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DSHS Authors: 2008 Research Articles by DSHS Staff

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The following list includes peer-reviewed research articles that have been written by staff of the Texas Department of State Health Services since its formation in September 2004. For more information about these articles or for a full-text copy, please contact the Medical and Research Library by e-mail at library@dshs.state.tx.us by calling (512) 776-7559.

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mrl-diamond2008 Articles (in date order with most recent first)

Enzootic Rabies Elimination from Dogs and Reemergence in Wild Terrestrial Carnivores, United States
Velasco-Villa A, Reeder SA, Orciari LA, Yager PA, Franka R, Blanton JD, Zuckero L, Hunt P, Oertli EH, Robinson LE, Rupprecht CE.
Emerg Infect Dis. 2008 Dec;14(12):1849-54.
To provide molecular and virologic evidence that domestic dog rabies is no longer enzootic to the United States and to identify putative relatives of dog-related rabies viruses (RVs) circulating in other carnivores, we studied RVs associated with recent and historic dog rabies enzootics worldwide. Molecular, phylogenetic, and epizootiologic evidence shows that domestic dog rabies is no longer enzootic to the United States. Nonetheless, our data suggest that independent rabies enzootics are now established in wild terrestrial carnivores (skunks in California and north-central United States, gray foxes in Texas and Arizona, and mongooses in Puerto Rico), as a consequence of different spillover events from long-term rabies enzootics associated with dogs. These preliminary results highlight the key role of dog RVs and human-dog demographics as operative factors for host shifts and disease reemergence into other important carnivore populations and highlight the need for the elimination of dog-related RVs worldwide.

Selective Serotonin Re-Uptake Inhibitor Warnings and Trends in Exposures Reported to Poison Control Centres in Texas.
Forrester MB.
Public Health 2008 Dec;122(12):1356-62.
OBJECTIVES: Since January 2002, the US Food and Drug Administration (FDA) has issued a number of advisories about the use of antidepressants, including selective serotonin re-uptake inhibitors (SSRIs). These advisories may have influenced the number of SSRI exposures reported to poison control centres. The purpose of this study was to examine time trends in SSRI exposures reported to poison control centres in Texas with respect to the timing of the various advisories. STUDY DESIGN: Retrospective review of data from poison control centres. METHODS: Cases were divided into two groups: (1) paroxetine exposures and (2) other SSRI exposures reported to poison control centres in Texas between 1998 and 2006. The month and year of the call, and patient age and gender were identified. The mean monthly number of ingestions for the two groups was calculated for six time periods related to the FDA advisories. RESULTS: The mean monthly number of total paroxetine ingestions between January 2002 and June 2003 was 77.6. This declined by 23.3% to 59.6 in July 2003-March 2004 after an advisory about the risk of suicidality in youths using paroxetine. Comparable mean monthly numbers for patients aged <20 years were 33.3 and 20.3, respectively (decline of 38.9%); and for patients aged >/=20 years were 44.0 and 38.6, respectively (decline of 12.4%). Mean monthly numbers for total other SSRI ingestions were 206.4 and 243.1, respectively (increase of 17.8%). CONCLUSIONS: The FDA advisory in June 2003 appeared to initiate a decline in paroxetine ingestions, particularly among patients aged <20 years, but did not appear to influence other SSRI ingestions reported to poison control centres in Texas.

Multistate Outbreak of Pseudomonas Fluorescens Bloodstream Infection after Exposure to Contaminated Heparinized Saline Flush Prepared by a Compounding Pharmacy.
Gershman MD, Kennedy DJ, Noble-Wang J, Kim C, Gullion J, Kacica M, Jensen B, Pascoe N, Saiman L, McHale J, Wilkins M, Schoonmaker-Bopp D, Clayton J, Arduino M, Srinivasan A.
Clin Infect Dis. 2008 Dec 1;47(11):1372-9.
BACKGROUND: Pharmaceutical compounding, the manipulation of ingredients to create a customized medication, is a widespread practice. In January 2005, the Centers for Disease Control and Prevention was notified of 4 cases of Pseudomonas fluorescens bacteremia that were traced to contaminated heparinized saline intravenous flush syringes prepared as a compounded medical product. PATIENTS AND METHODS: We reviewed medical records of symptomatic patients with P. fluorescens-positive cultures of blood specimens or sections of explanted catheters, reviewed the production process of syringes, performed syringe cultures, compared isolates by pulsed-field gel electrophoresis (PFGE), and examined catheters by scanning electron microscopy. RESULTS: We identified 80 patients in 6 states with P. fluorescens-positive cultures during December 2004-March 2006. Sixty-four patients (80%) had received a diagnosis of cancer. Seventy-four (99%) of 75 patients for whom information about catheter type was available had long-term indwelling catheters. Thirty-three (41%) of 80 cases were diagnosed 84-421 days after the patient's last potential exposure to a contaminated flush (delayed-onset cases). Compared with patients with early infection onset, more patients with delayed infection onset had venous ports (100% versus 50%; P <.001). By PFGE, clinical isolates from 50 (98%) of 51 patients were related to isolates cultured from unopened syringes. Scanning electron microscopy of explanted catheters revealed biofilms containing organisms morphologically consistent with P. fluorescens. CONCLUSION: This outbreak underscores important challenges in ensuring the safety of compounded pharmaceuticals and demonstrates the potential for substantially delayed infections after exposures to contaminated infusates. Exposures to compounded products should be considered when investigating outbreaks. Patients exposed to contaminated infusates require careful follow-up, because infections can occur long after exposure.

Impact of Hurricane Dolly on Texas Poison Center Calls.
Forrester MB.
Texas Public Health Journal, Fall 2008 ;60(4):24-6.
Hurricane Dolly made landfall in South Texas on Wednesday, July 23, 2008. The intent of this investigation was to determine whether calls involving drug identifications or exposures to carbon monoxide, gasoline, food poisoning, water contamination, or bites and stings received by Texas poison centers were more or less common after Hurricane Dolly made landfall. For fourteen counties with disaster declarations as a result of Hurricane Dolly, the numbers of calls such as drug identifications or exposures to carbon monoxide, gasoline, food poisoning, water contamination, or bites and stings received by Texas poison centers during the week after landfall were compared to the numbers during the previous week, following week, and a historic mean from a similar time period during 2005, 2006, and 2007. The total number of calls was lower during the first week after hurricane landfall than for the previous and subsequent weeks as well as the historic mean. The number of drug identifications reported during the week after hurricane landfall was higher than that in the week prior to hurricane landfall as well as the historic mean. The number of drug identifications increased even further during the second week after hurricane landfall. The total number of exposures decreased during the week after hurricane landfall but then increased in the next week. The numbers of exposures involving carbon monoxide, gasoline, food poisoning, and bites and stings were all higher during the week after hurricane landfall. However, the numbers of these specific exposures were similar to or even lower than the historic means. Hurricane Dolly appeared to alter both the total number of calls and calls involving drug identifications and exposures to carbon monoxide and gasoline received by Texas poison centers from the affected area. Poison centers and public health providers might use this information in order to prepare for future hurricanes and educate the population about potential hazards before such storms hit.

Proximity of Pediatric Genetic Services to Children with Birth Defects in Texas.
Case AP, Canfield MA, Barnett A, Raimondo P, Drummond-Borg M, Livingston J, Kowalik J.
Birth Defects Res A Clin Mol Teratol. 2008 Nov;82(11):795-8.
BACKGROUND: Families of children with major structural malformations often benefit greatly from genetic services. However, these services may not be readily available in all areas. The purpose of this study was to use data from a statewide birth defects registry and geographic information system methodology to compare the spatial distribution and to summarize the distance of pediatric clinical genetic service providers in relation to residential addresses of children with selected birth defects in Texas. METHODS: Live-born children delivered between 1999-2004 in the Texas Birth Defects Registry with major structural defects and chromosomal anomalies were selected by a clinical geneticist according to diagnosis code. Mother's address at delivery of the case infants was geocoded as was the location of offices where clinical geneticists in Texas see pediatric patients. Using geographic information system tools, the authors then computed distance from each case mother's residence to the location of the nearest office where pediatric patients can be seen by clinical geneticists, summarized these distances, and graphically plotted the location of each case in relation to the nearest provider. RESULTS: Nearly 25,000 Registry cases met the criteria for selection for geocoding. Of those, 22,875 (91.8%) were successfully geocoded to street level. CONCLUSIONS: Although 82% of addresses were within 30 miles of the nearest pediatric genetic clinic, 14% lived 31-100 miles from the nearest facility, and 4% of case families would need to drive more than 100 miles, including some who live in midsized cities, indicating geographic disparities in access to these necessary services.

