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HICNet Medical News Digest      Wed, 26 Oct 1994        Volume 07 :
Issue 53

Today's Topics:

  [MMWR 14 Oct 94] Homicides Among 15 to 19 yr olds
  [MMWR] Adolescent Suicides
  [MMWR] Prevalence of Disabilities and Associated Health Conditions
  [MMWR] Outbreak of Salmonella associated with Ice Cream
  [MMWR 21 Oct 94] Tobacco Use and Nicotine Withdrawal in Adolescents
  [MMWR] Lead-Contaminated Drinking Water in Bulk-Water Storage Tanks

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Date: Wed, 26 Oct 94 21:35:09 MST
From: [e-mail] (HICNet Medical News)
To: hicnews
Subject: [MMWR 14 Oct 94] Homicides Among 15 to 19 yr olds
Message-ID: <[e-mail]>

  Homicides Among 15-19-Year-Old Males -- United States, 1963-1991

     In 1991, nearly half (13,122 [49%]) of the 26,513 homicide
victims in the United States were males aged 15-34 years. In
addition, among males in this age group, homicide accounted for 18%
of all deaths and was the second leading cause of death (Table 1).
During 1963-1991, the pattern of homicide rates changed
substantially; the change was greatest for males aged 15-19 years,
for whom rates increased substantially (Figure 1). This report
summarizes these trends and presents strategies for violence
prevention and intervention.
     Mortality data were obtained from CDC's National Center for
Health Statistics; population estimates were projected from census
data. Arrest rates were calculated using data from the U.S.
Department of Justice.
     From 1985 to 1991, the annual crude homicide rate for the
United States increased 25% (from 8.4 to 10.5 per 100,000 persons).
The homicide rate for persons aged 15-34 years increased 50% during
this period (from 13.4 to 20.1 per 100,000), accounting for most of
the overall increase. Rates increased for both sexes and all 5-year
age groups within the 15-34-year age group. For persons in other
age groups, rates were relatively stable from 1985 to 1991: for
persons aged less than or equal to 14 years, 1.9 and 2.4,
respectively; for persons aged 35-64 years, 8.8 and 9.1,
respectively; and for persons aged greater than or equal to 65
years, 4.3 and 4.1, respectively.
     From 1963 through 1985, annual homicide rates for 15-
19-year-old males were one third to one half the rates for the next
three higher 5-year age groups (Figure 1). However, during 1985-
1991, annual rates for males aged 15-19 years increased 154% (from
13.0 to 33.0), surpassing the rates for 25-29- and 30-34-year-old
males, even though those rates increased 32% (from 24.4 to 32.3)
and 16% (from 22.1 to 25.7), respectively. The homicide rate for
20-24-year-old males increased 76% (from 23.4 to 41.2) from 1985
through 1991.
     During 1985-1991, age-specific arrest rates for murder and
nonnegligent manslaughter increased 127% for males aged 15-19
years, 43% for males aged 20-24 years, and declined 1% and 13% for
males aged 25-29 and 30-34 years, respectively (1,2). In 1991, 15-
19-year-old males were more likely to be arrested for murder than
males in any other age group.

Reported by: Div of Violence Prevention, National Center for Injury
Prevention and Control, CDC.

Editorial Note: The increase in the annual homicide rate for 15-
19-year-old males during 1985-1991 was a dramatic change from the
pattern during 1963-1984. Although the immediate and specific
causes of this problem are unclear, the increase in the occurrence
of homicide may be the result of the recruitment of juveniles into
drug markets, the use of guns in these markets, and the consequent
diffusion of guns to other young persons in the community,
resulting, in turn, in more frequent use of the guns for settling
disputes (3). Among 15-19-year-old males, firearm-related homicides
accounted for 88% of all homicides in 1991 and 97% of the increase
in the rate from 1985 through 1991. Factors underlying the
immediate precursors may include poverty, inadequate educational
and economic opportunities, social and family instability, and
frequent personal exposure to violence as an acceptable or
preferred method of resolving disagreements (4,5).
     Although the most effective strategies to prevent youth
violence have not been determined, efforts to prevent this problem
should employ established principles of health promotion and should
emphasize the use of multiple complementary interventions (6,7).
These interventions include

o    Strengthening the science base for prevention efforts.
Strategies and methods to prevent violence in youth should be
rigorously assessed (6).

o    Establishing primary-prevention programs. Primary prevention
aims to prevent the occurrence of violence rather than focusing on
known perpetrators and victims after the occurrence of violence.
This strategy addresses all forms of violence (e.g., spouse abuse,
child abuse, and violence among youth) and could affect both
potential perpetrators and victims.

o    Targeting youths of all ages. Violence-reduction efforts
should address the needs of infants, children, and older youths.
Measures that have been successful in reducing violent behavior and
its precursors in these age groups (8-10) should be considered when
developing new programs.

o    Involving adults (e.g., parents and other role models). They
influence violence-related attitudes and behaviors of youth and
should be provided the appropriate knowledge and skills to function
as role models.

o    Presenting messages in multiple settings. Lessons in one
setting (e.g., a school) should be reinforced in other settings in
which children and youth congregate, including homes, churches,
recreational settings, and clinics.

o    Addressing societal and personal factors. Societal factors
(e.g., poverty, unemployment, undereducation, and social acceptance
of violence [4,5]) should be addressed simultaneously with efforts
to affect personal behavior change through activities such as home
visitation, school-based training, or mentoring.

References
1. Federal Bureau of Investigation. Crime in the U.S., 1985.
Washington, DC: US Department of Justice, Federal Bureau of
Investigation, 1986.
2. Federal Bureau of Investigation. Crime in the U.S., 1991.
Washington, DC: US Department of Justice, Federal Bureau of
Investigation, 1992.
3. Blumstein A. Youth violence, firearms, and illicit drug markets
[Working paper]. Pittsburgh: Carnegie Mellon University, The Heinz
School, June 1994.
4. Reiss AJ Jr, Roth JA, eds. Understanding and preventing
violence. Washington, DC: National Academy Press, 1993.
5. National Committee for Injury Prevention and Control. Injury
prevention: meeting the challenge. Am J Prev Med
1989;5(suppl):1992-2203.
6. Mercy JA, Rosenberg ML, Powell KE, Broome CV, Roper WL. Public
health policy for preventing violence. Health Aff 1993 (Winter):7-
29.
7. Green LW, Kreuter MW. Health promotion planning: an educational
and environmental approach. 2nd ed. Mountain View, California:
Mayfield Publishing Company, 1991.
8. Olds DL, Henderson CR Jr, Chamberlin R, Tatelbaum R. Preventing
child abuse and neglect: a randomized trial of nurse home
visitation. Pediatrics 1986;78:65-78.
9. Zigler E, Taussig C, Black K. Early childhood intervention: a
promising preventative for juvenile delinquency. American
Psychologist 1992;47:997-1006.
10. Hammond RW, Yung BR. Preventing violence in at-risk
African-American youth. J Health Care Poor Underserved 1991;2:359-
73.



