The following are pre-publication drafts of articles from the Morbidity and Mortality Weekly Report dated June 23, 1995. Late-breaking articles, and final editorial revisions are not included; therefore, these articles should be considered preliminary, and not to be released to the public. --CDC -------------------------------------------------------------- Serious Eye Injuries Associated with Fireworks -- United States, 1990-1994 Eye injuries caused by fireworks are often severe and can cause permanently reduced visual acuity or blindness. Findings from the National Electronic Injury Surveillance System database maintained by the U.S. Consumer Product Safety Commission (CPSC) indicate that approximately 12,000 persons are treated each year in U.S. emergency departments because of fireworks-related injuries; of these, an estimated 20% are eye injuries. To improve characterization of fireworks-related eye injuries, data were analyzed from the United States Eye Injury Registry (USEIR) for July 1990-December 1994 and from the Eye Injury Registry of Alabama (EIRA) for August 1982-July 1989. This report summarizes the findings of these analyses. United States Eye Injury Registry USEIR, a nonprofit organization sponsored by the Helen Keller Eye Research Foundation, is a federation of state eye registries that uses a standardized form to obtain voluntarily reported data on eye injuries and to obtain 6-month follow-up information. Reports are made by ophthalmologists to the USEIR database in Birmingham, Alabama. The primary purpose of USEIR is to provide prospective, population-based, epidemiologic data to improve the prevention and control of eye injuries. The registry contains information only for patients who have sustained a serious eye injury, defined as "an injury resulting in permanent and significant, structural or functional ocular change." USEIR comprises 39 state registry affiliates (representing 89% of the U.S. population); 32 states registered injuries during 1990-1994, and 27 states reported fireworks-related injuries during this period. From July 1990 through December 1994, a total of 4575 serious eye injuries from all causes were reported to USEIR; of the 274 (6%) fireworks-related injuries, 255 (93%) were unintentional injuries. Persons injured by fireworks were aged 4-63 years (median: 15 years); 211 (77%) were males. The largest proportion (123 [45%]) of injured persons were bystanders; 96 (35%) were fireworks operators, and for 55 (20%), status was unknown. Most (219 [80%]) injuries occurred during the Independence Day holiday period*; 44 (16%) occurred during the New Year's holiday period*, and 11 (4%) at other times. Most (67%) injuries occurred at home; injuries also occurred in recreational settings (14%), on a street or highway (5%), and in parking lots or occupational settings (1%). Location was unknown for 13%. Most injuries were caused by bottle rockets (58%) (Figure 1). Bottle rockets accounted for 68% of the injuries to bystanders. Eye Injury Registry of Alabama A retrospective review was begun in 1989 of severely injured persons registered from August 1982 through July 1989 through the EIRA, the first state registry of USEIR. Reports to the EIRA are made by Alabama ophthalmologists. Data were obtained from EIRA standard report forms and from direct interviews with each injured person and/or family members. Of the 70 fireworks-related injuries reported, 40 (57%) occurred during the Independence Day holiday period, and 27 (39%) occurred during the New Year's holiday period. These injuries resulted in legal blindness in 31 (44%) injured persons; in addition, enucleation was required for seven (10%). Bottle rockets accounted for 58 (83%) injuries, including eight of 10 injuries resulting in permanent damage to the optic nerve and all those resulting in enucleation. Patients who sustained eye injuries resulting from bottle rockets reported that factors associated with their injuries included product misuse, (e.g., the intentional aiming of the device at others ["bottle rocket wars"] and throwing the device after it had been lit but before ignition), device malfunction (especially immediate explosion after ignition), erratic flight characteristics even when used according to manufacturers' instructions, and device ricochet off hard surfaces (e.g., a car or the street). Reported by: S Brown, MPH, CD Witherspoon, MD, R Morris, MD, SM Hamilton, MD, FI Camesasca, MD, JA Kimble, MD, United States Eye Injury Registry, Birmingham, Alabama. Directorate for Epidemiology and Health Sciences, Div of Hazard Analysis, US Consumer Product Safety Commission. Div of Unintentional Injury Prevention, National