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Most major medical organizations recommend routine screening for breast, cervical, and colorectal cancers. Screening can lead to early detection of these cancers, resulting in reduced mortality. Yet, not all people who should be screened are screened regularly or, in some cases, ever. This report presents results of systematic reviews of effectiveness, applicability, economic efficiency, barriers to implementation, and other harms or benefits of provider reminder/recall interventions to increase screening for breast, cervical, and colorectal cancers. These interventions involve using systems to inform healthcare providers when individual clients are due (reminder) or overdue (recall) for specific cancer screening tests. Evidence in this review of studies published from 1986 through 2004 indicates that reminder/recall systems can effectively increase screening with mammography, Pap, fecal occult blood tests, and flexible sigmoidoscopy. Additional research is needed to determine if provider reminder/recall systems are effective in increasing colorectal cancer screening by colonoscopy. Specific areas for further research are also suggested.

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

Most major medical organizations recommend routine screening for breast, cervical, and colorectal cancers. Screening can lead to early detection of these cancers, resulting in reduced mortality. Yet not all people who should be screened are screened, either regularly or, in some cases, ever. This report presents the results of systematic reviews of effectiveness, applicability, economic efficiency, barriers to implementation, and other harms or benefits of interventions designed to increase screening for breast, cervical, and colorectal cancers by increasing community demand for these services. Evidence from these reviews indicates that screening for breast cancer (mammography) and cervical cancer (Pap test) has been effectively increased by use of client reminders, small media, and one-on-one education. Screening for colorectal cancer by fecal occult blood test has been increased effectively by use of client reminders and small media. Additional research is needed to determine whether client incentives, group education, and mass media are effective in increasing use of any of the three screening tests; whether one-on-one education increases screening for colorectal cancer; and whether any demand-enhancing interventions are effective in increasing the use of other colorectal cancer screening procedures (i.e., flexible sigmoidoscopy, colonoscopy, double contrast barium enema). Specific areas for further research are also suggested in this report.

Most major medical organizations recommend routine screening for breast, cervical, and colorectal cancers. Screening can lead to early detection of these cancers, resulting in reduced mortality. Yet not all people who should be screened are screened, either regularly or, in some cases, ever. This report presents the results of systematic reviews of effectiveness, applicability, economic efficiency, barriers to implementation, and other harms or benefits of interventions designed to increase screening for breast, cervical, and colorectal cancers by increasing community demand for these services. Evidence from these reviews indicates that screening for breast cancer (mammography) and cervical cancer (Pap test) has been effectively increased by use of client reminders, small media, and one-on-one education. Screening for colorectal cancer by fecal occult blood test has been increased effectively by use of client reminders and small media. Additional research is needed to determine whether client incentives, group education, and mass media are effective in increasing use of any of the three screening tests; whether one-on-one education increases screening for colorectal cancer; and whether any demand-enhancing interventions are effective in increasing the use of other colorectal cancer screening procedures (i.e., flexible sigmoidoscopy, colonoscopy, double contrast barium enema). Specific areas for further research are also suggested in this report. (Am J Prev Med 2008;35(1S):S34-S55) © 2008 American Journal of Preventive Medicine

Most major medical organizations recommend routine screening for breast, cervical, and colorectal cancers. Screening can lead to early detection of these cancers, resulting in reduced mortality. Yet not all people who should be screened are screened, either regularly or, in some cases, ever. This report presents results of systematic reviews of effectiveness, applicability, economic efficiency, barriers to implementation, and other harms or benefits of two provider-directed intervention approaches to increase screening for breast, cervical, and colorectal cancers. These approaches, provider assessment and feedback, and provider incentives encourage providers to deliver screening services at appropriate intervals. Evidence in these reviews indicates that provider assessment and feedback interventions can effectively increase screening by mammography, Pap test, and fecal occult blood test. Health plans, healthcare systems, and cancer control coalitions should consider such evidence-based findings when implementing interventions to increase screening use. Evidence was insufficient to determine the effectiveness of provider incentives in increasing use of any of these tests. Specific areas for further research are suggested in this report, including the need for additional research to determine whether provider incentives are effective in increasing use of any of these screening tests, and whether assessment and feedback interventions are effective in increasing other tests for colorectal cancer (i.e., flexible sigmoidoscopy, colonoscopy, or double-contrast barium enema).

