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HICNet Medical News Digest      Mon, 12 Feb 1996        Volume 09 : Issue 10

Today's Topics:

  [MMWR] Morbidity and Mortality Surveillance in Rwandan Refugees
  [MMWR] Screening for Colorectal Cancer --- United States,
  [MMWR] Establishment of a National Surveillance Program for
  [MMWR Feb2] Surveillance for Injuries and Illnesses and Rapid
  [MMWR] Occupational Blood Lead Survey --- Armenia, 1991 and 1993

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----------------------------------------------------------------------

Date: Sat, 10 Feb 1996 23:27:19 -0500 (EST)
From: BUHLE@mscf.med.upenn.edu
To: hicnews
Subject: [MMWR] Morbidity and Mortality Surveillance in Rwandan Refugees
Message-Id: <01I12DWTXA3S0002JR@mscf.med.upenn.edu>

     Morbidity and Mortality Surveillance in Rwandan Refugees
                 -- Burundi and Zaire, 1994

     In April 1994, resumption of a longstanding conflict between
the Hutus and Tutsis--the two major ethnic groups in the central
African countries of Burundi and Zaire-- resulted in civil war and
mass genocide in Rwanda. An estimated 63,000 (primarily Tutsi)
refugees subsequently moved from Rwanda into northern Burundi, and
500,000 refugees fled to Tanzania (Figure 1). In early July 1994,
as armed strife subsided, many Tutsis returned home to Rwanda, and
an estimated 1 million Rwandan Hutus fled to Zaire, and 170,000
fled to Burundi. To monitor the health status of the refugees, the
Office of the United Nations High Commissioner for Refugees (UNHCR)
and nongovernmental organizations (NGOs) working in refugee camps
in both countries established systems for rapid surveillance of
morbidity and mortality. This report presents the findings of these
systems during May-September 1994 (the period of the most intensive
population migration) and indicates that mortality was high among
refugees in camps in both countries.
Burundi
     In May 1994, morbidity surveillance was initiated by using
health-unit data collected by NGOs in seven refugee camps in
northern Burundi. Denominator data were derived from UNHCR
estimates used to calculate quantities of rations. Clinical case
definitions for major causes of morbidity (bloody diarrhea,
nonbloody diarrhea, cholera, malaria, acute respiratory infections
[ARIs], measles, meningitis, trauma, and other conditions) had been
developed previously by the Ministry of Health in Burundi (1).
Mortality data were collected from three sources: a camp grave
watcher; home-health visitors who interviewed families of deceased
persons; and the camp health unit, which distributed free funeral
shrouds to the families of deceased persons.
     In May, daily crude mortality rates (CMR) varied substantially
among the camps, ranging from zero to eight deaths per 10,000
population per day. By July 1994, the CMR had declined to zero to
two deaths per 10,000 per day. The most commonly reported causes of
death were diarrheal diseases, and the major causes of morbidity
were malaria, bloody diarrhea, and ARI.
     An outbreak of nonbloody diarrhea in one camp in Ngozi had a
peak incidence of 980 cases per 100,000 per week; Vibrio cholerae
O1, biotype El Tor, serotype Ogawa, was isolated from stool samples
obtained from a sample of affected persons. Interventions included
improvements in the camp water system (e.g., chlorination) and
intensive health education and latrine-maintenance efforts; the
incidence of new cases declined to 350 cases per 100,000 per week
within 5 weeks.
     During May, the approximately 26,000 persons living in camps
in Ngozi and Kayanza were vaccinated against meningococcal
meningitis after suspected cases were reported during May 1-14. The
average weekly rate (54 cases per 100,000 per week) had
substantially exceeded the epidemic threshold rate (greater than or
equal to 15 cases per 100,000 per week) (2). Neisseria
meningitidis, serotype A, subsequently was isolated from
cerebrospinal fluid samples obtained from patients.
Zaire
     In August 1994, morbidity and mortality surveillance was
initiated by using information collected in NGO clinics in the
three primary refugee camps in eastern Zaire and the town of Goma.
Case definitions for six major causes of morbidity and mortality
(bloody diarrhea, nonbloody diarrhea, malaria, measles, meningitis,
and ARI) were standardized among all health agencies working in the
camps. The numbers of deaths occurring in the camps were obtained
from three sources: a body-collection system that recovered bodies
along the roadside using trucks, tallies of bodies buried in mass
graves, and health agency reports of deaths occurring in camp
hospitals. Initially, a range of denominators (600,000-800,000) was
used because no accurate records were available of the number of
refugees in the camps; however, in September, UNHCR determined the
number of refugees to be 600,000. Based on these denominator data,
the CMR ranged from 34.1 to 54.5 deaths per 10,000 per day during
August 8-21 (using the denominators of 600,000-800,000), then
decreased to 2.5 per 10,000 per day on September 29 (using the
denominator of 600,000) and to 0.2 per 10,000 per day on November
