Category : Science and Education
Archive   : HICN0235.ZIP
Filename : HICN0235.NWS

Volume 2, Number 35 September 25, 1989

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Editor: David Dodell, D.M.D.
St. Joseph's Hospital and Medical Center
10250 North 92nd Street, Suite 210, Scottsdale, Arizona 85258-4599 USA
Telephone (602) 860-1121

(c) 1989 - Distribution on Commercial/Pay Systems Prohibited without
Prior Authorization

International Distribution Coordinator: Robert Klotz
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Telephone (405) 366-3898

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T A B L E O F C O N T E N T S


1. Comments & News from the Editor
Notes from the Editor ................................................. 1

2. Medical News
Medical News for Week Ending September 25, 1989 ....................... 2

3. Center for Disease Control Reports
[MMWR 9-21-89] Health Objectives for the Nation ...................... 9
Contribution of Birth Defects to Infant Mortality ..................... 13
Varicella Outbreak in a Women's Prison ................................ 15
Surveillance for Occupational Lead Exposure ........................... 18

4. Articles
Delivery of Quality Service Success of Organ Procurement Organizations 22




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Volume 2, Number 35 September 25, 1989



===============================================================================
Comments & News from the Editor
===============================================================================

Notes from the Editor
David Dodell


A couple of quick notes. In the last couple of months readership in the
newsletter has grown tremendously. I would like to thank all of you who have
expressed an interest in the newsletter. I enjoy reading your comments and
suggestions that I regularly receive by electronic mail.

As always, we are looking for any articles that are medically related to be
published. We also will be glad to publish your meeting notices, seminar
notices, call for volunteers or any other announcements you might have.

A couple of side comments:

I thought it might be interesting to receive some articles about how the
medical systems in the Southeastern United States stood up under the impact of
Hurricane Hugo. I articles ranging from the Emergency Medical Services point
of view, to how hospitals contend with this type of mass disaster might be
interesting to our readers.

Also, I would appreciate any feedback on the articles we are publishing from
the American Council on Transplantation. They are supplying the articles to
us on disk, to make the conversion to electronic form much easier. If you
would like to see more articles like this, please let me know.

This weeks issue of the MMWR was cut short by one article. There was an
extremely long article concerning standards of treatment for sexually
transmitted diseases. Due to its size, I plan to publish it next week as a
seperate article.

I look forward to hearing from each of you to any of my electronic mailboxes.



















Health InfoCom Network News Page 1
Volume 2, Number 35 September 25, 1989



===============================================================================
Medical News
===============================================================================

Medical News for Week Ending September 25, 1989
Copyright 1989 - USA TODAY/Gannett National Information Network
Reproduced with Permission

---
Sept. 15-17, 1989
---


ACTIVISTS BLAST AZT COST:

AIDS activists and health experts want the cost of the AIDS drug AZT to be
more reasonable. On Thursday, they took aim at drug maker Burroughs Wellcome
Company. Researchers from Montefiore Medical Center in New York City charged
the price tag for fighting AIDS could be much lower if the company charged
fairer prices. (From the USA TODAY Life section.)

ARTHRITIS DRUG SHOWS PROMISE:

A new drug is showing promise in reducing the pain and joint swelling
suffered by rheumatoid arthritis patients. Research at the University of Miami
finds no side effects to the drug amilprilose hydrochloride. The drug still
needs further study, according to the Annals of Internal Medicine.

TREATING SLEEP DISORDERS:

The early treatment of sleep disorders might stave off depression and other
psychiatric problems, suggests a study in Friday's Journal of the American
Medical Association. It finds people whose sleep problems continued from one
year to the next in the study had new cases of depression and anxiety
disorders. (From the USA TODAY Life section.)

KIDS' FITNESS ON THE DECLINE:

Only 32 percent of American children ages 6 to 17 scored satisfactory
grades for strength, flexibility and muscular and cardiovascular endurance,
compared with 43 percent a decade ago, says an Amateur Athletic Union study of
12,000 students. Reasons noted: TV, video games, not enough exercise at school
because officials fear lawsuits. (From the USA TODAY News section.)

FOOD TO GET SEAL OF APPROVAL:

The American Heart Association wants to put its seal of approval on foods
that it thinks are good. The association wants to charge food makers for the
seal. Food makers are protesting because the plan could hurt manufacturers who
can't pay the fee, they said. (From the USA TODAY Life section.)

LASER GETS ITS FIRST OK:

A laser that destroys blockages in coronary arteries was deemed safe and
effective in its first U.S. clinical tests. If it wins final approval, the

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Volume 2, Number 35 September 25, 1989

cool-tip excimer could provide a non-surgical treatment for heart disease that
balloon angioplasty can't help, said Dr. Frank Litvak of Cedars-Sinai Medical
Center, Los Angeles. (From the USA TODAY Life section.)

COMPANIES DEVELOPING TEST KITS:

Union Carbide Chemicals and Plastics Company, Inc. said Thursday that it
had become partners with DNA Plant Technology Corp. The two companies plan to
develop and market on-site test kits used to detect diseases, contaminants and
pollutants in farm areas.

TESTS BEGIN FOR IGF-I USE:

Genentech, Inc. began clinical trails of insulin-like growth factor (IGF-I)
last week. The company said it planned to investigate the activities of IFG-I
in a variety of nutritional and growth disorders and tissue repair. It will
also be using the tests to determine the safety of IGF-I use in humans. The
study is expected to take six months.

CHLORINE IS REDUCED IN WATER:

General Electric scientists say they have discovered a technique that
accelerates the breakdown of cancer-causing polychlorinated biphenyls by
bacteria that live in sediments. The method, using nitrogen, phosphorus and
trace metals, reduces the level of PCBs by 70 percent in four weeks to eight
weeks.

---
Sept. 18, 1989
---

CAFFEINE LOWERS INFANT'S WEIGHT:

A study examining the effect of first trimester maternal caffeine
consumption supports previous findings that intake of coffee, cola and
caffeine from all sources was associated with a marginally increased risk of
low birthweight, reports the September issue of the American Journal of Public
Health.