Center for Injury Prevention and Control, CDC. Editorial Note: Irreversible consequences--including reduced visual acuity and blindness--can result from the use of consumer fireworks, especially bottle rockets. Analysis of the USEIR database indicated that a high proportion of fireworks-related injuries occurred among young males--a finding consistent with previous reports (1,2). These findings are similar to the results of a study in Washington in which injuries were associated with improper use (both intentional and unintentional), product malfunctions (e.g., short fuses, erratic flight, or tip-over), and high temperature (2). Consumer fireworks--including bottle rockets (classified as 1.4G [formally known as Class C] fireworks)--have been banned in 10 states (Arizona, Connecticut, Delaware, Georgia, Massachusetts, Minnesota, New Jersey, New York, Rhode Island, and Vermont). Six states (Illinois, Iowa, Maine, Maryland, Ohio, and Pennsylvania) permit the use only of sparklers and other novelties (e.g., poppers, wheels, and snaps). The District of Columbia and 32 states allow at least some 1.4G fireworks to be sold. Nevada and Hawaii have no laws regulating fireworks except for local ordinances. The CPSC has banned firecrackers with greater than 50 mg pyrotechnic composition (including cherry bombs, M-80s, and silver salutes) designed to detonate on or near the ground and reloadable shell devices with diameters exceeding 1.75 inches; bottle-rockets can contain up to 130 mg pyrotechnic composition. Because of the risks for injury associated with bottle rockets and other fireworks, several organizations have made specific recommendations regarding their use. USEIR recommends that persons attend public fireworks displays; however, if persons choose to use fireworks, USEIR recommends that they not use bottle rockets, and when other fireworks are used, eye protection should be worn by operators, bystanders, and spectators. CPSC and USEIR also advise that young children should never use fireworks, older children should be supervised when using fireworks, fireworks should be used only outdoors, a source of water should always be nearby for fire and to douse malfunctioning fireworks, instructions should be read and followed carefully, and malfunctioning fireworks should not be relit. Several states have prohibited bottle rocket sales, and such bans are supported by the American Academy of Ophthalmology (3), American Academy of Pediatrics (4), and American Public Health Association (5). Despite the advisories regarding the dangers of fireworks use and state bans on use, fireworks continue to cause serious eye injuries--fireworks purchasers often cross state borders during holiday seasons to obtain fireworks that are illegal in their own states. In addition, because USEIR is a voluntary registry and not all states are affiliated, the numbers presented in this report may underestimate the problem nationally. CDC, concurring with the USEIR recommendations, suggests that health-care providers urge patients and their families to attend professionally conducted public displays of fireworks. References 1. CDC. Fireworks-related injuries--Marion County, Indiana, 1986-1991. MMWR 1992;41:451-4. 2. CDC. Fireworks-related injuries--Washington. MMWR 1983;32:285-6. 3. Eye Safety and Sports Ophthalmology Committee. Fireworks remain serious health hazard and cause of blindness. San Francisco: American Academy of Ophthalmology, May 1995. 4. Committee on Injury and Poison Prevention. Children and fireworks. Pediatr 1991;88:652-3. 5. American Public Health Association. Resolution 9111--banning bottle rockets: prevention of ocular injuries. In: American Public Health Association. Public policy statements of the American Public Health Association. Washington, DC: American Public Health Association, 1994: 482-3. * The number of days for the holiday period varied each year. ** The U.S. Consumer Product Safety Commission (CPSC) staff contributed injury data and information for this article; however, the views expressed in the article do not necessarily represent those of the CPSC. Achievement of Dietary Goals -- Kansas, 1993 Fat intake and other dietary factors are associated with increased risk for important chronic diseases, including cardiovascular disease and cancer (1-4). To characterize the nutritional behaviors of residents of Kansas, the Kansas Department of Health and Environment (KDHE) conducted a nutrition assessment survey in 1993 and has used the results as a baseline for monitoring progress toward attaining Healthy Kansans 2000 (HK2000) nutrition objectives. This report summarizes selected findings from the nutrition