30 (using the denominator of 600,000).
     The highest rates of illness and death were associated with an
epidemic of diarrhea first documented at NGO clinics; subsequently,
V. cholerae O1, biotype El Tor, serotype Ogawa, was isolated from
stool samples obtained from patients. From July 21 (when sentinel
surveillance for diarrheal disease was initiated) through August
14, approximately 62,500 cases were reported from camp health
centers (rate*: 31.2-41.7 cases per 10,000 per day). Camp surveys
and clinic reports suggested that approximately 37,500 (60%) of
these cases (watery diarrhea) resulted from infection with V.
cholerae. However, by August 4, the incidence of bloody diarrhea
exceeded watery diarrhea, and infection with Shigella dysenteriae
type 1 was confirmed in persons with bloody diarrhea. During August
8-14, a total of 15,543 cases of bloody diarrhea (rate*: 27.8-37.0
cases per 10,000 per day) were reported. Findings of a survey in
one camp indicated that 47% of persons with fatal diarrheal disease
had never visited a health-care facility. Comparison of death rates
calculated using data from the surveillance system and the numbers
of bodies collected suggested that greater than 90% of deaths from
all causes occurred outside health-care facilities.
     From August 14 through September 11, the daily incidence of
ARIs among persons in all of these camps ranged from 5.6 to 7.4
cases per 10,000 persons*. The incidence of malaria could not be
calculated because cases were not laboratory confirmed and were
included in the category "fevers of unknown origin"; however, the
incidence of fevers of unknown origin ranged from 15.8 to 21.0
cases per 10,000 persons*. Although the reported incidence of
measles was low (201 cases) during this period, the United Nation's
Children's Fund (UNICEF) initiated a measles vaccination campaign
aimed at all children aged less than 5 years--estimated to be 25%
of the total population. In addition, because 83 cases of
meningococcal meningitis type A were confirmed during August 1-16
and exceeded World Health Organization (WHO) recommended threshold
limits, a vaccination campaign was conducted during late August and
early September.
Reported by: United Nations High Commissioner for Refugees, Geneva,
Switzerland. Ministry of Health, Zaire. World Health Organization,
Bujumbura, Burundi. Div of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion; Div of HIV/AIDS
Prevention, National Center for Prevention Svcs; International
Health Program Office, CDC.
Editorial Note: Death rates among refugee populations may be
substantially increased when exodus is rapid and large numbers of
persons are displaced. During nonemergency situations, the daily
CMR in developing countries is 0.5 per 10,000 persons (3). The
death rates in Zaire (34-54 deaths per 10,000 per day*) were among
the highest to be documented during recent refugee emergencies,
while those among refugees in Burundi were similar to those
recorded in border camps in Thailand in 1979 (10.6 per 10,000 per
day), in Somalia in 1980 (10.1 per 10,000 per day), and in Ethiopia
in 1991 (4.7 per 10,000 per day) (3). In Zaire, a high proportion
(initially 90%) of deaths occurred outside health-care facilities,
indicating either that health-care services were not accessible to
a high proportion of severely ill persons or services at clinic
sites were exceeded by demands. This finding emphasizes the need
for establishing community rehydration programs at the beginning of
the emergency phase.
     The differences in rates of illness and death among refugees
in Burundi and Zaire probably reflected three factors: 1) the daily
number of camp arrivals, 2) the total camp size, and 3) the
magnitude and speed of spread of the outbreaks of cholera. In
particular, in Burundi, 60,000 refugees arrived during the first
wave in April and 170,000 arrived during July; in comparison,
approximately 1 million refugees arrived in Zaire during a 5-day
period. These rapid influxes of large numbers of persons
facilitated transmission of infectious diseases and hindered
establishment of emergency health-care services in both areas.
     The surveillance systems in Burundi and Zaire assisted in the
identification of outbreaks, implementation and assessment of
interventions (e.g., control of diarrheal diseases through the
provision of clean water and sanitation systems, distribution of
soap, and training of clinical staff in aggressive rehydration
therapy), and recognition of the need for increased health-care
services. The experiences in both countries underscore the needs
for simplicity and for targeting surveillance efforts during the
emergency phase in refugee camps.
References
1. Ries AA, Wells JG, Olivola D, et al. Epidemic Shigella
dysenteriae type 1 in Burundi: panresistance and implications for
prevention. J Infect Dis 1994;169:1035-41.
2. Moore PS, Toole MJ, Nieburg P, Waldman RJ, Broome CV.
Surveillance and control of meningococcal meningitis epidemics in
refugee populations. Bull World Health Organ 1990;68:587-96.
3. CDC. Famine-affected refugee and displaced populations:
recommendations for public health issues. MMWR 1992;41(no. RR-13).