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

Date: Wed, 26 Oct 94 21:35:53 MST
From: [e-mail] (HICNet Medical News)
To: hicnews
Subject: [MMWR] Adolescent Suicides
Message-ID: <[e-mail]>

   Adolescent Homicide -- Fulton County, Georgia, 1988-1992

     In Fulton County, Georgia (1990 population: 648,951), during
1988-1992, 12% of homicides occurred among persons aged less than
or equal to 18 years, of whom 75% were adolescents aged 13-18 years
(1). Recognition of homicide as the leading cause of death among
adolescents in Fulton County has prompted planning of local
surveillance, prevention, intervention, advocacy, and mentoring
programs and antiviolence media campaigns. This report summarizes
descriptive information for homicides of adolescents in Fulton
County during 1988-1992 and addresses the use of this information
for local prevention and intervention programs.
     Data were obtained from death investigation records of the
Fulton County Medical Examiner (FCME), death certificates, and
birth certificates (of homicide victims who were born in Fulton
County). FCME data were used to identify decedents to be included
in the study, demographic information about the decedent, and
location of the homicide. Death certificates provided information
about the decedent's place of birth, county of residence, and
occupational status. For decedents who were born in Fulton County,
birth certificates were reviewed for mother's place of birth and
for maternal age and marital status when the decedent was born. A
map was used to divide Fulton County into 1-square-mile sectors,
plot the location of each homicide, and compare the location of the
homicide with the location of the decedent's residence.
     Based on names listed in FCME records, death certificates were
located for 106 of the 107 adolescent homicide victims during 1988-
1992. The number and rates of homicides increased with age (Table
1). Most (89 [84%]) decedents were black males. Almost all (104
[98%]) decedents were classified by family members (usually the
mother) as being of U.S. origin (i.e., an ancestor's foreign
birthplace or nationality group was not specified); 87 (82%) were
born in Georgia, and 76 (72%) were born in Fulton County.
Ninety-six (91%) were born in urban areas (i.e., counties included
in a metropolitan statistical area); 10 were born in rural areas or
place of birth was unknown. At the time of their deaths, 85 (80%)
were Fulton County residents, and 98 (92%) were residents of the
metropolitan Atlanta area; two were residents of other Georgia
counties, and six were residents of other states or residence was
unknown. Of the 106 decedents, 71 (67%) were students; 16 (15%),
employed; and 19 (18%), unemployed or had never worked.
     Birth certificate data were available for all 76 decedents who
were born in Fulton County (Table 2); two decedents killed in
separate incidents had the same mother. The mothers of 46 (61%)
decedents were aged less than or equal to 20 years when the
decedent was born, and 34 (45%) mothers were married at the time of
the decedent's birth. Sixty-nine (91%) of the mothers were born in
Georgia; 49 (64%) were born in Fulton County or the city of
Atlanta.
     Thirty-five (33%) of the 106 victims were killed in an area
located in the same map sector as their place of residence (i.e.,
within 1.4 miles of home), while 59 (56%) were killed within 2.8
miles of home. Of the 106 homicides, 102 occurred in the
incorporated areas of Fulton County (i.e., Atlanta, College Park,
East Point, or Union City). Homicides were clustered in the central
southwest and central northwest portions of the city of Atlanta.

Reported by: R Hanzlick, MD, P Schilke, MD, Dept of Pathology,
Emory Univ School of Medicine; Fulton County Vital Records Office,
Fulton County Health Dept; Fulton County Medical Examiner, Atlanta.
Surveillance and Programs Br, Div of Environmental Hazards and
Health Effects, National Center for Environmental Health, CDC.

Editorial Note: Violence is recognized as a public health emergency
in Fulton County by the county Board of Commissioners (R. Michael
Green, Fulton County Health Department, personal communication,
August 29, 1994). The findings in this report will be used to
assist in planning, implementing, and monitoring targeted
prevention and intervention programs in Fulton County. Because
these and previous findings in Fulton County indicate that most
decedents and perpetrators of adolescent homicide were black males
(1), prevention and intervention programs should be available for
young black males. The high proportion of decedents who were
students suggests that such programs might be school-based or
associated with school activities. In addition, the substantial
portion of young, single mothers suggests that programs could be
integrated with other services for single parents and their
children, including role-model mentoring programs.
     The data also provide a basis for geographic location of
neighborhood and other local community programs in selected areas
of the county, particularly in the incorporated and inner-city
areas of Atlanta. For example, detailed maps of locations where
homicides occurred can assist law enforcement agencies, other local
agencies, foundations, and prevention-oriented organizations in
targeting precincts or zones for special efforts. The finding that
a high portion of the decedents (and their mothers) were long-term
residents in the community provides a basis for incorporating
prevention programs into civic, social, and cultural activities and
locally available services.
     Interpretation of the findings in this study are subject to at
least two limitations. First, the study was not designed to assess
risk factors for homicide; as a consequence, for example, the high
proportion of decedents who were students or born to young mothers
cannot be interpreted to indicate that such persons are at higher
risk for homicide than nonstudents or those born to older mothers.
Second, the geographic clustering of deaths may reflect higher
population densities in some areas or other factors and may not
indicate increased risk for fatal or nonfatal violence.
     Although death certificate data have been used previously to
determine the geographic distribution of homicides in Fulton County
(1), these findings refine understanding of this problem by
providing additional information about the decedents, residences of
the decedents and their mothers, and the location of the homicide.
Poverty, lack of jobs, and other socioeconomic variables that
underlie the elevated risk for young black males in Fulton County
have not been evaluated in this study; however, other research
indicates that these factors must be considered when addressing
this public health problem. Other recent findings also support the
strategies of integrating drug-abuse and homicide-prevention
programs; developing programs that might influence the social
interactions of adolescents away from home between 6 p.m. and
midnight (1); and implementing measures to reduce fatalities
involving firearms (1). Additional efforts to assist in the
development of prevention and intervention programs include the
need to evaluate victim characteristics, perpetrators' access to
firearms (e.g., who owned the gun and where and when the
perpetrator obtained it), and demographic and psychosocial
characteristics of perpetrators, and the effectiveness of
intervention programs.

Reference
1. CDC. Homicides of persons aged less than or equal to 18 years--
Fulton County, Georgia, 1988-1992. MMWR 1994;43:254-5,261.



