Mary E. O'Connor

Risk factors associated with latent tuberculosis infection in Mexican American children.

Objectives. To determine risk factors that are associated with the presence of latent tuberculosis infection (LTBI) in Mexican American children. Methods. In this prospective cohort study, we administered tuberculin skin tests (TSTs) and a tuberculosis (TB) risk factor questionnaire to children who were aged 1 to 18 years in immigrant families at a Denver inner-city community health center and elementary school–based health center. Information requested on the questionnaire included child demographics, child and parent birth location, Bacille Calmette-Guérin (BCG) vaccination, and a history and the duration of child and family travel to and visitors from countries where TB is endemic. TST results were read at 48 to 72 hours and were interpreted as positive at 5- and 10-mm induration, depending on risk factor history. All participants received

Targeting Lead Screening: The Ohio Lead Risk Score

5 coupons on return for TST reading. Results. Of 584 children enrolled, 96% returned for TST evaluation, median age was 4 years, 48.6% were male, 98.5% were Latino, 66.3% were born in the United States, and 33% were born in Mexico. Overall, 12.4% of children had positive TSTs. For all children in the study, a positive TST was associated with birth in Mexico and no BCG received (adjusted odds ratio [OR]: 15.7; 95% confidence interval [CI]: 1.5–165.2), birth in Mexico and received BCG (adjusted OR: 29; 95% CI: 12.7–66.1), birth in the United States and received BCG (adjusted OR: 9.1; 95% CI: 2.4–34.1), and child travel to Mexico (adjusted OR: 2.8;95% CI: 1.5–5.4). Risk factors for having a positive TST in the 387 children who were born in the United States were travel to Mexico (unable to calculate the OR because all had traveled to Mexico), older age (median: 6 years; adjusted OR: 1.2/year; 95% CI: 1.02–1.40), and a history of BCG vaccination (adjusted OR: 8.2; 95% CI: 2.0–34.0). For the 195 children who were born in Mexico, logistic regression of the following variables showed that none of the variables remained in the model: child age, gender, BCG status, family travel to Mexico, visitors to the United States, child travel to Mexico, years lived in Mexico, and years since BCG. Conclusions. In a population of primarily Mexican American children, those who were born in the United States had an increased risk for developing LTBI when they had a history of BCG vaccination or had traveled to Mexico. For children who were born in Mexico, we were unable to identify additional risk factors for the presence of LTBI, besides their birth in Mexico. Incentives for return for TST reading, such as grocery coupons, are highly effective.

Children with Moderately Elevated Lead Levels: Is Chelation with DMSA Helpful?

Objective. Annual blood lead (BPb) screening is recommended for children ≤2 years of age residing in high-risk areas. Strategies for identifying these areas exist but lack specificity. We sought to develop an efficient method for identifying risk factors for undue lead exposure in children by using community variables. Design. Logistic regression for model development in one half of the sample followed by validation of the model in the remaining half. Methods. The association between selected census tract characteristics from 19 Ohio counties and the BPb test results of children living in those census tracts was evaluated. The dependent variable, high-risk status, was defined as a census tract with ≥12% of BPb test results ≥10 μg/dL. Results. Data from 897 census tracts were available. Higher risk for lead toxicity existed in areas where: 1) ≥55% of houses were built before 1950 (adjusted odds ratio [AOR]: 10.9 [6.1,19.6]); 2) ≥35% of residents were black (AOR: 3.5 [2.0,6.3]); 3) ≥35% of residents had less than a high school education (AOR: 6.1 [3.6,10.4]); and 4) ≥50% of housing units were renter-occupied (AOR: 3.6 [2.1,6.2]). Receiver operator characteristic (ROC) curves demonstrated no significant differences after applying the model in a second dataset. Conclusions. Several community characteristics predict risk for lead toxicity in children and may provide a useful approach to focus lead screening, especially in communities where public health resources are limited. The approach described here may also prove helpful in identifying factors within a community associated with other environmental public health hazards for children.