* Rates were calculated using the denominators 600,000-800,000.
* Rates were calculated using the denominators 600,000-800,000.


------------------------------

Date: Sat, 10 Feb 1996 23:27:40 -0500 (EST)
From: BUHLE@mscf.med.upenn.edu
To: hicnews
Subject: [MMWR] Screening for Colorectal Cancer --- United States,
Message-Id: <01I12DX8QBF20002JR@mscf.med.upenn.edu>

   Screening for Colorectal Cancer -- United States, 1992-1993
            and New Guidelines
     Colorectal cancer is the third most commonly diagnosed cancer
for both men and women in the United States and is the second
leading cause of cancer-related deaths (1). During 1996,
approximately 133,500 new cases of colorectal cancer will be
diagnosed, and 54,900 persons will die from the disease (1). Recent
evidence of the efficacy of colorectal cancer screening to reduce
mortality was reviewed by the U.S. Preventive Services Task Force
(USPSTF), an independent expert advisory panel to the Public Health
Service (2). The revised USPSTF recommendations on cancer screening
suggest that the risk for colorectal cancer-related mortality can
be reduced by the use of specific screening tests (i.e., annual
fecal occult blood testing [FOBT] and/or periodic flexible
sigmoidoscopy for persons aged greater than or equal to 50 years)*.
To estimate the prevalence of colorectal cancer screening
practices, CDC analyzed data on use of colorectal cancer screening
methods from the 1992 and 1993 Behavioral Risk Factor Surveillance
System (BRFSS). This report summarizes the results of that
analysis, which documents low rates of use of colorectal cancer
screening and underscores the need for efforts to increase
screening.
     In 1993, a total of 49 states and the District of Columbia
participated in the BRFSS, a population-based, random-digit-dialed
telephone survey of the U.S. civilian, noninstitutionalized
population. A total of 38,063 respondents aged greater than or
equal to 50 years were asked whether they ever had had a digital
rectal examination (DRE) or a proctoscopic examination and when the
last examination was performed. Data were weighted and aggregated,
and composite estimates and standard errors were calculated using
SUDAAN. Data are presented for the proportion of respondents
reporting a DRE during the year preceding the interview and the
proportion reporting proctosigmoidoscopy during the 5 years
preceding the interview for selected groups (i.e., sex, race, age,
annual household income, and education level). Race-specific data
are presented because screening rates and death rates previously
have varied by these categories; data are presented only for whites
and blacks because numbers for other racial groups were too small
to calculate precise estimates.
     Overall, 43% of respondents reported a DRE during the
preceding year, and 28% reported a proctosigmoidoscopy during the
preceding 5 years. Men were more likely than women to have had a
proctosigmoidoscopy (33% and 24%, respectively) and to have had a
DRE (47% and 40%, respectively) (Figures 1 and 2). Whites were more
likely than blacks to have had a proctosigmoidoscopy (29% and 26%,
respectively) and to have had a DRE (44% and 39%, respectively).
The proportion of respondents reporting proctosigmoidoscopy
increased with age, from 23% of persons aged 50-59 years to 32% of
persons aged greater than or equal to 70 years.
     For both DRE and proctosigmoidoscopy, the proportion of
respondents tested was directly related to income and level of
education. Among those earning less than $15,000 annually, 35%
reported a DRE, and 24% reported a proctosigmoidoscopy; among those
earning greater than $50,000 annually, 55% reported a DRE, and 35%
reported a proctosigmoidoscopy. Among those with less than 12 years
of education, 37% reported a DRE, and 24% reported a
proctosigmoidoscopy; among those with a college education, 49%
reported a DRE, and 32% reported a proctosigmoidoscopy. Although
there were differences in race-specific crude rates, these rates
were similar when analyzed by education and income categories.
     In 1992, four states (California, Delaware, New Jersey, and
New York) used a BRFSS module that included questions about FOBT.
In these states, the overall proportion of persons reporting having
had an FOBT during the year preceding the interview was 34% for men
and 29% for women.
Reported by: State Behavioral Risk Factor Surveillance System
coordinators. Office of Disease Prevention and Health Promotion, US
Dept of Health and Human Svcs. Epidemiology and Statistics Br, Div
of Cancer Prevention and Control, National Center for Chronic
Disease Prevention and Health Promotion, CDC.
Editorial Note: Well-established risk factors for colorectal cancer
include older age, male sex, inflammatory bowel disease, certain
hereditary conditions (e.g., familial polyposis), and family
history of colorectal cancer. In addition, dietary fat, alcohol,
sedentary lifestyle, and obesity are potential risk factors (3).
Because the well-established risk factors are not amenable to
change, the primary strategy for preventing colorectal cancer
deaths is to detect and remove precancerous polyps or to detect and
treat cancer in its earliest stages. The efficacy of colorectal
cancer screening by FOBT and sigmoidoscopy as means for reducing
colorectal cancer deaths has been well documented (4-6).
     The findings in this report document low overall rates of use
of colorectal cancer screening in the United States. DRE was the
most commonly used test for colorectal cancer, probably reflecting
its practical incorporation into routine physical examinations.
However, DRE can detect tumors only in the distal 10 cm of the
colon, and the efficacy of DRE has not been documented. Although
FOBT data were available only from four states, because the use of
DRE and proctosigmoidoscopy in these states was not substantially
different from the nationwide average, the FOBT data may be
representative of the national average. The BRFSS questionnaire
does not distinguish between tests conducted for diagnosis and for
screening. However, because procto-sigmoidoscopies are more likely
to be used for diagnosis than FOBT and DRE (41% versus 24% and 20%,
respectively) (7), proctosigmoidoscopy may be the least used
screening test for colorectal cancer.
     The findings in this report are subject to at least two
limitations. First, because the BRFSS is a telephone survey,
persons without telephones are not represented. Therefore, because
of the association between absence of residential telephones and
lower socioeconomic status, persons without telephones may be less
likely to have been screened and testing rates may have been
overestimated. Second, the BRFSS findings are based on self-reports
and have not been validated.
     The findings in this report document the need for efforts to
increase screening for colorectal cancer, especially by using
methods shown to be effective (e.g., FOBT and proctosigmoidoscopy).
However, evidence is insufficient to determine which of these
screening methods is preferable or whether the combination of FOBT
and sigmoidoscopy produces greater benefits than either test alone.
The prevalences of screening for colorectal cancer are lower than
those for screening for breast and cervical cancer; the substantial
increase during the 1980s in the use of mammography has not
occurred for use of colorectal cancer screening tests (8-10).
Public health officials and policy makers should intensify efforts
to educate providers and the public about the effectiveness of
screening, to promote widespread use of the colorectal cancer
screening guidelines developed by USPSTF, and to ensure access to
screening tests for persons with low income.
References
1. American Cancer Society. Cancer facts and figures, 1996.
Atlanta: American Cancer Society, 1996; publication no. 5008.96.
2. US Preventive Services Task Force. Guide to clinical preventive
services, 2nd ed. Baltimore: Williams and Wilkins, 1996.
3. Potter JD, Slattery ML, Bostick RM, Gapstur SM. Colon cancer: a
review of the epidemiology. Epidemiol Reviews 1993;15:499-545.
4. Mandel JS, Bond JH, Church TR, et al. Reducing mortality from
colorectal cancer by screening for fecal occult blood. N Engl J Med
1993;328:1365-71.
5. Selby JV, Friedman GD, Quesenberry CP Jr, Weiss NS. A case
control study of screening sigmoidoscopy and mortality from
colorectal cancer. N Engl J Med 1992;326:653-7.
6. Newcomb PA, Norfleet RG, Storer BE, Surawicz TS, Marcus PM.
Screening sigmoidoscopy and colorectal cancer mortality. J Natl
Cancer Inst 1992;84:1572-5.
7. NCHS. National Health Interview Survey cancer control public use
record. Hyattsville, Maryland: US Department of Health and Human
Services, Public Health Service, CDC, NCHS, 1994.
8. Howard J. Using mammography for cancer control: an unrealized
potential. CA 1987;37:33-48.
9. CDC. Trends in cancer screening--United States, 1987 and 1992.
MMWR 1995;45:57-61.
10. Anderson LM, May DS. Has the use of cervical, breast, and
colorectal cancer screening increased in the United States? Am J
Public Health 1995;85:840-2.