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

Date: Wed, 26 Oct 94 21:36:57 MST
From: [e-mail] (HICNet Medical News)
To: hicnews
Subject: [MMWR] Prevalence of Disabilities and Associated Health
Conditions
Message-ID: <[e-mail]>

Prevalence of Disabilities and Associated Health Conditions --
               United States, 1991-1992

     An estimated 35-49 million persons in the United States have
a disability (1); estimated direct and indirect annual costs
related to disability (including medical expenses and lost
workdays) total $170 billion (2). Because definitions of disability
used in previous analyses generally contained limited measures of
disability, the prevalence of disability in the United States may
have been underestimated. The Survey of Income and Program
Participation (SIPP), a subsample of the 1990 U.S. census,
collected comprehensive data about disability using several
measures. The U.S. Bureau of the Census and CDC analyzed data from
SIPP to provide more precise prevalence estimates of disability and
health conditions associated with disability in the United States
during 1991-1992. This report summarizes the findings from that
analysis.
     From October 1991 through January 1992, SIPP collected
information about disability during personal household interviews
of a representative sample (n=97,133 persons in 34,100 households)
of the U.S. civilian, noninstitutionalized population. Only data
for persons aged greater than or equal to 15 years are presented in

·
(continued next message)


 @FROM   :[e-mail]
· (Continued from last message)
this analysis. The measures of disability used in SIPP were derived
from D- and I-codes in the International Classification of
Impairments, Disabilities, and Handicaps (ICIDH) (1). Disability
was assessed using five measures: 1) ability to perform functional
activities* (ICIDH D-codes 21, 23, 26, 40-45, and 48), 2)
activities of daily living (ADLs)** (ICIDH D-codes 30, 33, 35, 36,
37-39, and 46), or 3) instrumental activities of daily living
(IADLs)*** (ICIDH D-codes 50, 51, 60, and 61), 4) presence of
selected impairments**** (ICIDH D-codes 15 and 16 and I-codes 14-
18), and 5) use of assistive aids (e.g., wheelchair or cane).
Participants were asked whether they had "difficulty" performing
functional activities, ADLs, and IADLs; whether they had selected
impairments; and whether they used assistive aids for 6 months or
longer. In addition, participants who had difficulty with
activities other than seeing, hearing, and having their speech
understood by others were asked to select up to three conditions
(from a list of 30) that they believed caused limitation or
difficulty with a functional activity, ADL, or IADL. Data were
weighted to calculate national estimates.
     Based on SIPP, during 1991-1992, of the 195.7 million persons
in the United States aged greater than or equal to 15 years, 34.2
million (17.5%) had difficulty performing one or more functional
activities (Table 1, page 737); most persons had difficulty
climbing one flight of stairs (17.5 million [8.9%]) or walking one
quarter mile (17.3 million [8.9%] persons). A total of 7.9 million
(4.0%) persons had difficulty performing one or more ADLs, and 11.7
million (6.0%) persons had difficulty performing one or more IADLs.
Use of a wheelchair for 6 months or longer was reported by 1.5
million ( less than 1%) persons. Of the persons who did not use a
wheelchair, 4.0 million (2.0%) persons had used a cane, crutches,
or a walker for 6 months or longer.
     For all five measures of disability, the age-specific
prevalence of disability was higher for persons aged greater than
or equal to 65 years than persons aged less than 65 years (Table 1,
page 737). The prevalence of disability among men and women was
18.7% and 20.2%, respectively.
     Overall, 42.0 million (21%) persons reported one or more
conditions they believed to be associated with their disability
(Table 2, page 738). The most commonly reported condition was
arthritis or rheumatism (7.2 million [17.1%]), followed by back or
spine problems (5.7 million [13.5%]), and heart trouble (including
coronary heart disease and arteriosclerosis) (4.6 million [11.1%]).

Reported by: JM McNeil, Bur of the Census, Economics and Statistics
Administration, US Dept of Commerce. Statistics and Epidemiology
Br, Div of Surveillance and Epidemiology, Epidemiology Program
Office; Disabilities Prevention Program, Office of the Director,
National Center for Environmental Health, CDC.

Editorial Note: The prevalence estimates of disability in this
report indicate that nearly one fifth (19.4%) of the U.S.
population aged greater than or equal to 15 years has a disability.
Prevalence estimates of disability derived from SIPP are based on
broader measures of disability than previously used for estimates
derived from the 1992 Current Population Survey (3), the 1990
census (4), and the National Health Interview Surveys (5,6). This
broader definition--which included an assessment of limitations in
functional activities, ADLs, IADLs, and selected impairments--
provided a more comprehensive assessment of the scope, extent, and
epidemiology of disability in the United States.
     Definitions used for surveillance and assessment of disability
are more clearly understood by linking them to a conceptual
framework of consequences of disease and injury, such as the ICIDH
(7). In the ICIDH, three concepts define the consequences of
disease and injury: 1) impairment (i.e., the loss of psychological,
physiological, or anatomical structure or function), 2) disability
(i.e., the limitation in functional performance resulting from an
impairment), and 3) handicap (i.e., the disadvantage experienced by
a person as a result of impairments and/or disabilities, which
limits interaction of the person with the physical and social
environment).
     Despite the usefulness of the estimates based on SIPP, the
findings in this report are subject to limitations that may
underestimate the public health impact of disability in the United
States. For example, SIPP failed to collect data about the effects
of physical and social barriers (e.g., within the home, community,
school, or workplace) and ex-periences with discrimination. Recent
efforts underscore the importance of clarifying the role of
environment in determining the consequences of an impairment or
disability (8). Therefore, efforts to provide more precise national
estimates of disability should include development of measures that
address environmental factors (i.e., physical and social barriers)
and the effects of discrimination. Revision of the ICIDH is under
way and should improve collection of valid and reliable survey
information about physical and social barriers (8,9).

References
1. McNeil JM. Americans with disabilities, 1991-1992. Washington,
DC: US Department of Commerce, Bureau of the Census, 1993. (Current
population reports; series P70, no. 33).
2. Chirikos TN. Aggregate economic losses from disability in the
United States: a preliminary assay. Milbank Q 1989;67(suppl 2):59-
91.
3. CDC. Prevalence of work disability--United States, 1990. MMWR
1993;42:757-9.
4. CDC. Prevalence of mobility and self-care disability--United
States, 1990. MMWR 1993;42: 760-1,767-8.
5. LaPlante MP. Data on disability from the National Health
Interview Survey, 1983-1985. Washington, DC: Department of
Education, National Institute on Disability and Rehabilitation
Research, 1988.
6. LaPlante MP, Hendershot GE, Moss AJ. Assistive technology
devices and home accessibility features: prevalence, payment, need,
and trends. Hyattsville, Maryland: US Department of Health and
Human Services, Public Health Service, CDC, NCHS, 1992. (Advance
data no. 217).
7. World Health Organization. International classification of
impairments, disabilities, and handicaps. Geneva: World Health
Organization, 1993.
8. Badley EM. An introduction to the concepts and classifications
of the International Classification of Impairments, Disabilities,
and Handicaps. Disabil Rehabil 1993;15:161-78.
9. Fougeyrollas P. Documenting environmental factors as determining
variables in the performance of day-to-day activities and the
fulfillment of social roles by persons with impairments and
functional limitations. ICIDH International Network 1993;5:8-13.

