Asthma hospitalizations in Wisconsin: a missed opportunity for prevention.

Asthma is the most common chronic disease of children and the third leading cause of preventable hospitalizations in the United States. To assess the impact of this disease on Wisconsin, we examined 1996-1998 state-wide and county-specific asthma hospitalization rates and compared these rates to Wisconsin 1990-1992 rates, national rates, and United States Healthy People 2010 asthma target objectives. Wisconsin's average asthma hospitalization rate has decreased from 13.4/10,000 during 1990-1992 to 12.1/10,000 during 1996-1998. Wisconsin children 0-4 years of age had the highest asthma-related hospitalization rate (38.0/10,000) of all age groups, during 1996-1998. Wisconsin African American residents had an average asthma hospitalization rate 6.6 times higher than whites (58.5 vs. 8.8 per 10,000, respectively) during 1996-1998. Milwaukee County had the highest county-specific asthma hospitalization rate in the state (26.4/10,000). Unless significant reductions are achieved, Wisconsin will not reach the Healthy People 2010 target objectives. Interventions should be directed to preventing asthma hospitalizations, especially among Wisconsin's youth and African American population.

Correlations among human blood levels of specific PCB congeners and implications for epidemiologic studies.

Specific congeners of PCBs may differ with respect to their human health risks. For epidemiologic studies, however, measuring levels of specific congeners--as compared with estimating the concentration of total PCBs present, may be of limited value if levels of specific congeners are highly correlated. We examined the correlations among levels of specific congeners in three groups: controls from a case-control study of breast cancer in North Carolina and two groups from Wisconsin with exposure to fish from contaminated waters. Levels of specific congeners were, in general, highly correlated (Pearson r > 0.80). However, the level of congener 180, a heptachlorobiphenyl, tended to be less correlated with levels of lower-chlorinated biphenyls. Among the implications of these findings are that measurement of a select group of congeners may yield essentially the same information as measurement of a large panel, and may be more cost efficient.

SMRFIT: a Statistical Analysis System (SAS) program for standardized mortality ratio analyses and Poisson regression model fits in community disease cluster investigations.

Increasingly, health departments are being pressed by the public to respond to disease risk with cluster investigations in communities and neighborhoods. This is a direct result of growing concern about the role that the environment may play in disease risk. While extensive analyses directly inputing exposures or numbers at risk are often necessary to thoroughly investigate clusters, it is quite useful to perform an exploratory analysis with existing morbidity and mortality data as a first level of response. To meet this need for timely evaluation, the authors describe a user-friendly Statistical Analysis System (SAS) program called SMRFIT to automate community disease cluster evaluations. The program creates frequency tables for number at risk and number of disease outcomes for the community, balance of parent county, and balance of state. SMRFIT then constructs standardized mortality ratios, with the community compared with balance of county and balance of state referents. Poisson regression is offered as an option for the modeling of community disease rates.

State health department response to disease cluster reports: a protocol for investigation.

State health departments are increasingly faced with the task of responding to reports of apparent cancer and other disease clusters. Since 1979, 141 requests for investigation have been received by the Wisconsin Division of Health, with over 60% of these requests occurring since 1985. Mounting public concern and limited resources have resulted in the development of a "disease cluster investigation and analysis protocol." Protocol steps include: 1) circumscribing the cluster; 2) ascertaining cases; 3) assessing risk of the exposed versus a referent population; 4) statistically analyzing disease rates; 5) examining potential exposure; 6) assessing biologic plausibility; 7) determining cluster significance and need for further investigation; and 8) reporting results. To demonstrate the protocol, the authors present a case example of an investigation of an apparent cancer cluster. Since 1979, 62 reports were resolved with initial contact with informant education (step 1), 61 reports required descriptive analysis (steps 1-8) with no site visit, and 18 reports required site visits. None of the reports required further in-depth epidemiologic investigation. This protocol provides a systematic approach to investigation and analysis, prioritizes the need for more in-depth study, and, when necessary, assuages community concerns when a disease cluster is reported.

Cigarette smoking: the clinician's role in cessation, prevention, and public health.

Cigarette smoking is the most important preventable cause of illness and death in the United States, responsible for 390,000, or one sixth, of all deaths. Although smoking prevalence has decreased among adults, from 40% in 1965 to 29% in 1987, 49 million Americans continue to smoke. Smoking rates have declined at a slower rate among blacks, women, young people, and the less educated, groups that must be targeted for tobacco use prevention interventions. The clinician is uniquely positioned to reduce the enormous health toll from cigarette smoking. As a first step, physicians are urged to assess tobacco use during every patient visit by making smoking status a new vital sign. Although 85% of all smokers quit on their own, physicians can greatly facilitate this process. A brief intervention for physicians to help their smoking patients quit, based on a program of the National Cancer Institute, is presented. This program includes asking about smoking status during every clinic visit, advising all smoking patients to quit, assisting smokers by setting a quit date and using nicotine gum, if appropriate, and arranging follow-up with smokers who try to quit. Cessation rates of 5% to 25%, sustained for at least 1 year, are consistent with a successful, physician-mediated intervention program. Physicians are also urged to prevent smoking initiation among adolescents, particularly young girls and those not aspiring to attend college. Physicians can also reduce the enormous toll of tobacco use by acting at the public health and public policy levels. Recording tobacco use as a contributing or the underlying cause on death certificates, if appropriate, will assist in public health surveillance. Also, clinicians are urged to work at the organizational, community, and governmental levels to promote tobacco-free environments.

Sport fish consumption and body burden levels of chlorinated hydrocarbons: a study of Wisconsin anglers.

Sport-caught fish consumption is the major source of polychlorinated biphenyls (PCBs) exposure for the general population. To assess this and 2,2'-bis-(p-chlorophenyl)-1,1-dichloroethylene (DDE) exposure, we surveyed 801 Wisconsin anglers for fishing and consumption habits and comprehension of and compliance with the Wisconsin fish consumption health advisory. The mean annual number of sport-caught fish meals was 18. Seventy-two percent of anglers were familiar with the health advisory and 57% had changed their fishing or fish consumption habits as a result of the advisory. The mean PCB serum congener sum level for 192 anglers was 2.2 micrograms/l (range = nondetectable to 27.1 micrograms/l); mean DDE was 6.3 micrograms/l (range = nondetectable to 40.0 micrograms/l). Statistically significant positive Spearman correlations were observed between sport-caught fish meals and PCB and DDE sera levels (R = .21 and .14, respectively) and between kilograms of fish caught and PCB sera levels (R = .25). These results demonstrate that anglers may provide a population for assessment of PCBs and DDE associated morbidity and mortality.