EGG PRODUCERS SCRAMBLING IDEAS:

New methods for producing cholesterol-free or reduced-cholesterol eggs
could revive a slumping market. This idea has egg producers looking toward a
rosier future. To tap the market, and produce eggs with 118 milligrams of
cholesterol, compared to the normal 274 milligrams, producers are feeding
their hens special diets and changing their environment.

DOCTOR COMPUTER SOLVING CASES:

Pediatricians and computer scientists are offering the public FamilyCare
Software. The program, which operates a PC, has a database for more than 1,500
questions and recommendations on the emergency and nonemergency care of
children of any age. It asks questions about symptoms and can recommend
medicines to buy. Cost: $99, reports Compute! October issue.


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Volume 2, Number 35 September 25, 1989

SMOKING HARMS PREGNANCY:

A case-controlled study conducted between 1983 and 1987 has strengthened
researchers' argument that smoking might be a reason for the development of
ectopic pregnancy. The report said women who smoked had a greater than twofold
risk of ectopic pregnancy compared to those who never smoked, reports the
September issue of American Journal of Public Health.

WORK AFFECTS FEEDING PATTERN:

First-time mothers returning to the work on a part-time or full-time basis
are likely to curtail or stop breast-feeding their child, reports the
September issue of the American Journal of Public Health. A recent studied
showed that black and white women who returned to professional occupations
breast-fed their babies longer than those returning to sales or technical
jobs.

FORMING BIASES IS NATURAL:

The human mind is predisposed toward bias, said John Dovidio, psychologist
at Colgate University, Hamilton, N.Y. It has a need to categorize to cope with
the daily flood of information. To nip harmful racial biases institutions
should change the way people categorize each other, he said.

---
Sept. 19, 1989
---

AZT PRICE COMES DOWN:

The price for the drug AZT is coming down. Boroughs Wellcome Company is
cutting the price to $1.20 a capsule, down from $1.50. The price of the drug
raised concern last month when it was reported that AZT would cost $8,000 a
year retail. Studies have shown that the drug could postpone AIDS in some
infected people. (From the USA TODAY Money section.)

AIDS PATIENTS OUT ON A LIMB:

In an attempt to get well, a survey of 144 AIDS patients of the University
Clinic San Francisco found that 39, or 28 percent used treatments not approved
by the U.S. Food and Drug Administration in addition to those prescribed by
their physicians. Unapproved drugs used: Megadose vitamin C, dextran, AL-721
and fetal sheep blood injections.

FIRM INVESTS IN AIDS RESEARCH:

New York Life said Monday it would invest up to $20 million in a program
with Biogen, Inc., Cambridge, Mass., to jointly fund research, development and
clinical trials of AIDS therapeutic products. Biogen said it planned to study
the use of Receptin to treat AIDS.

DIURETICS TIED TO CORONARIES:

Diuretics, which are taken by about 10 million U.S. residents for
hypertension, might sharply raise their coronary risk, a study of 902 people

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Volume 2, Number 35 September 25, 1989

with mild high blood pressure (90 to 99 diastolic) suggests. If people on the
diuretic were taking an Alpha blocker instead there could be 15 percent fewer
heart attacks, says Dr. Richard H. Grimm Jr. of University of Minnesota,
Minneapolis.

MEMORY DEVICE HELPING AMNESIACS:

Researchers are studying a way to use computer programs tailored to an
individual's memory loss and daily routine to help patients with memory loss.
The studies are being conducted at the Boston University School of Medicine
and the Memory Disorders Research Center at the Boston Veterans Administration
Medical Center.

BACTERIA STOPS ACID BUILD-UP:

In a study using rabbit stomach cells, researchers at University Hospital,
Boston, discovered that Campylobacter pylori, a bacteria found in 40 percent
of the population, inhibits the release of acid. The discovery might lead to a
new treatment for ulcers, reports a recent issue of The Lancet.

FDA APPROVES NEW CATHETER:

The U.S. Food and Drug Administration has approved a new angioplasty
catheter developed by Schneider, Inc. The Monorail Piccolino catheter is used
to open obstructed coronary arteries. It is made with a short channel through
which the coronary guidewire passes, the company said.

HEALTHY WHEELCHAIRS ON ROLL:

Researchers at the State University of New York at Buffalo are designing
wheelchairs with hand cranks and pedals that exercise the user's muscles and
heart. The chairs are designed for paraplegic use, too. With electrical
stimulation their muscles could work the pedals.

HIGH-FIBER CEREALS RANK HIGH:

The most nutritious cereals are the ones that are highest in fiber content
and low on sugar and fat, according to the October Consumer Reports magazine.
The cereals to top the list: Fiber One, Quaker Puffed Wheat, Uncle Sam, Nutri-
Grain Nuggets, Nabisco Shredded Wheat 'n Bran, Nabisco Shredded Wheat and
Cheerios. (From the USA TODAY Life section.)

SENIOR'S DRUG USE WATCHED:

Older people who take medication should have periodic tests to monitor drug
levels in the blood, kidney and liver functions. That's because older people
have have less stomach fluid and a slower system that can hinder a drug's
effectiveness, said Phillip Levine, dean of Drake University's College of
Pharmacy.

---
Sept. 20, 1989
---

ENCAPSULATION HELPS CANCER DRUG:

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Volume 2, Number 35 September 25, 1989


Encapsulating interferon in liposomes significantly improved the drug's
effect on bladder tumors, according to researchers reporting in Wednesday's
issue of the Journal of the National Cancer Institute. Liposomes, tiny spheres
made of lipids, allow a larger dosage and more sustained drug release as they
slowly break down.

MALARIA VACCINE DEALT A BLOW:

A promising candidate for a malaria vaccine has been dealt a setback
because scientists have found that the segment of a protein it was designed to
target isn't as universal as previously thought. The target lies on the
surface of an encapsulated form of a protozoan delivered into the human body
by a mosquito's bite, reports last week's Science.

BETTER TO CARRY BABIES ON BACK:

New mothers should not carry their babies in front baby carriers because it
can cause back strain. Research by the Mayo Medical School in Rochester,
Minn., says new mothers are vulnerable to back injury because hormones have
caused their ligaments and joints to soften for birth. Big babies and heavier
women led to the most strain.