* Printed copies of Guide to Clinical Preventive Services, 2nd
Edition, are available from the Superintendent of Documents, U.S.
Government Printing Office, telephone (202) 512-1800 (stock no.
017-001-00525-8). The single-copy price is $35, including shipping.
The guide can be accessed on the Internet beginning March 1996 at
either http://text.nlm.nih.gov or http://odphp.osophs.dhhs.gov.


------------------------------

Date: Sat, 10 Feb 1996 23:28:22 -0500 (EST)
From: BUHLE@mscf.med.upenn.edu
To: hicnews
Subject: [MMWR] Establishment of a National Surveillance Program for
Message-Id: <01I12DXRBF8K0002JR@mscf.med.upenn.edu>

   Screening for Colorectal Cancer -- United States, 1992-1993
            and New Guidelines
     Colorectal cancer is the third most commonly diagnosed cancer
for both men and women in the United States and is the second
leading cause of cancer-related deaths (1). During 1996,
approximately 133,500 new cases of colorectal cancer will be
diagnosed, and 54,900 persons will die from the disease (1). Recent
evidence of the efficacy of colorectal cancer screening to reduce
mortality was reviewed by the U.S. Preventive Services Task Force
(USPSTF), an independent expert advisory panel to the Public Health
Service (2). The revised USPSTF recommendations on cancer screening
suggest that the risk for colorectal cancer-related mortality can
be reduced by the use of specific screening tests (i.e., annual
fecal occult blood testing [FOBT] and/or periodic flexible
sigmoidoscopy for persons aged greater than or equal to 50 years)*.
To estimate the prevalence of colorectal cancer screening
practices, CDC analyzed data on use of colorectal cancer screening
methods from the 1992 and 1993 Behavioral Risk Factor Surveillance
System (BRFSS). This report summarizes the results of that
analysis, which documents low rates of use of colorectal cancer
screening and underscores the need for efforts to increase
screening.
     In 1993, a total of 49 states and the District of Columbia
participated in the BRFSS, a population-based, random-digit-dialed
telephone survey of the U.S. civilian, noninstitutionalized
population. A total of 38,063 respondents aged greater than or
equal to 50 years were asked whether they ever had had a digital
rectal examination (DRE) or a proctoscopic examination and when the
last examination was performed. Data were weighted and aggregated,
and composite estimates and standard errors were calculated using
SUDAAN. Data are presented for the proportion of respondents
reporting a DRE during the year preceding the interview and the
proportion reporting proctosigmoidoscopy during the 5 years
preceding the interview for selected groups (i.e., sex, race, age,
annual household income, and education level). Race-specific data
are presented because screening rates and death rates previously
have varied by these categories; data are presented only for whites
and blacks because numbers for other racial groups were too small
to calculate precise estimates.
     Overall, 43% of respondents reported a DRE during the
preceding year, and 28% reported a proctosigmoidoscopy during the
preceding 5 years. Men were more likely than women to have had a
proctosigmoidoscopy (33% and 24%, respectively) and to have had a
DRE (47% and 40%, respectively) (Figures 1 and 2). Whites were more
likely than blacks to have had a proctosigmoidoscopy (29% and 26%,
respectively) and to have had a DRE (44% and 39%, respectively).
The proportion of respondents reporting proctosigmoidoscopy
increased with age, from 23% of persons aged 50-59 years to 32% of
persons aged greater than or equal to 70 years.
     For both DRE and proctosigmoidoscopy, the proportion of
respondents tested was directly related to income and level of
education. Among those earning less than $15,000 annually, 35%
reported a DRE, and 24% reported a proctosigmoidoscopy; among those
earning greater than $50,000 annually, 55% reported a DRE, and 35%
reported a proctosigmoidoscopy. Among those with less than 12 years
of education, 37% reported a DRE, and 24% reported a
proctosigmoidoscopy; among those with a college education, 49%
reported a DRE, and 32% reported a proctosigmoidoscopy. Although
there were differences in race-specific crude rates, these rates
were similar when analyzed by education and income categories.
     In 1992, four states (California, Delaware, New Jersey, and
New York) used a BRFSS module that included questions about FOBT.
In these states, the overall proportion of persons reporting having
had an FOBT during the year preceding the interview was 34% for men
and 29% for women.
Reported by: State Behavioral Risk Factor Surveillance System
coordinators. Office of Disease Prevention and Health Promotion, US
Dept of Health and Human Svcs. Epidemiology and Statistics Br, Div
of Cancer Prevention and Control, National Center for Chronic
Disease Prevention and Health Promotion, CDC.
Editorial Note: Well-established risk factors for colorectal cancer
include older age, male sex, inflammatory bowel disease, certain
hereditary conditions (e.g., familial polyposis), and family
history of colorectal cancer. In addition, dietary fat, alcohol,
sedentary lifestyle, and obesity are potential risk factors (3).
Because the well-established risk factors are not amenable to
change, the primary strategy for preventing colorectal cancer
deaths is to detect and remove precancerous polyps or to detect and
treat cancer in its earliest stages. The efficacy of colorectal
cancer screening by FOBT and sigmoidoscopy as means for reducing
colorectal cancer deaths has been well documented (4-6).
     The findings in this report document low overall rates of use
of colorectal cancer screening in the United States. DRE was the
most commonly used test for colorectal cancer, probably reflecting
its practical incorporation into routine physical examinations.
However, DRE can detect tumors only in the distal 10 cm of the
colon, and the efficacy of DRE has not been documented. Although
FOBT data were available only from four states, because the use of
DRE and proctosigmoidoscopy in these states was not substantially
different from the nationwide average, the FOBT data may be
representative of the national average. The BRFSS questionnaire
does not distinguish between tests conducted for diagnosis and for
screening. However, because procto-sigmoidoscopies are more likely
to be used for diagnosis than FOBT and DRE (41% versus 24% and 20%,
respectively) (7), proctosigmoidoscopy may be the least used
screening test for colorectal cancer.
     The findings in this report are subject to at least two
limitations. First, because the BRFSS is a telephone survey,
persons without telephones are not represented. Therefore, because
of the association between absence of residential telephones and
lower socioeconomic status, persons without telephones may be less
likely to have been screened and testing rates may have been
overestimated. Second, the BRFSS findings are based on self-reports
and have not been validated.
     The findings in this report document the need for efforts to
increase screening for colorectal cancer, especially by using
methods shown to be effective (e.g., FOBT and proctosigmoidoscopy).
However, evidence is insufficient to determine which of these
screening methods is preferable or whether the combination of FOBT
and sigmoidoscopy produces greater benefits than either test alone.
The prevalences of screening for colorectal cancer are lower than
those for screening for breast and cervical cancer; the substantial
increase during the 1980s in the use of mammography has not
occurred for use of colorectal cancer screening tests (8-10).
Public health officials and policy makers should intensify efforts
to educate providers and the public about the effectiveness of
screening, to promote widespread use of the colorectal cancer
screening guidelines developed by USPSTF, and to ensure access to
screening tests for persons with low income.
References
1. American Cancer Society. Cancer facts and figures, 1996.
Atlanta: American Cancer Society, 1996; publication no. 5008.96.
2. US Preventive Services Task Force. Guide to clinical preventive
services, 2nd ed. Baltimore: Williams and Wilkins, 1996.
3. Potter JD, Slattery ML, Bostick RM, Gapstur SM. Colon cancer: a
review of the epidemiology. Epidemiol Reviews 1993;15:499-545.
4. Mandel JS, Bond JH, Church TR, et al. Reducing mortality from
colorectal cancer by screening for fecal occult blood. N Engl J Med
1993;328:1365-71.
5. Selby JV, Friedman GD, Quesenberry CP Jr, Weiss NS. A case
control study of screening sigmoidoscopy and mortality from
colorectal cancer. N Engl J Med 1992;326:653-7.
6. Newcomb PA, Norfleet RG, Storer BE, Surawicz TS, Marcus PM.
Screening sigmoidoscopy and colorectal cancer mortality. J Natl
Cancer Inst 1992;84:1572-5.
7. NCHS. National Health Interview Survey cancer control public use
record. Hyattsville, Maryland: US Department of Health and Human
Services, Public Health Service, CDC, NCHS, 1994.
8. Howard J. Using mammography for cancer control: an unrealized
potential. CA 1987;37:33-48.
9. CDC. Trends in cancer screening--United States, 1987 and 1992.
MMWR 1995;45:57-61.
10. Anderson LM, May DS. Has the use of cervical, breast, and
colorectal cancer screening increased in the United States? Am J
Public Health 1995;85:840-2.

