbreak of rubeola (measles), the Alaska State Health Department studied 57 persons with febrile illness accompanied by a rash. Efforts were made to obtain serum specimens from all persons with these symptoms during the investigation. Using an enzyme immunoassay kit for rubeola IgM approved by the Food and Drug Administration, and commercially available, the State Public Health Laboratory identified 16 specimens that were positive for rubeola IgM, indicating acute rubeola illness. After noticing that several of the 16 people with IgM-positive specimens did . . .

Residents of Fairbanks, Alaska reported health complaints when 15%, by volume, methyl tertiary butyl ether (MTBE) was added to gasoline during an oxygenated fuel program. We conducted an exposure survey to investigate the effect of the program on human exposure to MTBE. We studied 18 workers in December 1992 during the program and 28 workers in February 1993 after the program was suspended. All workers were heavily exposed to motor vehicle exhaust or gasoline fumes. In December, the median post-shift blood concentration of MTBE in the workers was 1.8 micrograms/l (range, 0.2-37.0 micrograms/l), and in February the median post-shift blood concentration of MTBE in the 28 workers was 0.24 micrograms/l (range, 0.05-1.44 micrograms/l; p = .0001). Blood MTBE levels were measurably higher during the oxygenated fuel program in Fairbanks than after the program was suspended.

Acute fluoride poisoning produces a clinical syndrome characterized by nausea, vomiting, diarrhea, abdominal pain, and paresthesias. In May 1992, excess fluoride in one of two public water systems serving a village in Alaska caused an outbreak of acute fluoride poisoning.We surveyed residents, measured their urinary fluoride concentrations, and analyzed their serum-chemistry profiles. A case of fluoride poisoning was defined as an illness consisting of nausea, vomiting, diarrhea, abdominal pain, or numbness or tingling of the face or extremities that began between May 21 and 23.Among 47 residents studied who drank water obtained on May 21, 22, or 23 from the implicated well, 43 (91 percent) had an illness that met the case definition, as compared with only 6 of 21 residents (29 percent) who drank water obtained from the implicated well at other times and 2 of 94 residents (2 percent) served by the other water system. We estimated that 296 people were poisoned; 1 person died. Four to five days after the outbreak, 10 of the 25 case patients who were tested, but none of the 15 control subjects, had elevated urinary fluoride concentrations. The case patients had elevated serum fluoride concentrations and other abnormalities consistent with fluoride poisoning, such as elevated serum lactate dehydrogenase and aspartate aminotransferase concentrations. The fluoride concentration of a water sample from the implicated well was 150 mg per liter, and that of a sample from the other system was 1.1 mg per liter. Failure to monitor and respond appropriately to elevated fluoride concentrations, an unreliable control system, and a mechanism that allowed fluoride concentrate to enter the well led to this outbreak.Inspection of public water systems and monitoring of fluoride concentrations are needed to prevent outbreaks of fluoride poisoning.

Average annual, age-adjusted death rates from cardiovascular diseases and atherosclerosis from 1980-86 among Alaskan Natives were lower than rates among other Alaskans (162.0 vs 242.1; RR = 0.67), while death rates from other causes were higher (954.4 vs 618.6; RR = 1.54). These suggest that Alaskan Natives have less cardiovascular disease than other populations. Additional research on the role of marine omega-3 fatty acids is needed.

Objective. To determine the most effective outbreak control strategy for school-based measles outbreaks as the proportion of children with two doses of measles-containing vaccine (MCV) increases. Setting. A school-based measles outbreak during 1996 involving 63 cases in Juneau, Alaska (population 29 288), where systematic revaccination with MCV was not implemented. Design. A retrospective evaluation using chain-of-transmission data of three possible outbreak control strategies: no school revaccination, targeted school revaccination (affected schools only), and community-wide school revaccination (all schools). Two-dose MCV coverage among students was estimated from school vaccination records and a survey issued to parents. Primary Outcome Measures. Potentially preventable cases of measles and doses of MCV administered per case prevented. Results. Two-dose MCV coverage among Juneau students was estimated to be 44% and 53% immediately before and after the outbreak, respectively. Of all the measles cases, an estimated 24 to 28 and 27 to 31 were potentially preventable by the targeted and community-wide school revaccination strategies, respectively. Either strategy might have optimally decreased the outbreak duration by 1 month, sparing one of seven affected schools and 10 of 12 unvaccinated children who had measles. Approximately 133 to 155 and 139 to 160 doses of MCV per case prevented would have been required for targeted and community-wide school revaccination, respectively. Conclusions. Either targeted or community-wide school revaccination would have been effective control strategies for this outbreak. Targeted school revaccination is probably the intervention of choice for school-based measles outbreaks in larger communities with higher two-dose MCV coverage. As two-dose MCV coverage continues to increase in the United States, public health control measures to respond to outbreaks need to be reevaluated.