STRAIN ON HEALTH CARE SEEN:

Early detection and treatment of patients infected with the HIV virus will
severely strain the U.S. health care systems, says a study in the Journal of
the American Medical Association. The economic impact will be greatest in
urban areas but can be managed if the federal government takes a greater
financial responsibility, the authors say.

DOCTORS CITE CHILD ABUSE CUES:

A study by Johns Hopkins pediatrics suggests that if doctors had handy
details on the kinds of injuries linked to common household accidents, they'd
be more likely to detect injuries due to child abuse. The study was reported
at a Stockholm conference Monday.
---
Sept. 21, 1989
---

ALZHEIMER'S PROTEIN LOCATED:

A protein that researchers associated with Alzheimer's disease has been
discovered for the first time in tissues outside of the brain in other areas
of the body. This discovery could lead to new methods of diagnosis and
treatments, researchers said. (From the USA TODAY News section.)

LEUKEMIA DRUG WAITS APPROVAL:

Enzon, Inc. said Wednesday it was preparing to file a license application
with the Food and Drug Administration to market the drug PEG-L asparaginase,
which is used to treat acute lymphoblastic leukemia. The company is studying
the use of the product to treat Non-Hodgkins lymphoma and other forms of
lymphoma.

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Volume 2, Number 35 September 25, 1989


TRAUMA KILLING THOSE UNDER 45:

Trauma is the leading cause of deaths in people under 45, said the American
Trauma Society on Wednesday. Trauma kills 100,000 people a year and disables
350,000. The reason: most United States emergency centers have no or
inadequate trauma centers. (From the USA TODAY Life section.)

ANTIVIRAL STUDY ANNOUNCED:

Research Industries Corp. said Wednesday that it had completed clinical
studies of 301 patients experiencing a recurrence of herpes labialis (cold
sores). The study found that patients who applied a proposed product
HERPID(TM) - a drug containing an antiviral agent - at the onset of a cold
sore had less pain and a fast healing rate.

CONTACT WEARERS ARE AT RISK:

Researchers have found that wearing soft, extended-wear and daily-wear
contact lenses overnight increases a person's risk of eye inflammation, which
can lead to blindness, said a report in Thursday's New England Journal of
Medicine. It also said the risks are higher for wearing extended-wear lenses.
(From the USA TODAY News section.)

GETTING MAMMOGRAM WORD OUT:

Early detection is the key to successful survival of breast cancer, said
speakers Wednesday at the Women's Leadership Summit on Mammography. More than
200 women's, community, and business leaders met on Capitol Hill to discuss
how to spread the word that women over 40 should get mammograms. The disease
will kill 43,000 of the 142,000 women diagnosed this year.

SIBLINGS REDUCE BLOOD PRESSURE:

Children who had no siblings are more likely to get high blood pressure
when they grow up than children who grew up with sisters and brothers,
according to a new study by researchers at the State University of New York's
University at Buffalo. Researchers think stress caused by higher expectations
placed on an only child is the cause.


HEART MACHINE COULD SAVE LIVES:

Automated defibrillators, computerized versions of the electric-shock
devices medical personnel use to restore heartbeats, might become increasingly
common in homes. Computerized defibrillators that need little training to
operate and cost about $5,000, automatically analyze the heart rhythm and give
shocks, if needed, said Dr. Richard Cummins of the University of Washington,
Seattle.

MALE PROSTITUTES HARBORING AIDS:

One of the first studies of AIDS in male prostitutes, done in Atlanta from
July 1988 to March 1989, shows 27 percent of 152 tested positive for
antibodies to the virus. The study in Thursday's New England Journal of
Medicine also reports that 40 percent were intravenous drug abusers, 22

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Volume 2, Number 35 September 25, 1989

percent tested positive for syphillis and 58 percent for hepatitis B.

---
Sept. 22-24, 1989
---

RULES NEEDED FOR MEDICAL WASTE:

Infectious medical waste from hospitals is usually handled properly, but
tighter rules might be needed for clinics, nursing homes and physicians'
offices, which might rival hospitals' volume and often aren't regulated, says
a study in Friday's Journal of the American Medical Association.

CHRISTIAN SCIENTISTS' DEATHS UP:

Christian Scientists have a higher death rate than average, says a study of
5,558 adherents in Friday's Journal of the American Medical Association.
Reason: Rejection of most medical treatment. It questions recognition of
Christian Science health care by Medicare, IRS, schools, some insurance
companies.

GENETICS PLAY ROLE IN DISEASE:

Some women might be more susceptible to urinary tract infections than
others, said a recent study in the New England Journal of Medicine by a
urologist at Northwestern University Medical School. The study showed that
urinary tract infections appear linked to the ability of certain genes to
influence the cells lining the urinary tract.

WHY WE CONTROL CALORIE INTAKE:

People watch the amount of calories they intake to ensure good health, said
two-thirds of respondents to a Calorie Control Council survey. Others say they
count calories to maintain their weight, while about half say they do it to
stay attractive. Slightly less than half add up their calories to reduce
weight.



















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Volume 2, Number 35 September 25, 1989



===============================================================================
Center for Disease Control Reports
===============================================================================

Morbidity and Mortality Weekly Report
Thursday September 21, 1989

Health Objectives for the Nation

Introduction

This issue of the MMWR introduces a new series, "Health Objectives for the
Nation." Future articles will address efforts by health agencies at all levels
to meet national objectives and by the public and private sectors to develop
and implement comparable prevention and health promotion objectives. This
first article provides background to the origin of national health objectives,
outlines the process used to develop the objectives, lists the broad
categories of objectives, and describes an approach to implementing the
objectives.