* Printed copies of Guide to Clinical Preventive Services, 2nd
Edition, are available from the Superintendent of Documents, U.S.
Government Printing Office, telephone (202) 512-1800 (stock no.
017-001-00525-8). The single-copy price is $35, including shipping.
The guide can be accessed on the Internet beginning March 1996 at
either http://text.nlm.nih.gov or http://odphp.osophs.dhhs.gov.


------------------------------

Date: Sat, 10 Feb 1996 23:34:49 -0500 (EST)
From: BUHLE@mscf.med.upenn.edu
To: hicnews
Subject: [MMWR Feb2] Surveillance for Injuries and Illnesses and Rapid
Message-Id: <01I12E72SM2Y0002JR@mscf.med.upenn.edu>

    Surveillance for Injuries and Illnesses and Rapid Health-Needs
   Assessment Following Hurricanes Marilyn and Opal, September-October
                      1995
     Hurricanes rated a category three or greater (on a scale of
one to five) strike the United States or its territories
approximately once every 1.5 years (1). In 1995, both a category
two and category three hurricane struck the United States within 18
days, causing approximately 40 deaths (2). This report summarizes
the surveillance for injuries and illnesses and a rapid
health-needs assessment conducted after the storms.
MORBIDITY SURVEILLANCE Hurricane Marilyn, September 1995
During September 15-16, Hurricane Marilyn struck the U.S. Virgin
Islands (USVI), passing over St. Croix (1990 population: 50,139) on
September 15, with sustained winds of 80 mph, and over St. Thomas
(1990 population: 48,166) on September 15-16, with sustained winds
of 100 mph and gusts of 125 mph. On St. Thomas, 92% of houses were
damaged (habitable) or destroyed (uninhabitable); on St. Croix and
St. John (1990 population: 3504), 71% and 76%, respectively, of
housing units were affected.
     On September 16, the USVI Department of Social and Health
Services, in collaboration with CDC and the Preventive Medicine
Task Force of the Public Health Service National Disaster Medical
System, inititated public health surveillance to 1) maintain daily
contact with primary health-care facilities, including deployed
Disaster Medical Assistance Teams (DMATs); 2) characterize adverse
health events during the early post-hurricane phase; 3) coordinate
disease outbreak investigations; 4) provide reliable information to
health planners for determining priorities; and 5) recommend public
health interventions.
     Because of the disruption of health-care systems, active
posthurricane surveillance was initiated on St. Thomas. Independent
surveillance systems were established on each of the three islands.
Daily patient summaries were obtained from the Governor Juan F.
Luis Hospital and Medical Center, three outpatient treatment
clinics, two smaller clinic sites that provided summary information
only, and DMATs deployed to provide supplemental health care.
Patient logs were abstracted into 20 diagnostic surveillance
categories.
     During September 16-30, a total of 3265 patient visits were
recorded at the four primary medical treatment sites (i.e., the
hospital and three DMAT sites). Of the 3265 visits, 1084 (33%) were
storm-associated injuries involving minor wounds (i.e., abrasions,
lacerations, punctures, and foreign-body removal) or trauma to the
musculoskeletal system (i.e., fractures, sprains, strains, and
dislocations). In addition, eight persons sustained burns while
operating or refueling portable power generators. Other problems
reported included upper and lower respiratory tract illnesses (383
[12%]) (e.g., sore throat, cough, pneumonia, and asthma) and
dermatologic disorders (199 [6%]) (e.g., rashes, sores, and
infections). Of the 167 visits for gastrointestinal disorders, 77
were for diarrheal illness (2.4% of total patient visits). The
second largest category of visits (23.5%) was grouped as
miscellaneous and was for problems unrelated to the storm (e.g.,
blood pressure and blood glucose screening, prescription refills,
vaccinations, and other health-care services).
Hurricane Opal, October 1995
     On October 4, Hurricane Opal made landfall at Navarre,
Florida, approximately 20 miles east of Pensacola, with sustained
winds of 115 mph. The storm caused extensive damage along the 100
miles of coastline from Navarre east to Mexico Beach. Efforts to
evaluate the impact of the hurricane on the health of residents in
the affected area included review of records of emergency
department (ED) visits to the two hospitals serving one of the most
severely affected counties. The frequencies of 20 conditions were
determined for the 6 days after the hurricane (i.e., posthurricane)
(October 4-9) and were compared with those observed for the 6 days
before the storm (i.e., prehurricane) (September 27-October 3)
(Table 1).
     EDs treated 996 patients during the prehurricane period and
1135 during the post-hurricane period. For both periods, the
proportion of ED visits were similar for lacerations, puncture
wounds, musculoskeletal injuries, rashes, and gastrointestinal or
respiratory illnesses. During the posthurricane period, the
proportion of visits for insect bites increased from 0.2% to 1.7%
(p less than 0.05). These findings were shared with local health
officials and emergency management officials coordinating disaster
relief.
HEALTH NEEDS ASSESSMENT
     Population-based surveys were conducted on St. Thomas on
September 23, 1 week after Hurricane Marilyn. Based on maps and
population data, the island was divided into four population zones,
which then were subdivided into clusters. In each of the 30
clusters, a survey team interviewed an adult member of selected
households. Respondents were asked about the number and age of
residents, number of sick and injured persons, supply of food and