Purpose: To determine the contribution of the C282Y and H63D mutations in the HFE gene to clinical expression of hereditary hemochromatosis. Methods: Pooled analysis of 14 case-control studies reporting HFE genotype data, to evaluate the association of different HFE genotypes with iron overload. In addition, we used data from the pooled analysis and published data to estimate the penetrance of the C282Y/C282Y genotype. Results: Homozygosity for the C282Y mutation carried the largest risk for iron overload (OR = 4383, 95% Cl 1374 to >10,000) and accounted for the majority of hemochromatosis cases (attributable fraction (AF) = 0.73). Risks for other genotypes were much smaller: OR = 32 for genotype C282Y/H63D (95% Cl 18.5 to 55.4, AF = 0.06); OR = 5.7 for H63D/H63D (95% Cl 3.2 to 10.1, AF = 0.01); OR = 4.1 for C282Y heterozygosity (95% Cl 2.9 to 5.8, with heterogeneity in study results, making this association uncertain); and OR = 1.6 for H63D heterozygosity (95% Cl 1 to 2.6, AF = 0.03). Estimates of penetrance for the C282Y/C282Y genotype were highly sensitive to estimates of the prevalence of iron overload disease. At a prevalence of 2.5 per 1000 or less, penetrance of the C282Y/C282Y genotype is unlikely to exceed 50%. Penetrance of other HFE genotypes is much lower. Conclusions: C282Y homozygosity confers the highest risk for iron overload but the H63D mutation is also associated with increased risk. Our data indicate a gradient of risk associated with different HFE genotypes and thus suggest the presence of other modifiers, either genetic or environmental, that contribute to the clinical expression of hemochromatosis.

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.

On 1 January 1989, in an effort to reduce diversion of benzodiazepines for illicit use and reduce inappropriate prescribing, a regulation was implemented requiring the reporting of all benzodiazepine prescriptions to the New York State Department of Health. To assess the impact of the regulation on prescribing practices to the elderly, we followed the number of benzodiazepines and other central nervous system medications prescribed to a cohort of participants in an elderly pharmaceutical insurance program. Benzodiazepines were prescribed for 4652 (22%) of the 20,944 patients studied. By the last quarter of 1989, benzodiazepines were prescribed for 3120 (15%) patients, a decrease of 33%. The number of prescriptions of benzodiazepines decreased by 5010 (45%), from 11,123 to 6113. Decreases in the number of prescriptions were similar across benzodiazepine brands (range 40-56%). Statistically significant (p0.05) decreases were seen in all sex, age, race and marital status groups. Increases in number (and percent increases) of prescriptions for miscellaneous anxiolytics (i.e. hydroxyzine (399, 69%), meprobamate (299, 149%), buspirone (263, 111%), chloral hydrate (138, 265%), antidepressants (658, 19%), barbiturates (150, 29%), and tranquilizers (198, 19%), some of which may be more toxic or less effective, were noted. New York State's reporting regulation was effective in reducing both the number of patients being prescribed benzodiazepines and the number of prescriptions given to those who remain on benzodiazepines in the elderly population studies.

