Sue Mallonee

Surveillance and prevention of residential-fire injuries

BACKGROUND The majority of severe and fatal burn injuries result from residential fires. We studied the effectiveness of a smoke-alarm-giveaway program in the prevention of burn injuries in an area with a high rate of such injuries. METHODS We collected data on burn injuries in Oklahoma City from September 1987 through April 1990. The target area for the intervention was an area of 24 square miles (62 km2) with the highest rate of injuries related to residential fires in the city. We distributed smoke alarms door to door in the target area and then surveyed alarm use and function in a sample of the homes that had received an alarm. We also calculated the rates of fire injury per 100,000 population and per 100 fires for both the target area and the rest of the city before and after the smoke-alarm giveaway. RESULTS Before the intervention the rate of burn injuries per 100,000 population was 4.2 times higher in the target area than in the rest of Oklahoma City. An initial survey indicated that 11,881 of the 34,945 homes in the target area (34 percent) did not have smoke alarms. A total of 10,100 smoke alarms were distributed to 9291 homes; 45 percent were functioning four years later. The annualized fire-injury rates declined by 80 percent in the target area during the four years after the intervention (from 15.3 to 3.1 per 100,000 population), as compared with a small increase in the rest of the city (from 3.6 to 3.9 per 100,000 population). There was also a 74 percent decline in the target area in the injury rate per 100 fires (from 5.0 to 1.3; rate ratio, 0.3; 95 percent confidence interval, 0.1 to 0.6), as compared with a small increase in the rest of the city. CONCLUSIONS A targeted intervention involving a smoke-alarm-giveaway program can reduce the incidence of injuries from residential fires.

Fatal Necrotizing Colitis Following a Foodborne Outbreak of Enterotoxigenic Clostridium perfringens Type A Infection

BACKGROUND Enterotoxigenic Clostridium perfringens type A is the third leading cause of foodborne disease in the United States, resulting annually in an estimated 250,000 cases of a typically mild, self-limiting gastrointestinal illness. METHODS A retrospective cohort study was conducted to determine the cause of a small cluster of cases of gastrointestinal illness, which included cases of severe necrotizing colitis. Participants in the study consisted of residents and staff of a residential care facility for the mentally ill in Oklahoma (n = 20). An inspection of food preparation and food storage areas of the residential care facility was conducted as part of an environmental investigation. The investigation included extensive microbiological and molecular testing of the C. perfringens isolates and tissue specimens collected at autopsy. RESULTS A total of 7 (3 confirmed and 4 probable) cases of foodborne enterotoxigenic C. perfringens type A were identified (attack rate, 35%) after the consumption of high-risk foods. Three residents developed acute necrotizing colitis; 2 of them died. Each patient with confirmed infection presented with evidence of constipation or fecal impaction. C. perfringens enterotoxin (CPE)-positive C. perfringens type A was cultured on samples from each patient with necrotizing colitis. Although statistical analyses failed to implicate a food source, the isolates carried a chromosomal cpe gene, which supports a foodborne origin. CONCLUSIONS This study confirms that foodborne CPE-positive C. perfringens type A can affect the colon, resulting in potentially fatal necrotizing colitis. Drug-induced constipation and fecal impaction, resulting in prolonged exposure of the colonic mucosal tissue to C. perfringens type A toxins, contributed to the development of necrotizing colitis.

A large nosocomial outbreak of hepatitis C and hepatitis B among patients receiving pain remediation treatments.

BACKGROUND AND OBJECTIVE In August 2002, the Oklahoma State Department of Health received a report of six patients with unexplained hepatitis C virus (HCV) infection treated in the same pain remediation clinic. We investigated the outbreaks extent and etiology. DESIGN, SETTING, AND PARTICIPANTS We conducted a retrospective cohort study of clinic patients, including a serologic survey, interviews of infected patients, and reviews of medical records and staff infection control practices. Patients received outpatient pain remediation treatments one afternoon a week in a clinic within a hospital. Cases were defined as HCV or hepatitis B virus (HBV) infections among patients who reported no prior diagnosis or risk factors for disease or reported previous risk factors but had evidence of acute infection. RESULTS Of 908 patients, 795 (87.6%) were tested, and 71 HCV-infected patients (8.9%) and 31 HBV-infected patients (3.9%) met the case definition. Multiple HCV genotypes were identified. Significantly higher HCV infection rates were found among individuals treated after an HCV-infected patient during the same visit (adjusted odds ratio [AOR], 6.2; 95% confidence interval [CI95], 2.4-15.8); a similar association was observed for HBV (AOR, 2.9; CI95, 1.3-6.5). Review of staff practices revealed the nurse anesthetist had been using the same syringe-needle to sequentially administer sedation medications to every treated patient each clinic day. CONCLUSIONS Reuse of needles-syringes was the mechanism for patient-to-patient transmission of HCV and HBV in this large nosocomial outbreak. Further education and stricter oversight of infection control practices may prevent future outbreaks.