Current Status of State Policies that Support School-Based Health Centers.
Schlitt JJ, Juszczak LJ, Haby Eichner N.
Public Health Rep; 2008 Nov/Dec;123(6):731-8.
Objectives. This study explored the current status of the role of state school-based health center (SBHC) initiatives, their evolution over the last two decades, and their expected impact on SBHCs' long-term sustainability. Methods. A national survey of states was conducted to determine (1) the amount and source of funding dedicated by the state directly for SBHCs, (2) criteria for funding distribution, (3) designation of staff/office to administer the program, (4) provision of technical assistance by the state program office, (5) types of performance data collected by the program office, (6) state perspective on future outlook for long-term sustainability, and (7) Medicaid and the State Children's Health Insurance Program (SCHIP) policies for reimbursement to SBHCs. Results. Nineteen states reported allocating a total of $55.7 million to 612 SBHCs in school year 2004-2005. The two most common sources of state- directed funding for SBHCs were state general revenue ($27 million) and Title V of the Social Security Act ($7 million). All but one of the 19 states have a program office dedicated to administering and overseeing the grants, and all mandate data reporting by their SBHCs. Sixteen states have established operating standards for SBHCs. Eleven states define SBHCs as a unique provider type for Medicaid; only six do so for SCHIP. Conclusions. In 20 years, the number of state SBHC initiatives has increased from five to 19. Over time, these initiatives have played a significant role in the expansion of SBHCs by earmarking state and federal public health funding for SBHCS, setting program standards, collecting evaluation data to demonstrate impact, and advocating for long-term sustainable resources.

Seroprevalence of Select Bloodborne Pathogens and Associated Risk Behaviors among Injection Drug Users in the Paso del Norte Region of the United States – Mexico Border
Baumbach JP, Foster LN, Mueller M, Cruz MF, Arbona S, Melville S, Ramos R, Strathdee SA.
Harm Reduct J. 2008 Nov 16;5:33.
BACKGROUND: The region situated where the borders of Mexico, Texas and New Mexico meet is known as 'Paso del Norte'. The Paso del Norte Collaborative was formed to study the seroprevalence of select pathogens and associated risk behaviors among injection drug users (IDUs) in the region. METHODS: Respondent-driven sampling (RDS) was used: 459 IDU participants included 204 from Mexico; 155 from Texas; and 100 from New Mexico. Each of the three sites used a standardized questionnaire that was verbally administered and testing was performed for select bloodborne infections. RESULTS: Participants were mostly male (87.4%) and Hispanic/Latino (84.7%) whose median age was 38. In Mexico,Texas and New Mexico, respectively: hepatitis B virus (HBV) was seen in 88.3%, 48.6% and 59.6% of participants; hepatitis C virus (HCV) in 98.7%, 76.4% and 80.0%; human immunodeficiency virus (HIV) in 2.1%, 10.0% and 1.0%; and syphilis in 4.0%, 9.9% and 3.0%. Heroin was the drug injected most often. More IDUs in New Mexico were aware of and used needle exchange programs compared with Texas and Mexico. CONCLUSION: There was mixed success using RDS: it was more successfully applied after establishing good working relationships with IDU populations. Study findings included similarities and distinctions between the three sites that will be used to inform prevention interventions.

Attempted Breastfeeding before Hospital Discharge on Both Sides of the US-Mexico Border, 2005: The Brownsville-Matamoros Sister City Project for Women's Health.
Castrucci BC, Piña Carrizales LE, D'Angelo DV, McDonald JA, Foulkes H, Ahluwalia IB, Gossman GL, Acuña J, Erickson T, Clatanoff K, Lewis K, Mirchandani G, Smith B.
Prev Chronic Dis. 2008 Oct;5(4):A117.
INTRODUCTION: The US-Mexico border region has a growing population and limited health care infrastructure. Preventive health behaviors such as breastfeeding ease the burden on this region's health care system by reducing morbidity and health care costs. We examined correlates of attempted breastfeeding before hospital discharge on each side of the US-Mexico border and within the border region. METHODS: The cross-sectional study included women who delivered a live infant in Matamoros, Tamaulipas, Mexico (n = 489), and Cameron County, Texas (n = 457), which includes Brownsville, Texas. We interviewed women before hospital discharge from August 21 through November 9, 2005. We used multivariate logistic regression to estimate the odds of attempted breastfeeding before hospital discharge in Cameron County, Texas, the municipality of Matamoros, Mexico, and the 2 communities combined. RESULTS: Prevalence of attempted breastfeeding before hospital discharge was 81.9% in Matamoros compared with 63.7% in Cameron County. After adjusting for potential confounders, the odds of attempted breastfeeding before hospital discharge were 90% higher in Matamoros than in Cameron County (adjusted odds ratio [AOR], 1.93; 95% confidence interval [CI], 1.31-2.84 for the combined model). In the 2 communities combined, odds of attempted breastfeeding before hospital discharge were higher among women who had a vaginal delivery than among women who had a cesarean delivery (AOR, 1.98; 95% CI, 1.43-2.75) and were lower among women who delivered infants with a low birth weight than among women who delivered infants with a normal birth weight (AOR, 0.26; 5% CI, 0.15-0.44). CONCLUSION: The rate of attempted breastfeeding in Matamoros was significantly higher than in Cameron County. Additional breastfeeding support and messages on the US side of the US-Mexico border are needed.

Illnesses and Injuries Related to Total Release Foggers--Eight States, 2001-2006
MMWR Morb Mortal Wkly Rep. 2008 Oct 17;57(41):1125-9. Reprinted in JAMA: 2008; 300(22):2600-2.
Centers for Disease Control and Prevention (CDC). DSHS Contributor: B Diebolt-Brown.
Total release foggers (TRFs), sometimes called "bug bombs," are pesticide products designed to fill an area with insecticide and often are used in homes and workplaces to kill cockroaches, fleas, and flying insects. Most TRFs contain pyrethroid, pyrethrin, or both as active ingredients. TRFs also contain flammable aerosol propellants that can cause fires or explosions. The magnitude and range of acute health problems associated with TRF usage has not been described previously. This report summarizes illnesses and injuries that were associated with exposures to TRFs during 2001--2006 in eight states (California, Florida, Louisiana, Michigan, New York, Oregon, Texas, and Washington) and were investigated by the California Department of Pesticide Regulation (CDPR) and state health departments participating in the SENSOR-Pesticides program. During 2001-2006, a total of 466 TRF-related illnesses or injuries were identified. These illnesses or injuries often resulted from inability or failure to vacate before the TRF discharged, reentry into the treated space too soon after the TRF was discharged, excessive use of TRFs for the space being treated, and failure to notify others nearby. The findings indicate that TRFs pose a risk for acute, usually temporary health effects among users and bystanders. To reduce the risk for TRF-related health effects, integrated pest management control strategies that prevent pests' access to food, water, and shelter need to be promoted and adopted. In addition, awareness of the hazards and proper use of TRFs need to be better communicated on TRF labels and in public media campaigns.

