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Introduction: In 2021, among all age groups, falls ranked as the third leading cause of unintentional injury death in the USA. Unlike fatal data, which rely on death certificates as the gold standard, there is not a gold standard for non-fatal data. Non-fatal falls data are often based on insurance claims or administrative billing data. The purpose of our study is to compare three claims databases to estimate rates of unintentional fall-related hospitalisations in 2019, the most recent year of available data across the three sources., Methods: Three databases were used to produce incidence rates of fall-related hospitalisations for the year 2019: (1) Merative MarketScan research databases, (2) Centers for Medicare and Medicaid Services (CMS) data and (3) Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample. Inpatient falls were identified using International Classification of Diseases, 10th Revision, Clinical Modification codes. Incidence rates per 100 000 people were then produced across all three datasets by payer type. Unadjusted incidence rate ratios were estimated with corresponding 95% CIs., Results: There were wide disparities among fall rates between the three datasets by payer type. HCUP had the highest rate of falls among Medicare (1087.6 per 100 000) and commercial enrollees (74.7 per 100 000), while CMS had the highest rates of falls among Medicaid enrollees (148.0 per 100 000)., Conclusions: This study shows wide variation in fall hospitalisation rates based on the claims data used to estimate rates. This study suggests that database selection is an important consideration when determining incidence of non-fatal falls., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Differences in social and environmental factors contribute to disparities in fatal injury rates. This study assessed the relationship between social vulnerability and homicide and suicide rates across United States counties., Methods: County-level age-adjusted homicide and suicide rates for 2016-2020 were linked with data from the Centers for Disease Control and Prevention's 2020 Social Vulnerability Index (SVI), a dataset identifying socially vulnerable communities. We conducted negative binomial regressions to examine the association between SVI and homicide and suicide rates, overall and by Census region/division. We mapped county-level data for SVI and homicide and suicide rates in bivariate choropleth maps., Results: Overall SVI was associated with homicide rates across U.S. counties. While no association was found for overall SVI and suicide rates, Socioeconomic Status and Racial & Ethnic Minority Status domains were associated. The geographic distribution of SVI and homicide and suicide rates varied spatially; notably, counties in the South had the greatest levels of social vulnerability and greatest homicide rates., Conclusions: Our findings demonstrate county-level social vulnerability is associated with homicide rates but may be more nuanced for suicide rates. A modified SVI for injury should include additional social and structural determinants and exclude variables not applicable to injuries., Practical Applications: This study combines the SVI with homicide and suicide data, enabling researchers to examine related social and environmental factors. Modifying the SVI to include relevant predictors could improve injury prevention strategies by prioritizing efforts in areas with high social vulnerability., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Published by Elsevier Ltd.)

Background: Injury is a leading cause of preventable morbidity and mortality in the USA. Ongoing surveillance is needed to understand changing injury patterns to effectively target prevention efforts. Launched jointly in 2000 by the Consumer Product Safety Commission (CPSC) and the Centers for Disease Control and Prevention (CDC), the National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) provides national-level estimates of US emergency department visits for nonfatal injuries. A scoping review of peer-reviewed articles was conducted to characterize how NEISS-AIP data have been used for injury surveillance in the USA., Main Body: This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Three bibliographic databases (PubMed, Scopus, and Google Scholar) were systematically searched for English language peer-reviewed articles that used NEISS-AIP data as the primary data source during 2001-2021. Key article characteristics from included articles were abstracted to generate descriptive summary statistics to understand the use and limitations of NEISS-AIP for injury surveillance. Database queries returned 6944 citations; 594 citations were manually reviewed, and 167 non-duplicate journal articles were identified. An average of 8.0 articles (range: 1-14) were published annually during 2001-2021. Articles appeared in 72 different journals representing a diverse audience with the majority of articles written by CDC authors. Starting in 2013, a higher proportion of articles were published by non-CDC authors. The largest number of articles examined injury among all age groups (n = 71); however, the pediatric population was the specific age group of greatest interest (n = 48), followed by older adults (n = 23). Falls (n = 20) and motor-vehicle-related injuries (n = 10) were the most studied injury mechanisms. The most commonly identified limitation identified by authors of reviewed articles was that NEISS-AIP only produces national estimates and therefore, cannot be used for state- or county-level injury surveillance (n = 38)., Conclusions: NEISS-AIP has contributed to nonfatal injury surveillance in the USA. CDC and CPSC continue to work together to expand and enhance NEISS-AIP data collection. Researchers are encouraged to continue using this publicly available dataset for injury surveillance., (© 2023. Columbia University Center for Injury Epidemiology and Prevention.)

Background: Differences in social and environmental factors can contribute to disparities in fatal injury rates. The purpose of this study was to examine the relationship between social and environmental factors and unintentional fatal injury across counties in the United States and how this relationship varies by geography., Methods: County-level vital statistics on age-adjusted unintentional fatal injury rates for 2015-2019 were linked with county-level data from the 2018 Social Vulnerability Index (SVI), a dataset identifying socially vulnerable communities. We conducted linear regression to examine the association between SVI and unintentional fatal injury, overall and by Census region/division. We mapped county-level data for SVI and unintentional fatal injury rates in bivariate choropleth maps using quartiles., Results: SVI was positively associated with unintentional fatal injury (β = 18.29, p < 0.001) across U.S. counties. The geographic distribution of SVI and unintentional fatal injury rates varied spatially and substantially for U.S. counties, with counties in the South and West regions having the greatest levels of SVI and rates of unintentional fatal injury., Conclusions: Our findings demonstrate that the social vulnerability of counties is associated with unintentional fatal injury rates. Modification of the SVI for injury research could include additional social determinants and exclude variables not applicable to injuries. A modified SVI could inform unintentional injury prevention strategies by prioritizing efforts in areas with high levels of social vulnerability., Practical Applications: This study is the first step in combining the SVI and injury mortality data to provide researchers with an index to investigate upstream factors related to injury., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Published by Elsevier Ltd.)