CaEDTA vs CaEDTA plus BAL to treat children with elevated blood lead levels

This study evaluates the effectiveness (use under routine circumstances) of DMSA (2,3 dimercaptosuccinic acid) and environmental remediation as compared with placebo and environmental remediation on children with blood lead (BPb) levels of 30-45 pg/dL (1.45-2.17 pmol/L). The endpoints were BPb at 1 month and 6 months after study entry. This double-blind placebo-controlled trial involved 39 children aged 2-5 years, who were randomized to one course of DMSA or placebo. The mean BPb levels of the two groups at study entry were similar, placebo group 33.0 pg/dL (1.59 pmol/L) and the DMSA group 34.9 pg/dL (1.68 pmol/L). At 1 month (the end of treatment) the mean BPb levels of the two groups were: placebo group 33.2 pg/dL (1.60 pmol/L) and the DMSA group 27.4 pg/dL (1.32 pmol/L), p=0.16. At 6 months, the mean BPb levels were 25.1 pg/dL (1.21 pmol/L) for the placebo group and 28.8 pg/dL (1.39 pmol/L) for the DMSA-treated group, p=0.06. Neither of these differences is statistically significant. All children with BPb, in the range studied here, should receive environmental evaluation and remediation; DMSA does not improve long-term blood lead levels.

Impact of Short-Stay Legislation of Length of Stay, Cost of Care, and Rehospitalization for Infants Born Vaginally. † 1215

The effectiveness of CaEDTA alone vs CaEDTA plus BAL was compared retrospectively in a group of 72 children with lead levels between 2.41 μmol/L (50 μg/dL) and 2.90 μmol/L (60 μg/dL). The children who received both drugs had higher median zinc protoporphyrin (ZnP) concentrations at the initiation of therapy than children who received CaEDTA alone (160 μg/dL vs 96 μg/dL, p <.01). There was a significantly increased incidence of vomiting and abnormal liver-function test results in the children who received both drugs. The children who received CaEDTA alone had a greater percent mean fall in lead level at one to three weeks postchelation (30.5 % vs 18.1 %, p <.05). Children who received both CaEDTA and BAL had a greater percent decrease in ZnP at four to eight months postchelation, but there was no difference in percent decrease in lead levels. Children who received both drugs also had a greater number of repeat courses of chelation by six months. The addition of BAL to CaEDTA for treatment of children with lead levels of 2.41 μmol/L (50 μg/dL) to 2.90 μmol/L (60 μg/dL) produced greater toxicity and does not seem to prevent repeat chelations within six months.

Comparison of the Sheffield Birth Score in an Insured Managed Care Population vs. a Medicaid Managed Care Population. † 674

Legislation designed to permit longer post-partum hospitalization of mothers and infants has been enacted at state and national levels. This prospective study was designed to determine how legislation in the State of Ohio permitting 48h postpartum stay would affect duration of infant hospitalization, cost of care, and infant readmission rate. In 1996, 269 infants delivered vaginally were enrolled during 3 month periods before(N=121) and after (N=148) enactment of state legislation (Oct 1996). Eligibility for early infant discharge followed AAP guidelines and included an integrated plan for follow-up with a home nursing visit in 85% of infants discharged ≤48h as well as intensive breast feeding support. Duration of hospitalization and readmission to the ER or hospital were determined from the medical record as well as phone questionnaire. Cost of care was estimated by microcost analysis (CMIS). Duration of infant stay increased from 29±12 to 39±14 hrs pre- and post-legislation, respectively. Maternal and infant cost for vaginal delivery increased from

Success in Breast Feeding by Early Discharge Mothers is Associated with Intensive Support. ♦ 1214

3593±880 to

Maternity Leave Policies: A Comparison Between Children's Hospitals And Fortune 500 Companies. † 586

4154±1076 (16% increase). Readmission rate to hospital or ER did not differ between the two groups (4.0% vs 5.4%, pre- and post-legislation, respectively). We speculate that implementation of AAP guidelines may have optimized the medical decision for early infant discharge. These preliminary observations suggest that, under such circumstances, legislative mandate may increase cost of hospitalization without altering infant outcome. Supported by the March of Dimes. Figure

Evaluation of the 'Best Start' breast-feeding education program

Comparison of the Sheffield Birth Score in an Insured Managed Care Population vs. a Medicaid Managed Care Population. † 674

Effect of Open Access Scheduling on Missed Appointments, Immunizations, and Continuity of Care for Infant Well-Child Care Visits

Success in Breast Feeding by Early Discharge Mothers is Associated with Intensive Support. ♦ 1214