Cervical Cancer Screening among Women Who Gave Birth in the US-Mexico Border Region, 2005: The Brownsville-Matamoros Sister City Project for Women's Health.
Castrucci BC, Echegollen Guzmán A, Saraiya M, Smith BR, Lewis KL, Coughlin SS, Gossman GL, McDonald JA, Foulkes H, Mirchandani G, Correa-Nieto Canedo L, Garcia IM, Acuña J.
Prev Chronic Dis. 2008 Oct;5(4):A116.
INTRODUCTION: The objective of this study was to examine correlates of ever having had a Papanicolaou (Pap) test among women who recently delivered a live infant and who resided near the US-Mexico border. METHODS: This cross-sectional study included women who delivered a live infant in Matamoros, Mexico (n = 488) and Cameron County, Texas (n = 453). Women were interviewed in the hospital before discharge between August 21 and November 9, 2005. Multivariable logistic regression was used to estimate the odds of ever having had a Pap test. RESULTS: Significantly fewer Matamoros women (62.1%) than Cameron County women (95.7%) reported ever having had a Pap test. Only 12% of Matamoros women said they received their most recent Pap test during prenatal care, compared with nearly 75% of Cameron County women. After adjusting for potential confounders, the odds of ever having had a Pap test were 7.41 times greater in Cameron County than in Matamoros (95% confidence interval, 4.07-13.48). CONCLUSION: The Healthy Border 2010 goals are to cut cervical cancer mortality by 20% to 30% in the border region. The significant difference in Pap test prevalence among our survey respondents may reflect that routine prenatal Pap testing is more common in the United States than in Mexico. Because women who are receiving prenatal care have increased interaction with health care providers, Matamoros providers may need to be educated about the need to screen for cervical cancer during this time.

Characteristics of Young Women Who Gave Birth in the US-Mexico Border Region, 2005: The Brownsville-Matamoros Sister City Project for Women's Health.
Galván González FG, Mirchandani GG, McDonald JA, Ruiz M, Echegollen Guzmán A, Castrucci BC, Gossman GL, Lewis KL.
Prev Chronic Dis. 2008 Oct;5(4):A120.
INTRODUCTION: Childbearing during adolescence and young adulthood is associated with adverse effects on health and quality of life. Lowering birth rates among young women is a binational priority in the US-Mexico border region, yet baseline information about birth rates and pregnancy risk is lacking. Increased understanding of the characteristics of young women who give birth in the region will help target high-risk groups for sexual and reproductive health services. METHODS: We examined data on reproductive health characteristics collected in hospitals from 456 women aged 24 years or younger who gave birth from August 21 through November 9, 2005, in Matamoros, Tamaulipas, Mexico, and Cameron County, Texas. We calculated weighted percentages and 95% confidence intervals (CIs) for each characteristic and adjusted odds ratios (AORs) for Matamoros and Cameron County women by using multiple logistic regression techniques. RESULTS: Numbers of births per 1,000 women aged 15 to 19 years and 20 to 24 years were similar in the 2 communities (110.6 and 190.2 in Matamoros and 97.5 and 213.1 in Cameron County, respectively). Overall, 38.5% of women experienced cesarean birth. Matamoros women reported fewer prior pregnancies than did Cameron County women and were less likely to receive early prenatal care but more likely to initiate breastfeeding. Few women smoked before pregnancy, but the prevalence of alcohol use in Cameron County was more than double that of Matamoros. In both communities combined, 34.0% of women used contraception at first sexual intercourse. CONCLUSION: Despite geographic proximity, similar ethnic origin, and comparable birth outcomes, young Mexican and US women showed different health behavior patterns. Findings suggest possible pregnancy prevention and health promotion
interventions.

Lessons Learned from a Binational Survey to Examine Women’s Health Status in the US-Mexico Border Region. [Editorial].
Delgado E, Castrucci BC, Fonseca V, Dutton RJ, Berrahou F.
Prev Chronic Dis 2008;5(4).

Prenatal HIV Testing in the US-Mexico Border Region, 2005: The Brownsville-Matamoros Sister City Project for Women's Health.
Gossman GL, Carillo Garza CA, Johnson CH, Nichols JJ, Castrucci BC, McDonald JA, Lewis KL, Mirchandani GG.
Prev Chronic Dis. 2008 Oct;5(4):A121.
INTRODUCTION: Routine prenatal human immunodeficiency virus (HIV) screening provides a critical opportunity to diagnose HIV infection, begin chronic care, and prevent mother-to-child transmission. However, little is known about the prevalence of prenatal HIV testing in the US-Mexico border region. We explored the correlation between prenatal HIV testing and sociodemographic, health behavior, and health exposure characteristics. METHODS: The study sample consisted of women who delivered live infants in 2005 in hospitals with more than 100 deliveries per year and resided in Matamoros, Tamaulipas, Mexico (n = 489), or Cameron County, Texas (n = 458). We examined univariate and bivariate distributions of HIV testing in Matamoros and Cameron County and quantified the difference in odds of HIV testing by using logistic regression. RESULTS: The prevalence of prenatal HIV testing varied by place of residence--57.6% in Matamoros and 94.8% in Cameron County. Women in Cameron County were significantly more likely than those in Matamoros to be tested. Marital status, education, knowledge of methods to prevent HIV transmission (adult-to-adult), discussion of HIV screening with a health care professional during prenatal care, and previous HIV testing were significantly associated with prenatal HIV testing in Matamoros, although only the latter 2 variables were significant in Cameron County. CONCLUSION: Although national policies in both the United States and Mexico recommend prenatal testing for HIV, a greater proportion of women in Cameron County were tested, compared with women in Matamoros. Efforts between Matamoros and Cameron County to improve HIV testing during pregnancy in the border region should consider correlates for testing in each community.

Prior Contraceptive Use among Women Who Gave Birth in the US-Mexico Border Region, 2005: The Brownsville-Matamoros Sister City Project for Women's Health.
Robles JL, Lewis KL, Folger SG, Ruiz M, Gossman G, McDonald JA, Castrucci BC, Perez M, Zapata L, Garcia I, Marchbanks PA.
Prev Chronic Dis. 2008 Oct;5(4):A128.
INTRODUCTION: Dramatic population growth in the US-Mexico border region suggests more effective family planning services are needed, yet binational data are scarce. The Brownsville-Matamoros Sister City Project for Women's Health collected binational, standardized data from 947 postpartum women in Cameron County (Texas) and Matamoros (Tamaulipas, Mexico) hospitals from August through November 2005. METHODS: We analyzed these data to estimate the proportion of women with unintended pregnancy and the proportion of these women who reported contraceptive use, and to identify associated factors. RESULTS: The current pregnancy was unintended for 48% of women overall. Almost half of these women reportedly used birth control at conception, but many used low-efficacy methods. Among women with unintended pregnancy who did not use contraception, 34.1% of Mexico residents believed they could not become pregnant and 28.4% of US residents reported no reason for nonuse. Overall, contraceptive use to prevent pregnancy was less common among younger than older women and among women who had not graduated high school compared with those who had. Among Mexico residents, those who had a source of routine health care were more likely than those who did not to have used contraception. CONCLUSION: More effective contraceptive practices are needed in this population, especially among younger and less-educated women. A cooperative binational approach that integrates reproductive and family planning services may be most effective.

Survey of Mosquito Fauna in Lubbock County, Texas.
Bradford CM, Gellido W, Presley SM.
J Am Mosq Control Assoc. 2008 Sep;24(3):453-6.
Records of mosquito species occurring in Lubbock County, TX, have not been reported since 1970. An updated mosquito survey was conducted as part of the West Nile virus surveillance program conducted throughout Lubbock County, TX from July 2002 through December 2004. A large number of species not previously recorded occurring in this area were collected, whereas several species historically occurring in the area were not collected during this survey. Based upon the data from this study, dominant species in Lubbock County include Aedes sollicitans, Aedes vexans, and Culex tarsalis.

The Public Health Nutrition Workforce and Its Future Challenges: the US Experience.
Haughton B, George A.
Public Health Nutr. 2008 Aug;11(8):782-91.
OBJECTIVES: To describe the US public health nutrition workforce and its future social, biological and fiscal challenges. DESIGN: Literature review primarily for the four workforce surveys conducted since 1985 by the Association of State and Territorial Public Health Nutrition Directors. SETTING: The United States. SUBJECTS: Nutrition personnel working in governmental health agencies. The 1985 and 1987 subjects were personnel in full-time budgeted positions employed in governmental health agencies providing predominantly population-based services. In 1994 and 1999 subjects were both full-time and part-time, employed in or funded by governmental health agencies, and provided both direct-care and population-based services. RESULTS: The workforce primarily focuses on direct-care services for pregnant and breast-feeding women, infants and children. The US Department of Agriculture funds 81.7 % of full-time equivalent positions, primarily through the WIC Program (Special Supplemental Nutrition Program for Women, Infants, and Children). Of those personnel working in WIC, 45 % have at least 10 years of experience compared to over 65 % of the non-WIC workforce. Continuing education needs of the WIC and non-WIC workforces differ. The workforce is increasingly more racially/ethnically diverse and with 18.2 % speaking Spanish as a second language. CONCLUSIONS: The future workforce will need to focus on increasing its diversity and cultural competence, and likely will need to address retirement within leadership positions. Little is known about the workforce's capacity to address the needs of the elderly, emergency preparedness and behavioural interventions. Fiscal challenges will require evidence-based practice demonstrating both costs and impact. Little is known about the broader public health nutrition workforce beyond governmental health agencies.