Tornado-Related Deaths and Injuries in Oklahoma due to the 3 May 1999 Tornadoes

During the evening hours of 3 May 1999, 58 tornadoes occurred in Oklahoma. One tornado reached F5 intensity and left a widespread path of death, injury, and destruction in and around the Oklahoma City metropolitan area. Other communities across the state were also affected. Data on persons who died or were injured were collected from medical examiner reports, hospital medical records, and follow-up questionnaires. In addition, community surveys were conducted in the damaged areas, and a random telephone survey of people in the Oklahoma City area was conducted. A total of 45 persons died, and 645 survivors were treated at a hospital for injuries/health conditions related to the tornadoes. Detailed analyses were conducted on the 40 deaths and 512 nonfatal injuries that resulted directly from the tornadoes. The average age of persons who died was significantly higher than that of injured survivors. Almost three-fourths (74%) of survivors were treated in an emergency department and released; 26% were hospitalized, with an average stay of 7 days. The most common kinds of injuries were soft-tissue injuries (cuts, bruises, and scrapes), fractures/dislocations, and brain injuries. The most common causes of injuries for survivors were being hit by flying/falling debris and being picked up or blown by the tornado. Probable causes of death included multiple injuries (50%), head injuries (23%), chest trauma (18%), and traumatic asphyxia (10%). The proportion of deaths among injured persons was higher in mobile homes, apartment buildings, and outdoors than in houses. The vast majority of persons received television warnings; few persons received warnings by weatherband radio. Survey data indicated that since the tornadoes there had been only a slight increase in the proportion of persons with a storm shelter on their home premises and in the proportion of persons who know the location of the nearest shelter. Effective preparedness plans should be developed in advance of situations with tornadic potential and implemented in a timely manner when warnings are issued. The accessibility and knowledge of the location of shelters also needs to be increased. Warning systems should be integrated and duplicative, and they should include traditional methods and new technology.

Ocular injuries sustained by survivors of the Oklahoma City bombing

OBJECTIVE The purpose of this study is to provide a review of the ocular injuries sustained by survivors of the April 19, 1995, bombing of the Alfred P. Murrah Federal Building in Oklahoma City. DESIGN Retrospective, noncomparative case series. PARTICIPANTS The authors retrospectively evaluated data collected on all surviving persons receiving ocular injuries during the bombing and on all at-risk occupants of the federal building and four adjacent buildings. METHODS Injury data from survivors were collected from multiple sources to include hospital medical records, a physician survey, emergency medical services run reports, written survivor accounts, building occupant survey, telephone interviews, and mail surveys. MAIN OUTCOME MEASURES The types of ocular injuries, the associated systemic injuries, and the location of the injured at the time of the blast were evaluated. RESULTS Fifty-five (8%) of the 684 injured bombing survivors sustained an ocular injury. Persons injured in the Murrah building were more than three times more likely to sustain an ocular injury than other injured persons. Seventy-one percent of ocular injuries occurred within 300 feet of the point of detonation. The most common serious ocular injuries included lid/brow lacerations (20 patients, 23 eyes), open globe injuries (12 eyes), orbital fractures (6 eyes), and retinal detachment (5 eyes). A retained intraocular foreign body accounted for only two of the injuries (4%). Glass accounted for nearly two thirds of the ocular injuries. CONCLUSIONS Blasts involving explosions inflict severe ocular injury, mostly as a result of secondary blast effects from glass, debris, etc. Eye injuries in bombings can probably be prevented by increasing the distance from and orientation away from windows (i.e., by facing desks away from windows). Use of such products as laminated glass, toughened window glazing, and Mylar curtains may reduce glass projectiles in the blast vicinity.

The EMS Response to the Oklahoma City Bombing

This is a descriptive study of the Emergency Medical Services response to a bombing of a United States Federal Building in Oklahoma City, Oklahoma on 19 April 1995. The explosion emanated from a rented truck parked in the front of the building. The force of the explosion destroyed three of the four support columns in the front of the building and resulted in a pancaking effect of the upper floors onto the lower floors. There were three distinct phases of the medical response: 1) Immediately available local EMS ambulances and staff; 2) Additional ambulances staffed by recalled, off-duty personnel; and 3) mutual-aid ambulances and personnel from the surrounding communities. There were 361 persons in the building at the time of the explosion, 163 of these perished. Within the first hour of the explosion, 139 patients were transported to area hospitals. Of these, 32% were in critical condition. During the day of the explosion, 444 persons were treated for physical injuries: 410 of these were related to the explosion and 14, including one with fatal injuries, were sustained during search and rescue attempts. A total of 354 (80%) were treated and released from emergency departments, and 90 (20%) were admitted to hospitals. Six of the transported victims either were dead on arrival to the emergency department or died after admission to the hospital. Of those who died, 95% of the deaths were related to blunt trauma associated with the collapse of the structure. Only three persons were extricated alive after the first five hours following the explosion. The scene became flooded with volunteers who, although their intentions were to provide help and aid to those injured, created a substantial logistical problem for Incident Command. Several other lessons were learned: 1) Telephone lines and cells became overloaded, but the Hospital Emergency Administrative Radio system was operational only in three of the 15 hospitals; 2) Volunteer personnel should have responded to the hospitals and not to the scene; and 3) Training was an essential for the success of such a response. Thus, the success of this operation was a function of the intense training, practice, and coordination between multiple agencies.