water, water purification and access to sanitary toilets, extent of
damage to housing, access to telephone and electricity,
availability of transportation, and monitoring of local radio
broadcasts. One week after the initial survey, the process was
repeated. A similar clustering technique was used on St. Croix and
St. John and on the Florida panhandle following Hurricane Opal.
     For Hurricane Marilyn, most (93%-99%) respondents reported
having drinking water that had been purified, access to a motor
vehicle (77%-89%), and having listened to a local radio station
(79%-99%) (Table 2). For Hurricane Opal, most persons reported
having access to electricity (89%), running water (96%), medical
care (91%), and transportation (99%).
Reported by: N George-McDowell, MD, AB Hendry, LB
SewerBridges-Williams, MSW, K Nickel, St. Thomas; J Heyliger, N
Michael, PhD, St. Croix; A Wade, St. John, US Virgin Islands. J
Stringer, C Reedy, Winston-Salem, North Carolina; L McDaniel,
Pensacola, Florida; C Budd, Toledo, Ohio; A Wallace, MD, T Walton,
Tulsa, Oklahoma; D McClure, C Perry, Ft. Thomas, Kentucky; L
Patton, Fort Wayne, Indiana; S Briggs, MD, Boston, Massachusetts;
K Yeskey, MD, Rockville/Bethesda, Maryland; L Stringer, MD,
Disaster Medical Assistance Teams, Emergency Support Function No.
8. M Moore, Bay Medical Center, D Abbot, HCA Gulf Coast Medical
Center, M Pettis, District 2, P Sylvester, MD, Bay County Health
Dept, Panama City, Florida; G Hlady, MD, R Hopkins, MD, State
Epidemiologist, Florida Dept of Health and Rehabilitative Svcs. S
Bright, K Lawton, Office of Disaster Medical Svc, Dept of Veterans
Affairs. F Young, MD, National Disaster Medical System, Office of
Emergency Preparedness, Public Health Svc. Special Pathogens Br,
Div of Viral and Rickettsial Diseases, National Center for
Infectious Diseases; Program Operations Br, National Immunization
Program; Div of Reproductive Health, National Center for Chronic
Disease Prevention and Health Promotion; Div of Birth Defects and
Developmental Disabilities, and Emergency Response Coordination
Group, Disaster Assessment and Epidemiology Section, Health Studies
Br, Div of Environmental Hazards and Health Effects, National
Center for Environmental Health; Div of Field Epidemiology,
Epidemiology Program Office, CDC.
Editorial Note: Rapid assessment of health needs in populations
affected by disasters is an important first step in guiding relief
efforts (3). The cluster sampling survey method used for hurricanes
Marilyn and Opal were based on methods used after Hurricane Andrew
in 1992 (4) and provided some of the earliest objective data
describing the status of affected populations after the storm.
Similarly, after hurricanes Marilyn and Opal, the rapid collection
of morbidity data from permanent and temporary facilities provided
timely and reliable data for assessing the health impact of the
disasters.
     Increased frequencies of injuries such as those observed after
Hurricane Marilyn and illnesses such as skin rashes and heat stress
have been documented after recent storms (5-7). Most of the
injuries reported after Hurricane Marilyn were associated with
clean-up and restoration activities, including several burns
associated with the use of portable gasoline generators. These
findings underscore the need for public awareness campaigns that
address the risks related to specific activities, including the use
and maintenance of emergency power sources and general safety
precautions in the immediate recovery phase.
     The objective estimates from the surveys of health needs and
from morbidity surveillance enabled conservation of medical and
monetary resources. For example, based on survey findings,
officials in the USVI decided not to provide door-to-door community
outreach health care because a high proportion of the affected
population had access to relief information through radio reports
and transportation to a central relief location. In addition,
following both storms, expensive interventions (e.g., mass aerial
spraying for disease vectors and nuisance insects) were determined
to be unnecessary.
     Scientifically valid information is critical to enable
decision making and resource prioritization by health-care
providers and emergency management officials during the immediate
response phase following disasters. To enhance surveillance in
disaster settings, relief officials should 1) refine the
statistical methods for estimating the size of affected
populations; 2) ensure the availability of trained surveillance
workers; 3) establish standardized assessment instruments--
including computerized interviewing instruments--and use wireless
communications technologies; and 4) modify surveillance data
collection to indicate whether an illness or injury was "disaster
related."
References
1. Herbert P, Taylor G, Case R. Hurricane experience levels of
coastal county population--Texas to Maine. Miami: US Department of
Commerce, National Oceanographic and Atmospheric Administration,
1984. (Technical memorandum no. NWS NHC 25).
2. CDC. Deaths associated with hurricanes Marilyn and Opal--United
States, September-October 1995. MMWR 1996;45:32-8.
3. Lillibridge S, Noji E, Burkle F. Disaster assessment: the
emergency health evaluation of a population affected by a disaster.
Ann Emerg Med 1993;22:1715-20.
4. CDC. Rapid health needs assessment following Hurricane Andrew--
Florida and Louisiana, 1992. MMWR 1992;41:685-8.
5. CDC. Injuries and illnesses related to Hurricane Andrew--
Louisiana, 1992. MMWR 1993;42:242-3,249-51.
6. CDC. Work-related electrocutions associated with Hurricane Hugo--
Puerto Rico. MMWR 1989;38:718-25.
7. Longmire AW, Ten Eyck RP. Morbidity of Hurricane Frederic. Ann
Emerg Med 1984;13:334-8.