*Functional activities: ability to 1) "see words and letters in
ordinary newspaper print," 2) "hear normal conversations," 3) "have
speech understood by others," 4) "lift and carry up to 10 pounds
(e.g., a full bag of groceries)," 5) "climb a flight of stairs
without resting," and 6) "walk one quarter mile."
**ADLs: ability to 1) "get around inside the home"; 2) "get in and
out of bed or a chair"; and 3) take a bath or shower, dress, and
eat; and 4) get to and use the toilet.
***IADLs: ability to 1) "get around outside the home," 2) "keep
track of money and bills," 3) "prepare meals," 4) "do light
housework," and 5) "use the telephone."
****Learning disabilities; mental retardation; other developmental
disabilities; and Alzheimer disease, senility, dementia, and other
mental or emotional conditions.

Prevalence of Disabilities and Associated Health Conditions --
               United States, 1991-1992

     An estimated 35-49 million persons in the United States have
a disability (1); estimated direct and indirect annual costs
related to disability (including medical expenses and lost
workdays) total $170 billion (2). Because definitions of disability
used in previous analyses generally contained limited measures of
disability, the prevalence of disability in the United States may
have been underestimated. The Survey of Income and Program
Participation (SIPP), a subsample of the 1990 U.S. census,
collected comprehensive data about disability using several
measures. The U.S. Bureau of the Census and CDC analyzed data from
SIPP to provide more precise prevalence estimates of disability and
health conditions associated with disability in the United States
during 1991-1992. This report summarizes the findings from that
analysis.
     From October 1991 through January 1992, SIPP collected
information about disability during personal household interviews
of a representative sample (n=97,133 persons in 34,100 households)
of the U.S. civilian, noninstitutionalized population. Only data
for persons aged greater than or equal to 15 years are presented in
this analysis. The measures of disability used in SIPP were derived
from D- and I-codes in the International Classification of
Impairments, Disabilities, and Handicaps (ICIDH) (1). Disability
was assessed using five measures: 1) ability to perform functional
activities* (ICIDH D-codes 21, 23, 26, 40-45, and 48), 2)
activities of daily living (ADLs)** (ICIDH D-codes 30, 33, 35, 36,
37-39, and 46), or 3) instrumental activities of daily living
(IADLs)*** (ICIDH D-codes 50, 51, 60, and 61), 4) presence of
selected impairments**** (ICIDH D-codes 15 and 16 and I-codes 14-
18), and 5) use of assistive aids (e.g., wheelchair or cane).
Participants were asked whether they had "difficulty" performing
functional activities, ADLs, and IADLs; whether they had selected
impairments; and whether they used assistive aids for 6 months or
longer. In addition, participants who had difficulty with
activities other than seeing, hearing, and having their speech
understood by others were asked to select up to three conditions
(from a list of 30) that they believed caused limitation or
difficulty with a functional activity, ADL, or IADL. Data were
weighted to calculate national estimates.
     Based on SIPP, during 1991-1992, of the 195.7 million persons
in the United States aged greater than or equal to 15 years, 34.2
million (17.5%) had difficulty performing one or more functional
activities (Table 1, page 737); most persons had difficulty
climbing one flight of stairs (17.5 million [8.9%]) or walking one
quarter mile (17.3 million [8.9%] persons). A total of 7.9 million
(4.0%) persons had difficulty performing one or more ADLs, and 11.7
million (6.0%) persons had difficulty performing one or more IADLs.
Use of a wheelchair for 6 months or longer was reported by 1.5
million ( less than 1%) persons. Of the persons who did not use a
wheelchair, 4.0 million (2.0%) persons had used a cane, crutches,
or a walker for 6 months or longer.
     For all five measures of disability, the age-specific
prevalence of disability was higher for persons aged greater than
or equal to 65 years than persons aged less than 65 years (Table 1,
page 737). The prevalence of disability among men and women was
18.7% and 20.2%, respectively.
     Overall, 42.0 million (21%) persons reported one or more
conditions they believed to be associated with their disability
(Table 2, page 738). The most commonly reported condition was
arthritis or rheumatism (7.2 million [17.1%]), followed by back or
spine problems (5.7 million [13.5%]), and heart trouble (including
coronary heart disease and arteriosclerosis) (4.6 million [11.1%]).

Reported by: JM McNeil, Bur of the Census, Economics and Statistics
Administration, US Dept of Commerce. Statistics and Epidemiology
Br, Div of Surveillance and Epidemiology, Epidemiology Program
Office; Disabilities Prevention Program, Office of the Director,
National Center for Environmental Health, CDC.

Editorial Note: The prevalence estimates of disability in this
report indicate that nearly one fifth (19.4%) of the U.S.
population aged greater than or equal to 15 years has a disability.
Prevalence estimates of disability derived from SIPP are based on
broader measures of disability than previously used for estimates
derived from the 1992 Current Population Survey (3), the 1990
census (4), and the National Health Interview Surveys (5,6). This
broader definition--which included an assessment of limitations in
functional activities, ADLs, IADLs, and selected impairments--
provided a more comprehensive assessment of the scope, extent, and
epidemiology of disability in the United States.
     Definitions used for surveillance and assessment of disability
are more clearly understood by linking them to a conceptual
framework of consequences of disease and injury, such as the ICIDH
(7). In the ICIDH, three concepts define the consequences of
disease and injury: 1) impairment (i.e., the loss of psychological,
physiological, or anatomical structure or function), 2) disability
(i.e., the limitation in functional performance resulting from an
impairment), and 3) handicap (i.e., the disadvantage experienced by
a person as a result of impairments and/or disabilities, which
limits interaction of the person with the physical and social
environment).
     Despite the usefulness of the estimates based on SIPP, the
findings in this report are subject to limitations that may
underestimate the public health impact of disability in the United
States. For example, SIPP failed to collect data about the effects
of physical and social barriers (e.g., within the home, community,
school, or workplace) and ex-periences with discrimination. Recent
efforts underscore the importance of clarifying the role of
environment in determining the consequences of an impairment or
disability (8). Therefore, efforts to provide more precise national
estimates of disability should include development of measures that
address environmental factors (i.e., physical and social barriers)
and the effects of discrimination. Revision of the ICIDH is under
way and should improve collection of valid and reliable survey
information about physical and social barriers (8,9).