Epidemiology of homicide-suicide events: Oklahoma, 1994-2001.

In Oklahoma, all nonnatural deaths must be reported to the Office of the Chief Medical Examiner (ME), whose trained investigators report cause of death using a centralized, statewide, standardized reporting system. The purpose of this study was to determine temporal trends of Oklahoma homicide-suicide events and characterize the epidemiology of these events. By reviewing all ME reports of homicides and suicides from 1994 through 2001, we identified 73 homicide-suicide events resulting in 73 suicides and 89 homicides. Suicidal perpetrators of homicide-suicide events were most often white men aged ≥30 years who killed a current or ex-spouse or intimate partner. Homicide victims tended to be younger women the same race as their killer. Firearms were the predominant method of death in both homicides and suicides, with handguns used most frequently. Divorce/estrangement was the main contributing factor to these events, and the most common relationship type was possessive. The existence of a statewide, centralized, and computerized ME system and the ability to access the detailed information in the ME narratives were critical to identifying homicide-suicide events and obtaining the type of detailed information necessary to fully investigate these events.

Evaluation of three smoke detector promotion programs

CONTEXT Seventy percent of U.S. residential fire deaths occur in homes without a working smoke detector. To help prevent residential fire deaths, many programs have distributed or installed detectors in unprotected homes. Because persons receiving a detector may not install it and because detector batteries require annual replacement, the enduring effectiveness of these programs may be questioned. OBJECTIVE We evaluated the long-term functional status of smoke detectors distributed to high-risk households in eight areas of Minnesota, Cherokee County (North Carolina), and Oklahoma City (Oklahoma). DESIGN Cross-sectional. SETTING Home visits were made to check the detectors that were distributed 3 to 4 years earlier. PARTICIPANTS Randomly selected households from the three detector promotion programs. MAIN OUT-COME MEASURE: At least one working smoke detector. RESULTS Participation rates ranged from 72% to 82%. The percentage of evaluation households with at least one working detector ranged from 58% in Oklahoma to 73% in North Carolina. In 76% of households with nonworking detectors, the batteries were either missing or disconnected. When batteries in nonworking detectors were replaced, 83% of the detectors regained function. CONCLUSIONS Future programs should consider distributing detectors that do not require annual battery changes or find effective ways to ensure that batteries are routinely replaced. Programs should also provide each household with the number of detectors needed to meet the most current recommended standard of the National Fire Protection Agency. The evaluations participation rates support the practicality of unannounced home visits to evaluate home injury prevention programs in high-risk groups.

A Large, Travel-Associated Outbreak of Legionellosis among Hotel Guests: Utility of the Urine Antigen Assay in Confirming Pontiac Fever

BACKGROUND During March 2004, a large outbreak of legionnaires disease and Pontiac fever occurred among hotel guests in Oklahoma. An investigation was conducted to identify the source and evaluate the utility of the Legionella urine antigen assay and serologic testing for the identification of Pontiac fever. METHODS A retrospective cohort investigation of hotel guests and employees and an environmental evaluation were performed. Participants were interviewed, and clinical specimens were collected from consenting individuals. RESULTS Six cases of legionnaires disease and 101 cases of Pontiac fever were identified. Exposure to the indoor pool and hot tub area was associated with legionellosis (relative risk, 4.4; 95% confidence interval, 2.8-6.9). Specimens from the pool and hot tub tested positive for Legionella pneumophila serogroup 1 by polymerase chain reaction. For Pontiac fever, the sensitivity and positive predictive value were 35.7% and 100%, respectively, for the urine antigen assay, and 46.4% and 90%, respectively, for serologic testing. The specificity and negative predictive value were 100% and 47.8%, respectively, for the urine antigen assay, and 89.3% and 45.5%, respectively, for serologic testing. CONCLUSIONS Urine antigen testing, with or without serologic testing, can be used to confirm outbreak-associated cases of Pontiac fever caused by L. pneumophila serogroup 1.

Estimating the proportion of homes with functioning smoke alarms: a comparison of telephone survey and household survey results

OBJECTIVES This study determined the proportion of homes with functioning smoke alarms in a low-income area experiencing a high rate of residential fire-related injuries. METHODS An on-site survey of households was conducted to confirm the results of a telephone survey. RESULTS In the telephone survey, 71% of households reported having functioning smoke alarms. In the household survey, 66% of households reported having functioning alarms; however, when the alarms were tested, the percentage dropped to 49%. CONCLUSIONS Telephone surveys may overestimate the presence of functioning smoke alarms in some populations. Thus, the use of telephone surveys to establish baseline measures could significantly affect the evaluation of smoke-alarm giveaway programs.