Year 2000 National Health Objectives

In July 1979, the publication Healthy People: The Surgeon General's Report
on Health Promotion and Disease Prevention described for the first time a
national public health agenda. This report established five quantifiable goals
for improving the health of all Americans and documented the importance of
disease prevention and health promotion in achieving these goals (1). In 1980,
a companion piece--Promoting Health/Preventing Disease: Objectives for the
Nation--set forth 226 specific, measurable health objectives in a plan of
action for reaching these goals (2). These objectives, referred to as "the
1990 health objectives," called for improvements in health status, risk
reduction, public and professional awareness, health services and protective
measures, and surveillance and evaluation.
Successes in attaining these objectives have been documented in areas such
as hypertension, childhood infectious diseases, and injury prevention (3-5).
However, many of the objectives will not be met by 1990, and new public health
problems and challenges have arisen. Therefore, in 1987, the Public Health
Service (PHS) began developing the Year 2000 Objectives for the Nation.
The planning process for these new objectives has taken into account the
need to 1) involve as many groups as possible in early stages, 2) set
objectives addressing high-risk minority populations and specific age groups
when appropriate, and 3) emphasize the roles for citizens, the private sector,
and the public sector in meeting the objectives. Process
To ensure a broad base of input, PHS and the Institute of Medicine invited
more than 300 national organizations and the state and territorial health
departments to join a consortium to develop the year 2000 objectives. Regular
mailings and meetings are used to sustain the participation of these
organizations. Twenty-five public hearings provided a forum for persons and
organizations in different areas of the country to participate in the process
and make recommendations; PHS narrowed the list of recommendations to 21
priority areas (Table 1). Specific PHS agencies then drafted objectives in
each priority area using work groups made up of subject-area experts from
federal, state, and local agencies and from academia. Each work group used the
testimony from the public hearings in writing the objectives.
In January 1989, a draft of the objectives developed by the work groups

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Volume 2, Number 35 September 25, 1989

was sent to other experts, both within and outside the federal government, for
critical review. The revised objectives were then sent to the Office of
Disease Prevention and Health Promotion, Office of the Assistant Secretary for
Health (which is coordinating the process), for incorporation into the draft
publication Promoting Health/Preventing Disease: Year 2000 Objectives for the
Nation (6). More than 7000 persons and organizations have participated in
developing the draft now available for review.
On September 18, PHS solicited public review of and comment on the
objectives, with a November 15 deadline (7). A national conference is planned
for July 1990 to release the final Year 2000 Objectives for the Nation and to
begin the decade-long implementation effort. Goals and Objectives
The draft Year 2000 Objectives proposes five specific, measurable goals--
similar to those set forth in Healthy People in 1979--that the comprehensive
set of objectives in the 21 priority areas is designed to achieve by the year
2000 (6):

o Reduce infant mortality to no more than seven deaths per 1000 live births
(baseline: 10.4 per 1000 in 1986).

o Increase life expectancy to at least 78 years (baseline: 74.9 years in
1987).

o Reduce disability caused by chronic conditions to a prevalence of no more
than 6% of all persons (age-adjusted baseline: 8.9%).

o Increase years of healthy life to at least 65 years (baseline: an estimated
60 years in 1987).

o Decrease disparity in life expectancy between white and minority populations
to no more than 4 years (baseline: 5.8 years in 1987).

The 21 priority areas have served as a framework for drafting the year
2000 objectives. These priority areas include many of the 15 areas established
for 1990 and extend into additional areas, such as human immunodeficiency
virus (HIV) infection, cancer, and the vitality and functional independence of
older people (Table 1). The priority areas and the specific objectives under
each are grouped into four major sections in the publication: Health
Promotion, Health Protection, Preventive Services, and System Improvement
Priorities.

The year 2000 draft contains 339 objectives (compared with the 226
objectives established for 1990) characterized by 1) an increased emphasis on
prevention of disability and morbidity, 2) greater attention to improvements
in the health status of specific groups at highest risk for premature death,
disease, and disability, and 3) inclusion of more screening interventions to
detect asymptomatic diseases and conditions early enough to prevent early
death or disability.
Specific targets for special populations were developed for groups
demonstrating higher risk than the general population for a particular disease
or condition. These groups start at a lower baseline for the health condition
and thus are at a disadvantage in attaining the same target level as the
general population. For example, the draft objective on the initiation of
smoking aims to reduce the proportion of youth who start to smoke from 29.5%
in 1987 to no more than 15%. However, a special-population target of 20% is
set for youth of low socioeconomic status whose baseline rate was 40% in 1987.
Implementing the Objectives

Health InfoCom Network News Page 10
Volume 2, Number 35 September 25, 1989

Because many states and communities may wish to develop and attain their
own health objectives relating to the year 2000, PHS is working with the Model
Standards Project through the American Public Health Association to develop a
community implementation workbook. The workbook will integrate the national
health objectives with the approaches of the publication Model Standards: A
Guide for Community Preventive Health Services (8) to enable state and local
health agencies to tailor the national objectives to their specific local
health and demographic needs. The work book is scheduled for release in the
fall of 1990, as a companion to the Year 2000 Objectives for the Nation.

Reported by: Office of Disease Prevention and Health Promotion, Office of the
Assistant Secretary for Health, US Dept of Health and Human Svcs. Office of
Program Planning and Evaluation, Office of the Director, CDC.

Editorial Note: The 1979 publication Healthy People is a landmark in the
history of public health. At the time, the Secretary of Health, Education, and
Welfare characterized this report as a document "to encourage a second public
health revolution" (1) and suggested that it reflected an emerging consensus
among the health community that the nation's health strategy must emphasize
the prevention of disease.
Public health efforts at the local, state, and national levels have
resulted in documented progress toward meeting many objectives, but
improvement is still needed in others. For example, by 1987, considerable
progress had been made toward the objectives related to childhood vaccines
even though the goal of immunizing children by the earliest appropriate year
(age 2) had not been reached. Five of the eight objectives addressing
morbidity reduction from childhood vaccine-preventable diseases appeared to
have been attained, including those for diphtheria (1990 target, 50 cases;
1987 level, three cases), poliomyelitis (target, 10; level, no cases), and
tetanus, rubella, and congenital rubella syndrome (all of which fell below the
1990 target in 1987). In contrast, immunization targets for adults were not
likely to be achieved. The 1990 objective for influenza vaccination targeted
immunization of at least 60% of high-risk populations annually. However, the
1985 U.S. Immunization Survey showed that only about 20% of high-risk persons
had received the vaccine during the preceding year (4).
The draft Year 2000 Objectives affirms the commitment to addressing public
health problems that persist, as well as problems that have appeared or
intensified since the inception of the national health objectives in the late
1970s. For example, the current document contains a section on HIV, which was
unknown when the 1990 objectives were developed.
The extensive participation by representatives of state and local
governments, academic institutions, business and labor, and community and
professional organizations at each step in the process is helping to establish
the broad network needed for successful implementation of programs. This
network is vital to the efforts to meet the objectives, as well as to achieve
the goal of the World Health Organization of "Health for All by the Year
2000."

