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A patient with an ICD received therapies from his ICD while exercising in an indoor swimming pool. Interrogation of the ICD revealed inappropriate detection of 60-Hz alternating current artifact and delivery of ICD therapies.
PROBLEM/CONDITION: Since 1971, CDC and the U.S. Environmental Protection Agency (EPA) have maintained a collaborative surveillance system for collecting and periodically reporting data relating to occurrences and causes of waterborne-disease outbreaks (WBDOs). REPORTING PERIOD COVERED: This summary includes data from January 1997 through December 1998 and a previously unreported outbreak in 1996. DESCRIPTION OF THE SYSTEM: The surveillance system includes data regarding outbreaks associated with drinking water and recreational water. State, territorial, and local public health departments are primarily responsible for detecting and investigating WBDOs and voluntarily reporting them to CDC on a standard form. RESULTS: During 1997-1998, a total of 13 states reported 17 outbreaks associated with drinking water. These outbreaks caused an estimated 2,038 persons to become ill. No deaths were reported. The microbe or chemical that caused the outbreak was identified for 12 (70.6%) of the 17 outbreaks; 15 (88.2%) were linked to groundwater sources. Thirty-two outbreaks from 18 states were attributed to recreational water exposure and affected an estimated 2,128 persons. Eighteen (56.3%) of the 32 were outbreaks of gastroenteritis, and 4 (12.5%) were single cases of primary amebic meningoencephalitis caused by Naegleria fowleri, all of which were fatal. The etiologic agent was identified for 29 (90.6%) of the 32 outbreaks, with one death associated with an Escherichia coli O157:H7 outbreak. Ten (55.6%) of the 18 gastroenteritis outbreaks were associated with treated pools or ornamental fountains. Of the eight outbreaks of dermatitis, seven (87.5%) were associated with hot tubs, pools, or springs. INTERPRETATION: Drinking water outbreaks associated with surface water decreased from 31.8% during 1995-1996 to 11.8% during 1997-1998. This reduction could be caused by efforts by the drinking water industry (e.g., Partnership for Safe Water), efforts by public health officials to improve drinking water quality, and improved water treatment after the implementation of EPA's Surface Water Treatment Rule. In contrast, the proportion of outbreaks associated with systems supplied by a groundwater source increased from 59.1% (i.e., 13) during 1995-1996 to 88.2% (i.e., 15) during 1997-1998. Outbreaks caused by parasites increased for both drinking and recreational water. All outbreaks of gastroenteritis attributed to parasites in recreational water were caused by Cryptosporidium, 90% occurred in treated water venues (e.g., swimming pools and decorative fountains), and fecal accidents were usually suspected. The data in this surveillance summary probably underestimate the true incidence of WBDOs because not all WBDOs are recognized, investigated, and reported to CDC or EPA. ACTIONS TAKEN: To estimate the national prevalence of waterborne disease associated with drinking water, CDC and EPA are conducting a series of epidemiologic studies to better quantify the level of waterborne disease associated with drinking water in nonoutbreak conditions. The Information Collection Rule implemented by EPA in collaboration with the drinking water industry helped quantifythe level of pathogens in surface water. Efforts by CDC to address recreational water outbreaks have included meetings with the recreational water industry, focus groups to educate parents on prevention of waterborne disease transmission in recreational water settings, and publications with guidelines for parents and pool operators.
The aim of this study was to evaluate the prevalence, clinical manifestations, and etiology of dental erosion among children. A total of 153 healthy, 11-year-old children were sampled from a downtown public school in Istanbul, Turkey comprised of middle-class children. Data were obtained via: (1) dinical examination; (2) questionnaire; and (3) standardized data records. A new dental erosion index for children designed by O'Sullivan (2000) was used. Twenty-eight percent (N=43) of the children exhibited dental erosion. Of children who consumed orange juice, 32% showed erosion, while 40% who consumed carbonated beverages showed erosion. Of children who consumed fruit yogurt, 36% showed erosion. Of children who swam professionally in swimming pools, 60% showed erosion. Multiple regression analysis revealed no relationship between dental erosion and related erosive sources (P > .05).