Background: Assessing disparities in injury is crucial for injury prevention and for evaluating injury prevention strategies, but efforts have been hampered by missing data. This study aimed to show the utility and reliability of the injury surveillance system as a trustworthy resource for examining disparities by generating multiple imputed companion datasets., Methods: We employed data from the National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) for the period 2014-2018. A comprehensive simulation study was conducted to identify the appropriate strategy for addressing missing data limitations in NEISS-AIP. To evaluate the imputation performance more quantitatively, a new method based on Brier Skill Score (BSS) was developed to assess the accuracy of predictions by different approaches. We selected the multiple imputations by fully conditional specification (FCS MI) to generate the imputed companion data to NEISS-AIP 2014-2018. We further assessed health disparities systematically in nonfatal assault injuries treated in U.S. hospital emergency departments (EDs) by race and ethnicity, location of injury and sex., Results: We found for the first time that significantly higher age-adjusted nonfatal assault injury rates for ED visits per 100,000 population occurred among non-Hispanic Black persons (1306.8, 95% Confidence Interval [CI]: 660.1 - 1953.5), in public settings (286.3, 95% CI: 183.2 - 389.4) and for males (603.5, 95% CI: 409.4 - 797.5). We also observed similar trends in age-adjusted rates (AARs) by different subgroups for non-Hispanic Black persons, injuries occurring in public settings, and for males: AARs of nonfatal assault injury increased significantly from 2014 through 2017, then declined significantly in 2018., Conclusions: Nonfatal assault injury imposes significant health care costs and productivity losses for millions of people each year. This study is the first to specifically look at health disparities in nonfatal assault injuries using multiply imputed companion data. Understanding how disparities differ by various groups may lead to the development of more effective initiatives to prevent such injury., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Objectives: The adverse effects that racial and ethnic minority groups experience before, during, and after disaster events are of public health concern. The objective of this study was to examine disparities in the epidemiologic and geographic patterns of natural disaster and extreme weather mortality by race and ethnicity., Methods: We used mortality data from the Centers for Disease Control and Prevention from January 1, 1999, through December 31, 2018. We defined natural disaster and extreme weather mortality based on International Classification of Diseases, 10th Revision codes X30-X39. We calculated age-adjusted mortality rates by race, ethnicity, and hazard type, and we calculated age-adjusted mortality rate ratios by race, ethnicity, and state. We used geographic mapping to examine age-adjusted mortality rate ratios by race, ethnicity, and state., Results: Natural disasters and extreme weather caused 27 335 deaths in the United States during 1999-2018. Although non-Hispanic White people represented 68% of total natural disaster and extreme weather mortality, the mortality rate per 100 000 population among non-Hispanic Black people was 1.87 times higher (0.71) and among non-Hispanic American Indian/Alaska Native people was 7.34 times higher (2.79) than among non-Hispanic White people (0.38). For all racial and ethnic groups, exposure to extreme heat and cold were the 2 greatest causes of natural disaster and extreme weather mortality. Racial and ethnic disparities in natural disaster and extreme weather mortality were highest in the South, Southwest, Mountain West, and Upper Midwest., Conclusions: Racial and ethnic minority populations have a greater likelihood of mortality from natural disaster or extreme weather events than non-Hispanic White people. Our study strengthens the current knowledge base on these disparities and may inform and improve disaster preparedness and response efforts.

Introduction: Geographic and urbanization differences in female suicide trends across the U.S. necessitates suicide prevention efforts on the basis of geographic variations. The purpose of this study was to assess female suicide rates by mechanism within Census divisions and by urbanicity to help inform geographically tailored approaches for suicide prevention strategies., Methods: Data from 2004 to 2018 were obtained from the National Vital Statistics System (analyzed in 2021). Annual counts of female suicides were tabulated for firearm, suffocation, and drug poisoning and stratified by the U.S. Census division and urbanicity. Age-adjusted rates were calculated to describe female suicide incidence by geographic areas and urbanicity. Data were analyzed annually and by 5-year timeframes. Trends in annual female suicide rates by mechanism for 3 urbanization levels were identified using Joinpoint Regression. Annual percent change estimates were calculated for age-adjusted female suicide rates between 2004 and 2018., Results: Female suicide rates by mechanism were not homogeneous within Census divisions or by urbanization levels. Suicide rates by mechanism across Census divisions within the same urbanization level varied (range=3.38-11.15 [per 100,000 person per year]). From 2014 to 2018 in large metropolitan areas in the northern divisions, rates for suffocation were higher than for firearms and drug poisoning. During the same period, in all urbanization levels in southern divisions, rates for firearms were higher than for suffocation and drug poisoning., Conclusions: Female suicide mechanisms vary by urbanization level, and this variation differs by region. These results could inform female suicide prevention strategies on the basis of mechanism, urbanization, and geographic region., (Published by Elsevier Inc.)

Introduction: On March 13, 2020, the U.S. declared COVID-19 to be a national emergency. As communities adopted mitigation strategies, there were potential changes in the trends of injuries treated in emergency department. This study provides national estimates of injury-related emergency department visits in the U.S. before and during the pandemic., Methods: A secondary retrospective cohort study was conducted using trained, on-site hospital coders collecting data for injury-related emergency department cases from medical records from a nationally representative sample of 66 U.S. hospital emergency departments. Injury emergency department visit estimates in the year before the pandemic (January 1, 2019-December 31, 2019) were compared with estimates of the year of pandemic declaration (January 1, 2020-December 31, 2020) for overall nonfatal injury-related emergency department visits, motor vehicle, falls-related, self-harm-, assault-related, and poisoning-related emergency department visits., Results: There was an estimated 1.7 million (25%) decrease in nonfatal injury-related emergency department visits during April through June 2020 compared with those of the same timeframe in 2019. Similar decreases were observed for emergency department visits because of motor vehicle‒related injuries (199,329; 23.3%) and falls-related injuries (497,971; 25.1%). Monthly 2020 estimates remained relatively in line with 2019 estimates for self-harm‒, assault-, and poisoning-related emergency department visits., Conclusions: These findings provide updates for clinical and public health practitioners on the changing profile of injury-related emergency department visits during the COVID-19 pandemic. Understanding the short- and long-term impacts of the pandemic is important to preventing future injuries., (Published by Elsevier Inc.)