survey relative to three HK2000 objectives: 1) increase to 35% the proportion of adults who consume five or more daily servings of fruits and vegetables; 2) increase to 40% the proportion of adults whose dietary fat intake constitutes less than 30% of their total food-energy intake (a lower fat diet); and 3) increase to 70% the proportion of adults who consume greater than or equal to 600 mg of calcium daily (75% of the Recommended Dietary Allowance for adults aged greater than or equal to 25 years [5]). A representative sample of 1387 civilian, noninstitutionalized adults (aged greater than or equal to 18 years) was selected using a random-digit-dialing telephone method; 1119 (80.6%) completed the survey, and 268 (19.3%) persons refused or were unable to respond. The interviews were completed during June-July 1993. Participants responded to an interviewer-administered 24-hour dietary recall for the day before the call. Food portion sizes were estimated (e.g., a small apple is the size of a tennis ball), and a mention of a fruit or vegetable was used as a surrogate for a serving. Food Intake and Analysis Software was used to estimate nutrient amounts reported in the 24-hour dietary recall data (6). Point estimates were weighted by the age and sex of the Kansas population and by the number of adults in each household. Overall, few (12.5%) respondents reported eating five or more fruits and vegetables during the previous day (Table 1); the prevalence of this behavior was higher among women (15.2%) than men (9.7%), and increased directly with age (persons aged 18-34 years: 7.0%; persons aged 35-64 years: 12.8%; and persons aged greater than or equal to 65 years: 20.7%) and education (persons with less than or equal to 12 years of education: 9.5%; persons with 13-15 years: 12.1%; and persons with greater than or equal to 16 years: 18.4%). Nearly one third (29.8%) of respondents acquired less than 30% of their total food-energy intake from fat. The prevalence of this behavior was higher among women (33.4%) than men (26.5%), but did not vary by age or education. Approximately one half (47.9%) of respondents consumed greater than or equal to 600 mg of calcium. The prevalence of this behavior was lower in women (40.7%) than men (55.3%) and varied inversely with age (persons aged 18-34 years: 56.3%; persons aged 35-64 years: 44.7%; and persons aged greater than or equal to 65 years: 41.7%). Reported by: K Fitzgerald, MS, J Johnston, MS, P Marmet, MS, K Pippert, Bur of Chronic Disease and Health Promotion, A Pelletier, MD, Acting State Epidemiologist, Kansas Dept of Health and Environment. Div of Field Epidemiology, Epidemiology Program Office; Div of Health Promotion Statistics, National Center for Health Statistics; Div of Nutrition, National Center for Chronic Disease Prevention and Health Promotion, CDC. Editorial Note: The findings in this report indicate that most respondents did not meet the HK2000 goals, which were based on national nutrition guidelines (7) and were similar to the national health objectives for the year 2000 (4). Because national nutrition surveys (4) do not provide state-specific estimates and are often available only after prolonged periods, state population-based dietary surveys, such as that in Kansas, are essential for providing state-specific data to measure the effect of interventions and for monitoring progress toward state-specific year 2000 goals. The survey methodology used in Kansas may serve as a model for other states to establish baselines and to monitor the impact of interventions. KDHE plans to conduct these or similar surveys every 3-5 years. The survey results from Kansas are subject to at least two limitations. First, because participants were interviewed during summer months when consumption of fruits and vegetables is likely to be higher than during other seasons of the year (8), reported fruit consumption may have been higher than if the survey had been conducted during other seasons. Second, 24-hour recall surveys may be less representative than multiple-day recall surveys because the actual amount of food consumed may differ from the usual intake of the respondent (9). The results of the survey in Kansas are being used as a baseline for monitoring progress among statewide interventions. Kansas LEAN ("Low-fat Eating for America Now"), a state health department program involving a coalition of businesses, health agencies, schools and others, is working to improve dietary habits through interventions such as the statewide worksite promotion "Take the Challenge, Be a Leaner Eater" to reduce the proportion of total food-energy intake from fat. In addition to