Adult Metformin Ingestions Reported to Texas Poison Control Centers.
Forrester MB.
Hum Exp Toxicol 2008;27:575-583.
ABSTRACT: Metformin is a oral hypoglycemic agent used in the management of type 2 diabetes mellitus. Limited information exists on adult metformin ingestions reported to poison control centers. The distribution of adult metformin ingestions reported to Texas poison control centers during 2000-2006 was determined for various factors. In addition, triage guidelines for the management of isolated ingestions were drafted. Of 1,528 total metformin ingestions, 58% involved coingestants. Of the 264 ingestions of metformin alone where the final medical outcome was known, dose ingested was reported for 66%. The mean reported dose was 4,739 mg (range 500-60,000 mg). Ingestions of <2,500 mg and >5,000 mg reported doses differed with respect to the proportion involving suspected attempted suicide (6% versus 81%), serious final medical outcome (3% versus 19%), and referral to a health care facility (3% versus 83%). Using 5,000 mg as a threshold dose for referral to a healthcare facility, 91% of cases not already at/en route to a healthcare facility were managed according drafted triage guidelines.

Population Growth: An Appropriate Predictor of Water Demand?
Vela Acosta MS, Sosa D, Sanderson M, Mena KD.
Texas Public Health Journal, 2008; 60(1):8-12.
The article discusses the regional water planning area in South Texas. It consists of the eight southernmost counties adjacent to or in close proximity to the Rio Grande River which caters Cameron, Hidalgo, Jim Hogg, Maverick, Starr, Webb, Willacy, and Zapata counties. The population in Region M south Texas is projected to grow from an estimated 1.26 million in 2000 to 3.05 million in 2050, resulting in an expected increase in water demand.

A Multi-State Salmonella Typhimurium Outbreak Associated with Frozen Vacuum-Packed Rodents Used to Feed Snakes.
Fuller CC, Jawahir SL, Leano FT, Bidol SA, Signs K, Davis C, Holmes Y, Morgan J, Teltow G, Jones B, Sexton RB, Davis GL, Braden CR, Patel NJ, Deasy MP, Smith KE.
Zoonoses and Public Health 2008;55(8-10):481-7.
From December 2005 through January 2006, the Minnesota Department of Health (MDH) identified four human clinical isolates of Salmonella Typhimurium that were indistinguishable by pulsed-field gel electrophoresis (PFGE). During routine interviews, three of the cases reported attending the same junior high school and two handled snakes in the science classroom. MDH collected environmental samples from the school's science classroom for Salmonella culturing; these included environmental samples and frozen vacuum-packed mice purchased over the internet to feed the classroom snakes. Through PulseNet, a national molecular subtyping surveillance network for enteric bacteria, 21 human S. Typhimurium isolates with indistinguishable PFGE patterns were identified in the United States since December 2005. Each state determined whether these human cases had recent exposure to snakes fed vacuum-packed rodents. Texas state officials conducted tracebacks of the vacuum-packed mice and collected samples at the breeding facility. Nineteen of 21 cases were interviewed, and seven reported contact with frozen vacuum-packed rodents from the same internet-based supplier in Texas. In Minnesota, the outbreak PFGE subtype of S. Typhimurium was isolated from the snakes, frozen feed rodents, and the classroom environment. Three human cases were identified in Michigan, Pennsylvania, and Wyoming. The outbreak PFGE subtype of S. Typhimurium was isolated from the Pennsylvania case's frozen rodents and the Michigan case's pet snake. The outbreak PFGE subtype of S. Typhimurium was also isolated from the supplier's rodent facility. This was a S. Typhimurium outbreak associated with frozen rodents. Human transmission likely occurred through direct contact with snakes and contaminated environmental surfaces. This report represents the second recent multi-state salmonellosis outbreak associated with commercially distributed rodents. Stronger oversight of the commercial rodent industry is warranted.

Impact of Hurricane Rita on Texas Poison Center Calls.
Forrester MB.
Prehospital Disaster Med 2008;23:248-254.
Introduction: On 24 September 2005, Hurricane Rita made landfall in eastern Texas, resulting in the mandatory evacuation of 16 counties beforehand and declaration of disaster areas in 22 counties afterward. Hypothesis: This study tested whether the evacuation and hurricane landfall affected the pattern of Texas poison center calls. Methods: Texas poison center calls received from the 22 disaster area counties were identified for three time periods: (1) 10-20 September 2005 (pre-evacuation), (2) 21-25 September 2005 (evacuation and hurricane landfall), and (3) 26 September-8 October 2005 (post-evacuation). The numbers of calls reviewed during the latter two time periods were compared to a baseline range (BR) derived from the number of calls received during corresponding time periods in 2002, 2003, and 2004. This comparison was made for total calls as well as calls involving pill identifications, other information, total exposures, carbon monoxide exposures, gasoline exposures, food poisoning, water contamination, and other information. Results: The daily call volume was relatively level during the pre-evacuation period (mean 291), declined during the evacuation period (mean 191), and returned to normal volume during the post-evacuation period (mean 283). During the evacuation and landfall period, only gasoline exposure calls were higher than expected (n=68, BR 11-30). During the post-evacuation period, the only higher than expected call volumes were for carbon monoxide exposures (n=11, BR -2-10) and gasoline exposures (n=40, BR 12-28). Conclusion: During an evacuation, total poison center call volume in the affected area may decline, although certain calls such as those involving gasoline exposures might increase. After a hurricane, the total call volume returns to normal, but certain calls such as those involving carbon monoxide and gasoline exposures might increase. This information allows for poison centers and public health providers to prepare their response to hurricanes and to educate the population before such events occurs.

A Statewide Strategy for Nursing Workforce Development through Partnerships in Texas.
Kishi A, Green A.
Policy Polit Nurs Pract. 2008 Aug;9(3):210-4.
Statewide efforts and partnerships were used for nursing workforce development to address the nursing shortage in Texas. A statewide strategic action plan was developed where partnerships and collaboration were the key components. One of the most important outcomes of these statewide partnerships was the passage of the Nursing Shortage Reduction Act 2001. Through this legislation, the Texas Center for Nursing Workforce Studies and its advisory committee were established. This article describes how a statewide infrastructure for nursing workforce policy and legislative and regulatory processes were further developed. An overview is provided on the contributions made by the organizations involved with these strategic partnerships. The ingredients for establishing successful, strategic partnerships are also identified. It is hoped that nursing and health care leaders striving to address the nursing shortage could consider statewide efforts such as those used in Texas to develop nursing workforce policy and legislation.

Are Maternal Occupation and Residential Proximity to Industrial Sources of Pollution Related?
Brender JD, Suarez L, Langlois PH, Steck M, Zhan FB, Moody K.
J Occup Environ Med. 2008 Jul;50(7):834-839.
OBJECTIVE:: We examined the relation between maternal occupation and residential proximity to industrial sources of pollution in two case-control study populations of birth defects. METHODS:: Occupational and residential information were obtained from Texas live birth records and maternal interviews of Texas participants in the National Birth Defects Prevention Study. Residential proximity to industrial sources of air pollution was determined through geographic information systems. RESULTS:: With adjustment for maternal race/ethnicity and education, women in production occupations were twice as likely (95% confidence interval 1.3 to 3.0) to reside near these facilities than women in management/professional occupations and more likely to reside near such facilities than other occupational groups. CONCLUSION:: Occupation and residence appear related; therefore, both sources of potential exposures may need to be considered to understand the relative contribution of either source to risk of adverse pregnancy outcomes.