Aseptic meningitis is an inflammation of the tissues covering the brain and spinal cord and caused by a virus, most frequently an enterovirus. In August 2003, the Connecticut Department of Public Health (CDPH) received a report of three viral meningitis cases among recreational vehicle (RV) campers staying at a campground in northeastern Connecticut. CDPH, assisted by CDC, conducted an investigation, which 1) identified a total of 12 cases of aseptic meningitis and 24 cases of enterovirus-like illness among 201 campers interviewed, 2) demonstrated how transmission of enterovirus from persons with mild illness contributed to the aseptic meningitis outbreak, and 3) determined that crowded conditions inside RVs and in the campground swimming pool likely facilitated spread of enterovirus. Pool operators should check chlorine and pH levels frequently, particularly during peak pool occupancy; adults should take precautions against passing enterovirus to children, who are at greater risk for severe illness.
It is generally accepted that improving epidemiological knowledge of accidents in childhood and adolescence leads to a better implementation of more efficient prevention programs. Nevertheless, it is not yet generally admitted that any new preventive measure addressing these accidents has to be evaluated by competent epidemiologists. Obviously, there are exceptions regarding these two rules. Four examples of successful implementation are presented in this paper: safety packaging of aspirin; fences around private swimming pools; changes in minimal drinking and driving age in adolescence; bicycle accidents. The discussion is focused on four intervention levels suggested for the epidemiologists.
During a 2-week period three unrelated children presented with severe aplastic anaemia at a general hospital serving a population of 25,000 children aged 0-15 years. The probability of this occurring by chance alone was 0.00009 (exact probability cluster analysis). Serology for common viral infections including hepatitis A & B and infectious mononucleosis was negative. It was not possible to demonstrate IgM antibodies to human parvovirus (HPV) by radioimmunoprecipitation or HPV virions by DNA hybridization in the patients or any members of their families. Epidemiological investigation failed to demonstrate a common environmental toxin. It did reveal, however, that all three patients had spent time, within the preceding 3 months in a swimming pool and its surrounding area in a region of Cardiff where none of them resided. Pool maintenance was satisfactory and water analysis showed no abnormality. The possibility must remain that the cluster was caused by an undisclosed environmental toxin.
A study of all serious childhood immersion accidents (both drowned and near-drowned cases) is reported from Hawaii. This is a total population-based survey of 140 consecutive cases (0--15 years) occurring during the five-year period (1973--1977. Age-specific, sex-specific, and osmolality-specific (salt versus fresh water) data are presented both for survivors and fatalities. The overall annual drowning rate of 3.1 per 100,000 children at risk is low, for a water-oriented society. The survival rate following loss of consciousness in the water is 73 per cent. There is no evidence from this study that osmolality affected the probability of survival. The rank order of importance of drowning sites is swimming pools, surf, sheltered salt water bathing, domestic bath tubs, fresh water streams, salt water canals, and garden fish ponds. Specific accident rates, by sex, outcome, and site of immersion are also presented. No secular trend in the rate of drowning was observed in this study. Comparison with the only other available total population survey (Australia) of childhood immersions reveals common epidemiological and demographic patterns in modern urban societies and suggests that safety regulations play a role in reducing swimming accidents and fatalities in children.
Systematic observations were made of five lifeguards at indoor public swimming pools. Scanning by lifeguards was associated with lower incidences of rule violations by swimmers. Greater numbers of lifeguards patrolling the pool areas tended to reduce violations. Rules violations tended to be fewer when adult-to-child ratios were low, suggesting that monitoring by a parent or an adult may encourage rule compliance.
A generalized pruritic pustular rash was reported by 32 of 61 (53%) persons who had used the swimming pool and whirlpool at a Minnesota motel in March 1975. A questionnaire survey indicated that attack rates were highest in periods of heaviest bather load. The rash appeared 8 to 48 hours after exposure and resolved within seven days. No rash was reported by 37 motel guests who did not use the pool. Pseudomonas aeruginosa, serogroup 11, was isolated from the skin lesions of two patients and from the water from both pools. Circumstantial evidence implicated the whirlpool as the most probable source of infection. Deficiencies in disinfecting equipment and technique were identified and corrected.