References
1. McNeil JM. Americans with disabilities, 1991-1992. Washington,
DC: US Department of Commerce, Bureau of the Census, 1993. (Current
population reports; series P70, no. 33).
2. Chirikos TN. Aggregate economic losses from disability in the
United States: a preliminary assay. Milbank Q 1989;67(suppl 2):59-
91.
3. CDC. Prevalence of work disability--United States, 1990. MMWR
1993;42:757-9.
4. CDC. Prevalence of mobility and self-care disability--United
States, 1990. MMWR 1993;42: 760-1,767-8.
5. LaPlante MP. Data on disability from the National Health
Interview Survey, 1983-1985. Washington, DC: Department of
Education, National Institute on Disability and Rehabilitation
Research, 1988.
6. LaPlante MP, Hendershot GE, Moss AJ. Assistive technology
devices and home accessibility features: prevalence, payment, need,
and trends. Hyattsville, Maryland: US Department of Health and
Human Services, Public Health Service, CDC, NCHS, 1992. (Advance
data no. 217).
7. World Health Organization. International classification of
impairments, disabilities, and handicaps. Geneva: World Health
Organization, 1993.
8. Badley EM. An introduction to the concepts and classifications
of the International Classification of Impairments, Disabilities,
and Handicaps. Disabil Rehabil 1993;15:161-78.
9. Fougeyrollas P. Documenting environmental factors as determining
variables in the performance of day-to-day activities and the
fulfillment of social roles by persons with impairments and
functional limitations. ICIDH International Network 1993;5:8-13.

*Functional activities: ability to 1) "see words and letters in
ordinary newspaper print," 2) "hear normal conversations," 3) "have
speech understood by others," 4) "lift and carry up to 10 pounds
(e.g., a full bag of groceries)," 5) "climb a flight of stairs
without resting," and 6) "walk one quarter mile."
**ADLs: ability to 1) "get around inside the home"; 2) "get in and
out of bed or a chair"; and 3) take a bath or shower, dress, and
eat; and 4) get to and use the toilet.
***IADLs: ability to 1) "get around outside the home," 2) "keep
track of money and bills," 3) "prepare meals," 4) "do light
housework," and 5) "use the telephone."
****Learning disabilities; mental retardation; other developmental
disabilities; and Alzheimer disease, senility, dementia, and other
mental or emotional conditions.



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

Date: Wed, 26 Oct 94 21:38:50 MST
From: [e-mail] (HICNet Medical News)
To: hicnews
Subject: [MMWR] Outbreak of Salmonella associated with Ice Cream
Message-ID: <[e-mail]>

             Outbreak of Salmonella enteritidis Associated
          with Nationally Distributed Ice Cream Products --
            Minnesota, South Dakota, and Wisconsin, 1994

     From September 19 through October 10, 1994, a total of 80
confirmed cases of Salmonella enteritidis (SE) infection were
reported to the Minnesota Department of Health (MDH); in
comparison, 96 cases were reported statewide during all of 1993.
Cases were characterized by diarrhea, abdominal cramps, and fever.
Recent increases in SE cases also were reported from South Dakota
(14 cases during September 6-October 7, compared with 20 cases
during all of 1993) and Wisconsin (48 cases during September 6-
October 7, compared with 187 during all of 1993). This report
summarizes preliminary findings from the outbreak investigation.
     On October 5 and 6, to assess potential risk factors for
infection, the MDH conducted a case-control study of 15 cases and
15 age- and neighborhood-matched controls. A case was defined as
culture-confirmed SE in a person with onset of illness during
September. Eleven case-patients (73%) and two controls (13%)
reported consumption of Schwan's ice cream within 5 days of illness
onset for case-patients and a similar period for controls (odds
ratio=10.0; 95% confidence interval=1.4-434.0).
     On October 7 and 9, the MDH issued press releases informing
the public of this problem and advising persons who had been ill
since September 1 and who had consumed Schwan's ice cream to
contact the health department. During October 8-11, a total of 2014
persons who had consumed suspected products and had been ill with
diarrhea contacted the MDH by telephone. Samples of ice cream from
households of ill persons grew SE.
     Ill persons reported eating all types and flavors of ice cream
products produced at the Schwan's plant in Marshall, Minnesota,
including ice cream, sherbet, frozen yogurt, and ice cream
sandwiches and cones; these products had production dates in August
and September. The implicated products are distributed nationwide,
primarily by direct delivery to homes, and are sold only under the
Schwan's label. Investigations to examine the extent and causes of
the outbreak are under way.
     On October 7, the company voluntarily stopped distribution and
production at the Marshall plant pending further findings from
these investigations.

Reported by: Acute Disease Epidemiology Section, Minnesota Dept of
Health. South Dakota Dept of Health. Wisconsin Dept of Health and
Social Svcs. Center for Food Safety and Applied Nutrition, Food and
Drug Administration. Foodborne and Diarrheal Diseases Br, Div of
Bacterial and Mycotic Diseases, National Center for Infectious
Diseases, CDC.

Editorial Note: Gastroenteritis caused by Salmonella is
characterized by abdominal cramps and diarrhea, vomiting, fever,
and headache. Antimicrobial therapy is not indicated in
uncomplicated gastroenteritis, which typically resolves within 1
week. Persons at increased risk for infection or more severe
disease include infants; the elderly; persons with achlorhydria;
those receiving immunosuppressive therapy; persons who may have
received antimicrobials for another illness; and those persons with
sickle-cell anemia, cancer, or acquired immunodeficiency syndrome
(1). Complications include meningitis, septicemia, Reiter syndrome,
and death (1).
     Salmonella sp. are second only to Campylobacter as a cause of

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 @FROM   :[e-mail]
· (Continued from last message)
bacterial diarrheal illness in the United States, causing an
estimated 2 million illnesses annually (2). Among the more than
2000 Salmonella serotypes, SE has ranked first or second in
frequency of isolation from humans since 1988 and accounted for 21%
of reported isolates in 1993. Each year, an average of 55 outbreaks
of SE infections are reported to CDC; approximately 11% of patients
are hospitalized, and 0.3% die (3).
     Preliminary findings from this outbreak indicate that the
number of persons exposed to contaminated products may be
substantial. Approximately 400,000 gallons of the implicated
products are produced weekly and are distributed throughout the
contiguous United States. Previous investigations have established
the potential for large-scale outbreaks of foodborne salmonellosis;
for example, in 1985, pasteurized milk produced at one dairy plant
caused up to 197,000 Salmonella infections (4).
     Consumers should discard or return any Schwan's ice cream
products. Persons who have become ill since September 1 with
diarrhea and who have consumed Schwan's ice cream products are
urged to contact their state health departments.