The Relationship between Equine and Human West Nile Virus Disease Occurrence.
Ward MP, Scheurmann JA.
Vet Microbiol. 2008 Jun 22;129(3-4):378-83.
Cases of human and equine West Nile virus (WNV) disease reported in Texas in 2002 were analyzed to assess their temporal relationship. For each human case with a known residential location, the closest equine case (within a 5km radius) was selected. A total of 80 human-equine case pairs were identified, 51 (64%) of which were located in urban areas. Dates-of-onset of human and equine cases were positively correlated (r(SP)=0.494, P<0.001). Although overall there was no significant (P=0.207) difference between the dates-of-onset of human and equine cases, in urban areas of Texas equine cases were reported significantly (P=0.011) earlier (August 7) than corresponding human cases (August 19). Monitoring equine populations that are susceptible to WNV disease within close proximity to urban human populations might be useful for predicting disease risk in human populations.

Descriptive Epidemiologic Features Shared by Birth Defects Thought To Be Related To Vascular Disruption in Texas, 1996-2002.
Husain T, Langlois PH, Sever LE, Gambello MJ.
Birth Defects Res A Clin Mol Teratol 2008 Jun;82(6):435-40.
BACKGROUND: In utero vascular disruptions are thought to be associated with a variety of birth defects. This study examined the descriptive epidemiology of several of those defects using data from a large birth defects registry. METHODS: Data on birth defects ascertained from pregnancies in 1996-2002 were obtained from the Texas Birth Defects Registry. Using Poisson regression, we calculated crude and adjusted associations between maternal and infant characteristics and birth defects thought to be related to vascular disruption. We repeated the analysis using isolated cases and cases occurring in mothers <20 years. RESULTS: The most commonly shared pattern was observed for plurality and five defects: large intestinal atresia (PR 3.67; CI: 1.63-7.13), renal agenesis (PR 2.05; CI: 1.55-2.65), transverse limb deficiency (PR 1.85; CI: 1.28-2.57), porencephaly (PR 5.18; CI: 2.40-9.87), and Goldenhar syndrome (PR 3.45; CI: 1.04-8.53). Hispanics had the highest prevalence of gastroschisis (PR 1.21; CI: 1.05-1.40), transverse limb deficiency (PR 1.19; CI: 1.01-1.40), microtia/anotia (PR 2.22; CI: 1.83-2.70), and Poland anomaly (PR 1.90; CI: 1.26-2.93). Male infants were at greatest risk for renal agenesis (PR 1.58; CI: 1.40-1.80), porencephaly (PR 1.66; CI: 1.03-2.72), and Poland anomaly (PR 1.52; CI: 1.05-2.21). CONCLUSIONS: Our study confirmed findings in previous studies, but also uncovered several new associations.

Primary Amebic Meningoencephalitis-- Arizona, Florida, and Texas, 2007
MMWR Morb Mortal Wkly Rep. 2008 May 30;57(21):573-7. Reprinted in JAMA. 2008;300(2):161-3.
Centers for Disease Control and Prevention (CDC). DSHS Contributor: N Pascoe.
Primary amebic meningoencephalitis (PAM) is a rare but nearly always fatal disease caused by infection with Naegleria fowleri, a thermophilic, free-living ameba found in freshwater environments. Infection results from water containing N. fowleri entering the nose, followed by migration of the amebae to the brain via the olfactory nerve. In 2007, six cases of PAM in the United States were reported to CDC; all six patients died. This report summarizes the investigations of the cases, which occurred in three southern tier states (Arizona, Florida, and Texas) during June-September and presents preliminary results from a review of PAM cases during 1937-2007. Because deaths from PAM often prompt heightened concern about the disease among the public, an updated and consistent approach to N. fowleri risk reduction messages, diagnosis and treatment, case reporting, and environmental sampling is needed.

Maternal Exposures to Cigarette Smoke, Alcohol, and Street Drugs and Neural Tube Defect Occurrence in Offspring.
Suarez L, Felkner M, Brender JD, Canfield M, Hendricks K.
Matern Child Health J. 2008 May;12(3):394-401.
OBJECTIVES: Cigarettes, alcoholic beverages, and street drugs contain substances potentially toxic to the developing embryo. We investigated whether maternal cigarette smoking, secondhand smoke exposure, and alcohol or street drug use contributed to neural tube defect (NTD) occurrence in offspring. METHODS: We conducted a population-based case-control study among Mexican American women who were residents of the 14 Texas counties bordering Mexico. Case women had an NTD-affected pregnancy and delivered during 1995-2000. Control women were those who delivered live born infants in the same study area, without an apparent congenital malformation, randomly selected by year and facility. We interviewed women in person, 1-3 months postpartum, to solicit relevant information. RESULTS: Nonsmoking mothers exposed to secondhand smoke during the first trimester had an NTD odds ratio (OR) of 2.6 (95% confidence interval (CI) = 1.6, 4.0) compared to those who neither smoked nor were exposed to secondhand smoke. Compared to the referent, the OR among women who smoked less than half a pack a day during the first trimester was 2.2 (95% CI = 1.0, 4.8) and 3.4 (95% CI = 1.2, 10.0) among those who smoked a half pack or more. Adjustment for maternal age, education, body mass index, and folate intake had a negligible effect on results. Alcohol and street drug use had no relation to NTD risk when adjusted for cigarette smoking. CONCLUSIONS: This study suggests that cigarette smoke including secondhand exposure is not only hazardous to the mother but may also interfere with neural tube closure in the developing embryo.

Primary Cesarean Deliveries Prior to Labor in the United States, 1979-2004.
Joesch JM, Gossman GL, Tanfer K.
Matern Child Health J. 2008 May;12(3):323-31.
Objectives: To provide for the United States yearly estimates of first-time (primary) cesareans prior to labor and to examine factors associated with 1979-2004 trends. Methods: We estimated the annual percent of total, primary, and repeat cesareans with and without labor for 15- to 44-year-old women with live births in the 1979-2004 National Hospital Discharge Survey (NHDS; N = 706,062). For women without prior cesareans (N = 628,064), we used logistic regression to examine whether trends in primary cesarean before labor are explained by changes over time in: (1) the frequency of pregnancy complications, women's age, principal source of payment for delivery, hospital ownership, size, and region; and (2) the decision to deliver by cesarean when complications are present. Results: Annually 4.5-6.6% of women delivered by primary cesarean prior to labor in 1979-2004. Recently, there has been a rise. An increase in reported pregnancy complications contributed to more primary cesareans before labor in 1979-2004. Changes in women's age, principal payment source, and hospital characteristics do not explain 1979-2004 trends. Changes in delivery practices with respect to seven complications increased primary cesareans before labor in the 1980s. Conclusions: From 1979 to 2004, primary cesareans before labor contributed less to total cesareans than primary cesareans during labor and repeat cesareans without labor. Since 1998, primary cesareans pre-labor have increased less than previously reported. The recent increase is not explained by changes in the frequency of pregnancy complications, women's age, insurance, or delivery hospital characteristics. Changes in delivery practices regarding pregnancy complications may have contributed to the recent increase.

Pattern of Lionfish Envenomations Reported to Texas Poison Control Centers, 1998-2006.
Forrester MB.
Toxicol Environ Chem 2008;90:385-391.
The purpose of this study was to describe a large number of lionfish envenomations reported to poison control centers. Cases were lionfish envenomations reported to Texas poison control centers during 1998-2006. The distribution of cases was determined for selected parameters. A total of 188 cases were identified. Of the cases with a known location of envenomation, 94% involved the finger or hand. The patient was male in 72% of the cases, and the mean age was 32 years (range 4-65 years). The most frequently reported adverse clinical effects were dermal pain (89%) and a puncture or wound (66%). The most commonly reported treatments were immersion in hot water (84%) and tetanus antitoxin/status (48%). Patients with lionfish envenomations reported to Texas poison control centers were most often adults and males. The reported adverse clinical effects were typical of lionfish envenomations, and the treatments were generally consistent with the recommended guidelines.