Objective: The purpose of this research is to identify how data science is applied in suicide prevention literature, describe the current landscape of this literature and highlight areas where data science may be useful for future injury prevention research., Design: We conducted a literature review of injury prevention and data science in April 2020 and January 2021 in three databases., Methods: For the included 99 articles, we extracted the following: (1) author(s) and year; (2) title; (3) study approach (4) reason for applying data science method; (5) data science method type; (6) study description; (7) data source and (8) focus on a disproportionately affected population., Results: Results showed the literature on data science and suicide more than doubled from 2019 to 2020, with articles with individual-level approaches more prevalent than population-level approaches. Most population-level articles applied data science methods to describe (n=10) outcomes, while most individual-level articles identified risk factors (n=27). Machine learning was the most common data science method applied in the studies (n=48). A wide array of data sources was used for suicide research, with most articles (n=45) using social media and web-based behaviour data. Eleven studies demonstrated the value of applying data science to suicide prevention literature for disproportionately affected groups., Conclusion: Data science techniques proved to be effective tools in describing suicidal thoughts or behaviour, identifying individual risk factors and predicting outcomes. Future research should focus on identifying how data science can be applied in other injury-related topics., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

In April 2010, a fatal explosion on the Deepwater Horizon drilling rig in the Gulf of Mexico resulted in the largest marine oil spill in history. This research describes the association of oil exposure with anxiety after the Deepwater Horizon Oil Spill and evaluates effect modification by self-mastery, emotional support and cleanup participation. To assess the impacts of the Deepwater Horizon Oil Spill, the Centers for Disease Control and Prevention (CDC) conducted the Gulf States Population Survey (GSPS), a random-digit-dial telephone cross-sectional survey completed between December 2010 and December 2011 with 38,361 responses in four different Gulf Coast states: Louisiana, Florida, Alabama and Mississippi. Anxiety severity was measured using the Generalised Anxiety Disorder (GAD) symptom inventory. We used Tobit regression to model underlying anxiety as a function of oil exposure and hypothesised effect modifiers, adjusting for socio-demographics. Latent anxiety was higher among those with direct contact with oil than among those who did not have direct contact with oil in confounder-adjusted models [β = 2.84, 95% confidence interval (CI): 0.78, 4.91]. Among individuals with direct contact with oil, there was no significant interaction between participating in cleanup activities and emotional support for anxiety ( p = 0.20). However, among those with direct contact with oil, in confounder-adjusted models, participation in oil spill cleanup activities was associated with lower latent anxiety (β = -3.55, 95% CI: -6.15, -0.95). Oil contact was associated with greater anxiety, but this association appeared to be mitigated by cleanup participation., Competing Interests: Conflicts of interest statement Dr. Gribble is a current Editor for this journal. All authors declare no conflict of interest with the content of this work.

Prior studies of oil spills have reported adverse impacts on mental health, but have not examined some potentially important moderators. In this cross-sectional analysis of n=38,361 responses to the 2010-2011 Gulf States Population Survey, we assessed the association of direct oil contact with depression severity following the Deepwater Horizon oil spill, and modification by self-mastery, emotional support, and cleanup participation using Tobit regression models accounting for the complex survey design. Oil contact was associated with increased depression severity. Among respondents with oil contact, depression was more severe for those reporting lower self-mastery. However, respondents with oil contact had lower depression severity if they participated in cleanup efforts, compared to exposed individuals who did not participate. This potential protective effect was larger for respondents with lower self-mastery. Our results are consistent with the notion that participation in recovery efforts may reduce depressive symptoms following oil spills among impacted individuals.

Objectives. To assess preparedness levels of communities to help public health and others plan for disasters or emergencies and tailor messaging to increase community preparedness. Methods. US Virgin Islands Department of Health conducted a Community Assessment for Public Health Emergency Response (CASPER) in June 2017, 2 hurricane response CASPERs in November 2017, and a recovery CASPER in February 2018. CASPER is a 2-stage cluster sampling method designed to provide household-based information about a community's needs in a timely, inexpensive, and representative manner. Results. Roughly the same amount of households reported having a 3-day supply of food and water before and 3 months after the hurricanes. During the response, approximately a third of households resupplied between 3 and 6 days and an additional approximately 40% between days 7 and 14. Conclusions. On the basis of the CASPERs, we were able to track whether households had an emergency preparedness kit, whether they used it during the storms (and what was missing), and if they resupplied their kit in recovery. Public Health Implications. CASPER is a promising tool to measure community preparedness to help state, local, tribal, and territorial jurisdictions plan for disasters or emergencies.

Effective communication is a critical part of managing an emergency. During an emergency, the ways in which health agencies normally communicate warnings may not reach all of the intended audience. Not all communities are the same, and households within communities are diverse. Because different communities prefer different communication methods, community leaders and emergency planners need to know their communities' preferred methods for seeking information about an emergency. This descriptive report explores findings from previous community assessments that have collected information on communication preferences, including television (TV), social media, and word-of-mouth (WoM) delivery methods. Data were analyzed from 12 Community Assessments for Public Health Emergency Response (CASPERs) conducted from 2014-2017 that included questions regarding primary and trusted communication sources. A CASPER is a rapid needs assessment designed to gather household-based information from a community. In 75.0% of the CASPERs, households reported TV as their primary source of information for specific emergency events (range = 24.0%-83.1%). Households reporting social media as their primary source of information differed widely across CASPERs (3.2%-41.8%). In five of the CASPERs, nearly one-half of households reported WoM as their primary source of information. These CASPERs were conducted in response to a specific emergency (ie, chemical spill, harmful algal bloom, hurricane, and flood). The CASPERs conducted as part of a preparedness activity had lower percentages of households reporting WoM as their primary source of information (8.3%-10.4%). The findings in this report demonstrate the need for emergency plans to include hybrid communication models, combining traditional methods with newer technologies to reach the broadest audience. Although TV was the most commonly reported preferred source of information, segments of the population relied on social media and WoM messaging. By using multiple methods for risk communication, emergency planners are more likely to reach the whole community and engage vulnerable populations that might not have access to, trust in, or understanding of traditional news sources. Multiple communication channels that include user-generated content, such as social media and WoM, can increase the timeliness of messaging and provide community members with message confirmation from sources they trust encouraging them to take protective public health actions.WolkinAF, SchnallAH, NakataNK, EllisEM. Getting the message out: social media and word-of-mouth as effective communication methods during emergencies. Prehosp Disaster Med. 2019;34(1):89-94.

Objective: We evaluated the usefulness and accuracy of media-reported data for active disaster-related mortality surveillance., Methods: From October 29 through November 5, 2012, epidemiologists from the Centers for Disease Control and Prevention (CDC) tracked online media reports for Hurricane Sandy-related deaths by use of a keyword search. To evaluate the media-reported data, vital statistics records of Sandy-related deaths were compared to corresponding media-reported deaths and assessed for percentage match. Sensitivity, positive predictive value (PPV), and timeliness of the media reports for detecting Sandy-related deaths were calculated., Results: Ninety-nine media-reported deaths were identified and compared with the 90 vital statistics death records sent to the CDC by New York City (NYC) and the 5 states that agreed to participate in this study. Seventy-five (76%) of the media reports matched with vital statistics records. Only NYC was able to actively track Sandy-related deaths during the event. Moderate sensitivity (83%) and PPV (83%) were calculated for the matching media-reported deaths for NYC., Conclusions: During Hurricane Sandy, the media-reported information was moderately sensitive, and percentage match with vital statistics records was also moderate. The results indicate that online media-reported deaths can be useful as a supplemental source of information for situational awareness and immediate public health decision-making during the initial response stage of a disaster. (Disaster Med Public Health Preparedness. 2017;11:460-466).