References
1. Pavia AT, Tauxe RV. Salmonellosis: nontyphoidal. In: Evans AS,
Brachman PS, eds. Bacterial infections in humans: epidemiology and
control. 2nd ed. New York: Plenum Medical Book Company, 1991:573-
91.
2. Helmick CG, Griffin PM, Addiss DG, Tauxe RV, Juranek DD.
Infectious diarrheas. In: Everheart JE, ed. Digestive diseases in
the United States: epidemiology and impact. Washington, DC: US
Department of Health and Human Services, Public Health Service,
National Institutes of Health, National Institute of Diabetes and
Digestive and Kidney Diseases, 1994:85-123; DHHS publication no.
(NIH)94-1447.
3. CDC. Outbreaks of Salmonella enteritidis gastroenteritis--
California, 1993. MMWR 1993; 42:793-7.
4. Ryan CA, Nickels MK, Hargrett-Bean NT, et al. Massive outbreak
of antimicrobial-resistant salmonellosis traced to pasteurized
milk. JAMA 1987;258:3269-74.



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

Date: Wed, 26 Oct 94 21:51:58 MST
From: [e-mail] (HICNet Medical News)
To: hicnews
Subject: [MMWR 21 Oct 94] Tobacco Use and Nicotine Withdrawal in
Adolescents
Message-ID: <[e-mail]>

                  Reasons for Tobacco Use and Symptoms
                 of Nicotine Withdrawal Among Adolescent
            and Young Adult Tobacco Users -- United States, 1993

     Cigarettes and other forms of tobacco are addictive because of
the presence of nicotine (1). Among adults in the United States who
have ever smoked daily, 91.3% tried their first cigarette and 77.0%
became daily smokers before age 20 years (2). Among high school
seniors who had ever tried smokeless tobacco (SLT), 73% did so by
the ninth grade (2). To further characterize the development of
nicotine addiction among persons aged 10-22 years, CDC analyzed
data from the 1993 Teenage Attitudes and Practices Survey
(TAPS-II). This report summarizes the results of that analysis and
focuses on assessments of reasons for using tobacco and symptoms of
nicotine withdrawal.
     For TAPS-II, data about knowledge, attitudes, and practices of
tobacco use were collected by telephone interviews; persons who
could not be contacted by telephone were contacted in person. The
TAPS-II sample for this analysis had two components: 1) of the 9135
respondents (aged 12-18 years) to the 1989 TAPS telephone
interview*, 7960 (87.1%) participated in TAPS-II (these respondents
were aged 15-22 years); and 2) an additional 4992 persons from a
new probability sample of 5590 persons aged 10-15 years (89.3%
response rate) participated in TAPS-II. Data were weighted to
provide national estimates, and 95% confidence intervals (CIs) were
calculated using SUDAAN (3).
     Persons who had smoked cigarettes (n=2121) or who had used SLT
(n=470) during the 30 days preceding the survey were asked if they
used tobacco because "it relaxes or calms me" and if they used it
because "it's really hard to quit" (either answer indicates an
influence of the psychopharmacologic properties of nicotine [1]).
Smokers who had tried to quit and persons who had quit smoking
(n=1925)** were asked, "When you quit/tried to quit did you feel a
strong need or urge to have a cigarette; feel more irritable; find
it hard to concentrate; feel restless; feel hungry more often; feel
sad, blue, or depressed?" SLT users who had tried to quit and
persons who had discontinued use (n=1216) were asked similar
questions adapted to SLT use.
     Lifetime history of tobacco use was assessed through three
categories for cigarette smoking (20 or fewer cigarettes smoked
during lifetime, 21-98 cigarettes smoked, and 100 or more
cigarettes smoked) and with two categories for SLT use (never used
regularly versus ever used regularly). Frequency of use was
measured by the number of days on which cigarettes were smoked or
SLT was used during the preceding month (0, 1-14, 15-29, or 30
days). Intensity of use was measured by the average number of
cigarettes smoked per day during the preceding 7 days (five or
fewer, 6-15, or 16 or more) and by the number of times SLT was used
on the days it was used (1-2, or three or more).
     For persons who had smoked during the preceding 30 days and
for those who had used SLT during the preceding 30 days, the
frequency of reporting that tobacco was used because it is relaxing
or because it is hard to quit increased in relation to increasing
lifetime use, frequency of use, and intensity of use (Table 1);
this pattern characterized the overall sample and persons in both
age categories (10-18 years and 19-22 years). The percentages of
persons who reported smoking cigarettes or using SLT for these two
reasons also were similar across age groups. Among smokers and SLT
users with the greatest lifetime use or intensity of use, the
proportions who reported using tobacco to relax were similar to
those who reported using it because it was hard to quit. Among
those with the lowest lifetime use or frequency or intensity of
use, relaxation was more commonly cited as a reason for use than
was difficulty quitting. For every category of usage frequency,
cigarette smokers were more likely to report use for relaxation
than were SLT users. Regardless of age, approximately three fourths
of daily cigarette smokers (73.8%) and daily SLT users (74.2%)
reported that one of the reasons they used tobacco was because it
was hard to quit.
     The likelihood of reporting symptoms of nicotine withdrawal
increased in relation to frequency (Table 2) and intensity (Figure
1) of use. Younger and older smokers were equally likely to report
increasing nicotine withdrawal symptoms as exposure to nicotine
increased (Table 2). The same pattern characterized SLT users among
both age groups combined (group-specific analyses are not presented
because of limitations in sample sizes of persons who used SLT
during the preceding 30 days). Among persons aged 10-22 years,
those who smoked cigarettes and those who used SLT on a daily basis
were equally likely to report symptoms of nicotine withdrawal (with
the exception of depression, which was less prevalent among SLT
users). Among persons who reported using tobacco on 1-14 days
during the preceding 30 days, those who smoked cigarettes were
generally more likely to report symptoms of nicotine withdrawal
than were persons who used SLT. At least one symptom of nicotine
withdrawal was reported by 92.4% of daily cigarette smokers and
93.3% of daily SLT users who had previously tried to quit. Persons
who smoked six or more cigarettes per day were more likely than
those who smoked five or fewer cigarettes per day to report
difficulty concentrating, feeling more irritable, and craving
cigarettes during a previous quit attempt; however, among persons
who smoked five or fewer cigarettes per day, 28.7% reported
difficulty concentrating; 47.5%, feeling more irritable; and 56.9%,
craving cigarettes during a previous quit attempt (Figure 1).