interventions targeted toward adults, Kansas LEAN emphasizes the education of children about appropriate nutrition. Long-term nutritional habits can be improved by introducing new foods to children, lowering the fat content of school lunches, and educating children (10). For example, a "Check Your Six" program targeted toward fifth-grade and preschool-aged children has been initiated to increase the quantity of grain products consumed. References 1. Schaefer EJ, Lichtenstein AH, Lamon-Fava S, McNamara JR, Ordovas JM. Lipoproteins, nutrition, aging, and atherosclerosis. Am J Clin Nutr 1995;61(suppl):726S-40S. 2. Block C, Patterson B, Subar A. Fruit, vegetables and cancer prevention: a review of the epidemiologic evidence. Nutr Cancer 1992;18:1-29. 3. Bunker VW. The role of nutrition in osteoporosis. Br J Biomed Sci 1994;51:228-40. 4. Public Health Service. Healthy people 2000; national health promotion and disease prevention objectives--full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212. 5. National Research Council. Recommended dietary allowances. 10th ed. Washington, DC: National Academy Press, 1989. 6. University of Texas Health Science Center. Food intake analysis system, version 2.2 [Computer software]. Houston, Texas: University of Texas Health Science Center, 1993. 7. US Department of Agriculture/U.S. Department of Health and Human Services. Nutrition and your health: dietary guidelines for Americans. 3rd ed. Washington, DC: US Department of Agriculture/US Department of Health and Human Services, 1990:25-6. 8. Sugarman S, Ballew C, Lai G. Seasonal produce consumption in Chicago Hispanic women. J Am Diet Assoc 1992;92(suppl):874. 9. Thompson FE, Byers T. Dietary assessment resource manual. J Nutr 1994;124(suppl):2246S-7S. 10. Institute of Medicine. Improving America's diet and health: from recommendations to action. Washington, DC: National Academy Press; 1991. Lyme Disease -- United States, 1994 For surveillance purposes, Lyme disease (LD) is defined as the presence of an erythema migrans rash greater than or equal to 5 cm in diameter or laboratory confirmation of infection with Borrelia burgdorferi and at least one objective sign of musculoskeletal, neurologic, or cardiovascular disease (1). In 1982, CDC initiated surveillance for LD, and in 1990, the Council of State and Territorial Epidemiologists adopted a resolution that designated LD a nationally notifiable disease. This report summarizes surveillance data for LD in the United States during 1994. In 1994, 13,083 cases of LD were reported to CDC by 44 state health departments, 4826 (58%) more than the 8257 cases reported in 1993 (Figure 1). As in previous years, most cases were reported from the northeastern and north-central regions (Figure 2). The overall incidence of reported LD was 5.2 per 100,000 population. Eight states reported incidences of more than 5.2 per 100,000 (Connecticut, 62.2; Rhode Island, 47.2; New York, 29.2; New Jersey, 19.6; Delaware, 15.5; Pennsylvania, 11.9; Wisconsin, 8.4; and Maryland, 8.3); these states accounted for 11,476 (88%) of nationally reported cases. Six states (Alaska, Arizona, Hawaii, Mississippi, Montana, and North Dakota) reported no cases. Reported incidences were greater than or equal to 100 per 100,000 in 15 counties in Connecticut, Maryland, Massachusetts, New Jersey, New York, Pennsylvania, and Wisconsin; the incidence was highest in Nantucket County, Massachusetts (1197.6). Six northeastern states accounted for 95% of the increase in reported cases for 1994: Maryland, New Jersey, New York, Rhode Island, Connecticut, and Pennsylvania. Reported cases increased by 218 cases (121%) in Maryland, 747 cases (95%) in New Jersey, 2382 cases (85%) in New York, 199 cases (73%) in Rhode Island, 680 cases (50%) in Connecticut, and 353 cases (33%) in Pennsylvania. Reported cases remained stable in the states with endemic disease in the north-central region (Minnesota and Wisconsin) and decreased in California (36%). Males and females were nearly equally affected in all age groups except those aged 10-19 years (males: 55%) and those aged 30-39 years (females: 56%). Reported by: State health departments. Bacterial Zoonoses Br, Div of Vector-Borne Infectious Diseases, National Center for Infectious Diseases, CDC. Editorial Note: LD is the most commonly reported vectorborne infectious disease in the United States. Infection with B. burgdorferi results from exposure to nymphal and adult forms of tick vectors of the genus Ixodes: I. scapularis (black-legged tick) in the northeastern and upper north-central United States, and I. pacificus (western black-legged tick) in the Pacific coastal states. Risk for exposure