Disease Control Bulletin: January 2002

Contents

disease control bulletin

Cold Weather and Residential Fire Deaths in Vermont

The loss of life by fire in Vermont over the past few years is among the worst in the country on a per capita basis. According to data from the State Fire Marshal, in the four-year period 1997-2000, 65 people died from fire in Vermont with 57 (88%) of those fatalities in residential structures. On average there are more than four hospitalizations for every fire death in Vermont. Fires in rental housing claimed the most lives, with smoking materials – cigarettes, cigars, ashtrays, matches, etc. – being the leading cause of fire deaths. Three firefighters died during that same time period due to fire-related causes. Similar to national statisticyns, most of our losses occur in single and multiple family dwellings.

Despite efforts to reduce the casualties and fire loss in Vermont undertaken by the State Fire Marshal’s office, Vermont State Police, local fire departments and public health agencies, the fire death rate in Vermont has been increasing over the past few years. This trend is distinctly divergent from the national fire death rate, which has shown a decrease over the same time period.

In the United States, December, January and February are the leading months for residential fires and associated deaths. Approximately one-third of residential fire deaths in 1998 occurred during these months. Heating equipment is the second leading cause of residential fire deaths in the U.S. (following smoking) and the leading cause during December and January. In Vermont, during the three-year period 1998-2000 there were 42 residential fire-related deaths, 23 of those (55%) during December, January and February (1998, 1999, 2000 Vermont Report of the Fire Marshal).

All Fire Deaths—Age Adjusted
(Vt Rates are 3 yr Averages Centered on Midpoint)

Vermont Residential fire deaths by month chart

Vermont Residential Fire Deaths by Month
Source: Report of the Fire Marshall

The most effective way to prevent deaths and injuries from fires is to install and maintain smoke alarms in households. The majority of fire-related deaths are due to smoke inhalation rather than burns. Early warning of fire, especially at night when people are sleeping, will add critical time to the escape period. Properly maintained smoke alarms are an effective, inexpensive way to alert residents to fire and are 50 to 80 percent effective at preventing death or injury (Hall JR, The US experience with smoke detectors. NFPA Journal, Sept/Oct 1994; 88:4).

Counseling on fire-related injury prevention

Health care providers have a unique opportunity to intervene with patients to promote a variety of safety practices, including smoke alarm use. Studies have shown that counseling in the clinical setting resulted in a greater likelihood of smoke alarm ownership. The following prevention strategies are recommended by the Centers for Disease Control and Prevention.

  1. Install smoke alarms outside each separate sleeping area and on every floor of the home, including the basement.

    • Use smoke alarms with lithium-powered batteries and a “hush button.” A lithium-powered battery lasts up to 10 years, and a hush button allows you to quickly stop nuisance alarms that are caused by steam or oven smoke.
    • If 10-year, long-life smoke alarms are not available, install smoke alarms that use a regular nine-volt battery, and be sure to replace the battery every year.
    • Smoke alarms have a useful life of about 10 years. At that age, the entire alarm should be replaced, even if it seems to be working.
    • Test smoke alarms every month to make sure they work properly. This can be done by pushing the test button. If the smoke alarm is out of reach, you can push the test button with a broom handle or yard stick.
  2. Make a family fire escape plan and practice it every six months.

    In a typical home fire, people have only about two minutes to get outside. It’s easy for anyone to panic and be confused during that short time, especially children. During a fire, children often try to hide in a closet or under beds, where they feel safe, rather than going outside. That is why it is so important to make a fire escape plan for everyone in the family and practice it at least twice a year. However, in a national survey, only 53 percent of respondents said they had a plan to follow if there were a fire in their home, and of these, only three of 10 had ever practiced the plan.

    • In the plan, discuss at least two different ways to get out of every room and choose a safe place in front of the house or apartment building for family members to meet after escaping a fire. Having a meeting place will let you know that everyone has gotten out safely, and no one will be hurt looking for someone who is already safe.
    • Talk with your family about what to do in the event of a fire:
    • Get out as fast as possible and go to your family’s designated meeting place.
    • Do not stop to grab photographs or other belongings.
    • Do not go back into a burning house or apartment building.
    • Call the fire or rescue department from a neighbor’s house.
    • If there is smoke in the room, stay low or crawl to your exit.
    • If you cannot escape, put wet towels or fabric around doors to block off smoke, crawl to a window, and open it. Yell out the window for help and wave a sheet or cloth for attention. If there is a phone in the room, call for help.
  3. Prevent a fire from starting in your home.