Reported by: D Barker, MHS, Robert Wood Johnson Foundation,
Princeton, New Jersey. Office on Smoking and Health, National
Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note: This analysis of TAPS-II underscores the relation
between use of tobacco and reasons for using tobacco--a relation
that reflects the psycho- pharmocologic properties of nicotine. In
addition, the frequency of smoking and of using SLT strongly
correlated with self-reported symptoms of nicotine withdrawal.
These findings are consistent with previous studies that indicated
high prevalences of symptoms of nicotine addiction among adolescent
and adult smokers (2,4,5).
     Previous reports indicate that adolescents initially tried
cigarettes for reasons related to social norms, advertising, social
pressure, and curiosity (2,6). However, once the behavior becomes
established, regular smokers are more likely than beginning smokers
to report that they smoke for pleasure and because they are
addicted (2,6). Among students who were high school seniors during
1976-1986, a total of 44% of daily smokers believed that in 5 years
they would not be smoking; however, follow-up indicated that 5-6
years later, 73% of these persons remained daily smokers (2). This
finding suggests that many of these persons could not overcome the
social, psychological, and chemical influences that maintain or
advance the smoking behavior once it is established (2) and
indicates that many adolescents do not understand the personal
risks of smoking, including nicotine addiction (7).
     The findings in this report are subject to at least two
limitations. First, because of small sample sizes, the prevalence
of SLT withdrawal symptoms could not be analyzed in relation to
lifetime history of cigarette smoking; however, SLT users who tried
to quit were probably less likely to experience symptoms of
nicotine withdrawal if they concurrently smoked cigarettes (1).
Second, the relation of nonpharmacologic (e.g., social and
psychological) influences on tobacco use were not quantified;
however, the findings are consistent with previous reports
documenting the psychopharmacologic effects of nicotine on tobacco
use and tobacco withdrawal (1,2,4).
     In 1992, approximately two thirds of adolescent smokers
reported that they wanted to quit smoking, and 70% indicated that
they would not have started smoking if they could choose again (8).
Most adults probably could be prevented from becoming tobacco users
if they could be kept tobacco-free during adolescence (2). Four
strategies that may assist in supporting tobacco-free adolescence
include 1) strict enforcement of the prohibition of sales to minors
(sales to persons aged less than 18 years are illegal in all 50
states), 2) reduction of advertising and promotion practices that
stimulate demand, 3) increases in the real (i.e.,
inflation-adjusted) prices of tobacco products, and 4) school
health education programs that are reinforced by media-based and
other community programs (2).
     The Institute of Medicine recently published recommendations
for a comprehensive national strategy to prevent nicotine addiction
among youth (9). These recommendations especially address
tobacco-free policies; restrictions on tobacco advertising and
promotion; tobacco taxation; enforcement of youth access laws;
regulation of the labeling, packaging, and contents of tobacco
products; further research on nicotine addiction and on prevention
and cessation programs; and the coordination of policies and
research. Copies of this report can be purchased from National
Academy Press, telephone [phone] or [phone].

References
1. CDC. The health consequences of smoking: nicotine addiction--a
report of the Surgeon General. Rockville, Maryland: US Department
of Health and Human Services, Public Health Service, CDC, 1988;
DHHS publication no. (CDC)88-8406.
2. US Department of Health and Human Services. Preventing tobacco
use among young people: a report of the Surgeon General. Atlanta:
US Department of Health and Human Services, Public Health Service,
CDC, National Center for Chronic Disease Prevention and Health
Promotion, Office on Smoking and Health, 1994.
3. Shah BV, Barnwell BG, Hunt PN, LaVange LM. Software for Survey
Data Analysis (SUDAAN) version 5.5 [Software documentation].
Research Triangle Park, North Carolina: Research Triangle
Institute, 1991.
4. McNeill AD, West RJ, Jarvis M, Jackson P, Bryant A. Cigarette
withdrawal symptoms in adolescent smokers. Psychopharmocology
1986;90:533-6.
5. Giovino GA, Shelton DM, Schooley MW. Trends in cigarette smoking
cessation in the United States. Tobacco Control 1993;2(suppl):S3-
S10.
6. Sarason IG, Mankowski ES, Peterson AV, Dinh KT. Adolescents'
reasons for smoking. J School Health 1992;62:185-90.
7. Leventhal H, Glynn K, Fleming R. Is the smoking decision an
"informed choice"?: effect of smoking risk factors on smoking
beliefs. JAMA 1987;257:3373-6.
8. George H. Gallup International Institute. Teen-age attitudes and
behavior concerning tobacco: report of the findings. Princeton, New
Jersey: George H. Gallup International Institute, 1992.
9. Institute of Medicine. Growing up tobacco free: preventing
nicotine addiction in children and youths. Washington, DC: National
Academy Press, 1994.

 *TAPS respondents who completed the survey by mail questionnaire
were not eligible for TAPS-II. TAPS-II included household
interviews of persons who did not respond by telephone.
**Persons who reported that they had never smoked regularly were
excluded from these analyses.



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

Date: Wed, 26 Oct 94 21:52:51 MST
From: [e-mail] (HICNet Medical News)
To: hicnews
Subject: [MMWR] Lead-Contaminated Drinking Water in Bulk-Water Storage
Tanks
Message-ID: <[e-mail]>

             Lead-Contaminated Drinking Water in Bulk-Water
             Storage Tanks -- Arizona and California, 1993

     Lead poisoning is a major environmental health problem for
children in the United States (1,2): during 1988-1991,
approximately 1.7 million U.S. children aged 1-5 years had elevated
blood lead levels (BLLs) (greater than or equal to 10 ug/dL) (3).
To determine the source of lead exposure for children with BLLs
greater than or equal to 20 ug/dL, the Arizona Department of Health
Services (ADHS) conducts environmental investigations. In 1993, as
a result of investigations of increased BLLs in two children in
southwestern Arizona, ADHS detected lead levels approximately 30
times the Environmental Protection Agency (EPA) action level of 15
parts per billion (ppb) in bulk-delivered drinking water in the
homes of these children. Because two of the three companies that
supplied bulk water to southwestern Arizona were based in
California, ADHS notified the California State Department of Health
Services (CSDHS) about the problem. As a result, CSDHS conducted a
separate investigation and identified one child with an elevated
BLL whose drinking water sources included bulk-delivered water with
lead levels exceeding EPA standards. This report summarizes the
investigations of elevated BLLs in these three children and high
lead levels in bulk-delivered drinking water in Arizona and
California.

Arizona
     In July 1993, routine screening by ADHS for lead poisoning
detected a BLL of 42 ug/dL (CDC BLL of concern=10 ug/dL) in a
6-month-old infant in Yuma County, Arizona. To determine the source
of lead exposure, ADHS initiated an environmental investigation.
Lead was not detected in a first-draw water sample from the kitchen
faucet, which was connected to a private well. However, the parents
reported that the child's formula was prepared using bulk-stored
water, and a first-draw water sample taken through the brass
fitting of a bulk-water storage tank contained 495 ppb lead. Other
potential environmental sources of lead included peeling lead paint
on the outside of the house and on one kitchen wall covered with
wallpaper. ADHS advised the parents to stop drinking bulk-stored
water, informed them about professional paint removal and
encapsulation, recommended measures to prevent lead exposure, and
notified the water-delivery company about the high lead level in
the bulk-stored water.
     In August 1993, a BLL of 37 ug/dL was detected in a
12-month-old child in Yuma County who was tested by ADHS for lead
poisoning following a complaint of abdominal pain. Lead was not
detected in a first-draw water sample from the kitchen faucet,
which was connected to the municipal water supply. However, the
parents reported that the child's source of drinking water was
bulk-delivered water, and a first-draw water sample obtained from
a kitchen faucet supplied by a bulk-water storage tank contained
450 ppb lead. The investigation also identified lead-contaminated
soil (68 ppm) at a relative's home where the child routinely stayed
during the day. ADHS advised the parents to stop drinking
bulk-stored water, recommended measures to prevent lead exposure,
and notified the water-delivery company about the high lead levels
in the bulk-delivered water. Two weeks after the first-draw sample
was obtained, lead levels in water taken through the brass fitting
on the tank and directly from the tank were 1050 ppb and 602 ppb,
respectively.
     Because the source of bulk-delivered water for both cases was
a California-based water-delivery company, ADHS notified CSDHS
about the potential problem of lead-contaminated bulk-delivered
water.

