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In this report, the author documents the many successes in California's history of tobacco control efforts, and the primary role given to evaluation. She provides a comprehensive overview of California's multidimensional evaluation structure and concludes with key lessons gleaned from a decade of evaluation research.
Measuring exposure levels for epidemiologic research is time consuming and expensive and therefore subjective exposure estimates are sometimes used instead. In this study we related the subjective dust exposure estimates of workers in California agriculture to personal dust exposure measurements. One hundred and twenty-four observations were available for comparison of subjective dust estimates and inhalable dust measurements and 129 observations for comparison of subjective dust estimates and respirable dust measurements. Individual subjective dust estimates showed weak to moderate correlations with measured dust concentrations for both the inhalable (Rs = 0.67) and respirable dust fraction (Rs = 0.36). The within-worker reliability coefficients were low (0.2 and 0.1, respectively). Grouped subjective dust estimates performed better and showed a consistent increase with average measured dust levels, in particular for the inhalable dust fraction (R2 = 0.81). Age, the number of years working in agriculture, education level, the presence of any respiratory symptoms, and the language of the questionnaire did not have a significant independent effect on the relationship between measured dust levels and subjective dust estimates. California agricultural workers appear to be reasonably good at estimating inhalable dust levels, in particular if an average of many different workers is taken, but they are unable to provide good estimates of respirable dust levels. Measuring dust levels remains the preferred option.
We conducted a cross-sectional study of tuberculin reactivity among residents of two northern California migrant-farm-worker housing centers. Participants completed a brief health questionnaire and were offered tuberculin skin testing with radiologic and medical follow-up. Four hundred and sixty-nine persons (estimated participation rate: 70%) completed questionnaires. All but one were Hispanic. Two hundred and ninety-six (63%) participants completed tuberculin skin testing and 49 (16.6%) showed reactivity (> or = 10 mm induration at 48-72 hours). Increased prevalence was seen for the 15-39-year age group (vs. persons younger than 15: OR 2.59; 95% CI 0.79-8.47), former smokers (vs. never smokers: OR 3.11; 95% CI 1.20-8.09), and persons born outside the U.S. (OR 2.09; 95% CI 0.66-6.61). Prophylaxis with isoniazid was recommended for 23 persons; nine (39%) completed therapy. No cases of active tuberculosis were found. Prevalence of tuberculin reactivity in this population is lower than reported among Hispanic farm workers in the eastern and midwestern U.S. Higher prevalence may obtain among California farm workers not included in the study population, including homeless, single, and highly mobile persons. Public-health efforts in this population should focus on ever-smokers, young adults, and persons born outside the U.S.
BACKGROUND: Work-related asthma is a leading cause of occupational respiratory illness. METHODS: Work-related asthma was studied in California over a 36-month period, from March 1, 1993 to February 29, 1996. The surveillance system identified cases from Doctor's First Reports (DFRs), a mandated physician reporting system. Structured follow-up telephone interviews of DFR asthma cases were conducted to collect work history, exposure, and medical information. Statewide employment data was used to calculate disease rates among industry groups. RESULTS: Based on 945 cases of work-related asthma, the average annual reporting rate for work-related asthma in California was 25/million workers. We estimate that the actual rate is 78/million, adjusted for likely underreporting. Janitors and cleaners (625/million) and firefighters (300/million) had the highest reporting rates of work-related asthma. Half of all work-related asthma cases were associated with agents not known to be allergens. CONCLUSIONS: A greater proportion of work-related asthma associated with irritant exposures was identified than has previously been reported. The surveillance data provide a very conservative estimate of the incidence of work-related asthma.
As part of a program for evaluation of environmental contaminants in drinking water, risk assessments are being conducted to develop Public Health Goals (PHGs) for chemicals in drinking water, based solely on public health considerations. California's Safe Drinking Water Act of 1996 mandated the development of PHGs for over 80 chemicals by 31 December 1999. The law allowed these levels to be set higher or lower than federal maximum contaminant levels (MCLs), including a level of zero if data are insufficient to determine a specific level. The estimated safe levels and toxicological rationale for the first 26 of these chemicals are described here. The chemicals include alachlor, antimony, benzo[a]pyrene, chlordane, copper, cyanide, dalapon, 1,2-dichlorobenzene, 1,4-dichlorobenzene, 2,4-D, diethylhexylphthalate, dinoseb, endothall, ethylbenzene, fluoride, glyphosate, lead, nitrate, nitrite, oxamyl, pentachlorophenol, picloram, trichlorofluoromethane, trichlorotrifluoroethane, uranium and xylene(s). These risk assessments are to be considered by the State of California in revising and developing state MCLs for chemicals in drinking water (which must not exceed federal MCLs). The estimates are also notable for incorporation or consideration of newer guidelines and principles for risk assessment extrapolations.