Context: Epidemiological preparedness is vital in providing relevant, transparent, and timely intelligence for the management, mitigation, and prevention of public health impacts following major environmental health incidents. A register is a set of records containing systematically collected, standardized data about individual people. Planning for a register of people affected by or exposed to an incident is one of the evolving tools in the public health preparedness and response arsenal., Objective: We compared and contrasted the instigation and design of health registers in the epidemiological response to major environmental health incidents in England, France, Italy, the Netherlands, and the United States., Design: Consultation with experts from the 5 nations, supplemented with a review of gray and peer-reviewed scientific literature to identify examples where registers have been used., Setting: Populations affected by or at risk from major environmental health incidents in England, France, Italy, the Netherlands, and the United States., Methods: Nations were compared with respect to the (1) types of major incidents in their remit for considering a register; (2) arrangements for triggering a register; (3) approaches to design of register; (4) arrangements for register implementation; (5) uses of registers; and (6) examples of follow-up studies., Results: Health registers have played a key role in the effective public health response to major environmental incidents, including sudden chemical, biological, radiological, or nuclear, as well as natural, more prolonged incidents. Value has been demonstrated in the early and rapid deployment of health registers, enabling the capture of a representative population., Conclusion: The decision to establish a health register must ideally be confirmed immediately or soon after the incident using a set of agreed criteria. The establishment of protocols for the instigation, design, and implementation of health registers is recommended as part of preparedness activities. Key stakeholders must be aware of the importance of, and protocols for, establishing a register.Agencies will find value in preparing and implementing registers as part of an effective public health response to major environmental incidents, including sudden chemical, biological, radiological, or nuclear incidents, as well as natural, more prolonged incidents.

Timely morbidity surveillance of sheltered populations is crucial for identifying and addressing their immediate needs, and accurate surveillance allows us to better prepare for future disasters. However, disasters often create travel and communication challenges that complicate the collection and transmission of surveillance data. We describe a surveillance project conducted in New Jersey shelters after Hurricane Sandy, which occurred in November 2012, that successfully used cellular phones for remote real-time reporting. This project demonstrated that, when supported with just-in-time morbidity surveillance training, cellular phone reporting was a successful, sustainable, and less labor-intensive methodology than in-person shelter visits to capture morbidity data from multiple locations and opened a two-way communication channel with shelters. (Disaster Med Public Health Preparedness. 2015;10:525-528).

Introduction: Community Assessment for Public Health Emergency Response (CASPER) is an epidemiologic technique designed to provide quick, inexpensive, accurate, and reliable household-based public health information about a community's emergency response needs. The Health Studies Branch at the Centers for Disease Control and Prevention (CDC) provides in-field assistance and technical support to state, local, tribal, and territorial (SLTT) health departments in conducting CASPERs during a disaster response and in non-emergency settings. Data from CASPERs conducted from 2003 through 2012 were reviewed to describe uses of CASPER, ascertain strengths of the CASPER methodology, and highlight significant findings., Methods: Through an assessment of the CDC's CASPER metadatabase, all CASPERs that involved CDC support performed in US states and territories from 2003 through 2012 were reviewed and compared descriptively for differences in geographic distribution, sampling methodology, mapping tool, assessment settings, and result and action taken by decision makers., Results: For the study period, 53 CASPERs were conducted in 13 states and one US territory. Among the 53 CASPERS, 38 (71.6%) used the traditional 2-stage cluster sampling methodology, 10 (18.8%) used a 3-stage cluster sampling, and two (3.7%) used a simple random sampling methodology. Among the CASPERs, 37 (69.9%) were conducted in response to specific natural or human-induced disasters, including 14 (37.8%) for hurricanes. The remaining 16 (30.1%) CASPERS were conducted in non-disaster settings to assess household preparedness levels or potential effects of a proposed plan or program. The most common recommendations resulting from a disaster-related CASPER were to educate the community on available resources (27; 72.9%) and provide services (18; 48.6%) such as debris removals and refills of medications. In preparedness CASPERs, the most common recommendations were to educate the community in disaster preparedness (5; 31.2%) and to revise or improve preparedness plans (5; 31.2%). Twenty-five (47.1%) CASPERs documented on the report or publications the public health action has taken based on the result or recommendations. Findings from 27 (50.9%) of the CASPERs conducted with CDC assistance were published in peer-reviewed journals or elsewhere., Conclusion: The number of CASPERs conducted with CDC assistance has increased and diversified over the past decade. The CASPERs' results and recommendations supported the public health decisions that benefitted the community. Overall, the findings suggest that the CASPER is a useful tool for collecting household-level disaster preparedness and response data and generating information to support public health action.

Disaster epidemiology (i.e., applied epidemiology in disaster settings) presents a source of reliable and actionable information for decision-makers and stakeholders in the disaster management cycle. However, epidemiological methods have yet to be routinely integrated into disaster response and fully communicated to response leaders. We present a framework consisting of rapid needs assessments, health surveillance, tracking and registries, and epidemiological investigations, including risk factor and health outcome studies and evaluation of interventions, which can be practiced throughout the cycle. Applying each method can result in actionable information for planners and decision-makers responsible for preparedness, response, and recovery. Disaster epidemiology, once integrated into the disaster management cycle, can provide the evidence base to inform and enhance response capability within the public health infrastructure.

Introduction: Approximately 1.2 million persons in Oakland County, Michigan (USA) reside less than 50 miles from the Fermi Nuclear Power Plant, Unit 2, but information is limited regarding how residents might react during a radiation emergency. Community Assessment for Public Health Emergency Response (CASPER) survey methodology has been used in disaster and non disaster settings to collect reliable and accurate population-based public health information, but it has not been used to assess household-level emergency preparedness for a radiation emergency. To improve emergency preparedness plans in Oakland County, including how residents might respond during a radiation emergency, Oakland County Health Division (OCHD), with assistance from the Centers for Disease Control and Prevention (CDC) and the Michigan Department of Community Health (MDCH), conducted a CASPER survey., Methods: During September 2012, a 2-stage cluster sampling design was used to select 210 representative households in Oakland County. By using in-person surveys, the proportion of households with essential needs and supplies, how residents might respond to public health authorities' instructions, and their main source for obtaining information during a radiation emergency were assessed. Data were weighted to account for the complex sampling design., Results: Of the goal of 210 households, 192 (91.4%) surveys were completed: 64.7% and 85.4% of respondents indicated having 3-day supplies of water and of non perishable food, respectively; 62.8% had a 7-day supply of prescription medication for each person who needed it. Additionally, 64.2% had a working carbon monoxide detector; 67.1% had a first-aid kit; and 52% had an alternative heat source. In response to instructions from public health officials during a radiation emergency, 93.3% of all respondents would report to a radiation screening center; 96% would evacuate; and 91.8% would shelter-in-place. During a radiation emergency, 55.8% of respondents indicated their main information source would be television, 18.4% radio, and 13.6% the Internet. The most trusted source for information would be the local public health department (36.5%), local news (23%), a physician (11.2%), and family members (11.1%). Including completed and incomplete interviews, refusals, and non respondents, 517 total households were contacted., Conclusions: CASPER data regarding how residents might react during a radiation emergency provided objective and quantifiable information that will be used to develop Oakland County's radiation emergency preparedness plans. Survey information demonstrates the feasibility and usefulness of CASPER methodology for radiation emergency preparedness planning.