To formulate an epidemiologic description of West Virginia spinal cord injury (SCI) resulting in hospitalization, we used data collected during the West Virginia Spinal Cord Injury Registry’s first three years of operation, July 1985 through June 1988, supplemented by data from registries in neighboring states. The West Virginia registry was established to detect newly injured persons potentially in need of rehabilitation services. Because reporting is hospital based, the registry records only injured patients surviving until hospitalization. The overall incidence of hospitalized SCI patients was 25 per million per year; the sex-specific rate among men was 4.6 times the rate among women. Age-specific rates peaked in the 15—24 years age group and declined with increasing age. Motor vehicle crashes accounted for 69% of all hospitalized SCI; falls, for 21%; and sports, falling objects, and violence, for less than 10% each. Most cause-specific incidence rates were highest for young males; however, falls were more common for the elderly. At least 25% of victims used drugs or alcohol shortly before injury, and none injured in auto or truck crashes reported wearing seat belts. Quadriplegia resulted for 56% of recorded SCI patients, whereas paraplegia resulted for the remaining 44%. SCI was more common in the summer months, on weekends, and during late afternoon hours. Both neurologic deficit and time of occurrence varied by cause. Although limitations exist, registry data has proved useful in describing spinal cord injury in West Virginia and has potential public health use in guiding prevention programs.

On 11 August 1985, a large inadvertent release occurred from a chemical manufacturing plant in Institute, West Virginia. The emission was related to overheating of a storage tank that contained chemicals for the production of aldicarb, a cholinesterase inhibiting pesticide. As a result of this emission, 136 persons were treated in five local emergency rooms, 29 of whom were hospitalized for one or more days, mostly for observation. No fatalities resulted. Interviews with treated persons and non-treated community residents confirmed that the health effects were transient and compatible with exposure to irritating vapors rather than with exposure to methyl isocyanate (a chemical used in the process) or to aldicarb. Only 5% of the treated persons and 5% of the community residents surveyed were adequately warned of the emission by the plant siren. Because persons in the nearby community are potentially vulnerable to chemical injury, we recommend the development of an improved warning system, a formal evacuation procedure, and other measures to limit exposure of persons in this area in the event of a future release.

We conducted a survey of 1,184 women 35 years of age or older who were employees of a company in Los Angeles County, California, to determine why some women participated in a worksite mammography screening program whereas others did not. Of the 111 who accepted a mammogram, 90 responded to the survey; of the 1,073 who declined mammography, 620 responded. The women were predominantly white, were well educated, and had health insurance. Of the 111 women who received mammograms, one was diagnosed with carcinoma. Seventy-three percent of the respondents to the survey 40 years of age or older who declined mammograms had already fulfilled American Cancer Society (ACS) guidelines for mammography screening at the time of the program. Women who accepted a mammogram were more likely to have had at least one previous mammogram than were women who had not met ACS guidelines yet who declined screening. We conclude that many female employees who are white, are well educated, and have health insurance may not participate in a worksite mammography screening program because they have been screened elsewhere. Companies providing worksite mammography screening should target education to women who have not met ACS guidelines, especially those who have never had a mammogram.

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.

Most major medical organizations recommend routine screening for breast, cervical, and colorectal cancers. Screening can lead to early detection of these cancers, resulting in reduced mortality. Yet, not all people who should be screened are screened regularly or, in some cases, ever. This report presents results of systematic reviews of effectiveness, applicability, economic efficiency, barriers to implementation, and other harms or benefits of provider reminder/recall interventions to increase screening for breast, cervical, and colorectal cancers. These interventions involve using systems to inform healthcare providers when individual clients are due (reminder) or overdue (recall) for specific cancer screening tests. Evidence in this review of studies published from 1986 through 2004 indicates that reminder/recall systems can effectively increase screening with mammography, Pap, fecal occult blood tests, and flexible sigmoidoscopy. Additional research is needed to determine if provider reminder/recall systems are effective in increasing colorectal cancer screening by colonoscopy. Specific areas for further research are also suggested.

Most major medical organizations recommend routine screening for breast, cervical, and colorectal cancers. Screening can lead to early detection of these cancers, resulting in reduced mortality. Yet not all people who should be screened are screened, either regularly or, in some cases, ever. This report presents results of systematic reviews of effectiveness, applicability, economic efficiency, barriers to implementation, and other harms or benefits of two provider-directed intervention approaches to increase screening for breast, cervical, and colorectal cancers. These approaches, provider assessment and feedback, and provider incentives encourage providers to deliver screening services at appropriate intervals. Evidence in these reviews indicates that provider assessment and feedback interventions can effectively increase screening by mammography, Pap test, and fecal occult blood test. Health plans, healthcare systems, and cancer control coalitions should consider such evidence-based findings when implementing interventions to increase screening use. Evidence was insufficient to determine the effectiveness of provider incentives in increasing use of any of these tests. Specific areas for further research are suggested in this report, including the need for additional research to determine whether provider incentives are effective in increasing use of any of these screening tests, and whether assessment and feedback interventions are effective in increasing other tests for colorectal cancer (i.e., flexible sigmoidoscopy, colonoscopy, or double-contrast barium enema).