    • When cooking, never leave food on a stove or in an oven unattended. Avoid wearing clothes with long, loose-fitting sleeves. Do not hang potholders and towels near burners.
    • If you are a smoker, do not smoke in bed, never leave burning cigarettes unattended, do not empty smoldering ashesin a trash can, and keep ashtrays away from upholstered furniture and curtains.
    • Keep matches and lighters away from children’s reach, never leave burning candles unattended, and safely store flammable substances used around the home.
    • Never leave young children alone in the home, even for a short period. Unattended children can start a fire by trying to cook or by using a heater or electrical appliance incorrectly.
    • Keep space heaters at least three feet from items that can burn, including furniture, bedding and clothing. Do not leave space heaters on when you are not in the room or when you go to sleep.
  4. 4. Teach children to stop, drop, and roll.

    Clothing fires are a major cause of burn injuries to children. Children can set their clothes on fire by playing with matches or getting too close to open fires or stoves. If this happens, children’s natural reaction is to run, which will make the situation worse. Parents should teach their children the “stop, drop, and roll” maneuver to smother the flames. This has saved many lives, and parents should practice the maneuver with their children. The moment clothes start to burn:

    • stop where you are,
    • drop to the ground,
    • and roll over and over with your hands covering your face.

Injury Prevention at the Department of Health

In 1999 the Department of Health was awarded a grant from the Centers for Disease Control and Prevention to provide capacity building for injury prevention activities in the state. The department has been working with a statewide advisory committee to review the scope of the injury problem in Vermont and recommend strategies for prevention. Injury in Vermont, as in the rest of the country, is a public health problem of epidemic proportions. Injury is the leading killer of our children, adolescents and young adults. Nearly 300 Vermonters lose their lives to injuries each year and thousands more are seriously hurt.

Preventing injuries is a priority area in Healthy Vermonters 2010, the state’s blueprint for improving public health. With the help of the statewide advisory committee, the department is developing a set of specific actions to help reach the Healthy Vermonters 2010 goals. For example, to meet the goal of reducing residential fire deaths to no more than 0.2 per 100,000, actions include promoting widespread and proper installation and maintenance of smoke alarms and educating children and families about fire and burn prevention in the home.

The action plan is nearing completion and will be available soon at the department’s website www.state.vt.us/health.

For any poison, here is the antidote:

1-800-222-1222

New telephone number—Nationwide Poison Control

TOP OF PAGE

Emergency Response to Biological Incidents

Update: October – December, 2001

Work intensified significantly for several divisions of the Vermont Department of Health following the identification of inhalational anthrax as the cause of death of a patient in Florida (October 4) and of cutaneous anthrax in patients in New York City (October 12). Fortunately, no cases of anthrax were identified in Vermont. However, citizens had many concerns to address, there were suspicious powders to evaluate, and health care providers and the public needed a great deal of information. Although incidents requiring evaluation for the possible presence of anthrax spores or disease decreased in number during December, the Vermont Department of Health continues to plan and prepare for additional biological threats.

Anthrax response

During the week ending October 13, the Epidemiology Field Unit documented over 250 telephone calls related to bioterrorism concerns. For the next four weeks, well over 100 calls were documented weekly (almost 200 during the week ending October 27). Calls remained in the double digits into December. The 12 district offices also received numerous calls. During most of October, all of November, and the beginning of December, department staff provided 23 educational presentations to various groups throughout the state, including health care providers, law enforcement, and first responders. Staff also attended many statewide and local meetings of first responders, hospitals, task forces and emergency planning work groups. Media requests peaked during the week ending October 20 and have continued since then, with the exception of weeks including Thanksgiving Day and Christmas.