To understand hair-discoloration in relation to swimming, we examined sixty-seven elite swimmers of the Japan National Swimming Team and fifty-four, age-matched subjects as controls. The incidence of hair discoloration (61%) in the swimmers' group was significantly higher than that in controls (0%) (p<0.0001). Interestingly, surface damage of the nail plates coexisted in the swimmers with the scalp-hair discoloration. The hairs picked from the eight swimmers and two age-matched individuals as controls were examined by electron microscope (EM) and EM X-ray microanalyzer. The swimmers' discolored, golden hair revealed complete disappearance of hair cuticle both by scanning EM (SEM) and transmission EM (TEM). The quantity of melanosomes in the cortex decreased, and their diameter was smaller than that of controls. In addition, irregularly shaped melanosomes with variable electron density and less electron-dense melanosomes with white haloes were frequently observed in the swimmers' golden hair. The X-ray elemental spectrograph by SEM revealed that the content of sulfur in all the swimmers' discoloured hair was lower than that in the normal controls and that the content of chlorine in the male swimmers' discoloured hair was higher than that in the female swimmers and the normal controls. The X-ray elemental microanalysis by TEM focused on melanosomes in the cortex of the cross section and detected elemental chlorine in all swimmers' golden hairs. It did not detect any element in the control hairs. The 14C-tyrosine uptake test of hairbulbs found no significant difference between the swimmers and the normal controls. These findings suggest that hair discoloration was mainly due to cuticle damage by friction with water. Hypochlorous acid in the swimming pool water can penetrate to the hair cortex through the cuticle. It can oxidize and degenerate melanosomes there.
In July and August 1988, an outbreak of gastroenteritis affected 44 of 60 (73%) persons from 5 separate swimming groups who had used the same swimming pool in Los Angeles. Cryptosporidium was identified in 5 of 8 (63%) stool specimens, and the clinical picture was consistent with Cryptosporidium infection. Resistance of Cryptosporidium to chlorine, an inadequately maintained pool filtration system, repeated exposure to pool water, and possible continuing pool contamination may have contributed to ongoing transmission. Cryptosporidium should be considered a potential etiologic agent of gastroenteritis associated with recreational water use.
We present the results of a residence-based study of drownings among Sacramento County, California children and adolescents ages 0-19 years for the years 1974-84. Children ages 1-3 had the highest drowning rates. The majority of drownings in this group, and one-third of all drownings in the study, occurred in residential swimming pools. Males ages 15-19 had a high drowning rate as well; at least 38 per cent of drownings in that age group were alcohol-associated. The implications for preventive efforts are discussed.
A reverse phase high performance liquid chromatographic (HPLC) assay for the quantitative determination of cyanuric acid (CA) in urine and water is described. For purification, samples are passed through a pre-activated reverse phase C18 column. The effluent is dried by lyophilization, and the residue is reconstituted in hexane-washed water and then passed through a prewashed Dowex-1 column. The effluent is again dried by lyophilization, and the dry residue is extracted with hot dioxane. The solution is cooled to ambient temperature and centrifuged. The supernatant liquid is removed, dried under a nitrogen steam, and dissolved in water for final extraction by reverse phase chromatography. This effluent is dried, dissolved in the sodium phosphate monohydrate in methanol (pH 7.0) mobile phase, and injected into a pre-equilibrated chromatographic system. An external standard is used for quantification by peak height comparison. A sample of HPLC column effluent is collected, dried, dissolved in methanol, and used for mass spectrometric confirmation by a solid probe insert procedure. Average combined recovery determined at 1.0, 5.0 and 10.0 micrograms CA/mL is 103 +/- 3% with an average coefficient of variation of 8.6%. Standard deviations for the 3 concentration levels are 0.04, 0.58, and 0.76, respectively, with average precisions of 4.28, 10.92, and 7.61%. The limits of detection are approximately 0.05 micrograms/mL for urine and 0.1 micrograms/mL for swimming pool water. Recorder response to CA is linear over the concentration range 1-10 microgram/mL.