PHS welcomes comments on the draft objectives. The draft is available for
public review from ODPHP National Health Information Center, P.O. Box 1133,
Washington, DC 20013-1133; telephone (301) 565-4167 or (800) 336-4797.
Comments should be sent by November 15, 1989, to:

Deputy Assistant Secretary for Health
(Disease Prevention and Health Promotion)

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Volume 2, Number 35 September 25, 1989

U.S. Department of Health and Human Services
330 C Street, S.W., Room 2132
Washington, DC 20201

References

1. Public Health Service. Healthy people: the Surgeon General's report on
health promotion and disease prevention. Washington, DC: US Department of
Health, Education, and Welfare, Public Health Service, 1979; DHEW publication
no. (PHS)79-55071.

2. Public Health Service. Promoting health/preventing disease: objectives for
the nation. Washington, DC: US Department of Health and Human Services, Public
Health Service, 1980.

3. CDC. Advancements in meeting the 1990 hypertension objectives. MMWR
1987;36:144, 149-51.


4. CDC. Progress toward achieving the national 1990 objectives for
immunization. MMWR 1988; 37:613-7.

5. CDC. Progress toward achieving the national 1990 objectives for injury
prevention and control. MMWR 1988;37:138-40,145-9.

6. Public Health Service. Promoting health/preventing disease: year 2000
objectives for the nation (Draft). Washington, DC: US Department of Health and
Human Services, Public Health Service, 1989.

7. Office of the Assistant Secretary for Health, Office of Disease Prevention
and Health Promotion. Announcement of year 2000 health promotion and disease
prevention objectives availability for public review and comment. Federal
Register 1989;54:38453. (FR doc. 89-21974).

8. American Public Health Association/Association of State and Territorial
Health Officials/National Association of County Health Officials/US Conference
of Local Health Officers/CDC. Model standards: a guide for community
preventive health services. 2nd ed. Washington, DC: American Public Health
Association, 1985.

















Health InfoCom Network News Page 12
Volume 2, Number 35 September 25, 1989

Contribution of Birth Defects to Infant Mortality -- United States, 1986

As infant mortality in the United States has declined during the 20th
century, the proportion of infant deaths attributed to birth defects has
increased steadily (1) (Figure 1). Birth defects also contribute substantially
to years of potential life lost before age 65 (2).
To evaluate the contribution of birth defects to infant mortality in the
United States, mortality data for 1986 from CDC's National Center for Health
Statistics were analyzed. Birth defects were defined as conditions coded
within Congenital Anomalies (740.0-759.9) of the International Classification
of Diseases, Ninth Revision (ICD-9). Excluded from this group were 460 babies
with lung hypoplasia (748.5), patent ductus arteriosus (747.0), or
hydrocephalus (742.3) secondary to intraventricular hemorrhage (772.1) who
also had ICD-9 codes 764 or 765 (disorders relating to low birthweight and
short gestation).

Of 38,957 reported infant deaths in 1986, 8005 (20.5%) had birth defects
listed as the underlying cause of death; birth defects were the leading cause
of infant mortality (Figure 2). Birth defects were listed as a contributing
cause of death for an additional 1088 infants. Thus, in 1986 birth defects
were an underlying or contributing cause of death for 9093 (23.3%) infants.
Cardiovascular defects, the most frequent type of birth defect, were
present in 3057 (38.2%) of the 8005 babies. Central nervous system defects
(including anencephalus and similar anomalies, spina bifida, and other
congenital anomalies of the central nervous system and eye) were the second
largest group, occurring in 1191 (14.9%). Birth defects of the respiratory
system comprised the third largest group (870 (10.9%)). Reported by: Birth
Defects and Genetics Br, Div of Birth Defects and Developmental Disabilities,
Center for Environmental Health and Injury Control, CDC. Editorial Note: The
rapid decline of infant mortality rates in the 1970s has been attributed
largely to the advent of medical technology in the care of premature and other
critically ill newborns. In the 1980s, this decline has slowed considerably--
partly because of a lack of progress in primary prevention of conditions which
lead to infant death. As a consequence, the 1990 health objective of nine
infant deaths per 1000 live births is unlikely to be met (3). Additionally, to
meet the year 2000 objectives, health agencies will have to make substantial
efforts to prevent the leading causes of infant mortality.
Birth defects, prematurity, and sudden infant death syndrome account for
52% of all infant deaths. Epidemiologic and basic research are integral to the
development of prevention programs for infant mortality. The federal
government and 22 states maintain surveillance systems for birth defects.
These systems can assist in assessing the effectiveness of intervention
programs in preventing defects whose etiology is known (e.g., fetal alcohol
syndrome) and in serving as a basis for the epidemiologic research needed to
understand the causes of birth defects.

References

1. Warkany J. Congenital malformations. Chicago: Year Book Medical Publishers,
1971:41.

2. CDC. Premature mortality due to congenital anomalies--United States. MMWR
1988;37:505-6.

3. Public Health Service. The 1990 health objectives for the nation: a

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midcourse review. Washington, DC: US Department of Health and Human Services,
Public Health Service, 1986.





















































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Varicella Outbreak in a Women's Prison -- Kentucky

During January and February 1989, three cases of varicella (chickenpox)
occurred among inmates at the Federal Correctional Institution in Lexington,
Kentucky. This all-women prison is a 1200-bed facility with an onsite
hospital. At the time of the outbreak, 1276 inmates were housed in the
facility; approximately one fourth were Hispanic (primarily from Central and
South America); 36 (3%) were pregnant. Thirty-two (3%) inmates were
seropositive by enzyme-linked immunosorbent assay (EIA) and Western blot for
human immunodeficiency virus (HIV) infection, including six persons with
acquired immunodeficiency syndrome (AIDS).