Most major medical organizations recommend routine screening for breast, cervical, and colorectal cancers. Screening can lead to early detection of these cancers, resulting in reduced mortality. Yet not all people who should be screened are screened, either regularly or, in some cases, ever. This report presents the results of systematic reviews of effectiveness, applicability, economic efficiency, barriers to implementation, and other harms or benefits of interventions designed to increase screening for breast, cervical, and colorectal cancers by increasing community demand for these services. Evidence from these reviews indicates that screening for breast cancer (mammography) and cervical cancer (Pap test) has been effectively increased by use of client reminders, small media, and one-on-one education. Screening for colorectal cancer by fecal occult blood test has been increased effectively by use of client reminders and small media. Additional research is needed to determine whether client incentives, group education, and mass media are effective in increasing use of any of the three screening tests; whether one-on-one education increases screening for colorectal cancer; and whether any demand-enhancing interventions are effective in increasing the use of other colorectal cancer screening procedures (i.e., flexible sigmoidoscopy, colonoscopy, double contrast barium enema). Specific areas for further research are also suggested in this report.

Most major medical organizations recommend routine screening for breast, cervical, and colorectal cancers. Screening can lead to early detection of these cancers, resulting in reduced mortality. Yet not all people who should be screened are screened, either regularly or, in some cases, ever. This report presents the results of systematic reviews of effectiveness, applicability, economic efficiency, barriers to implementation, and other harms or benefits of interventions designed to increase screening for breast, cervical, and colorectal cancers by increasing community access to these services. Evidence from these reviews indicates that screening for breast cancer (by mammography) has been increased effectively by reducing structural barriers and by reducing out-of pocket client costs, and that screening for colorectal cancer (by fecal occult blood test) has been increased effectively by reducing structural barriers. Additional research is needed to determine whether screening for cervical cancer (by Pap test) can be increased by reducing structural barriers and by reducing out-of-pocket costs, whether screening for colorectal cancer (fecal occult blood test) can be increased by reducing out-of-pocket costs, and whether these interventions are effective in increasing the use of other colorectal cancer screening procedures (i.e., flexible sigmoidoscopy, colonoscopy, double contrast barium enema). Specific areas for further research are also suggested in this report.

Background and Objective We assessed the validity and utility of a claims-based ICD-9-CM algorithm for identifying preferred provider organization (PPO) enrollees ages 18–64 years at high risk for influenza complications. Methods PPO enrollees with ≥2 encounters in an ambulatory setting or ≥1 encounters in an inpatient or emergency room setting with ICD-9-CM diagnosis codes for the high-risk conditions were considered algorithm positive. Stratified random sampling was used to select 1,001 algorithm-positive and 330 algorithm-negative enrollees for medical chart abstractions. Results The prevalence of high-risk conditions using claims data was 2.5% compared to 18.2% according to medical records. The algorithm had a sensitivity of 12% and a specificity of 99%. Positive and negative predictive values were 87 and 84%, respectively. Sensitivity was twofold higher among adults aged 50–64 years than among younger adults (17 vs. 9%). Applying an algorithm definition of ≥1 encounters in any setting resulted in an increased sensitivity, but captured a higher proportion of false positives. Conclusion A claims-positive record was highly indicative of the presence of high-risk conditions, but such claims missed a large proportion of PPO enrollees with high-risk conditions. It is important to assess the validity of administrative data in different age groups.