------------------------------

Date: Sat, 10 Feb 1996 23:35:11 -0500 (EST)
From: BUHLE@mscf.med.upenn.edu
To: hicnews
Subject: [MMWR] Occupational Blood Lead Survey --- Armenia, 1991 and 1993
Message-Id: <01I12E7IQ94G0002JR@mscf.med.upenn.edu>

    Occupational Blood Lead Survey -- Armenia, 1991 and 1993

     The risk for lead exposure and lead poisoning is a persistent
problem for some workers (1) and is an important issue in both
industrialized and developing countries (2). In Armenia, where lead
is used widely in industry (3), the Armenian Engineers and
Scientists of America, Inc. (AESA), and the United Armenian Fund
(UAF)* initiated a program in 1991 to use blood lead determinations
to investigate lead exposures, identify industries and
circumstances associated with lead hazards, and define specific
jobs characterized by excessive exposures that increase the risk
for lead poisoning of workers. In 1991, team investigators surveyed
four factories that use lead; in 1993, one of the factories was
resurveyed. Because the capacity of laboratories in Armenia to
reliably determine blood lead levels (BLLs) is limited, blood
specimens were transported to the United States for lead testing.
This report presents the findings of both surveys and establishes
the feasibility of sample collection at remote sites for transport
to laboratories equipped and certified to process lead specimens.
     The Armenian Institute of General Hygiene and Occupational
Diseases in Yerevan selected four worksites for the initial survey
in November 1991 based on factors including accessibility and
operation.** Two sites were printing plants that used cast lead
type ("printing plant A" in Yerevan and "printing plant B" in
Hoktemberian); one was a research laboratory that periodically used
lead compounds in toxicologic experiments ("research institute" in
Yerevan); and the fourth was a lead crystal factory that used red
lead oxide in the manufacture of decorative glassware ("crystal
factory" in Arzni). Participation in the survey was offered to all
workers in jobs believed to be at high risk for lead exposure and
to some administrators considered not to have substantial exposure.
Of the workers who were present on the respective survey days,
approximately 75% volunteered and permitted whole blood samples to
be obtained. Because extremely high exposures were identified in
the crystal factory in 1991, the factory was resurveyed in
September 1993. For the 1991 survey, 34 workers at printing plant
A participated; 17 at printing plant B; 10 at the research
institute; and 38 at the crystal factory. For the 1993 follow-up
survey at the crystal factory, 19 workers participated, including
10 from the 1991 survey.
     Blood specimens from workers were collected by venipuncture
into lead-free, evacuated tubes containing sodium heparin
anticoagulant, stored at cool room temperature, and transported
within 7 days to an Occupational Safety and Health Administration
(OSHA)-approved laboratory in the United States for lead
determination by atomic absorption spectrophotometry (4). Analyses
were completed within 7 days of sample collection. Wipe samples of
surface dust were collected onto lead-free castile soap wipes from
1-sq-ft areas of floors and machinery surfaces (at breathing-zone
heights) and from the hands of workers, then were transported to
the United States for lead determination by atomic absorption
spectrophotometry (5). Routine external and internal
quality-control measures were applied for blood and environmental
analyses.
     In 1991, of the 51 workers surveyed at the two printing
plants, 50 had BLLs less than 25 ug/dL; none exceeded 40 ug/dL
(Table 1).*** Among the 10 workers surveyed at the research
institute, BLLs ranged from 2 ug/dL to 5 ug/dL. In both the 1991
and 1993 surveys at the glassworks, however, a substantial
proportion of the 39 total specimens obtained from the production
workers surveyed had elevated BLLs, and some were markedly
elevated: 31 (79%) were greater than or equal to 25 ug/dL, 19 (49%)
were greater than 40 ug/dL, and eight (21%) were greater than 65
ug/dL; among administrative and office workers, BLLs as high as 22
ug/dL were recorded.
     A walk-through inspection of the crystal factory in 1993
identified sites characterized by poor housekeeping practices and
conditions suggesting substantial airborne exposures.**** A total
of 24 wipe samples were obtained to assay dust: 19 samples were
from floors and machinery surfaces in working areas, two from an
office hallway, and three from workers' hands (Table 2). All dust
samples from processing areas were highly contaminated with lead
(levels ranged from 3800 to 415,000 ug/sq ft); in comparison,
guidelines for surface lead levels after residential lead abatement
in the United States specify levels of 100 ug/sq ft for floors, 500
ug/sq ft for window sills, and 800 ug/sq ft for window wells (8).
The highest values were detected in the lead oxide mixing area,
where spillage of raw material was visible. Remedial measures were
recommended to factory management.
Reported by: LA Saryan, PhD, Industrial Toxicology Laboratory, West
Allis Memorial Hospital, Wisconsin. EA Babayan, MD, Institute of
General Hygiene and Occupational Diseases, Republic of Armenia,
Yerevan. L Amirian, Palo Alto, California. Div of Surveillance,
Hazard Evaluations, and Field Studies, National Institute for
Occupational Safety and Health, CDC.
Editorial Note: Controlling workplace lead exposure is essential in
reducing the incidence of occupational disease caused by lead;
monitoring of BLLs among workers is a necessary component of a
comprehensive control strategy. In the United States, occupational