Heat-related illnesses (HRI) are the most frequent cause of environmental exposure-related injury treated in US emergency departments (ED). While most individuals with HRI evaluated in EDs are discharged to home, understanding predictors of individuals hospitalized with HRI may help public health practitioners and medical providers identify high risk groups who would benefit from educational outreach. We analyzed data collected by the Georgia Department of Public Health, Office of Health Indicators for Planning, regarding ED and hospital discharges for HRI, as identified by ICD-9 codes, between 2002 and 2008 to determine characteristics of individuals receiving care in EDs. Temperature data from CDC's Environmental Public Health Tracking Network were linked to the dataset to determine if ED visits occurred during an extreme heat event (EHE). A multivariable logistic regression model was developed to determine characteristics predicting hospitalization versus ED discharge using demographic characteristics, comorbid conditions, socioeconomic status, the public health district of residence, and the presence of an EHE. Men represented the majority of ED visits (75 %) and hospitalizations (78 %). In the multivariable model, the odds of admission versus ED discharge with an associated HRI increased with age among both men and women, and odds were higher among residents of specific public health districts, particularly in the southern part of the state. Educational efforts targeting the specific risk groups identified by this study may help reduce the burden of hospitalization due to HRI in the state of Georgia.

Dangerously cold weather threatens life and property. During periods of extreme cold due to wind chill, the National Weather Service (NWS) issues wind chill warnings to prompt the public to take action to mitigate risks. Wind chill warnings are based on ambient temperatures and wind speeds. Since 2010, NWS has piloted a new extreme cold warning issued for cold temperatures in wind and nonwind conditions. The North Dakota Department of Health, NWS, and the Centers for Disease Control and Prevention collaborated in conducting household surveys in Burleigh County, North Dakota, to evaluate this new warning. The objectives of the evaluation were to assess whether residents heard the new warning and to determine if protective behaviors were prompted by the warning. This was a cross-sectional survey design using the Community Assessment for Public Health Emergency Response (CASPER) methodology to select a statistically representative sample of households from Burleigh County. From 10 to 11 April 2012, 188 door-to-door household interviews were completed. The CASPER methodology uses probability sampling with weighted analysis to estimate the number and percentage of households with a specific response within Burleigh County. The majority of households reported having heard both the extreme cold and wind chill warnings, and both warnings prompted protective behaviors. These results suggest this community heard the new warning and took protective actions after hearing the warning.

Background: The Grand Canyon National Park has approximately 4 million visitors between April and September each year. During this period, outdoor activity such as hiking is potentially hazardous owing to extreme heat, limited shade, and steep, long ascents. Given the high visitation and the public health interest in the effects of extreme heat, this study calculated morbidity rates and described heat-related illness (HRI) among visitors., Methods: We conducted a retrospective cross-sectional study from April 1 through September 30, during 2004-2009. From a review of Ranger Emergency Medical Services (EMS) incident report files, we extracted information on those that met the case definition of greater than 1 hour of outdoor heat exposure with an HRI assessment or diagnosis, HRI self-report, or signs or symptoms of HRI without another etiology noted. Visitor and temperature data were obtained from respective official sources., Results: Grand Canyon EMS responded to 474 nonfatal and 6 fatal HRI cases, with the majority (84%) being US residents, 29% from Western states. Of the nonfatal cases, 51% were women, the median age was 43 years (range, 11-83 years), and 18% reported a cardiovascular condition. Clinical HRI assessments included dehydration (25%), heat exhaustion (23%), and suspected hyponatremia (19%). Almost all (90%) were hiking; 40% required helicopter evacuation. The highest HRI rates were seen in May., Conclusions: HRI remains a public health concern at the Grand Canyon. High-risk evacuations and life-threatening conditions were found. Majority were hikers, middle-aged adults, and US residents. These findings support the park's hiker HRI prevention efforts and use of park EMS data to measure HRI., (Published by Elsevier Inc.)

Objectives: We describe the demographics of the decedents from the tornado outbreak in Alabama on April 27, 2011; examine the circumstances of death surrounding these fatalities; and identify measures to prevent future tornado-related fatalities., Methods: We collected information about the decedents from death certificates, disaster-related mortality surveillance, and interview data collected by American Red Cross volunteers from the decedent's families. We describe demographic characteristics, circumstances and causes of death, and sheltering behaviors before death., Results: Of the 247 fatalities, females and older adults were at highest risk for tornado-related deaths. Most deaths were directly related to the tornadoes, on scene, and trauma-related. The majority of the deceased were indoors in single-family homes. Word of mouth was the most common warning mechanism., Conclusions: This tornado event was the third deadliest in recent US history. Our findings support the need for local community shelters, enhanced messaging to inform the public of shelter locations, and encouragement of word-of-mouth warnings and personal and family preparedness planning, with a special focus on assisting vulnerable individuals in taking shelter.

Objective: To describe the injuries and illnesses treated by the American Red Cross (Red Cross) during Hurricanes Gustav and Ike disaster relief operations reported on a new Aggregate Morbidity Report Form., Methods: From August 28 to October 18, 2008, 119 Red Cross field service locations in Louisiana, Mississippi, Tennessee, and Texas addressed the healthcare needs of people affected by the hurricanes. From these locations, individual client visit data were retrospectively collated per site onto new 24-hour Aggregate Morbidity Report Forms., Results: A total of 3863 clients were treated. Of the clients, 48% were girls and women and 44% were boys and men; 61% were 19 to 64 years old. Ninety-eight percent of the visits occurred in shelters. The reasons for half of the visits were acute illness and symptoms (eg, pain) and 16% were for routine follow-up care. The majority (65%) of the 2516 visits required treatment at a field location, although 34%, or 1296 visits, required a referral, including 543 healthcare facility transfers., Conclusions: During the hurricanes, a substantial number of displaced evacuees sought care for acute and routine healthcare needs. The capacity of the Red Cross to address the immediate and ongoing health needs of sheltered clients for an extended period of time is a critical resource for local public health agencies, which are often overwhelmed during a disaster. This article highlights the important role that this humanitarian organization fills, to decrease surge to local healthcare systems and to monitor health effects following a disaster. The Aggregate Morbidity Report Form has the potential to assist greatly in this role, and thus its utility for real-time reporting should be evaluated further.