OBJECTIVES: An investigation was conducted to determine whether ongoing transmission of Mycobacterium tuberculosis was occurring in a California state prison. METHOD: Prison pharmacy records were used to identify cases of active tuberculosis (TB). RESULTS: Ten of the 18 cases of active TB treated at the facility during 1991 were diagnosed at the prison that same year (an incidence of 184 per 100,000). Three inmates were infectious for a total of 7 months while imprisoned. The prevalence of TB skin test-positivity among inmates was 30%, and the incidence of new infection attributable to incarceration was 5.9 per 100 inmates per year. CONCLUSIONS: Transmission of M. tuberculosis may be occurring in the California prison system.

During May and June 1993, 10 patients and 5 members of the clinical staff at a hospital in California were diagnosed with Bordetella pertussis infection. In addition to erythromycin prophylaxis, 630 (48%) of 1330 staff members received a half dose of acellular pertussis vaccine with tetanus and diphtheria toxoids (DTaP). To identify side effects of the vaccine, a questionnaire was completed by 344 (54%) of 630 vaccinated staff. Side effects were reported by 117 respondents (34%); 64 were classified as mild (local reaction at injection site) and 50 as moderate (systemic complaints or local reaction resulting in limitation of arm movement). Three vaccinees (< 1%) reported missing 1 or more days of work because of their symptoms. Local reactions at the injection site occurred in 100 (29%), systemic symptoms in 38 (11%), and limitation of arm movement in 18 (5%). This study indicates that use of half dose of DTaP in adults appears safe and should be considered as an adjunct to chemoprophylaxis during institutional outbreaks.

Vertical transmission of hepatitis A virus (HAV) has not been reported. From 25 October to 15 November 1989, 10 cases of symptomatic HAV infection occurred among neonatal intensive care unit (NICU) staff. Testing of other NICU staff and patients identified 4 infected infants. Hepatitis A among staff was associated with caring for 1 of these infants, infant A (relative risk [RR], undefined; P = .05). Risk of illness was greater for staff who did not routinely wash their hands after treating infant A for apnea and bradycardia (RR = 4.9; P = .02). Staff, infants, visitors, and transfused blood products could not be implicated as a source of infant A's infection. Infant A's mother, however, was diagnosed with hepatitis A 10 days after premature labor and delivery. Evidence suggests that infant A was infected by his mother before or during birth. HAV then spread within the NICU because of breaks in infection control precautions. To prevent future outbreaks, NICU staff should adhere rigorously to body substance isolation measures.

In most years, La Crosse virus is the most common cause of reported mosquito-borne illness in the United States. The authors conducted a case-control study to determine if behavioral and environmental factors influenced the risk of La Crosse virus illness. Data were gathered on 31 serologically confirmed cases and 60 age-, sex-, and geography-matched controls in West Virginia in 1987 and 1988. Univariate analysis revealed minimal elevation of disease risk (odds ratios (ORs) less than 2.0) with increased time outdoors, non-use of insect repellent, non-use of air conditioning, lack of screened windows, and not wearing protective clothing. Univariate and multivariate analysis indicated that the presence of tree holes significantly increased disease risk (OR = 8.5 for greater than or equal to 1 tree hole vs. 0 tree holes). The following factors may also increase disease risk, although the findings were not statistically significant: discarded tires (OR = 3.2 for greater than or equal to 10 tires vs. 0-9 tires); non-tire artificial containers (OR = 4.1 for greater than or equal to 6 containers vs. 0-5 containers); and close proximity of the house to the forest edge (OR = 3.2 for 0-49 ft (0-14.9 m) vs. greater than or equal to 50 ft (greater than or equal to 14.9 m)). The authors conclude that the presence of natural breeding sites (tree holes) is an important risk factor for La Crosse virus illness. These results may be important in guiding future efforts aimed at preventing infection with La Crosse virus.

