Alden K. Henderson

Heat-related mortality during a 1999 heat wave in Chicago.

BACKGROUND During the summer of 1999, Chicagos second deadliest heat wave of the decade resulted in at least 80 deaths. The high mortality, exceeded only by a 1995 heat wave, provided the opportunity to investigate the risks associated with heat-related deaths and to examine the effectiveness of targeted heat-relieving interventions. METHODS We conducted a case-control study to determine risk factors for heat-related death. We collected demographic, health, and behavior information for 63 case patients and 77 neighborhood-and-age-matched control subjects and generated odds ratios (ORs) for each potential risk factor. RESULTS Fifty-three percent of the case patients were aged <65 years, and psychiatric illness was almost twice as common in the younger than the older age group. In the multivariate analysis, the strongest risk factors for heat-related death were living alone (OR=8.1; 95% confidence interval [CI], 1.4-48.1) and not leaving home daily (OR=5.8; 95% CI, 1.5-22.0). The strongest protective factor was a working air conditioner (OR=0.2; 95% CI, 0.1-0.7). Over half (53%) of the 80 decedents were seen or spoken to on the day of or day before their deaths. CONCLUSIONS A working air conditioner is the strongest protective factor against heat-related death. The relatively younger age of case patients in 1999 may be due to post-1995 interventions that focused on the elderly of Chicago. However, social isolation and advanced age remain important risk factors. Individual social contacts and educational messages targeted toward at-risk populations during heat waves may decrease the number of deaths in these groups.

Age at menarche and tanner stage in girls exposed in utero and postnatally to polybrominated biphenyl.

Accidental contamination of the Michigan food chain with polybrominated biphenyls (PBBs) led to the exposure of more than 4,000 individuals in 1973. Because PBB exposure is suspected to disrupt endocrine function, we assessed pubertal development in females 5–24 years of age (N = 327) who were exposed to PBB in utero and, in many cases, through breastfeeding. We estimated in utero PBB exposure using maternal serum PBB measurements taken after exposure (1976–1979) and extrapolated to time of pregnancy using a model of PBB decay. We found that breastfed girls exposed to high levels of PBB in utero (≥7 parts per billion) had an earlier age at menarche (mean age = 11.6 years) than breastfed girls exposed to lower levels of PBB in utero (mean age = 12.2–12.6 years) or girls who were not breastfed (mean age = 12.7 years). This association persisted after adjustment for potential confounders (menarche ratio = 3.4, 95% confidence interval = 1.3–9.0). Perinatal PBB exposure was associated with earlier pubic hair stage in breastfed girls, but little association was found with breast development. The associations observed here lend support to the hypothesis that pubertal events may be affected by pre- and postnatal exposure to organohalogens.

Heat-related death and mental illness during the 1999 Cincinnati heat wave.

During a 1999 heat wave in Cincinnati, Ohio, the Hamilton County Coroner reported 18 heat-related deaths. The Centers for Disease Control and Prevention and the Cincinnati Department of Health conducted a case–control study using surrogate case information and first-person control information to identify risk factors for mortality during the heat wave. Surrogate data were supplemented by systematic death scene investigation reports and comprehensive toxicologic screens, important sources of data that are routinely collected by the Hamilton County Coroner’s Office. The study included 17 case subjects and 34 controls from the decedents’ neighborhood. Among 17 case subjects, 8 (47.1%) had mental illness (odds ratio [OR], 14.0; 95% confidence interval [CI], 1.8–633). There was a suggestion of an interaction between age and mental health. A working air-conditioner was the strongest protective factor (OR, 0.03; 95% CI, 0–0.2). Toxicologic screening indicated that case subjects with reported mental illness and a prescription for psychotropic drugs may not have been medication compliant. Three decedents lived in group homes for people with mental illness, indicating that opportunities for prevention may have been missed. Systematic death investigations, including toxicologic screening, provide valuable information about the circumstances of heat-related death, particularly the role of medication compliance as a risk factor. Prevention programs during heat waves should target people with mental illness, especially those who take psychotropic medication.

The Application of Geographic Information Systems and Global Positioning Systems in Humanitarian Emergencies: Lessons Learned, Programme Implications and Future Research

Geographic information systems (GIS), global positioning systems and remote sensing have been increasingly used in public health settings since the 1990s, but application of these methods in humanitarian emergencies has been less documented. Recent areas of application of GIS methods in humanitarian emergencies include hazard, vulnerability, and risk assessments; rapid assessment and survey methods; disease distribution and outbreak investigations; planning and implementation of health information systems; data and programme integration; and programme monitoring and evaluation. The main use of GIS in these areas is to provide maps for decision-making and advocacy, which allow overlaying types of information that may not normally be linked. GIS is also used to improve data collection in the field (for example, for rapid health assessments or mortality surveys). Development of GIS methods requires further research. Although GIS methods may save resources and reduce error, initial investment in equipment and capacity building may be substantial. Especially in humanitarian emergencies, equipment and methodologies must be practical and appropriate for field use. Add-on software to process GIS data needs to be developed and modified. As equipment becomes more user-friendly and costs decrease, GIS will become more of a routine tool for humanitarian aid organisations in humanitarian emergencies, and new and innovative uses will evolve.

Breast cancer among women exposed to polybrominated biphenyls.