Context. —Injury is a major public health problem in Alaska, and alcohol consumption and injury death are associated. Objective. —To determine the association between injury death, particularly alcohol-related injury death, and alcohol availability in remote Alaska. Design, Setting, and Participants. —Survey using death certificate data and medical examiner records to compare mortality rates for total injury and alcohol-related injury during 1990 through 1993 among Alaskans aged 15 years and older who had resided in remote villages of fewer than 1000 persons. Main Outcome Measures. —Rate ratios of injury death among residents of wet villages (ie, those without a restrictive alcohol law) as compared with injury death among residents of dry villages (ie, those with laws that prohibited the sale and importation of alcohol). Results. —Of 302 injury deaths, blood alcohol concentrations (BACs) were available for 200 deaths (66.2%). Of these, 130 (65.0%) had a BAC greater than or equal to 17 mmol/L (≥80 mg/dL) and were, therefore, classified as alcohol related. The total injury mortality rate was greater among Alaska Natives from wet villages (rate ratio [RR],1.6; 95% confidence interval [CI], 1.3-2.1), whereas this difference was not present for nonnatives (RR, 1.1; 95% CI, 0.3-3.8). For Alaska Natives, the alcohol-related injury mortality rate was greater among residents of wet villages (RR, 2.7; 95% CI, 1.9-3.8) than among residents of dry villages. The strength of this association was greatest for deaths due to motor vehicle injury, homicide, and hypothermia. Conclusions. —Although insufficient data existed to adjust for the effects of all potential confounders, residence in a wet village was associated with alcohol-related injury death among Alaska Native residents of remote Alaska villages. These findings indicate that measures limiting access to alcoholic beverages in this region may decrease alcohol-related injury deaths.

Context. —Small round-structured viruses (SRSVs) are known to cause viral gastroenteritis, but until now have not been confirmed in the implicated vehicle in outbreaks. Objective. —Investigation of a gastroenteritis outbreak. Design. —After applying epidemiologic methods to locate the outbreak source, we conducted environmental and laboratory investigations to elucidate the cause. Setting. —Tourists traveling by bus through Alaska and the Yukon Territory of Canada. Participants. —Staff of a restaurant at a business complex implicated as the outbreak source, convenience sample of persons on buses that had stopped there, and bus employees. Main Outcome Measures. —Odds ratios (ORs) for illness associated with exposures. Water samples from the restaurant and stool specimens from tourists and restaurant staff were examined by nucleic acid amplification using reverse transcription polymerase chain reaction and sequencing of viral amplification products. Results. —The itineraries of groups of tourists manifesting vomiting or diarrhea were traced back to a restaurant where buses had stopped 33 to 36 hours previously. Water consumption was associated with illness (OR, 5.3; 95% confidence interval [CI], 2.3-12.6). Eighteen of 26 employees of the business complex were ill; although not the index case, an employee ill shortly before the outbreak lived in a building connected to a septic pit, which was found to contaminate the well supplying the restaurant's water. Genotype 2/P2B SRSV was identified in stool specimens of 2 tourists and 1 restaurant employee. Stools and water samples yielded identical amplification product sequences. Conclusions. —The investigation documented SRSVs in a vehicle epidemiologically linked to a gastroenteritis outbreak. The findings demonstrate the power of molecular detection and identification and underscore the importance of fundamental public health practices such as restaurant inspection, assurance of a safe water supply, and disease surveillance.

Objective. Lead poisoning is a well-recognized public health concern for children living in the United States. In 1992, Health Care Financing Administration (HCFA) regulations required lead poisoning risk assessment and blood lead testing for all Medicaid-enrolled children ages 6 months to 6 years. This study estimated the prevalence of blood lead levels (BLLs) ≥10 μg/dL (≥0.48 μmol/L) and the performance of risk assessment questions among children receiving Medicaid services in Alaska. Design. Measurement of venous BLLs in a statewide sample of children and risk assessment using a questionnaire modified from HCFA sample questions. Setting. Eight urban areas and 25 rural villages throughout Alaska. Patients. Nine hundred sixty-seven children enrolled in Medicaid, representing a 6% sample of 6-month- to 6-year-old Alaska children enrolled in Medicaid. Outcome Measure(s). Determination of BLL and responses to verbal-risk assessment questions. Results. BLLs ranged from Conclusions. In this population, the prevalence of lead exposure was very low (0.6%); only one child tested (0.1%) maintained a BLL ≥10 μg/dL on confirmatory testing; no children were identified who needed individual medical or environmental management for lead exposure. Universal lead screening for Medicaid-enrolled children is not an effective use of public health resources in Alaska. Our findings identify an example of the importance in considering local and regional differences when formulating screening recommendations and regulations, and continually reevaluating the usefulness of federal regulations. lead poisoning, child health services, mass screening, government regulations, Medicaid.