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)

Objective. —To determine the source of and describe a large outbreak of Escherichia coli O157:H7 infections in Washington State. Design. —Case-control study; environmental investigation; provider-based surveillance for E coli O157:H7 infections. Setting. —Chain of fast-food restaurants, hospitals, physician offices, local laboratories, and local health departments. Participants. —Patients with diarrhea and neighborhood controls. A case was defined as diarrhea with culture-confirmed E coli O157:H7 infection or postdiarrheal hemolytic uremic syndrome (HUS) occurring from December 1, 1992, through February 28, 1993, in a Washington State resident. Controls were age- and neighborhood-matched friends of the first 16 case patients. Interventions. —Announcement to the public; recall of implicated hamburger lots. Main Outcome Measure. —Abatement of outbreak due to E coli O157:H7. Results. —Infection was associated with eating at a fast-food chain (chain A) in the 10 days before symptoms began. Twelve (75%) of 16 case patients but no controls had eaten at chain A (matched odds ratio undefined; lower 95% confidence interval, 3.5; P E coli O157:H7 strains isolated from all regular hamburger lots of a single production date shipped to Washington was identical to that of the strains isolated from patients. Ten (63%) of 16 regular hamburgers cooked according to chain A policy had internal temperatures below 60°C. Public health action removed more than 250 000 potentially contaminated hamburgers, preventing an estimated 800 cases. Conclusions. —This E coli O157:H7 outbreak, the largest reported, resulted from errors in meat processing and cooking. Public health surveillance through state-mandated reporting of E coli O157:H7 infection as is carried out in Washington State was critical for prompt outbreak recognition and control. Measures should be developed to reduce meat contamination. Consumers and food service workers should be educated about cooking hamburger meat thoroughly. ( JAMA . 1994;272:1349-1353)

Objective: To examine the variation by age in the rates and causes of burn injury requiring hospitalization during early childhood. Design and Setting: Hospital discharge data and a burn unit admission log were used to identify all children in the Denver (Colo) metropolitan area younger than 5 years who sustained burn injuries and were hospitalized in 1989 and 1990. Patients' medical records were reviewed. Results: One hundred twenty-two children were identified with burn injuries that required hospitalization, an annual incidence of 40.5 per 100 000 children younger than 5 years. Children aged 6 months through 2 years accounted for 88% of all cases and were seven times more likely to be hospitalized for a burn injury than were children outside this age range. Scalding and contact with hot objects accounted for 64% and 20% of cases, respectively, and occurred primarily in the 6-month through 2-year age group. Conclusions: The findings underscore the importance of developmental stage as a determinant of risk and type of burn injury. Children aged 6 months through 2 years are at increased risk of severe burn injury and should be targeted for prevention efforts. (Arch Pediatr Adolesc Med. 1994;148:394-397)

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.

This is an entertaining, although sometimes shocking collection of anecdotes by a physician who has gained a reputation for looking at the lighter side of medicine. With humor and a sense of irony, Great Medical Disasters presents an array of calamitous misadventures that have befallen physicians, their patients, and the general public during the last several centuries. Gordon's examples of professional malpractice and buffoonery, deadly epidemics, bureaucratic blundering, and the misfortunes of some well-known patients, all but convince the reader to concentrate on prevention and never mind the cure. Included in these stories are such persons as the surgeon Robert Liston, who once performed an operation that resulted in a 300% mortality; James Boswell, whose sexual appetite led to an unsavory demise at the hands of the "clap"; (Typhoid) Mary Mallon, the itinerant housecook who did for Salmonella typhosa what Johnny Appleseed did for the Macintosh; and the enterprising scoundrels

During the period Sept 1 through Oct 1, 1978, an outbreak of enteroviral illness affected 43 (70%) of the 61 members of a high school football team. Thirty-three (54%) had symptoms of aseptic meningitis, a diagnosis confirmed for each of seven players hospitalized. Echovirus 16 was recovered from a throat swab of one hospitalized player and from the CSF of another. Enteroviruses isolated from stool specimens taken after the illness from other ill players and from stool specimens of non-ill team members were also identified as echovirus 16. A survey among students not on the team showed an attack rate for enteroviral-like illness that was half that experienced by team members during the same period. Symptoms reported by nonteam members were less severe. Only 10% had an aseptic meningitis-like syndrome, and none were hospitalized. Membership on the school football team was associated with an increased attack rate of illness and a greater risk for aseptic meningitis developing. ( JAMA 1982;248:1724-1727)