There are few published reports of epidemiologic studies of the risks of agricultural work. Members of this occupational group have been of special concern because of their exposure to pesticides, some of which are mutagens and animal carcinogens. A previous proportionate mortality study of California agricultural workers was based on deaths recorded among white males of this occupational group during 1959-1961. We have conducted a proportionate mortality analysis of all deaths recorded during 1978-1979 among California farm workers and farm owner/managers. In general, the findings of our study are consistent with those of the previous study. For farm workers, we found proportionate mortality ratios (PMRs) which were consistently elevated for all race and sex categories (in which there were 6 or more decedents) for deaths due to motor vehicle accidents, all respiratory disease, and all infective and parasitic diseases. The PMRs for the former three causes of death were also found to be elevated across several race and sex categories for farm owner/managers. We also found a significant and consistent deficit of deaths among farm workers and farm owner/managers due to arteriosclerotic heart disease. The proportionate cancer mortality ratios (PCMRs) for cancer of the stomach and cancer of other lymphatic tissue were elevated, although not necessarily statistically significantly, for several race and sex categories among farm workers and farm owner/managers. The PCMR for cancer of the cervix was statistically significant for white female farmworkers.
Standardized proportional mortality ratios (PMR) were computed for a population of highway workers. Hazards of highway maintenance work include exposure to solvents, herbicides, asphalt and welding fumes, diesel and auto exhaust, asbestos, abrasive dusts, hazardous material spills, and moving motor vehicles. Underlying cause of death was obtained for 1,570 workers who separated from the California Department of Transportation between 1970 and 1983, and who died in California between 1970 and 1983 (inclusive). Among 1,260 white males, the major findings were statistically significant excesses of cancers of digestive organs (PMR = 128), skin (PMR = 218), lymphopoietic cancer (PMR = 157), benign neoplasms (PMR = 343), motor vehicle accidents (PMR = 141), and suicide (PMR = 154). Black males (N = 66) experienced nonsignificant excesses of cancer of the digestive organs (PMR = 191) and arteriosclerotic heart disease (PMR = 143). Among 168 white females, deaths from lung cancer (PMR = 189) and suicide (PMR = 215) were elevated. White male retirees, a subgroup with 5 or more years of service, experienced excess mortality due to cancers of the colon (PMR = 245), skin (PMR = 738), brain (PMR = 556), and lymphosarcomas and reticulosarcomas (PMR = 514). Deaths from external causes (PMR = 135) and cirrhosis of the liver (PMR = 229) were elevated among white males with a last job in landscape maintenance. White males whose last job was highway maintenance experienced a deficit in mortality from circulatory diseases (PMR = 83) and excess mortality from emphysema (PMR = 250) and motor vehicle accidents (PMR = 196). Further epidemiologic and industrial hygiene studies are needed to confirm the apparent excess mortality and to quantify occupational and nonoccupational exposures. However, reduction of recognized hazards among highway maintenance workers is a prudent precautionary measure.
In 1986, the voters of California passed a law regarding the concept of extrapolating animal toxicity data to humans. The California Safe Drinking Water and Toxic Enforcement Act of 1986, known as Proposition 65, does five things: 1. It creates a list of chemicals (including a number of agricultural chemicals) known to cause cancer or reproductive toxicity; 2. It limits discharges of listed chemicals to drinking water sources; 3. It requires prior warning before exposure to listed chemicals by anyone in the course of doing business; 4. It creates a list of chemicals requiring testing for carcinogenicity or reproductive toxicity; and 5. It requires the Governor to consult with qualified experts (a 12-member "Scientific Advisory Panel" was appointed) as necessary to carry out his duties. This paper discusses the details and implications of this proposition. Areas of responsibility have been assigned. The definition of significant risk is being addressed.