Crime Rates and Sedentary Behavior among 4th Grade Texas School Children.
Brown HS 3rd, Perez A, Mirchandani GG, Hoelscher DM, Kelder SH.
Int J Behav Nutr Phys Act. 2008 May 14;5(1):28.
ABSTRACT: INTRODUCTION: Although per capita crime has generally fallen over the period which coincides with the obesity epidemic, it has not fallen uniformly across communities. It also has not fallen enough to allay fears on the part of parents. Over the past 30 years, technological changes have made the indoor alternatives to playing outside, where children are more vulnerable to criminal activity, more enjoyable (cable TV, video games, and the internet) and comfortable (the spread of air conditioning to low income neighborhoods). We determined whether indoor sedentary behavior patterns are associated with community crime statistics. 4th graders in the U.S. are typically 9 or 10 years old. METHODS: We used data from the 2004-2005 Texas School Physical Activity and Nutrition (SPAN) survey linked with U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics data for the years 2000 through 2005 and Texas State data on sexual offenders. The probability-based sample included a total of 7,907 children in grade four. Multistage probability sampling weights were used. The dependent variables included were hours of TV watching, video game playing, computer use and total indoor sedentary behavior after school. Incremental Relative Rates were computed for community crime rates including robberies, all violent crimes, murders, assaults, property crimes, rapes, burglaries, larcenies and motor vehicle thefts as well as for sexual offenders living in the neighborhood. The neighborhood refers to the areas where the students at each school live. In the case of sexual offenders, sexual offenders per capita are estimated using the per capita rate in the zip code of the school attended; all other crime statistics are estimated by the crimes per capita in the police department jurisdiction covering the school attended. After controlling for sex, age, and African-American and Hispanic, cross-sectional associations were determined using multivariate Poisson regression. RESULTS: 4th grade boys were more likely to play video games in communities with increased per 100 population rates of larceny and burglary as well as in communities with increased per capita sexual offenders; 4th grade girls were more likely to watch television in communities with increased per capita sexual offenders. While 4th grade girls were more likely to watch TV in communities with increased per capita sex offenders, they were less likely to use computers. Per capita sexual offenders were negatively related to computer use amongst 4th grade girls. CONCLUSION: By combining community crime and cross-sectional individual level data on indoor sedentary behavior, we found that there is an association between community crimes/sex offender rates and certain types of indoor sedentary behavior. The development of technologies in recent decades which makes supervising children easier indoors, where children are much less vulnerable to crime, may be contributing to the epidemic of childhood obesity.

Pattern of Ziprasidone Exposures Reported to Texas Poison Centers, 2001-2005.
Forrester MB.
Hum Exp Toxicol. 2008 Apr;27(4):355-61.
Information on potentially adverse exposures to the atypical antipsychotic drug ziprasidone is limited. This study described the pattern of exposures involving only ziprasidone (isolated exposures) reported to Texas poison control centers during 2001-2005. The mean dose was 666 mg. The patient age distribution was <or=5 years (11%), 6-19 years (30%), and >or=20 years (60%). The exposures were intentional in 53% of the cases. Seventy-five percent of the exposures were managed at health care facilities. The final medical outcome was classified as no effect for 39% of the cases and minor effects for 40% of the cases. Adverse clinical effects were listed for 53% of the patients; the most frequently reported being neurological (42%), cardiovascular (13%), and gastrointestinal (5%). The most frequently listed treatment was decontamination by charcoal (34%) or cathartic (28%). Potentially adverse ziprasidone exposures reported to poison control centers are likely to involve management at a health care facility and involve some sort of adverse clinical effect. With proper treatment, the outcomes of such exposures are generally favorable.

A Multiphasic Approach Reveals Genetic Diversity of Environmental and Patient Isolates of Mycobacterium Mucogenicum and Mycobacterium Phocaicum Associated with an Outbreak of Bacteremias at a Texas Hospital.
Cooksey RC, Jhung MA, Yakrus MA, Butler WR, Adékambi T, Morlock GP, Williams M, Shams AM, Jensen BJ, Morey RE, Charles N, Toney SR, Jost KC Jr, Dunbar DF, Bennett V, Kuan M, Srinivasan A.
Appl Environ Microbiol. 2008 Apr;74(8):2480-7.
Between March and May 2006, a Texas hospital identified five Mycobacterium mucogenicum bloodstream infections among hospitalized oncology patients using fluorescence HPLC analysis of mycolic acids. Isolates from blood cultures were compared to 16 isolates from environmental sites or water associated with this ward. These isolates were further characterized by hsp65, 16S rRNA, and rpoB gene sequencing, by hsp65 PCR restriction analysis and molecular typing methods including repetitive element PCR, random amplified polymorphic DNA PCR, and pulsed field gel electrophoresis (PFGE) of large restriction fragments. Three of five patient isolates were confirmed as M. mucogenicum and were in a single cluster as determined by all identification and typing methods. The remaining two patient isolates were identified as different strains of mycobacterium phocaicum by rpoB sequence analysis. One of these matched an environmental isolate from a swab of a hand shower in the patient's room while none of the clinical isolates of M. mucogenicum matched environmental strains. Among the other 15 environmental isolates, 11 were identified as M. mucogenicum and four as M. phocaicum strains, all of which were unrelated by typing methods. Although the 16S rDNA sequence matched for all 14 M. mucogenicum isolates there were two each hsp65 and rpoB sequevars, seven PCR typing patterns, and 12 PFGE patterns. Among the seven M. phocaicum isolates were three 16S rRNA sequevars, two hsp65 sequevars, two rpoB sequevars, six PCR typing patterns, and six PFGE patterns. This outbreak represents the first case of catheter-associated bacteremia caused by M. phocaicum and the first report of clinical isolates from an American hospital. The investigation highlights important differences in the available typing methods for mycobacteria and demonstrates the genetic diversity of these organisms even within narrow confines of time and space.

Dental Caries Trends in Primary Teeth among Third-Grade Children in Harris County, Texas.
Williamson DD, Narendran S, Gray WG.
Pediatr Dent. 2008 Mar-Apr;30(2):129-33.
PURPOSE: The purpose of this study was to assess trends in dental caries in the primary dentition of third-grade children in suburban Harris County, Texas. METHODS: The study populations for the 2 cross-sectional surveys consisted of 1,584 third-grade children in 1991 and 1,039 in 1998. Trained dentists collected data on decayed and filled tooth surfaces (dfs). Chi-square tests analyzed the differences in proportions of children with and without dental caries experience in 1991 and 1998 by demographic subgroups: (1) gender; (2) ethnicity; and (3) socioeconomic status (SES). Student's t test investigated the differences in mean dfs scores in subgroups. RESULTS: The prevalence of caries decreased significantly from 59% to 54% between 1991 and 1998 (P = .01). The caries prevalence was lower in 1998 than 1991 in certain subgroups: 1) females; 2) Caucasians; and 3) low SES. The mean dfs score decreased significantly from 4.81 to 3.16, and lower dfs scores were seen in certain demographic subgroups between the 2 studies (P < .05). Children from a low SES had high levels of untreated caries in both studies. CONCLUSIONS: Despite a decline in primary teeth caries of study participants, intergroup disparities exist, emphasizing the need for preventive strategies, especially for the low SES children.

Impact of Withdrawal from Market on the Pattern of Cyclooxygenase-2 Inhibitors Reported to Texas Poison Control Centers.
Forrester MB.
Toxicol Environ Chem 2008;90:285-292.
The cyclocygenase-2 (COX-2) inhibitor rofecoxib was withdrawn from the US market on September 30, 2004, and valdecoxib was withdrawn on April 7, 2005. The impact of these actions on COX-2 inhibitor exposures reported to poison control centers was unknown. The objective of this study was to describe the pattern of COX-2 inhibitor exposures reported to Texas poison control centers before and after rofecoxib and valdecoxib were withdrawn. The number of celecoxib, rofecoxib, and valdecoxib exposures reported to Texas poison control centers each month during 1999-2006 was identified and examined for changes over time. Comparisons were made with respect to those exposures reported immediately prior to withdrawal (October 2003-September 2004) to exposures after withdrawal (April 2005-December 2006). The mean monthly number of reported exposures prior to withdrawal was 18.8 for celecoxib, 20.3 for rofecoxib, 13.3 for valdecoxib, and 51.5 for total COX-2 inhibitors. The mean monthly number of reported exposures after withdrawal was 9.3 for celecoxib, 1.8 for rofecoxib, 1.3 for valdecoxib, and 12.3 for total COX-2 inhibitors, representing declines of 50.5%, 91.1%, 90.3%, and 76.1%, respectively. The withdrawal of rofecoxib and valdecoxib from the market resulted in a decrease in the number of COX-2 inhibitor exposures reported to Texas poison control centers. However, rofecoxib and valdecoxib exposures continued to be reported for a long time after withdrawal. Reported celecoxib exposures declined even though it was not withdrawn from the market.