Introduction: The Texas Department of State Health Services (DSHS) implemented an active mortality surveillance system to enumerate and characterize hurricane-related deaths during Hurricane Ike in 2008. This surveillance system used established guidelines and case definitions to categorize deaths as directly, indirectly, and possibly related to Hurricane Ike., Objective: The objective of this study was to evaluate Texas DSHS' active mortality surveillance system using US Centers for Disease Control and Prevention's (CDC) surveillance system evaluation guidelines., Methods: Using CDC's Updated Guidelines for Surveillance System Evaluation, the active mortality surveillance system of the Texas DSHS was evaluated. Data from the active mortality surveillance system were compared with Texas vital statistics data for the same time period to estimate the completeness of reported disaster-related deaths., Results: From September 8 through October 13, 2008, medical examiners (MEs) and Justices of the Peace (JPs) in 44 affected counties reported deaths daily by using a one-page, standardized mortality form. The active mortality surveillance system identified 74 hurricane-related deaths, whereas a review of vital statistics data revealed only four deaths that were hurricane-related. The average time of reporting a death by active mortality surveillance and vital statistics was 14 days and 16 days, respectively., Conclusions: Texas's active mortality surveillance system successfully identified hurricane-related deaths. Evaluation of the active mortality surveillance system suggested that it is necessary to collect detailed and representative mortality data during a hurricane because vital statistics do not capture sufficient information to identify whether deaths are hurricane-related. The results from this evaluation will help improve active mortality surveillance during hurricanes which, in turn, will enhance preparedness and response plans and identify public health interventions to reduce future hurricane-related mortality rates.

Objectives: We measured the burden of hypothermia- and hyperthermia-related health care visits, identified risk factors, and determined the health care costs associated with environmental heat or cold exposure among Medicare beneficiaries., Methods: We obtained Medicare fee-for-service claims data of inpatient and outpatient health care visits for hypothermia and hyperthermia from 2004 to 2005. We examined the distribution and differences of visits by age, sex, race, geographic regions, and direct costs. We estimated rate ratios to determine risk factors., Results: Hyperthermia-related visits (n = 10,007) were more frequent than hypothermia-related visits (n = 8761) for both years. However, hypothermia-related visits resulted in more deaths (359 vs 42), higher mortality rates (0.50 per 100,000 vs 0.06 per 100,000), higher inpatient rates (5.29 per 100,000 vs 1.76 per 100,000), longer hospital stays (median days = 4 vs 2), and higher total health care costs ($98 million vs $36 million)., Conclusions: This study highlighted the magnitude of these preventable conditions among older adults and disabled persons and the burden on the Medicare system. These results can help target public education and preparedness activities for extreme weather events.

The National Poison Data System (NPDS) is a national near-real-time surveillance system that improves situational awareness for chemical and poison exposures, according to data from US poison centers. NPDS is the successor to the Toxic Exposure Surveillance System. The Centers for Disease Control and Prevention (CDC) use these data, which are owned and managed by the American Association of Poison Control Centers, to improve public health surveillance for chemical and poison exposures and associated illness, identify early markers of chemical events, and enhance situational awareness during outbreaks. Information recorded in this database is from self-reported calls from the public or health care professionals. In 2009, NPDS detected 22 events of public health significance and CDC used the system to monitor several multistate outbreaks. One of the limitations of the system is that exposures do not necessarily represent a poisoning. Incorporating NPDS data into the public health surveillance network and subsequently using NPDS to rapidly identify chemical and poison exposures exemplifies the importance of the poison centers and NPDS to public health surveillance. This integration provides the opportunity to improve the public health response to chemical and poison exposures, minimizes morbidity and mortality, and serves as an important step forward in surveillance technology and integration., (Copyright © 2011 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.)

Introduction: Surveillance for health outcomes is critical for rapid responses and timely prevention of disaster-related illnesses and injuries after a disaster-causing event. The Disaster Surveillance Workgroup (DSWG) of the US Centers for Disease Control and Prevention developed a standardized, single-page, morbidity surveillance form, called the Natural Disaster Morbidity Surveillance Individual Form (Morbidity Surveillance Form), to describe the distribution of injuries and illnesses, detect outbreaks, and guide timely interventions during a disaster., Problem: Traditional data sources can be used during a disaster; however, supplemental active surveillance may be required because traditional systems often are disrupted, and many persons will seek care outside of typical acute care settings. Generally, these alternative settings lack health surveillance and reporting protocols. The need for standardized data collection was demonstrated during Hurricane Katrina, as the multiple surveillance instruments that were developed and deployed led to varied and uncoordinated data collection methods, analyses, and morbidity data reporting. Active, post-event surveillance of affected populations is critical for rapid responses to minimize and prevent morbidity and mortality, allocate resources, and target public health messaging., Methods: The CDC and the Georgia Department of Public Health (GDPH) conducted a study to evaluate a Morbidity Surveillance Form to determine its ability to capture clinical presentations. The form was completed for each patient evaluated in an emergency department (ED) during triage from 01 August, 2007 through 07 August, 2007. Data from the form were compared with the ED discharge diagnoses from electronic medical records, and kappa statistics were calculated to assess agreement., Results: Nine hundred forty-nine patients were evaluated, 41% were male and 57% were Caucasian. According to the forms, the most common reasons for seeking treatment were acute illness, other (29%); pain (12%); and gastrointestinal illness (8%). The frequency of agreement between discharge diagnoses and the form ranged from 3 to 100%. Kappa values ranged from 0.23-1.0, with nine of the 12 categories having very good or good agreement., Conclusion: With modifications to increase sensitivity for capturing certain clinical presentations, the Morbidity Surveillance Form can be a useful tool for capturing data needed to guide public health interventions during a disaster. A validated collection instrument for a post-disaster event facilitates rapid and standardized comparison and aggregation of data across multiple jurisdictions, thus, improving the coordination, timeliness, and accuracy of public health responses. The DSWG revised the Morbidity Surveillance Form based on information from this study.