Cohort mortality and nested case-control studies were conducted involving 2,901 men employed 1 year or more between 1940 and 1986 at any of four California facilities of a major chemical company. Employees experienced fewer deaths from each of the major causes than were expected based on U.S., California, and local county mortality rates. Respiratory cancer was significantly elevated in one socioeconomic category comprised of operators (SMR = 157, 95% CI = 109-220). The 34 cases who died from respiratory cancer and 136 matched controls, all of whom were operators, were included in a nested case-control study. Departments in which subjects had worked were grouped into 13 work assignment or product categories by an industrial hygienist without knowledge of case-control status. Smoking habits and other occupational exposures were ascertained by telephone interview from subjects or surrogate-responders. As expected, current cigarette smoking was strongly related to respiratory cancer. After adjustment for smoking, cases were significantly more likely than controls to have ever worked in one of the 13 work areas (supervision, services, and business support). However, no dose-response relationship was evident with duration of employment in this work area and the departments involved were associated with plant security and not chemical production. Results were similar when a 15-year latency period was assumed. These findings suggest that the excess of respiratory cancer mortality among operators was most likely due to differences in cigarette smoking or other factors not ascertained, rather than to a specific occupational exposure.
Previous studies reporting on mortality patterns in veterinarians have been restricted to deaths among white male veterinarians. In an effort to examine the mortality of male and female veterinarians of all races, we conducted a standardized proportionate mortality ratio (SPMR) analysis of 450 California veterinarians who died between January 1960 and December 1992. In comparison to State of California general population statistics, white male veterinarians had significantly elevated mortality from malignant melanoma of the skin (SPMR 3.47, 95% CI 1.74, 6.94), cancer of the large intestine (SPMR 1.74, 95% CI 1.04, 2.09), rheumatic heart disease (SPMR 3.50, 95% CI 1.90, 6.43), and suicide (SPMR 2.50, 95% CI 1.84, 3.38). White female veterinarians had significantly elevated mortality from suicide (SPMR 5.89, 95% CI 3.02, 11.48). We also examined veterinary mortality for different lengths of time in the profession. Significantly elevated SPMRs were noted for suicide in veterinarians in the profession for less than 30 years; deaths due to malignant melanoma of the skin and rheumatic heart disease in veterinarians in the profession 20 years or more; and cancer of the large intestine in veterinarians in the profession 30 years or more. Because of significant findings in mortality from suicide among veterinarians of both sexes, it was recommended that future studies and efforts toward suicide prevention include both male and female veterinarians.
There is a paucity of epidemiologic information about the eye malformations anophthalmia and microphthalmia. Using data from a large population-based registry, we explored prevalences and maternal/infant characteristics associated with anophthalmia and bilateral microphthalmia. Data were derived from the California Birth Defects Monitoring Program, a population-based active surveillance system for collecting information on infants and fetuses with congenital malformations using multiple source ascertainment. Approximately 2.5 million births (liveborn and stillborn) occurred during the ascertainment period, 1989-1997. Information on maternal and infant/fetal characteristics was obtained from California birth certificate and fetal death files. The prevalence per 10,000 livebirths and stillbirths for anophthalmia was 0.18 and for bilateral microphthalmia was 0.22. These estimates reflect prevalences among births without chromosomal anomalies. Relative risks of anophthalmia were modestly higher among women aged 40 or more (relative risk = 2.0, 95% confidence interval 0.5-8.6). Risks were substantially lower for those mothers with >12 years of education, even after adjusting for other study factors, relative risk = 0.6 (0.2-1.7). The risk of anophthalmia was approximately twofold among multiple births compared to singletons. Similar to results for anophthalmia, decreased risks for bilateral microphthalmia were observed for maternal education of 12 years or more and increased risks observed for multiple births. These data show descriptive epidemiologic features of anophthalmia and bilateral microphthalmia.