to B. burgdorferi is strongly associated with the prevalence of tick vectors and the proportion of those ticks that carry B. burgdorferi. The risk for exposure may be highly focal (2) and can differ substantially between adjacent states, counties, communities, and areas on the same residential property (3,4). In northeastern states with endemic disease, the infection rate of nymphal I. scapularis ticks with B. burgdorferi is commonly 20%-35%, and even modest changes in tick numbers can substantially affect the risk for exposure to infected vectors (5). In one area of Connecticut where approximately 15% of I. scapularis are infected with B. burgdorferi, changes in the annual incidence of LD have paralleled changes in I. scapularis densities (M. Cartter, Connecticut Department of Health and Addiction Services, K. Stafford, Connecticut Agricultural Experimental Station, personal communication, 1995). In 1994, tick surveillance in the Northeast indicated increases over previous years in vector tick density. For example, in one site in Westchester County, New York, population density of I. scapularis nymphs increased 400% from 0.4 nymphs per square meter in 1993 to 1.6 nymphs per square meter in 1994 (T. Daniels, Fordham University, R. Falco, Westchester County Department of Health, personal communication, 1995), and in Rhode Island, nymphal I. scapularis density measured at sites throughout the state increased 158% from 1993 to 1994 (T. Mather, University of Rhode Island, personal communication, 1995). Ascertainment of LD cases based only on passive surveillance may result in underreporting of cases (6,7). Because of this and in accordance with recommendations for control of emerging diseases (8), some states in which LD is endemic have expanded surveillance efforts. In 1994, the New York State Department of Health augmented surveillance with additional staff, intensified active case detection, and validated some cases reported in the previous year; these efforts probably accounted for some of the increase in reported cases for New York in 1994 (D. White, New York State Department of Health, personal communication, 1995). Active surveillance, with support from CDC, is conducted by health departments in Connecticut, Michigan, Minnesota, New Jersey, New York, Oregon, Rhode Island, and West Virginia. The risk for infection among persons residing in or visiting areas where LD is endemic can be reduced through avoidance of known tick habitats; other preventive measures include wearing long pants and long-sleeved shirts, tucking pants into socks, applying tick repellents containing N,N-diethyl-m-toluamide ("DEET") to clothing and/or exposed skin according to manufacturer's instructions, checking thoroughly and regularly for ticks, and promptly removing any attached ticks. Acaracides containing permethrin kill ticks on contact and can provide further protection when applied to clothing, but are not approved for use on skin. Additional information about LD is available from state and local health departments, from CDC's Voice Information System, telephone (404) 332-4555; from CDC's Bacterial Zoonoses Branch, Division of Vector-Borne Infectious Diseases, National Center for Infectious Diseases, telephone (970) 221-6453; and from the Office of Communications, National Institute of Allergy and Infectious Diseases, National Institutes of Health, telephone (301) 496-5717. References 1. CDC. Case definitions for public health surveillance. MMWR 1990;39(no. RR-13):19-21. 2. Piesman J, Gray JS. Lyme disease/Lyme borreliosis. In: Sonenshine DE, Mather TN, eds. Ecological dynamics of tick-borne zoonoses. New York: Oxford University Press, 1994:327-50. 3. Maupin GO, Fish D, Zultowsky J, Campos EG, Piesman J. Landscape ecology of Lyme disease in a residential area of Westchester County, New York. Am J Epidemiol 1991;133:1105-13. 4. Spielman A, Wilson ML, Levine JF, Piesman J. Ecology of Ixodes dammini-borne human babesiosis and Lyme disease. Ann Rev Entomol 1985;30:439-60. 5. Mather TN. The dynamics of spirochete transmission between ticks and vertebrates. In: Ginsberg HS, ed. Ecology and environmental management of Lyme disease. New Brunswick, New Jersey: Rutgers University Press, 1993:43-60. 6. Ley CT, Davila IH, Mayer NM, Murray RA, Rutherford GW, Reingold AL. Lyme disease in northwestern coastal California. Western J Med 1994;160:534-9. 7. Jung PI, Nahas JN, Strickland GT, McCarter R, Israel E. Maryland physicians' survey on Lyme disease. Maryland Medical Journal 1994;43:447-50. 