California
     In November 1993, a newspaper report about lead-contaminated
bulk-delivered water prompted parents in Imperial County,
California, to have their 14-month-old child screened for lead
poisoning by the county health department. A BLL of 15 ug/dL was
detected in the child. The parents reported that the child's
drinking water sources were bulk-delivered water and surface water.
A first-draw water sample from the kitchen faucet, which was
connected to a bulk-water tank supply, contained 66 ppb lead. After
running the water for 3 minutes, a second-draw water sample from
the same faucet contained 9 ppb lead. A first-draw water sample
from the refrigerator faucet, also connected to the bulk storage
tank, contained 50 ppb lead. First-draw water samples obtained from
two other faucets in the house, which were connected to a surface
water supply, had lead levels lower than the detection limit of 5
ppb. No other potential sources of lead exposure were identified.
The county health department advised the parents to stop drinking
bulk-delivered water and recommended measures to prevent lead
exposure.

Investigation of Bulk-Water Sources
     ADHS identified three water companies (two based in California
and one based in Arizona) that supplied bulk water to southwestern
Arizona. ADHS obtained water samples from 96 residential and
business storage tanks serviced by the two California water
companies; no water samples were obtained from the Arizona company
because the company used plastic tanks and fittings. Samples were
drawn directly from the tanks, from the brass fittings on the
tanks, and from the kitchen sinks. Twenty-two (23%) of the 96 water
samples contained lead levels exceeding EPA's action level. Samples
from three bulk-water delivery trucks containing the source water
for the storage tanks met EPA drinking water standards (i.e., less
than 15 ppb lead).
     Both California water companies notified their customers about
the possibility of lead leaching from soldered seams and brass
fittings in bulk-water storage tanks. In addition, one company
identified the sources of lead in its bulk-delivered water: lead
solder in tanks manufactured before March 1987, lead-containing
brass fittings, and lead solder in household plumbing. The company
initiated replacement of all lead-soldered storage tanks and brass
fittings and informed homeowners of the probable presence of
lead-soldered household plumbing.

Reported by: NJ Peterson, MS, FW Chromec, PhD, CM Fowler, MS, P

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 @FROM   :[e-mail]
· (Continued from last message)
Arreola, MS, E Arvizu, B Erickson, PhD, P Alder, J Soltis, L Sands,
DO, State Epidemiologist, Arizona Dept of Health Svcs. V Freeman,
M Miramontes, M Johnston, Imperial County Health Dept, El Centro;
J Flattery, MPH, R Gambatese, MPH, S Gilmore, MA, R Ehling, MD, AM
Osorio, MD, L Barrett, DVM, C Lee, PhD, I Small, GW Rutherford,
III, MD, State Epidemiologist, California State Dept of Health
Svcs. Lead Poisoning Prevention Br, Div of Environmental Hazards
and Health Effects, National Center for Environmental Health, CDC.

Editorial Note: In southwestern Arizona and southeastern
California, bulk water delivered and stored in tanks is not an
uncommon source of drinking water. Approximately 2500 residences
and businesses in southwestern Arizona and 8500 in Imperial and San
Diego counties, California, are served by bulk-delivered water.
Although lead in the bulk-delivered water probably contributed to
the high BLLs detected in the children described in this report,
the role of other potential sources of lead could not be
determined.
     The Food and Drug Administration (FDA) has proposed a
provisional total tolerable intake level of lead for infants and
children of 6 ug daily (4). U.S. residents ingest an estimated 5-11
ug of lead daily (5). On average, lead-containing drinking water is
estimated to contribute 10%-20% of the total lead exposure for
children in the United States (5). For infants and young children,
ingestion of only 0.5 L of water per day with a lead concentration
of 450 ppb (450 ug/L) will result in a daily dose of lead of 225
ug--a level approximately 38 times higher than FDA's total
tolerable intake level. The children described in this report
ingested daily doses of lead from six to 41 times higher than the
total tolerable intake level.
     Federal legislation authorizes both FDA and EPA to regulate
drinking water (6): the Food, Drug, and Cosmetic Act* empowers FDA
to regulate drinking water (including bottled water and water used
in food and for processing), and the Safe Drinking Water Act** and
other statutes enable EPA to regulate public water systems that
provide drinking water for human consumption. In 1986, an amendment
to the Safe Drinking Water Act*** prohibited the use of 1) water
pipes and pipe fittings with greater than 8% lead and 2) solder and
flux with greater than 0.2% lead in public water systems and
plumbing (in residential or nonresidential facilities) that provide
drinking water for humans and are connected to public water systems
(5). Although lead-containing faucets and fittings may comply with
the lead restrictions in the Safe Drinking Water Act, lead from
these fixtures can leach into the water supply and result in lead
levels in drinking water that exceed EPA's action level. To address
this concern, guidelines that further limit the amount of lead in
plumbing fixtures are being developed by EPA, National Sanitation
Foundation International (a nonprofit organization that tests and
certifies water products), and the Plumbing Manufacturers
Institute.

References
1. 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, CDC, October 21, 1991.
2. Committee on Environmental Health, American Academy of
Pediatrics. Lead poisoning: from screening to primary prevention.
Pediatrics 1993;92:176-83.
3. Brody DJ, Pirkle JL, Kramer RA, et al. Blood lead levels in the
US population: phase I of the Third National Health and Nutrition
Examination Survey (NHANES III, 1988 to 1991). JAMA 1994;272:277-
83.
4. Food and Drug Administration. Lead-soldered food cans: proposed
rule. Federal Register 1993;58;33860-71.
5. Bolger PM, Carrington CD, Capar SG, Adams MA. Reductions in
dietary lead exposure in the United States. Chemical Speciation
Bioavailability 1991;3:31-6.
6. US Environmental Protection Agency/Food and Drug Administration.
Memorandum of understanding between the EPA and FDA. Federal
Register 1979;44:42775-8.

  *21 U.S.C. 301 et seq.
 **42 U.S.C. 300 et seq, 1974 ed.
***42 U.S.C. 300 et seq, 1986 ed.



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End of HICNet Medical News Digest V07 Issue #53
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