Diethylene glycol (DEG), a chemical that has been implicated in multiple medication-associated mass poisonings, can result in renal and neurological toxicity if ingested. Three previous such mass poisonings implicated Chinese manufacturers as the origin of contaminated ingredients. No literature exists on potential DEG or triethylene glycol (TEG), a related compound, contamination of health products imported from Asian countries to the USA. Our primary objective was to quantitatively assess the amount of DEG present in a convenience sampling of these health products. The study's secondary objectives were to: (1) evaluate for, and quantify TEG levels in these samples; (2) compare DEG and TEG levels in these products directly to levels in medications implicated in previous similar mass poisonings; and (3) to estimate DEG dose (in mg/kg) based on the manufacturer's instructions and compare these values to toxic doses from past mass poisonings and the literature. A quantitative assessment of DEG and TEG was performed in a convenience sampling of over-the-counter health products imported from Asian countries. Results were converted to volume to volume (v/v) % and compared with DEG levels in medications implicated in previous mass poisonings. Estimated doses (based on the manufacturer's instructions) of each product with detectable levels of DEG for a 70 kg adult were compared to toxic doses of DEG reported in the literature. Seventeen of 85 (20%) samples were not able to be analyzed for DEG or TEG due to technical reasons. Fifteen of 68 (22%) samples successfully tested had detectable levels of DEG (mean, 18.8 μg/ml; range, 0.791-110.1 μg/ml; and volume to volume (v/v) range, 0.00007-0.01%). Two of 68 (3%) samples had TEG levels of 12.8 and 20.2 μg/ml or 0.0012% and 0.0018% TEG v/v. The product with the highest DEG% by v/v was 810 times less than the product involved in the Panama DEG mass poisoning (8.1%). The lowest reported toxic dose from a past DEG mass poisoning (14 mg/kg) was more than 150 times higher than the highest daily dose estimated in our study (0.09 mg/kg). Sixty-eight of 85 (80%) samples were able to be successfully analyzed for DEG and TEG. DEG and TEG were detectable in 15/68 (22%) and 2/68 (3%) samples, respectively. Based on current standards, these levels probably do not represent an acute public health threat. Additional research focusing on why DEG is found in these products and on the minimum amount of DEG needed to result in toxicity is needed., (© American College of Medical Toxicology 2010)

Background: On September 13, 2008, Hurricane Ike, a category 2 storm with maximum sustained winds of 110 mph, made landfall near Galveston, Texas. Ike produced a damaging, destructive, and deadly storm surge across the upper Texas and southwestern Louisiana coasts. Thirty-four Texas counties were declared disaster areas by the Federal Emergency Management Agency; 15 counties were under mandatory evacuation orders. To describe causes of death associated with this hurricane and identify prevention strategies during the response and recovery phases, the Texas Department of State Health Services (DSHS) monitored mortality data in 44 counties throughout the state. This report summarizes Ike-related deaths reported by Texas medical examiners, justices of the peace (coroners), forensic centers, public health officials, and hospitals., Methods: Based on the Centers for Disease Control and Prevention (CDC) disaster-related mortality surveillance form, DSHS developed a state-specific 1-page form and collected (optimally daily) data on demographic, date and place of death, and cause and circumstance of deaths. A case was defined as any death that was directly or indirectly related to Ike among evacuees, residents, nonresidents, or rescue personnel in the declared disaster counties, counties along the Texas Gulf coast or counties known to have evacuation shelters occurring September 8, 2008, through October 13, 2008. Analyzed data were shared with the state emergency operation center and the CDC on a daily basis., Results: The surveillance identified 74 deaths in Texas as directly (10 [14%]), indirectly (49 [66%]), or possibly (15 [20%]) related to Ike. The majority of deaths (n=57) were reported by medical examiners. Deaths occurred in 16 counties of the 44 counties covered by the surveillance. The majority of deaths occurred in Harris and Galveston (28 [38%] and 17 [23%]), respectively. The deceased ranged in age from younger than 1 year to 85 years, with an average age of 46 years (median 50 years); 70% were male. Of the 74 deaths, 47 (64%) resulted from injuries, 23 (31%) from illnesses, and 4 (5%) were undetermined. Among the injuries, carbon monoxide poisoning (13 [18%]) and drowning (8 [11%]) were the leading causes of injury-related deaths. Cardiovascular failure (12 [16%]) was the leading cause of illness-related deaths., Conclusions: Defining the relation of death to hurricane using an active mortality surveillance system is possible. The active mortality surveillance form used in Ike provided valuable daily information to DSHS, state emergency management officials, and the CDC regarding the characteristics of deaths in the state. Most of the Ike-related deaths were caused by injury (direct and indirectly related) such as carbon monoxide poisonings and drowning and may have been preventable by educating the public., (©2011 American Medical Association. All rights reserved.)

Introduction: On 13 September 2008, Hurricane Ike made landfall near Galveston, Texas, resulting in an estimated 74 deaths statewide and extensive damage in many counties. The Texas Department of State Health Services, US Public Health Service, and the Centers for Disease Control and Prevention conducted assessments beginning 12 days following hurricane landfall to identify the public health needs of three affected communities. The results of the assessment are presented, and an example of a type of public health epidemiological response to a disaster due to a natural hazard is provided., Methods: A one-page questionnaire that focused on household public health characteristics was developed. Using a two-stage cluster sampling methodology, 30 census blocks were selected randomly in three communities (Galveston, Liberty, and Manvel, Texas). Seven households were selected randomly from each block to interview., Results: The assessments were conducted on 25, 26, and 30 September 2008. At the time of the interview, 45% percent of the households in Galveston had no electricity, and 26% had no regular garbage collection. Forty-six percent reported feeling that their residence was unsafe to inhabit due to mold, roof, and/or structural damage, and lack of electricity. Sixteen percent of households reported at least one member of the household had an injury since the hurricane. In Liberty, only 7% of the household members interviewed had no access to food, 4% had no working toilet, 2% had no running water, and 2% had no electricity. In Manvel, only 5% of the households did not have access to food, 3% had no running water, 2% had no regular garbage collection, and 3% had no electricity., Conclusions: Post-Ike household-level surveys conducted identified the immediate needs and associated risks of the affected communities. Despite the response efforts, a high proportion of households in Galveston still were reportedly lacking electricity and regular garbage pickup 17 days post-storm. The proportion of households with self-reported injury in Galveston suggested the need to enhance public education on how to prevent injuries during hurricane cleanup. Galveston public health officials used the assessment to educate local emergency and elected officials of the health hazards related to lack of basic utilities and medical care in the community. This resulted in the provision of an extensive public health outreach education program throughout the island. The Liberty and Manvel assessment findings suggest that most households in both communities were receiving the basic utilities and that the residents felt "safe". The assessments reassured local health officials that there were no substantial acute public health needs and provided objective information that services were being restored.