We conducted a nested case-control study with 1,925 women enrolled in a polybrominated biphenyl (PBB) registry to examine the association between breast cancer and serum PBBs. Twenty women who developed breast cancer were matched to 290 control subjects on sex, race, and age. Women with serum PBB levels of 2.0-3.0 parts per billion (ppb) [odds ratio (OR) = 3.5; 95% confidence interval (CI) = 0.9-13] or 4.0 ppb or greater (OR = 3.1; 95% CI = 0.8-12) had a higher estimated risk for breast cancer than women with less than 2.0 ppb. The odds ratios were unchanged when available breast cancer risk factors were included in the analysis.

Heat-related mortality in selected United States cities, summer 1999.

As part of a public health response to severe heat waves in the midwestern and northeastern United States in the summer of 1999, the authors actively solicited the number of heat-related deaths from 38 medical examiner and coroner jurisdictions comprising 35 metropolitan areas to enumerate heat-related deaths in areas affected by heat waves. They also determined the usefulness of these data for surveillance and rapid investigation of heat-related deaths. A total of 334 heat-related deaths were reported during the study period of July 1–August 31. Minor changes in data collection and diagnostic criteria in some medical examiner and coroner jurisdictions would allow for greater comparability among jurisdictions. The National Association of Medical Examiners’ position paper on heat-related mortality diagnosis provides important guidance to medical examiners and coroners regarding the certification of heat-related deaths and may require some refinement to address certain issues. Among these are certifying manner of death and classifying potential causes of heat-related death not involving hyperthermia or heat stroke, but where heat is a potential contributing factor to death. Medical examiners and coroners are an important resource for heat-related mortality research, and improvements in data collection and reporting could yield tremendous benefits to our understanding of and interventions for heat-related deaths.

Menstrual function among women exposed to polybrominated biphenyls: A follow-up prevalence study

BackgroundAlteration in menstrual cycle function is suggested among rhesus monkeys and humans exposed to polybrominated biphenyls (PBBs) and structurally similar polychlorinated biphenyls (PCBs). The feedback system for menstrual cycle function potentially allows multiple pathways for disruption directly through the hypothalamic-pituitary-ovarian axis and indirectly through alternative neuroendocrine axes.MethodsThe Michigan Female Health Study was conducted during 1997–1998 among women in a cohort exposed to PBBs in 1973. This study included 337 women with self-reported menstrual cycles of 20–35 days (age range: 24–56 years). Current PBB levels were estimated by exponential decay modeling of serum PBB levels collected from 1976–1987 during enrollment in the Michigan PBB cohort. Linear regression models for menstrual cycle length and the logarithm of bleed length used estimated current PBB exposure or enrollment PBB exposure categorized in tertiles, and for the upper decile. All models were adjusted for serum PCB levels, age, body mass index, history of at least 10% weight loss in the past year, physical activity, smoking, education, and household income.ResultsHigher levels of physical activity were associated with shorter bleed length, and increasing age was associated with shorter cycle length. Although no overall association was found between PBB exposure and menstrual cycle characteristics, a significant interaction between PBB exposures with past year weight loss was found. Longer bleed length and shorter cycle length were associated with higher PBB exposure among women with past year weight loss.ConclusionThis study suggests that PBB exposure may impact ovarian function as indicated by menstrual cycle length and bleed length. However, these associations were found among the small number of women with recent weight loss suggesting either a chance finding or that mobilization of PBBs from lipid stores may be important. These results should be replicated with larger numbers of women exposed to similar lipophilic compounds.

Key factors for civilian injuries and deaths from exploding landmines and ordnance

Objective: To identify risk factors for death or injury from landmines and ordnance in Kabul City, Afghanistan, so programs can target preventive actions. Methods: Active surveillance in hospitals and communities for injuries and deaths from landmine and ordnance explosions in Kabul City. Results: Of the 571 people the authors identified during the 25-month period, 161 suffered a traumatic amputation and 94 were killed from a landmine or ordnance explosion. Of those asked, 19% of victims had received mine awareness education before the incident, and of those, the majority was injured while handling or playing with an explosive device. Most victims were young males with a few years of education. The occupation types most at risk were students and laborers, and unemployment was common among the victims. Collecting wood or paper and playing with or handling an explosive were the most frequent activities associated with injuries and deaths. Conclusions: From May 1996 to July 1998, explosions from landmines and ordnance claimed 571 victims and were an important preventable cause of injury and death among people in Kabul City. Prevention strategies should focus on high-risk groups and changing risky behaviors, such as tampering with explosive devices.

Polybrominated Biphenyl Exposure and Benign Breast Disease in a Cohort of US Women

PURPOSE We examined the relation between serum polybrominated biphenyl (PBB) levels and the risk of benign breast disease in a cohort of Michigan women unintentionally exposed to PBBs in 1973 and interviewed in 1997. METHODS We used extended Cox models to generate adjusted hazard ratios; models included polychlorinated biphenyls (PCBs) and risk factors for benign breast disease reported in the literature. RESULTS Two hundred fourteen (23%) of 951 women reported benign breast disease diagnosed by a physician. Compared with women with low PBB exposure, benign breast disease was not reported more frequently among those with moderate (>1-12 parts per billion [ppb]), (odds ratio [OR] 1.08, 95% confidence interval [CI] = 0.80-1.45), or high (>12 ppb), (OR 0.79, 95% CI = 0.46-1.38) PBB exposure. PCB exposure was also not associated with self-reported physician-diagnosed benign breast disease. Age, smoking, and annual number of health-care provider visits were significantly associated with benign breast disease. CONCLUSIONS Our analysis did not demonstrate an association between serum PBB level and self- reported physician-diagnosed benign breast disease. We did observe an increased risk of benign breast disease for women who smoked, an association that has not been consistently found in previous studies.