The first case of varicella developed on January 8 in a 25-year-old U.S.-
born black woman who had been on furlough in New Jersey with her 8-year-old
daughter who had chickenpox. The second case occurred on February 1 in a 23-
year-old Central American woman; she had given a hair permanent to the first
case-patient within 24 hours before the first patient developed a rash. The
third case was identified on February 19 in a 19-year-old U.S.-born Hispanic
woman who also has severe juvenile rheumatoid arthritis. The latter two women
attended the same class during late January.
The third case-patient lived in the chronic-care unit of the prison
hospital with 17 other women, including two with AIDS and one receiving low-
dose steroids for treatment of systemic lupus erythematosis. She potentially
exposed two groups of contacts. The first group comprised other inmates in the
chronic-care unit, the unit's medical staff, and inmate workers. To prevent
further transmission, persons with uncertain histories of previous chickenpox
infection were not permitted to enter the unit. Three nurses who were
uncertain of their histories were excluded from the unit pending results of
their varicella-zoster (VZ) antibody titer tests. In addition, 12 patients and
four inmate workers from the chronic-care unit were identified from histories
as possibly not immune.
The second group of contacts comprised all other identifiable social and
classroom contacts of the third case-patient and included greater than 200
inmates who attended the same programs or classes during the 3 days before she
developed symptoms. Of this group, 100 were uncertain about histories of
previous varicella infection, including 40 with self-identified risk behaviors
for HIV infection and one who may have been pregnant. Serum specimens were
obtained from 116 of these inmates and three staff members to measure VZ
antibody titers. Because of the time required to process the specimens, all
potentially susceptible inmates in this second group of contacts were
quarantined in a separate unit within the prison until their serologic results
became available.
Overall, 115 (99%) of the 116 persons with evaluative results* were immune
to VZ (immunity defined as titers greater than or equal to 1:8 by
immunofluorescent antibody (IFA) measurement); the one person who was
confirmed susceptible to VZ after duplicate IFA testing remained asymptomatic.
All pregnant women, AIDS patients, and staff were immune. In addition, all 40
persons reportedly at risk for HIV infection were negative for HIV antibody on
EIA testing. No cases of varicella have occurred since the third case.

Reported by: JB Williams, S Fawkes, Federal Correctional Institution,
Lexington, Kentucky. Div of Immunization, Center for Prevention Svcs, CDC.

Editorial Note: In the United States, exposure to and infection with the
highly communicable VZ virus is virtually unavoidable (1). VZ virus causes

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both varicella (the manifestation of primary infection in a susceptible
person) and zoster (the result of reactivation of latent virus); patients with
either disease may transmit the virus to susceptible persons (1-3). An
estimated 3.5 million cases of varicella and 300,000 cases of zoster occur in
the United States annually (2).
Varicella can be life threatening, particularly in adults, pregnant women,
neonates, and immunocompromised persons. VZ infection in pregnancy may also
produce fetal infection and an array of congenital abnormalities characterized
as "congenital varicella syndrome" (4). Zoster occurs and can be severe in
HIV-infected persons (5). Persons from rural tropical and subtropical regions
are less likely than persons from temperate zones to be infected as children,
leaving them susceptible as adults (6). Thus, in this prison population,
increased risk existed for transmission and severe health effects.
In this investigation, the estimated level of immunity for the inmate
population was at least 99%. Based on this nonrandom sample from the
population of 1267 inmates, at most, 13 persons were possibly susceptible to
varicella before the onset of disease in the first case-patient. Nonetheless,
the close confines and extensive socialization in a prison maximize the
potential spread of a highly contagious disease, such as varicella, despite
high levels of immunity.
Introduction and subsequent transmission of the VZ virus among patients
and staff can be reduced in health-care settings such as in this prison. CDC
has developed isolation precautions for hospitalized patients who either have
active disease or have been exposed to varicella or zoster (7). CDC has also
issued recommendations to minimize virus transmission to and from hospital
personnel (8); in institutions where varicella is prevalent or where there are
many high-risk patients, it may be useful to screen those personnel who have a
negative or equivocal history of varicella for the presence of serum
antibodies to VZ virus to document susceptibility or immunity (persons with a
positive history can be considered immune). In the absence of a licensed
vaccine against VZ, efforts should be taken to maximize the effectiveness of
existing recommendations for control of VZ virus infections.

References

1. Weller TH. Varicella and herpes zoster: changing concepts of the natural
history, control, and importance of a not-so-benign virus. N Engl J Med
1983;309:1362-8,1434-40.

2. Preblud SR. Varicella: complications and costs. Pediatrics
1986;78(suppl):728-35.

3. Ragozzino MW, Melton LJ III, Kurland LT, Chu CP, Perry HO. Population-
based study of herpes zoster and its sequelae. Medicine 1982;61:310-6.

4. Preblud SR, Cochi SL, Orenstein WA. Varicella-zoster infection in
pregnancy (Letter). N Engl J Med 1986;315:1416-7.

5. Melbye M, Grossman RJ, Goedert JJ, Eyster ME, Biggar RJ. Risk of AIDS
after herpes zoster. Lancet 1987;1:728-31.

6. Gershon AA. Varicella-zoster virus infections. In: Spittell JA Jr, ed.
Clinical medicine. Vol 3. Philadelphia: Harper and Row, 1985.

7. Garner JS, Simmons BP. Guideline for isolation precautions in hospitals.

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Infect Control 1983;4(suppl 4):245-325.