In Reply.— Dr Coleman suggests sleep apnea syndrome as a cause of sudden unexplained nocturnal death syndrome (SUNDS) in Southeast Asian refugees. We found no evidence to suggest this etiology. As discussed in our article, the hearts that we examined were all from SUNDS victims whose deaths had been reported to the Centers for Disease Control, Atlanta, and there was a thorough investigation of each case by the Centers for Disease Control. The epidemiologic aspects of this disorder have been previously reported, 1 and, specifically, evidence for sleep apnea syndrome was lacking. "Most were considered sound sleepers by their spouses, who reported no earlier episodes of respiratory distress or prolonged apnea during sleep, and none experienced daytime hypersomnolence." 1 Although cardiomegaly was a common finding at autopsy, there was no morphologic evidence for either pulmonary hypertension or systemic hypertension. Furthermore, no anatomic abnormality of the upper airways that might produce

In the period July 15, 1977, through March 30, 1982, there were at least 51 sudden, unexplained deaths in the United States among refugees from Southeast Asia. These deaths involved relatively young (median age, 33 years), previously healthy persons. All except one were male, and all died at night. Available data from studies among young adults in this country suggest that this specific phenomenon has an unusually high incidence among Laotian and Kampuchean refugees and, furthermore, has not previously been observed in the United States. Interviews with families of the decedents and a case-control study have failed to establish causal factors, but emotional stress cannot be ruled out as a contributing element. While reviews of the forensic investigations have confirmed the absence of important common pathological or toxicological findings, preliminary findings of special postmortem cardiac studies, now in progress, suggest that at least some of these deaths may be associated with developmentally abnormal conduction system pathways. Further studies are required to confirm this association, to define the apparently sleep-induced mechanism that triggers these deaths, and to explain the male preponderance in this disorder. ( JAMA 1983;250:2947-2951)

During 1978 and 1980, epidemiologists at the Centers for Disease Control investigated seven outbreaks of aseptic meningitis—like illness (AMLI) occurring in high school football players in four different states. One or more enterovirus types were isolated from affected students at all seven schools. Attack rates were highest among the varsity football teams (range, 21% to 68%), although junior varsity teams were also affected at most schools (range, 5% to 63%). Non—football athletes were relatively spared. The illness was also reported by nonathletes at all three schools where more extensive investigations were undertaken. At one school, the AMLI attack rate was higher among students who were close friends of football players than among students who were not close friends; at the other two schools, these rates were similar. Hospitalization was more likely for football players with AMLI than for affected nonfootball players. Transmission of enteroviruses among football players was probably from person to person, although there was additional evidence to implicate common vehicle transmission at two schools. We conclude that football players may or may not have been more likely to be exposed to the enteroviruses circulating in their communities, but once introduction of a virus into a team occurred, transmission potential may have been enhanced, resulting in a large number of AMLI cases in players. ( JAMA 1983;249:2039-2042)

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.

Sudden death during sleep has occurred among previously healthy Southeast Asian male refugees, but routine autopsies have not determined the cause of death in any of these cases. We report the first systematic attempt to define the cardiac abnormalities associated with this syndrome. Among 18 hearts examined, 14 showed slight to significant cardiomegaly, characteristic of increased cardiac work load. The reasons for the cardiomegaly remain unexplained. Conduction system anomalies were present in all but one heart. These included persistent fetal dispersion of the atrioventricular node and/or bundle of His, present in 14 hearts; accessory conduction fiber connections, found in 13 cases; and congenital heart block, observed in one case. These abnormalities were associated with variations in the structure of the cardiac base, suggesting a common aberrant developmental process. Although the functional significance of these findings has not been established, the conduction system anomalies may be the substrate for sleep-related cardiac arrhythmias and sudden death.(JAMA 1986;256:2700-2705)