Perchlorate exposure may be higher in infants compared with older persons, due to diet (infant formula) and body weight versus intake considerations. Our primary objective was to quantitatively assess perchlorate concentrations in commercially available powdered infant formulas (PIFs). Secondary objectives were: (1) to estimate exposure in infants under different dosing scenarios and compare them with the perchlorate reference dose (RfD); (2) estimate the perchlorate concentration in water used for preparing PIFs that would result in a dose exceeding the RfD; and (3) estimate iodine intakes from PIFs. We quantified perchlorate levels in three samples (different lot numbers) of reconstituted PIF (using perchlorate-free water) from commercial brands of PIF in each of the following categories: bovine milk-based with lactose, soy-based, bovine milk-based but lactose-free, and elemental (typically consisting of synthetic amino acids). Exposure modeling was conducted to determine whether the RfD might be exceeded in 48 dosing scenarios that were dependent on age, centile energy intake per unit of body weight, body weight percentile, and PIF perchlorate concentration. We obtained three different samples in each of the five brands of bovine- and soy-based PIF, three different samples in each of the three brands of lactose-free PIF, and three different samples in two brands of elemental PIF. The results were as follows: bovine milk-based with lactose (1.72 microg/l, range: 0.68-5.05); soy-based (0.21 microg/l, range: 0.10-0.44); lactose-free (0.27 microg/l, range: 0.03-0.93); and elemental (0.18 microg/l, range: 0.08-0.4). Bovine milk-based PIFs with lactose had a significantly higher concentration of perchlorate (P<0.05) compared with all. Perchlorate was a contaminant of all commercially available PIFs tested. Bovine milk-based PIFs with lactose had a significantly higher perchlorate concentration perchlorate than soy, lactose-free, and elemental PIFs. The perchlorate RfD may be exceeded when certain bovine milk-based PIFs are ingested and/or when PIFs are reconstituted with perchlorate-contaminated water.

Objectives: In this study we evaluated the concentrations of selected persistent organic pollutants in a sample of first-time pregnant females residing in the United States and assessed differences in these concentrations in all pregnant females during gestation., Methods: We reviewed demographic and laboratory data for pregnant females participating in the National Health and Nutrition Examination Survey, including concentrations of 25 polychlorinated biphenyls (PCBs), 6 polychlorinated dibenzo-p-dioxins (PCDDs), 9 polychlorinated dibenzofurans (PCDFs), and 9 organochlorine pesticides. We report serum concentrations for first-time pregnant females (2001-2002; n = 49) and evaluate these concentrations in all pregnant females by trimester (1999-2002; n = 203) using a cross-sectional analysis., Results: The chemicals with >or= 60% detection included PCBs (congeners 126, 138/158, 153, 180), PCDDs/PCDFs [1,2,3,4,6,7,8-heptachlorodibenzo-p-dioxin (1234678HpCDD), 1,2,3,6,7,8-hexachlorodibenzo-p-dioxin (123678HxCDD), 1,2,3,4,6,7,8-heptachlorodibenzofuran (1234678HpCDF), 1,1'-(2,2-dichloroethenylidene)-bis(4-chlorobenzene) (p,p'-DDE)], and trans-nonachlor. The geometric mean concentration (95% confidence intervals) for 1234678HpCDD was 15.9 pg/g lipid (5.0-50.6 pg/g); for 123678HxCDD, 9.7 pg/g (5.5-17.1 pg/g); and for 1234678HpCDF, 5.4 pg/g (3.3-8.7 pg/g). The differences in concentrations of these chemicals by trimester were better accounted for with the use of lipid-adjusted units than with whole-weight units; however, the increase in the third-trimester concentration was greater for PCDDs/PCDFs (123678HxCDD, 1234678HpCDF) than for the highest concentration of indicator PCBs (138/158, 153, 180), even after adjusting for potential confounders., Conclusion: The concentrations of these persistent organic pollutants in a sample of first-time pregnant females living in the United States suggest a decline in exposures to these chemicals since their ban or restricted use and emission. The redistribution of body burden for these and other persistent organic pollutants during pregnancy needs to be more carefully defined to improve the assessment of fetal exposure to them based on maternal serum concentrations. Additional studies are needed to further the understanding of the potential health consequences to the fetus from persistent organic pollutants.

Objective: To assess the risk of bladder cancer in dogs from exposure to drinking water disinfection by-products and determine whether dogs could serve as sentinels for human bladder cancer associated with such exposures., Design: Case-control study., Animals: 100 dogs with cancer of the urinary bladder and 100 control dogs., Procedures: Case and control dogs were frequency-matched by age (within 2 years) and sex. Owners of dogs enrolled provided verbal informed consent and were interviewed by telephone. The telephone questionnaire included a complete residence history for each dog. Each dog's total exposure history to trihalomethanes was reconstructed from its residence history and corresponding drinking water utility company data., Results: No association was detected between increasing years of exposure to chlorinated drinking water and risk of bladder cancer. Dogs with bladder cancer were exposed to higher total trihalomethanes concentrations than control dogs; however, the difference was not significant., Conclusions and Clinical Relevance: Although humans and their dogs live in the same household, the activity patterns of dogs may lead to lower exposures to household tap water. Thus, although exposure to disinfection by-products in tap water may be a risk factor for human bladder cancer, this may not be true for canine bladder cancer at the concentrations at which dogs are exposed.

Since September 11, 2001, concern about potential terrorist attacks has increased in the United States. To reduce morbidity and mortality from outbreaks of illness from the intentional release of chemical agents, we examine data from the Toxic Exposure Surveillance System (TESS). TESS, a national system for timely collection of reports from US poison control centers, can facilitate early recognition of outbreaks of illness from chemical exposures. TESS data can serve as proxy markers for a diagnosis and may provide early alerts to potential outbreaks of covert events. We use 3 categories of information from TESS to detect potential outbreaks, including call volume, clinical effect, and substance-specific data. Analysis of the data identifies aberrations by comparing the observed number of events with a threshold based on historical data. Using TESS, we have identified several events of potential public health significance, including an arsenic poisoning at a local church gathering in Maine, the TOPOFF 2 national preparedness exercise, and contaminated food and water during the northeastern US blackout. Integration of poison control centers into the public health network will enhance the detection and response to emerging chemical threats. Traditionally, emergency physicians and other health care providers have used poison control centers for management information; their reporting to these centers is crucial in poisoning surveillance efforts.