A total population study of all serious immersion accidents is reported from the Australian Capital Territory. The annual immersion accident rate of 4-69 per 100,000 of the population at risk is low, and the fresh water fatality rate of 2-58 per 100,000 is very low. The annual fatality rate for childhood swimming pool accidents is 0-34 per 100,000 children (that is, under 16 years of age) at risk. Serious immersion accidents are not increasing in frequency, in striking contrast to the epidemic trends seen from other centres. Factors which might explain this are discussed.
OBJECTIVE: To characterize children aged under 5 years who present to paediatricians following near-drowning and the circumstances surrounding the event, identify high-risk groups and document short-term outcome. METHODOLOGY: Monthly notifications to the Australian Paediatric Surveillance Unit (an active, national surveillance system) between 1994 and 1996. Collection of additional case information from reporting doctors by postal questionnaire. RESULTS: All 169 reported cases of near-drowning were admitted to hospital (mean (SD) stay 6 (17) days) and 15% required intensive care (mean (SD) stay 19 (32) days). The mean (SD) age for near drowning was 26 (13) months and 22% children were aged between 12 and 18 months. Males predominated (1.6:1) and 69 (41%) of episodes occurred in summer (December - February). The majority (82%) of near-drownings occurred in the child's home, usually in a swimming pool or bath. Children who nearly drowned at home were significantly younger than those who nearly drowned in natural waterways or public pools. Neurological damage at discharge following near-drowning was reported in 7%. CONCLUSIONS: Children reported in this national case series represent the severe end of the spectrum of those who nearly drown, as indicated by their presentation to a paediatrician, universal hospitalization and adverse neurological outcome. The home is the site of most near-drownings and males and toddlers were at particular risk. Unimpeded access to pools and lack of supervision were identified as potentially modifiable factors for prevention. The study suggests the need for additional community education regarding the risks of near-drowning and for further research on long-term neuro-developmental outcomes following near-drowning.
A large total population study of childhood fresh water immersion accidents is reported. The study was undertaken in the City of Brisbane over the five-year period 1971 to 1975 inclusive, and 111 fresh water immersion accidents involving children were studied and analysed. The childhood fresh water immersion accident rate, including drowning and near-drownings, of 10-43 per year per 100,000 at risk (fatality rate of 5-17) is the highest reported. If an unsupervised child gets into difficulties in fresh water and loses consciousness he has a 50% chance of dying. The immersion accident rate has doubled over the last six years. Age-specific immersion accident rates have been calculated, and have revealed that, in the toddler group (12 months to 23 months), the fresh water immersion accident rate is 50-01 per 100,000 (fatality rate of 22-55). Rates for drowning and near-drowning accidents after a fresh water immersion, by site, age and outcome (survival versus fatality), are also presented for the first time. Swimming pools produce 6-20 immersion accidents per year per 100,000 children at risk, and the domestic family bath tub produces 1-78. Possible factors explaining the high incidence are discussed, and comparisons of drowning rates from other centres are made.
The attitudes of a sample of 1123 mothers of five-year-old children participating in the Christchurch Child Development Study, to a series of issues relating to the compulsory protection of children were studied. The issues examined were: the introduction of car seat restraint legislation, compulsory fencing of domestic swimming pools, the desirability of linking child health care provisions to family benefit payments and the desirability of water fluoridation. Contrary to common assumptions, this sample showed strong support for the introduction of compulsory methods for protecting child health: approximately 90% of respondents favoured car restraint and pool fencing provisions, two-thirds were in favour of linking family benefit payments to routine child health care provisions but less than half were in favour of water fluoridation. The implications of these findings for the introduction of compulsory child health provisions are discussed.
Compartment syndromes of the interosseous musculature in the hands of children is a relatively rare phenomenon and is usually associated with crush injury, severe burn, or ischemic events. Two cases of intrinsic compartment syndrome in children, secondary to suction injuries of the hand, are presented. Two children experienced suction injuries to the upper extremity when their hands were caught in a swimming-pool intake pipe filtration system. The filtration system intake suction developed enough negative pressure to induce an acute compartment syndrome of the interosseous muscles, requiring acute surgical decompression. Early diagnosis, prompt surgical decompression, and early postoperative rehabilitation of this unusual etiology of compartment syndrome of the hand provided a favorable and functional outcome.