Validity of Parental Work Information on the Birth Certificate.
Brender JD, Suarez L, Langlois PH.
BMC Public Health 2008;8:95.
BACKGROUND: In the most recent revision (2003) of the U.S. standard certificate of live births, the National Center for Health Statistics recommended that all states collect maternal and paternal usual occupation. Because such information might be useful in the surveillance of job-related risk areas, we assessed the quality of parental work information on the U.S. birth certificate. METHODS: Occupational histories obtained from maternal interviews with Texas (USA) participants in the National Birth Defects Prevention Study were linked to and compared with parental work information on birth certificates. With occupational information from interviews serving as the gold standard, we assessed the quality of occupational information on the birth certificate with measures of sensitivity, specificity, and the kappa statistic. RESULTS: Of the 649 births available for study, parental occupation agreed between the birth certificate and interview for 77% of mothers and 63% of fathers with similar agreement by case-control status. Among occupations and industries with 10 or more workers by interview, sensitivity of the birth certificate information ranged from 35% to 100% for occupational groups and 55% to 100% for industrial sectors. Specificities of occupations/industries studied ranged from 93 to 100%. Kappa statistics for maternal occupations (0.76 to 0.90) and industries (0.59 to 0.94) were higher than those for paternal occupations (0.48 to 0.92) and industries (0.47 to 0.89). Mothers were frequently misclassified as homemakers or otherwise unemployed while the paternal information was often missing altogether on the birth certificate. Women who worked as health diagnosing and treating practitioners were the least likely (0%) and women in food preparation or serving occupations were the most likely (65%) to be misclassified as not employed on the birth certificate. Among fathers, the proportion of missing occupations was the lowest for occupations in business or financial operations (0%) and highest for occupations in food preparation and serving (30%). CONCLUSION: Sensitivity of occupation/industry information on birth certificates varies although the specificity of such information may exceed 95%. Quality of this information also varies by maternal and paternal occupation with misclassification as homemaker a limiting factor among maternal and missing information a limiting factor among paternal work information.

Pattern of Chlorine Gas Exposures Reported to Texas Poison Control Centers, 2000 through 2005.
Becker M, Forrester M.
Texas Medicine, 2008 March;104(3):51-57.
Exposure to chlorine gas can result in serious adverse effects including death. From 2000 through 2005, approximately 9000 chlorine gas exposures were reported annually to poison control centers in the United States. Because a review of the literature failed to produce any Texas-specific data concerning chlorine gas exposures, we conducted a retrospective review of Texas poison control center calls and found that 2643 calls related to human exposures to chlorine gas occurred during these 6 years. The number of these calls increased during this period. Of the exposures, 75% occurred at home and 65% occurred during the months of May through August. Inhalation was the primary mode of exposure. While most exposures resulted in no or minor effects, approximately one-fourth required that the affected person be seen at a health care facility. Preventive activities are needed to educate people about the potential dangers associated with products that contain chlorine.

Risk Factors for Meningococcal Disease in Students in Grades 9-12.
Harrison LH, Kreiner CJ, Shutt KA, Messonnier NE, O’leary M, Stefonek KR, Lin H, Lynfield R, Barrett NL, Arnold KE, Jones TF, Montero JT; for the Meningococcal High School Study Group.
Pediatr Infect Dis J. 2008 Mar;27(3):193-9.
BACKGROUND: Meningococcal disease is a serious problem in adolescents, including high school students. Universal immunization of adolescents with meningococcal conjugate vaccine was recently recommended. We studied risk factors for meningococcal disease in students in grades 9-12. METHODS:: This was a matched case-control study using surveillance for meningococcal disease in students in grades 9-12 in sites throughout the United States. For each case-patient, up to 4 controls were selected from the home room classroom. All subjects answered an extensive questionnaire. Logistic regression was performed to identify risk factors associated with meningococcal disease. Meningococcal isolates were characterized. RESULTS:: Of 69 eligible patients, 49 (71%) were enrolled and had at least 1 control. Isolates were available for 59 (86%) cases. Attending at least 1 barbeque or picnic [matched odds ratio (MOR): 0.26, P value = 0.003] or school dance (MOR: 0.30, P = 0.04) were independently associated with decreased risk of meningococcal disease. Male gender (MOR: 2.94, P = 0.009), upper respiratory infection symptoms (MOR: 2.43, P = 0.04), marijuana use (MOR: 4.21, P = 0.009), and nightclub/disco attendance (MOR: 3.30, P = 0.04) were associated with increased risk. Among 54 students not from Oregon (where serogroup B strains predominate) with available serogroup, 38 (73.1%) cases were potentially vaccine preventable: 18 (34.6%) serogroup C, 19 (36.5%) serogroup Y, and 1 (1.9%) serogroup W-135. CONCLUSIONS:: Certain behaviors increase the risk of meningococcal infection, whereas others are associated with decreased risk. Most meningococcal disease in high school students can be prevented if recommendations on use of meningococcal conjugate vaccine are implemented.

Parental Occupation, Hispanic Ethnicity, and Risk of Selected Congenital Malformations in Offspring.
Brender JD, Suarez L, Langlois PH.
Ethnicity & Disease 2008;18(2):218-24.
Objectives: Evidence suggests that parental occupation and Hispanic ethnicity may be risk factors for some birth defects. Because few studies have examined the effect of Hispanic ethnicity on occupational associations, we examined whether risk associated with certain occupations was heightened in Hispanics compared with non-Hispanic Whites. Design: In this case-control study among Texas births occurring from 1996 through 2000, cases of neural tube defects, isolated oral clefts, and chromosomal anomalies were linked to their respective live birth certificates. A random sample of 4965 live births without documented congenital malformations served as the comparison group. Parental occupations were categorized into groups according to previously published associations. Logistic regression was used to obtain odds ratios (OR) and 95% confidence intervals (CI) for the selected congenital malformations in relation to parental occupations. Results: Maternal occupations as cook or nurse were associated with oral clefts (OR 3.3, 95% CI .6-16.0) and neural tube defects (OR 3.1, 95% CI .5-13.1), respectively, among births to Hispanic mothers, but not with births to non-Hispanic White mothers. Hispanic fathers who were electricians were more likely to have offspring with chromosomal anomalies, especially trisomy 18 (OR 7.4, 95% CI 1.6-25.5), associations not seen among offspring of non-Hispanic White fathers. Risk estimates also differed by Hispanic ethnicity between oral clefts and paternal occupations of electronic equipment operator, farmworker, janitor, police officer, and printer. Conclusions: In this study, we found differences for risk of several congenital malformations by Hispanic ethnicity in relation to parental occupation. We recommend further study of these risks in other Hispanic populations.

Multistate Measles Outbreak Associated with an International Youth Sporting Event--Pennsylvania, Michigan, and Texas, August-September 2007.
Centers for Disease Control and Prevention (CDC). DSHS Contributor: R Espinoza.
MMWR Morb Mortal Wkly Rep. 2008 Feb 22;57(7):169-73. Reprinted in JAMA. 2008;299(13):1536-1538.
Measles, a highly infectious viral illness, is no longer endemic in the United States because of high coverage rates with an effective vaccine. However, imported cases continue to cause illness and outbreaks among susceptible U.S. residents. In August 2007, a participant in an international youth sporting event who traveled from Japan to the United States became ill with measles. Because he traveled while infectious to an event with thousands of participants and spectators, an outbreak investigation was conducted in multiple states by state and local health departments in coordination with CDC, using standard measles surveillance case definitions and classifications. This report summarizes the results of that investigation, which identified six additional measles cases that were linked epidemiologically to the index case and two generations of secondary transmission. Viral genotyping supported a single chain of transmission; six of the seven cases were linked by genetic sequencing. U.S. organizers of large-scale events attended by international travelers, especially youths, should consider documentation of adequate participant vaccination. This outbreak highlights the need to maintain the highest possible vaccination coverage in the United States, along with disease surveillance and outbreak-containment capabilities.