Laboratory response

The Vermont Department of Health Laboratory is a designated Level B laboratory in the national Laboratory Response Network (LRN). As such, the laboratory has the capability to conduct essential presumptive/confirmatory testing for the priority threat agents such as Bacillus anthracis, Yersinia pestis, Francisella tularensis and Brucella species. During fall 2001, the laboratory responded to nearly 70 requests to analyze suspect environmental samples for the presence of the biological threat agent B. anthracis. In most of these cases, suspect materials were transported to the laboratory in the custody of law enforcement officials. As these samples can be potential evidence in a criminal investigation, the laboratory is responsible for preserving evidence and for documenting chain of custody from initial receipt of the evidence, through processing and storage of the samples to the eventual release of the evidence to a law enforcement official. The laboratory also offers confirmatory testing of presumptive B. anthracis isolates received from clinical/hospital laboratories.

The laboratory uses well-validated LRN protocols and reagents to confirm or rule out the presence of B. anthracis in suspect samples. Bacillus anthracis can be ruled out in many cases using common microbiological procedures. These include culture on standard laboratory media, Gram stain, motility test and capsule stain. The laboratory also uses special tests such as gamma phage susceptibility and direct im-munofluorescence staining of capsule or cell-wall-associated polysaccharide antigens for the identification/confirmation of B. anthracis. To date, no suspect samples in Vermont have been positive for B. anthracis.

Smallpox planning

On November 21, 2001, the Centers for Disease Control and Prevention (CDC) released its Interim Smallpox Response Plan and requested that all states develop plans for responding to a case of smallpox. Even though the likelihood of smallpox appearing is extremely small, one case would be a public health emergency requiring an immediate response. Planning in Vermont started prior to the release of CDC’s plan and involves not only the Vermont Department of Health, but numerous community partners, including the Vermont Association of Hospitals and Healthcare Systems, private physicians and hospitals, Emergency Management, and many others. Three Health Department staff members attended an intense three-day training conducted by CDC in Atlanta during December, and work is underway to prepare district offices to provide education and information to their communities.

Health Alert Network expanded

The Health Alert Network, accessible from the Vermont Department of Health home page (www.state.vt.us/health), has been greatly expanded during the past several months. Specialized sections provide bioterrorism information for medical personnel (including emergency medical services and laboratorians), veterinary, policy and planning, and mental health and social services personnel. Within each of those sections are links to recent department publications, primary resource material from peer-reviewed journals, and CDC statements and alerts. The medical personnel section provides annotated links to over 30 journal articles from JAMA, MMWR, NEJM, Emerging Infectious Diseases, and others; anthrax and smallpox photos; informational letters sent to Vermont health care providers during fall 2001; sites with additional resources, including CDC, the World Health Organization, the Armed Forces Institute of Pathology, and others; and training opportunities. The home page is also the site for any fast-breaking news. During the first three weeks in October, health news updates were posted daily.

Planning efforts can be broadly applied

A great deal of time and effort has gone into planning for and responding to emergencies recently, and additional work proceeds. Although we are creating plans we hope never to have to use, the work of thinking through possibilities, enhancing professional and public education, and improving partnerships and communication will serve us well in the face of any disasters –– natural, man-made, biological, chemical, or radiological –– with which we are confronted.

Continue reporting

The Vermont Department of Health depends on providers and laboratories to report suspected and confirmed cases of infectious diseases. We request that providers please continue to consider agents of bioterrorism in their differential diagnosis of influenza-like illness and fever/rash illnesses. We are available to assist with obtaining appropriate specimens for diagnosis, researching prophylaxis and treatment options, consultation with the CDC, and instituting prevention and control measures.

TOP OF PAGE

Smoking During Pregnancy

Smoking during pregnancy is associated with poor pregnancy outcomes including low birthweight, infant mortality and health problems during childhood. The birth certificate is one means of monitoring smoking during pregnancy. However, some studies have suggested that smoking during pregnancy is underreported on the birth certificate. The standard question asks if the woman used tobacco during pregnancy (yes or no) and the average number of cigarettes smoked per day. A woman who stopped smoking as soon as she learned that she was pregnant might report that she did not smoke at all, particularly since most women are aware of the risks of smoking to the fetus.

Starting in 2000, the Vermont Department of Health adopted a new format for the smoking question that asks for the average number of cigarettes smoked per day for the three months before pregnancy and during each trimester. Compared to the more global question used in past years, this format provides a clear time reference for the smoking behavior; it establishes that the woman did smoke prior to the pregnancy; and it counteracts social desirability response bias by allowing women to confess that they smoked as well as take credit for quitting.