8. Williams WW. Guideline for infection control in hospital personnel.
Infect Control 1983;4(suppl 4):326-49.

*Three women had "interfering substances" in their serum preventing a
determination of VZ antibody presence, but subsequent interviews with family
members established a childhood history of chickenpox in all three cases.















































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Volume 2, Number 35 September 25, 1989

Surveillance for Occupational Lead Exposure -- United States, 1987

Since 1981, four states (California, New Jersey, New York, and Texas) have
implemented surveillance systems for occupational lead exposure. Although the
details of these systems, each state requires any laboratory that performs
blood-lead assays to report all elevated blood-lead levels (BLLs) to the state
health department (SHD) (Table 1). The SHD then uses telephone follow-up
(with either the physician who submitted the blood specimen or the patient) to
obtain demographic information and identify possible occupational lead
exposures.
This report summarizes 1987 surveillance data from these states on adults*
with BLL greater than or equal to 40 ug/dL of whole blood.** A person was
counted as a case-patient only once, even though some persons may have been
reported several times within the year. The highest BLL reported for each
person (peak BLL) was used for this report.
For 1987, 1926 adults with elevated BLLs were reported to the four SHDs;
for 524 (27.2%) persons, BLL exceeded 50 ug/dL.*** Most (93%) elevated BLLs
occurred in males, and most (94% (excluding New Jersey, for which specific
data were not available)) were work-related.**** The age distribution was
similar in the four states; the greatest proportions of persons with elevated
BLLs were aged 25-34 and 35-44 years. In California and Texas, 44% and 40% of
reported persons, respectively, were Hispanic; in contrast, Hispanics
represent approximately 24% and 25%, respectively, of these states'
populations (Bureau of the Census, unpublished data, 1988).
Elevated BLLs were most common in workers employed in industrial sectors
with well-known lead hazards, such as primary and secondary lead smelting,
brass foundries (both Standard Industrial Code (SIC) 33), and battery
manufacturing (SIC 36) (Table 2). Less common sources included: construction
(including bridge reconstruction and home rehabilitation), ceramics
manufacture, plastics production, stained-glass window production, ammunition
manufacture, and firing ranges (both for sport and law-enforcement training).
Case follow-up efforts vary by state, but all attempt to 1) confirm
occupational lead exposure by gathering more information about work history,
hobbies with possible lead exposures, symptoms, and household contacts from
the affected person or the reporting source, 2) provide educational and
technical information to affected workers, attending physicians, and
employers, and 3) arrange onsite evaluations of the lead hazard. Follow-up
procedures may entail telephone contact with all newly reported workers,
telephone contact only when a threshold BLL is exceeded, or telephone contact
with the initiator (physician or employer) of the blood-lead test. Educational
materials may be mailed to affected workers (and their physicians) or may be
distributed to all lead-exposed workers when worksite inspections are
conducted.
Worksite follow-up visits, including industrial hygiene evaluations, are
part of each state's program. For example, the New Jersey Department of Health
conducted 54 worksite visits from October 1985 through May 1989. In New York,
selected worksite industrial hygiene surveys are conducted by the SHD, which
refers employers to the State Department of Labor for technical assistance.
Less frequently, OSHA (either the consultation program or compliance section)
may be contacted. In Texas, the SHD refers employers to either the state OSHA
consultation program or to an industrial hygienist employed by the SHD.

Reported by: L Rudolph, MD, N Maizlish, PhD, California Dept of Health Svcs. A
Tepper, PhD, B Gerwel, MD, T Wenzl, MS, New Jersey Dept of Health. J Melius,
MD, R Stone, PhD, New York State Dept of Health. J Martin, PhD, J Pichette,

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Volume 2, Number 35 September 25, 1989

Texas Dept of Health. M Montopoli, MD, Univ of Illinois Occupational Health
and Safety Center. Surveillance Br, Div of Surveillance, Hazard Evaluations,
and Field Studies, National Institute for Occupational Safety and Health, CDC.

Editorial Note: Lead poisoning, first described by Hippocrates around 370
B.C., is the oldest recognized occupational disease. The clinical and
pathophysiologic effects of higher levels of lead exposure are well known, but
evidence continues to emerge concerning adverse health effects at lower BLLs
(2). In the occupational setting, inhalation of lead dust and fume is the
primary route of absorption. Data from the National Occupational Exposure
Survey conducted from 1981-1983 by the National Institute for Occupational
Safety and Health (NIOSH), CDC, indicate that approximately 827,000 U.S.
workers are potentially exposed***** to lead on the job (3; CDC, unpublished
data, 1989). Workplace exposure has also been described as a vector for
childhood and community lead exposure through contamination of work clothing
and the local environment (4).
In 1979, OSHA promulgated a Standard for Occupational Exposure to Lead
(1), which requires that, in workplaces where lead is used, employers must
monitor for airborne contamination. When airborne lead concentrations exceed
30 ug/m3 of air (averaged over an 8-hour workshift), employers must provide an
industrial hygiene program and medical surveillance (including the monitoring
of BLLs). The OSHA permissible exposure limit (PEL) for lead is 50 ug/m3 for
an 8-hour workshift (1). An employee with one BLL greater than or equal to 60
ug/dL or three BLLs that average greater than or equal to 50 ug/dL over a 6-
month period must be moved to a job without lead exposure until the worker's
BLL declines to an acceptable level (i.e., 40 ug/dL) (1). Although the OSHA
Lead Standard has been in effect for greater than 10 years, the data in this
report indicate that overexposures to lead continue in many industries.
Construction-related industries (SICs 16 and 17) accounted for the highest
proportion (30.4%) of workers with BLLs greater than or equal to 70 ug/dL. The
OSHA Lead Standard does not apply to the construction industry, for which OSHA
has established a separate PEL of 200 ug/m3 and does not require medical
monitoring (5). Although the construction industry has a higher PEL for lead,
this level is frequently exceeded when cutting or welding torches are used on
bridges coated with lead-containing paints (6,7). Lead overexposures in the
construction industry should be given greater attention.
In California and Texas, the rates of elevated BLLs for Hispanics were
higher than this group's relative proportion of population in those states.
(Occupational disease and injury rates are higher for minority workers than
for other groups, possibly because they may be employed disproportionately in
shops with suboptimal controls and greater exposures (8).) Because the
potential impact of occupational lead exposure as a minority health concern
has not been previously addressed, in California, Spanish-language educational
materials describing the hazards and control of lead in the workplace have
been developed for minority workers.

Since 1987, the Wisconsin, Maryland, and Colorado SHDs have implemented
similar BLL surveillance systems, and other states are considering such
systems. NIOSH, in collaboration with SHDs through the Sentinel Event
Notification System for Occupational Risks program, is supporting this program
development effort. A key consideration for surveillance of this problem is
selection of the BLL necessary for triggering a report to the SHD. Most of the
states conducting surveillance of lead toxicity in adults have adopted the
level recommended by CDC for nonoccupational settings (25 ug/dL) as an
indicator for elevated BLLs in children (9).