Workplace-Based Investigation of Contacts of a Patient with Highly Infectious Tuberculosis--Maryland, District of Columbia, and Virginia, 2006.
Centers for Disease Control and Prevention (CDC). DSHS Contributor: G. Mirchandani.
MMWR Morb Mortal Wkly Rep. 2008 Feb 1;57(4):94-8. 
In late April 2006, the Maryland Department of Health and Mental Hygiene (DHMH) was notified by a local health department of a case of pulmonary tuberculosis (TB) in a patient with cavitary lung lesions and numerous acid-fast bacilli (AFB) observed on a sputum smear. The patient worked for an office furniture installation company at multiple sites in Maryland, the District of Columbia (DC), and Virginia. An investigation was conducted to 1) determine the extent of TB transmission, including identifying and screening the exposed cohort of contacts, and 2) provide treatment, if indicated, to contacts with latent TB infection (LTBI) or TB disease. This report describes the multijurisdictional contact investigation and summarizes its results. The findings underscore the importance of prompt diagnosis of TB, the value of interjurisdictional cooperation during large contact investigations, and the effectiveness of workplace-based methods for rapidly identifying and screening contacts.

Residential Proximity to Waste Sites and Industrial Facilities and Chromosomal Anomalies in Offspring.
Brender JD, Zhan FB, Langlois PH, Suarez L, Scheuerle AE.
Int J Hyg Environ Health 2008;211(1-2):50-8.
A few studies have found chromosomal anomalies in offspring associated with a maternal residence near waste sites, but did not examine the effect of living near industrial facilities, and most combined specific anomalies into heterogeneous groups. With a case-control study design, we investigated whether maternal residential proximity to hazardous waste sites or industrial facilities with chemical air emissions was associated with chromosomal anomalies in births. Maternal residences of 2099 Texas births with chromosomal anomalies and 4368 control births without documented malformations were related to boundaries of hazardous waste sites and street addresses of industrial facilities through geographic information systems. With adjustment for maternal age, race/ethnicity, and education, maternal residence within 1mile of a hazardous waste site (relative to farther away) was not associated with chromosomal anomalies in offspring except for Klinefelter variants among Hispanic births (odds ratios (OR) 7.9, 95% confidence interval (CI) 1.1-42.4). Women 35 years or older who lived within 1mile of industries with emissions of heavy metals were two times more likely (95% CI 1.1-4.1) than women living farther away to have offspring with chromosomal anomalies including trisomies 13, 18, or 21 or sex chromosome abnormalities. Among women 40 years or older, maternal residence within a mile of industries with solvent emissions was associated with chromosomal anomalies in births (OR 4.8, 95% CI 1.2-42.8). Study findings suggest some relation between residential proximity to industries with emissions of solvents or heavy metals and chromosomal anomalies in births to older mothers.

Socioeconomic Status in Relation to Selected Birth Defects in a Large Multicentered US Case-Control Study.
Yang J, Carmichael SL, Canfield MA, Song J, Shaw GM, National Birth Defects Prevention Study.
Am J Epidemiol 2008;167(2):145-54.
This study examined individual and household socioeconomic status (SES) in relation to phenotypes of neural tube defects, orafacial clefts, and conotruncal heart defects using data from the National Birth Defects Prevention Study with 2,551 nonmalformed liveborn controls and 1,841 cases delivered in 1997-2000. The individual SES was measured by maternal and paternal education, occupation, and household income. All individual SES measures were combined to create a household SES index. Elevated risks were found for maternal low education in association with anencephaly and dextrotransposition of the great arteries (dTGA) (adjusted odds ratios (AORs) >/= 1.4); paternal low education in association with anencephaly, cleft palate, tetralogy of Fallot (TOF), and dTGA (AORs >/= 1.4); low household income in association with TOF (AOR = 1.4, 95% confidence interval (CI): 0.8, 2.5); maternal operator/laborer occupation in association with cleft palate, TOF, and dTGA (AORs >/= 1.4); paternal operator/laborer occupation in association with spina bifida (AOR = 1.4, 95% CI: 1.0, 2.0); and either parent's unemployment in association with dTGA (AOR >/= 1.4). Subjects with the lowest household SES index had the greatest risks of all selected birth defects except TOF. This study reveals consistently increased risks of selected birth defects in association with household SES index but not individual SES measures.

The Cost of Quality Improvements Due to Integrated Management of Childhood Illness (IMCI) in Uganda.
Bishai D, Mirchandani G, Pariyo G, Burnham G, Black R.
Health Econ. 2008 Jan;17(1):5-19.
The goal of this paper is to measure the marginal change in facility-level costs of medical care for children under five due to an increase in service quality achieved through the integrated management of childhood illness (IMCI) strategy. Since the beneficial effects of IMCI training on child health outcomes are due to IMCI's effects on service quality, costs of IMCI are regressed against measures of service quality in this paper. Our model shows that quality, as measured by a WHO-index of integrated child assessment is 44% higher in facilities with at least one health worker trained in IMCI as compared to facilities with no health workers trained in IMCI, adjusting for facility utilization as well as type of facility ownership. Our marginal analysis that tied IMCI training to quality and quality to costs shows that on the margin, investing in IMCI training at a primary facility level can yield a significant 44.3% improvement in service quality for a modest 13.5% increase in annual facility costs.

BART to HIVEd: Adapting an HIV Education Prevention Program.
Polacek GN, Coker J, Lewis KL, Minter M, Villela-Perez V, Scott AA.
Health Promot Pract. 2008 Jan;9(1):45-58.
One of the fastest growing segments of the population infected with HIV is the nation's youths. Thus, prevention in this high-risk population is vital. The authors detail the process of adapting an evidence-based HIV/AIDS educational program (HIVEd) to the unique needs of high-risk youths in adjudicated and detained facilities and alternative high schools. The HIVEd program derives from St. Lawrence's Becoming A Responsible Teen (BART) curriculum. This article describes the modification of BART into HIVEd, identifies the challenges encountered and lessons learned, and suggests future directions for HIVEd as a useful tool for prevention of HIV/AIDS and sexually transmitted infection in high-risk youths.

State Mental Health Policy: Mental Health Transformation: Moving toward a Public Health, Early-Intervention Approach in Texas.
Ganju V.
Psychiatr Serv. 2008 Jan;59(1):17-20.
This column describes a mental health system transformation initiative in Texas that aims to fully integrate mental health as a component of public health and early-intervention efforts. The process has included a formal needs assessment initiative and a broad-based interagency Transformation Workgroup made up of executive-level agency staff, consumers and family members, and representatives of the legislature and governor's office. Community collaboratives have been formed to instigate transformation at the local level. Major objectives include development of consumer and family networks, workforce development and training, and an improved data and technology infrastructure.

Compliance with Selective Serotonin Reuptake Inhibitor Triage Guidelines by Texas Poison Control Centers.
Forrester MB, Parra G.
J Toxicol Environ Health A 2008;71:304-309.
Although 2% of exposures reported to U.S. poison control centers involve selective serotonin reuptake inhibitors (SSRI), many poison control centers do not have standardized guidelines for the management of these exposures. Recently, such guidelines were published, although the utility of these guidelines has not been evaluated. Cases evaluated in this study are all ingestions of SSRI alone reported to Texas poison control centers during 2000-2006. A simplified version of the published management guidelines triage algorithm was created, and the proportion of cases that were managed according to these guidelines was calculated. Of the total cases, 85% not already at/en route to a health care facility and 88% already at/en route to a health care facility were managed according to the simplified algorithm. The respective rate ranges were 82-89% and 83-90% among the 6 poison control centers and 77-86% and 80-90% among the 6 specific SSRI. The majority of ingestions of SSRI alone reported to Texas poison control centers during a recent 7-yr period were managed according to a simplified version of recommended triage algorithm. This was the case for all of the poison control centers and all of the specific SSRI.

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Last updated July 16, 2014