8. CDC. Addressing emerging infectious disease threats: a prevention strategy for the United States. Atlanta, Georgia: U.S. Department of Health and Human Services, Public Health Service, 1994. African Pygmy Hedgehog-Associated Salmonellosis -- Washington, 1994 During 1994, the Washington Department of Health Public Health Laboratory reported the isolation from a human of a rare Salmonella serotype, Salmonella serotype Tilene. This report summarizes the epidemiologic investigation of the case by the Seattle-King County Department of Public Health, which suggested the infection was related to exposure to African pygmy hedgehogs. On April 9, 1994, a 10-month old girl was evaluated in a hospital emergency department in King County for an acute febrile, nonbloody diarrheal illness; the fever resolved without treatment but the diarrhea persisted for 3 weeks. On April 28, she was evaluated in an outpatient clinic; a stool sample yielded Salmonella Tilene. The infant had been breast-fed and received supplemental solid foods; she did not attend a child care center. Her parents were asymptomatic, and cultures of stool samples from both were negative. The family owned a dog and a breeding herd of 80 apparently healthy African pygmy hedgehogs; a stool sample from one of three hedgehogs cultured yielded Salmonella Tilene. Although the infant had not had direct contact with the hedgehogs, the hedgehogs were handled frequently by one member of the family. The infant's illness resolved after treatment for an upper respiratory infection with trimethoprim-sulfamethoxazole. Reported by: S Lipsky, Epidemiology Unit, T Tanino, Laboratory Section, Seattle-King County Dept of Public Health; JH Lewis, Public Health Laboratories, Washington Dept of Health. Foodborne and Diarrheal Diseases Br, Div of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, CDC. Editorial Note: Salmonella Tilene is an uncommon cause of human illness; the organism was first isolated in 1960 from a child in Senegal (1). Although the patient in Washington had the first documented human infection with this serotype in the United States,* since January 1991 the U.S. Department of Agriculture (USDA) has identified two isolates from animals at the National Veterinary Services Laboratory--both were from African pygmy hedgehogs (K. Ferris, USDA, personal communication, April 1995). Although the African pygmy hedgehog is an unusual pet, ownership of these animals is reportedly increasing in the United States (2). African pygmy hedgehogs are bred domestically in the United States; importation from Africa has been prohibited since 1991 because they can carry foot-and-mouth disease, a disease of livestock that is not found in the United States (R. Perkins, USDA, personal communication, May 1995). Salmonella spp. are found worldwide in domestic and wild animals, including mammals, reptiles, and birds. Although ingestion of contaminated food is the most important source of salmonellosis in humans (3), pets are another potential source of infection (4,5). The overall risk for acquiring salmonellosis from pets is low; however, the risk is increased with exposure to animals with high fecal carriage rates of Salmonella. In general, carriage rates are higher in animals that are young, have diarrhea, or live in overcrowded conditions (4). Reported carriage rates are highest in reptiles (as high as 90%), and lowest in dogs and cats (4). Carriage rates have not been reported for African pygmy hedgehogs. The investigation of this case and a recent report involving reptile-associated transmission of Salmonella (5) underscore the potential risk for transmission of Salmonella from an infected pet to members of the household who do not have direct contact with the pet. This risk can be reduced by handwashing after handling of pets, especially before eating or handling food, and by avoiding contact with pets' feces (6). References 1. Le Minor L, Pinhede N, Kerrest J, Armengaud M, Baylet R, Drean D. A new serotype of Salmonella, S. tilene (1,40:e,h:1,2) [French]. Bull Soc Path Exot 1960;53:777-8. 2. Lermayer RM. African pygmy hedgehogs: latest pet sensation. Live Animal Trade and Transport Magazine 1992;Dec:45-8. 3. Tauxe RV. Salmonella: a postmodern pathogen. J Food Protect 1991:54:563-8. 4. Glaser CA, Angulo FJ, Rooney J. Animal associated opportunistic infections in HIV-infected persons. Clin Infect Dis 1994;18:14-24. 5. CDC. Reptile-associated salmonellosis--selected states, 1994-1995. MMWR 1995;44:347-50. 6. Angulo FJ, Glaser CA, Juranek DD, Lappin MR, Reginery RL. Caring for pets of immunocompromised persons. J Am Vet Med Assoc 1994; 205:1711-8. * On June 21, the Texas Department of Health reported to CDC the second human infection with Salmonella Tilene in the United States; the patient's family owned a hedgehog.