lead exposure is regulated according to the provisions of the OSHA
inorganic lead standard, which mandates periodic exposure
assessment and blood lead monitoring for workers exposed above the
action level (30 ug/m3) (7). Results of blood lead monitoring of
workers are gathered by state agencies and compiled by CDC's
National Institute for Occupational Safety and Health (NIOSH) (6).
     Accurate blood lead analysis requires complex instrumentation
and careful adherence to protocol; in many countries, the capacity
of laboratories to reliably determine BLLs is limited. The findings
in this report are the first to document reliable blood lead data
reflecting occupational lead exposures in Armenia and establish the
technical feasibility of sample collection at remote sites for
transport to a laboratory appropriately equipped and certified to
process the specimens. Although similar approaches may be
applicable to the study of occupational lead exposures (and similar
occupational health problems) in developing countries, economic
constraints and other factors may limit the use of such approaches
for routine surveillance.
     Because of the small numbers of facilities and workers
studied, voluntary participation, and the methods used for
selection, the findings in this report are unlikely to be
representative of working conditions in Armenia. However, they
document conditions in the worksites studied.
     Although these findings suggest that some lead-using worksites
in Armenia are not associated with excessive risks for exposure,
evidence of high risk was detected in one factory. Specifically,
the BLLs in workers and environmental monitoring data from the lead
crystal manufacturer indicate the need for improvement of
conditions (including engineering controls, housekeeping, work
practices, and environmental and employee monitoring) at this
factory. The high BLLs measured in workers at this factory probably
resulted from a combination of high lead levels in dust and
presumed high airborne lead concentrations. Such exposures most
likely occur in other lead-using industries in Armenia,
particularly as a result of ongoing economic and social change. For
example, the current severe electricity shortage and other factors
reportedly have prompted the establishment of small, unregulated
battery shops, in which environmental controls and worker
protections probably are inadequate.
     Systematic surveys of lead-using facilities--especially in
industries associated with high risks for excessive lead exposures--
are necessary to characterize lead hazards and to identify workers
at risk for lead toxicity. In Armenia and in some other countries,
such efforts can be facilitated by establishing local capacity to
conduct more complete exposure assessments (including air
monitoring) and accurate laboratory analyses of routine blood lead
and environmental lead samples.
References
1. Saryan LA, Zenz C. Lead and its compounds. In: Zenz C, ed.
Occupational medicine. 3rd ed. St. Louis, Missouri: Mosby,
1994:506-41.
2. CDC. Occupational lead surveillance--Taiwan, July-December 1993.
MMWR 1995;44:181,187-9.
3. Saryan LA. Monitoring for human exposure to asbestos and toxic
metals. Proceedings of the First World Congress of Armenian
Engineers, Scientists, and Industrialists. Glendale, California:
Armenian Engineers and Scientists of America, Inc., 1989:27-40.
4. Saryan LA. Surreptitious lead exposure from an Asian Indian
medication. J Anal Toxicol 1991;15:336-8.
5. NIOSH. NIOSH manual of analytical methods [Method 7082]. 3rd ed.
Cincinnati, Ohio: US Department of Health and Human Services,
Public Health Service, CDC, 1984; DHHS publication no.
(NIOSH)84-100.
6. CDC. Adult blood lead epidemiology and surveillance--United
States, fourth quarter 1994. MMWR 1995;44:286-7.
7. Office of the Federal Register. Code of federal regulations:
occupational safety and health standards. Subpart Z: toxic and
hazardous substances--lead. Washington, DC: Office of the Federal
Register, National Archives and Records Administration, 1985. (29
CFR section 1910.1025).
8. Department of Housing and Urban Development. Guidelines for the
evaluation and control of lead-based paint hazards in housing.
Washington, DC: US Department of Housing and Urban Development,
June 1995.


* AESA is a nonprofit professional organization and UAF is a
nonprofit service organization; both are headquartered in Glendale,
California.
** The selection of survey sites was primarily dictated by time and
external economic constraints; access to energy and raw materials
for industry in Armenia had been restricted because of regional
political circumstances, which resulted in frequent, unpredictable
shutdowns of many factories. Study sites were factories in
operation at times that coincided with the investigators'
availability.
*** The cutoff level of greater than or equal to 25 ug/dL
corresponds to the reporting level in many U.S. states (6), and 40
ug/dL corresponds to the return-to-work (following medical removal
for elevated BLL) criterion in the OSHA general industry lead
standard (7). An additional cutoff of 65 ug/dL was selected to
exceed current permissible levels in the United States and as a
level at which overt or clinically observable toxic effects of lead
would be expected in adults with chronic occupational exposure.
**** Airborne lead exposures, which are generally the major source
of occupational exposure, were not measured in this survey because
of technical limitations.


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End of HICNet Medical News Digest V09 Issue #10
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