Figure 1: Smoking During Pregnancy

Results

If the new question format helped to reduce underreporting, then we would expect an increase in the percentage of women who reported smoking during pregnancy on the birth certificate. Figure 1 shows Vermont and US trends in smoking during pregnancy since 1990. Both trends were generally declining through the decade; the percentage of pregnant women smoking in Vermont dropped from 22.6 in 1990 to 16.5 in 1999. However, based on preliminary 2000 data, the percentage jumped up to 20 percent, counting all women who smoked during any trimester (Figure 2). This is a significant reversal of the earlier trend and it is likely that the increase is primarily due to the revised question format.

From a public health perspective, this apparent increase is disappointing even though we understand that it is likely a reporting effect. On the other hand, it provides a more accurate baseline for assessing the impact of new cessation interventions targeting pregnant women. Another benefit of the new question format is that it allows us to monitor the Healthy Vermonters 2010 objective to increase the percentage of pregnant women who quit smoking during the first trimester to 30 percent. According to the 2000 preliminary data, 24 percent quit by the second trimester.

TOP OF PAGE

Vermont: Selected Reportable Diseases
January 1, 2001 – December 29, 2001

reportable diseases jan 2002

TOP OF PAGE

New Death Certificate Form for 2002

Vermont has a new death certificate form to be used for all deaths occurring after January 1, 2002. The new Vermont Death Certificate includes a question in the Certifier section regarding the contribution of tobacco to death. New forms and instructions were mailed out December 17, 2001. If you did not receive new forms, please call the Office of Vital Records at the Vermont Department of Health (802-863-7275). Please be sure to properly dispose of (shred or return to the Office of Vital Records) any supplies of certificates you have on hand.

TOP OF PAGE

Pertussis Update

Preliminary analysis shows 112 cases of pertussis confirmed in Vermont during 2001. Among these cases, 49 (43.7%) were confirmed by culture; the remaining 63 cases met the Centers for Disease Control and Prevention (CDC) case definition as epidemiologically-linked cases. Symptoms reported from case patients include paroxysmal coughing (96%), post-tussive vomiting (43%), whooping (34%) and apnea (36%). Cases were confirmed in individuals ranging in age from one month to 57 years.

The majority of the identified cases occurred (see table). Since September 1, cases have been reported in 17 dif- ferent Vermont schools. Sixty-nine (62%) of the confirmed cases were reported in December, from six counties. There were outbreaks in two high schools. In both situations, cases were confirmed in late November. Parents and area health care providers were informed of these cases. Students with cough illness were referred for evaluation, and multiple new cases were discovered. The largest outbreak occurred in Chittenden County, where 40 cases were confirmed (10 by positive culture).

Confirmed pertussis in school-age children Vermont 2001 (preliminary)
Age range # cases (%)
< 1 3 (2.7%)
1–9 16 (14.3%)
10–19 73 (65.2%)
20 + 20 (17.5%)

For the 57 cases confirmed in December among children ages 10 to 18, 35 (71.4%) had received five doses of pertussis-containing vaccine; six (11.8%) had received three or fewer doses. Among the 16 children between the ages 1 through 10 with confirmed pertussis in 2001, immunization history was available for 15; six (40%) had received no pertussis-containing vaccine.

Physicians and other health care providers are encouraged to consider pertussis when evaluating patients with cough lasting longer than two weeks (or less, if confirmed pertussis is present in the community), post-tussive vomiting or gagging, paroxysmal cough or whooping. Culture remains the gold standard for pertussis diagnosis, and is important for confirming the presence of pertussis in the community. However, negative cultures are common, particularly late in the disease course, from immunized patients, or after antibiotic treatment. Treatment of patients and prophylaxis of close contacts are important public health control measures. Suspect and confirmed cases should be reported to the Health Department at 1-800-640-4374 or 863-7240.

REPORT DISEASE : VERMONT TOLL-FREE
1-800-640-4374 OR 1-802-863-7240

Vermont Department of Health
Division of Health Surveillance P.O. Box 70 Burlington, VT 05402-0070
Agency of Human Services
Jan K. Carney, MD, MPH
Commissioner

THIS BULLETIN IS PRODUCED BY THE DISEASE CONTROL BULLETIN EDITORIAL STAFF.

Ann R. Fingar, MD, MPH
State Epidemiologist Managing Editor

TOP OF PAGE