Information on Alaskan suicides has come primarily from studies based upon records obtained from the Alaska Bureau of Vital Statistics and the National Center for Health Statistics (NCHS). To evaluate the accuracy of these statistics, state and national (NCHS) vital statistics records were searched for suicide deaths in Alaska in 1983-1984. Of 195 deaths meeting our case definition of suicide, only 141 (72%) appeared in state records and 112 (57%) appeared in NCHS records. Native suicides were more likely to be underrecorded than non-Native suicides, even after differences in recording district personnel were adjusted for. Errors resulted primarily from delayed determinations of the cause of death and failure to update the records.

During a mass diphtheria-tetanus immunization campaign in November 1975, more than 220,000 doses of diphtheria-tetanus toxoid, adult type were administered to adults throughout Alaska. In Anchorage, where more than 87,000 doses were given, a survey was conducted to determine the frequency of side effects. Postcard questionnaires were mailed to 2,000 randomly selected Anchorage residents; 467 questionnaires were returned by the post office as undeliverable, and 697 questionnaires were completed and returned. A follow-up survey was done of a random sample of the 836 non-responders. Of those responding, 57.8 per cent reported at least one reaction to the toxoids. The most frequent side effects were sore arm (42.7 per cent), swelling at the site of injection (34.8 per cent), and itching (24.2 per cent). Serious side effects occurred less frequently—swelling of the arm below the elbow (1.1 per cent) and abscess or infection (0.7 per cent). Of those vaccinated, 0.5 per cent saw a physician. There were no statistically significant differences in reaction rates by age group, except for sore arms. The jet injector produced more arm swelling at the site of injection, hives, and itching. More women than men reported adverse reactions, especially sore arm, swelling at the site of injection, and itching. Fear of adverse side effects should not preclude mass vaccination of adults. (Am. J. Public Health (69:246-249,1979.)

The arctic form of Trichinella spiralis that infects terrestrial and marine mammals is of importance in public health because persons living in arctic regions still depend on wild animals for economic subsistence. In 1975, an extended common-source epidemic of trichinosis attributed to consumption of walrus meat involved 29 persons in Barrow, Alaska. Of those persons eating this meat, 64% became ill, and the rate of infection of persons eating meat prepared with little or no cooking was four times as great as that of persons eating cooked meat. One year later a second outbreak occurred when a family ate partially cooked meat from an infected walrus. Clinical illness differed little from the disease acquired in temperature climates; however, only 70% had a positive bentonite flocculation titer, whereas 96% had eosinophilia. These epidemics of trichinosis are the first reported in Alaska to be associated with the consumption of walrus meat.

We reviewed records of all food-borne outbreaks of botulism in Alaska from 1947 through 1985. Fifty-nine confirmed or suspected outbreaks with 156 cases were reported. All outbreaks occurred in Alaska Natives and were associated with eating traditional Alaska Native foods. Forty-four (75%) of the outbreaks were laboratory confirmed and involved 133 persons. The overall annual incidence of confirmed or suspected botulism was 8.6 cases per 100,000 population. Seventeen persons died, an overall case-fatality rate of 11%. Type E toxin accounted for 32 (73%) laboratory-confirmed outbreaks; type A, six (14%); and type B, five (11%). Forty-one cases demonstrated botulinal toxin in one or more specimens (serum, gastric contents, or stool). Of the 41 botulinal toxin-positive persons, 38 (93%) had at least three of the commonly recognized pentad of signs or symptoms--nausea and vomiting, dysphagia, diplopia, dilated and fixed pupils, or dry mouth and throat--and 20 (49%) required respiratory assistance.

Investigation of measles outbreaks during the fall of 1976 led to the discovery that Alkaska's school immunization law was not being enforced. In an effort to control a large outbreak of measles in Fairbanks, children were required to show proof of measles vaccination or be excluded from school. Of the Fairbanks schoolchildren, 25% were vaccinated against measles; 1,251 (11%) of 11,727 unvaccinated schoolchildren were excluded in January, and no further cases of measles occurred. Subsequently, the school law was enforced statewide, and on March 1, 1977, all children not immunized against diphtheria, tetanus, pertussis, polio, measles, and rubella were excluded from school (7,418 [8.3%] of 89,108). One month later, fewer than 51 children still did not meet immunization requirements. More than 35,000 children were vaccinated in the immunization campaign; no adverse side effects to any vaccine were reported.

From January 1983 through December 1984, twenty deaths and at least 534 injuries in Alaska were associated with three-wheeled, all-terrain vehicles. Age at death ranged from 12 to 53 years; 15 deaths (75%) were in the 15- to 34-year age group. Of the 20 fatalities, 12 (60%) might have been prevented had the riders been wearing a helmet. Alcohol use was detected or highly suspected as the major contributing cause of the fatal crash for 12 of 15 drivers and three of five female passengers. Potential risk factors for injuries associated with all-terrain vehicles include alcohol use, failure to use helmets, rider inexperience and inattention, and excessive speed. (JAMA1986;255:2454-2458)