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To eliminate occupational lead poisoning (10), blood-lead surveillance
programs, such as those described here, are crucial for identifying individual
workers and workplaces with overexposure to lead. These programs enable
targeting of public health, technical, and educational resources to those
worksites in need of assistance.

References

1. 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).

2. McMichael AJ, Baghurst PA, Wigg NR, Vimpani GV, Robertson EF, Roberts RJ.
Port Pirie Cohort Study: environmental exposure to lead and children's
abilities at the age of four years. N Engl J Med 1988;319:468-75.

3. Seta JA, Sundin DS, Pedersen DH, NIOSH. National Occupational Exposure
Survey: field guidelines. Vol 1. Survey manual. Cincinnati, Ohio: US
Department of Health and Human Services, Public Health Service, 1988; DHHS
publication no. (NIOSH)88-106.

4. Kaye WE, Novotny TE, Tucker M. New ceramics-related industry implicated in
elevated blood lead levels in children. Arch Environ Health 1987;42:161-4.

5. Office of the Federal Register. Code of federal regulations: safety and
health regulations for construction. Subpart J: Welding and cutting--welding,
cutting, and heating in way of preservative coatings. Washington, DC: Office
of the Federal Register, National Archives and Records Administration, 1988.
(29 CFR Section 1926.354).

6. Pollock CA, Ibels LS. Lead intoxication in paint removal workers on the
Sydney Harbour Bridge. Med J Aust 1986;145:635-9.

7. Landrigan PJ, Baker EL Jr, Himmelstein JS, Stein GF, Wedding JP, Straub
WE. Exposure to lead from the Mystic River Bridge: the dilemma of deleading. N
Engl J Med 1982;306:673-6.

8. US Department of Health and Human Services. Report of the Secretary's Task
Force on Black and Minority Health. Washington, DC: US Department of Health
and Human Services, Public Health Service, 1986.

9. CDC. Preventing lead poisoning in young children: a statement by the
Centers for Disease Control. Atlanta: US Department of Health and Human
Services, Public Health Service, 1985.

10. Public Health Service. Promoting health/preventing disease: objectives for
the nation. Washington, DC: US Department of Health and Human Services, Public
Health Service, 1980:42.


*For this report, California and New York define adults as persons aged
greater than or equal to 18 years; Texas uses age 15 years as the reporting
threshold, and New Jersey uses age 16 years.


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Volume 2, Number 35 September 25, 1989

**This threshold was chosen for this report to permit comparison of data among
the four states because Texas collects data only at or above this level.

***An average BLL of 50 ug/dL based on three blood samples over a 6-month
period or one sample greater than 60 ug/dL requires medical removal of
employee from lead exposure without loss of wages, benefits, or seniority
(Occupational Safety and Health Administration (OSHA) Lead Standard) (1).

****During follow-up interview, the affected person indicated that exposure to
lead occurred at work.

*****The survey defined potential exposure as 1) observation of the chemical
in sufficient proximity to an employee such that one or more physical phases
of the substance is likely to enter or contact the body of the worker and 2)
meeting minimum duration of exposure guidelines (3).








































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===============================================================================
Articles
===============================================================================

DELIVERY OF HIGH QUALITY SERVICE TO HOSPITALS
CALLED KEY TO SUCCESS OF ORGAN PROCUREMENT ORGANIZATIONS

Organ Procurement Organizations (OPOs) must deliver high quality service
and encourage hospitals to develop unique and innovative programs if they are
going to persuade the hospital to take ownership of organ and tissue donation,
according to a representative of a hospital recently cited by the American
Hospital Association as having a good program.
Speaking to individuals attending the fifth Annual Meeting of the
Association of Organ Procurement Organizations (AOPO) in Boston, Kim Reed, MD,
outlined elements of the efforts conducted by the Regional Organ Bank of
Illinois (ROBI) in assisting the development of the organ donation program at
LaGrange Hospital.
"The OPO has to have procurement people ready when consent is obtained
and must deliver high quality service or the hospital will become complacent
about the process," said Dr. Reed, medical director and vice president of
medical affairs at LaGrange Hospital.
Dr. Reed cited an intensive training program of hospital staff and
continual communication by ROBI as the keys to the development and ongoing
success of the organ donation program.
LaGrange initially sent 24 people to attend a two day "train the
trainers" program conducted by ROBI. The program consisted of sessions on the
role of the transplant liaison in the hospital; historical perspectives on
transplantation; brain death; donor identification and management; case
studies; who pays; bone, cornea and skin donation; liver disease; and a panel
discusion with a donor family. Attendees then returned to LaGrange and
trained other hospital personnel.
The key to the successful program, however, lies in the "continued
education" conducted by the OPO, Dr. Reed noted. Components include regular
inservice training, being "proactive" in promoting donation and providing
individuals in charge of the hospital program with updated information and on
the outcome of donations, Dr. Reed noted. ROBI personnel visit the hospital
at least every two weeks.
Larry Hopkins, ROBI director of operations, asked to explain how the
relationship with a hospital in their service area is established, explained
the first step must be a thorough fact finding about the hospital. "We look at
what their present policies are; what their attitude about donation is; do
they have a brain death pollicy; are there policies that need to be changed
and what we can do to help," he said. In addition, the "key players" at the
hospital are identified to whom the intital approach should be made.
Hopkins stressed that they do not make the approach by pointing out that
required request is a law, but rather underscore the notion that organ
donation works and that ROBI can play a major role in facilitating and
assiting the development of the policies and procedures and implementation of
the program.
ROBI is presently spreading the word that they would like to be involved
in every organ donation request even when the hospital has trained people on
staff, Hopkins pointed out.
"Two years ago our stress was on getting the hospitals to ask, now we are
reeducating our hospitals and asking them to call us in every case and the
hospitals are welcoming it," Hopkins said. This is particularly true in

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Volume 2, Number 35 September 25, 1989

ROBI's smaller hospitals which may only have six or ten donations a year and
may not be as experienced in making the right approach to the family. "We make
the right approach, we let the family know what the options are and we have
gotten good at it," Hopkins added.



















































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