Microcephaly is a severe developmental abnormality which is induced either genetically or environmentally. The archaeological evidence for the occurrence of this abnormality is minimal. Out of six possible cases, only three have been published; all are adult and represented solely by cranial remains. The focus of the current study is the nearly complete skeleton of a 3-year-old child recovered during archaeological excavations in San Jose, California. The individual is compared to a sample of 184 California Indians, ranging from 0.5 to 5 years, which were also recovered from archaeological excavations. In order to determine if microcephaly was the only disorder represented, metrical comparisons of the skull and postcrania and gross morphological comparisons of endocranial casts were made. Based on these comparisons the individual was determined to have a cranial vault size comparable to 6-month-old infants (630 cc), a facial skeleton equivalent to the 9-month-old to 2-year-old age groups, and a reduced stature. Due to the mosaic nature of the skull, the observed morphology was interpreted in terms of functional cranial components. Severe malformation of the orbital aspect of the frontal lobes was found in conjunction with a significant reduction in size of the cerebral cortex and left temporal lobe. On the basis of this analysis, the individual was found to exhibit the total morphological pattern associated with microcephaly. A differential diagnosis of other possible genetic disorders is also presented.
A maize-based iron- and protein-deficient diet is commonly cited as the most important cause of porotic hyperostosis among American Indian agriculturalists. An alternative to this maize dependence hypothesis is suggested by the analysis of 432 crania from the nonagricultural, fish-dependent population of the Channel Island area of southern California. Cribra orbitalia, a form of porotic hyperostosis associated with iron deficiency anemia, is just as common among these fisherpeople, whose diet was rich in iron and essential amino acids, as it is among maize-dependent agriculturalists. Northern Channel Island crania have much more cribra orbitalia than those from the California mainland. The highest incidence is on San Miguel, a small geographically isolated island with a shortage of fresh water and terrestrial resources. The Indians who lived on Santa Cruz, the largest of the northern Channel Islands with the greatest diversity of terrestrial plants and animals, have less cribra orbitalia than those who lived on Santa Rosa or San Miguel Island. This geographical distribution appears to be explained by island-mainland and interisland differences in water contamination, exposure to fish-borne parasites, and nutritional adequacy of the diet. The prevalence of porotic hyperostosis in a population with a heavy dietary dependence on marine resources shows that among prehistoric American Indians, this condition is not always associated with an iron- and protein-deficient diet of cultigens. It seems likely that high nutrient losses associated with diarrheal disease are often more significant in the etiology of porotic hyperostosis than a low dietary intake of essential nutrients.
OBJECTIVE: To investigate whether ethnicity was associated with differences in Medicaid eligibility, health care utilization, and direct medical costs in a systemic lupus erythematosus (SLE) population. METHODS: A retrospective analysis of California Medicaid claims data was conducted on patients with SLE. Patient eligibility and month-by-month utilization and costs were computed and compared across ethnic groups. Descriptive statistics are presented. A mixed regression model on patient-level data was used to verify the trends of the aggregate data, controlling for covariates. A survival regression model on time to ineligibility was used to show eligibility patterns adjusted for covariates. RESULTS: Hispanic patients were less likely to have a lengthy eligibility period as compared with other cohorts (approximately 50% versus 70% eligible at month 36, respectively). As treatment progressed, Hispanics generated lower total costs than other cohorts. Results for inpatient frequency, prescription costs, and outpatient/physician/supply (Part B) costs followed similar patterns. Mixed regression model findings revealed that when adjusted for age, sex, and aid program, total costs for Hispanic patients decreased as the length of care increased, in contrast to other ethnic groups. The interaction between ethnicity and treatment progression measured by quarter was significant (P <0.0001), but ethnicity as a main effect was not (P=0.091). This suggests that differences in total costs are small initially, but as the followup period extends, Hispanic patients experience lower total costs as compared with other ethnic groups. CONCLUSION: These California Medicaid program data reinforce the importance of investigating treatment differences in ethnic groups with SLE.
BACKGROUND: Although many studies have observed variations in the prevalence of specific malformations by sex, there is a lack of population-based data on potential malformation prevalence differences by sex at birth. METHODS: Our objective was to explore differences in the prevalence of structural congenital malformation phenotypes between sexes in a California population of 2.5 million live- and stillbirths, using data from a population-based active surveillance system. Ascertainment was performed among offspring of California women who delivered in nonmilitary hospitals during the period of 1989-1997. Malformations were grouped according to the four-digit malformation codes of the British Pediatric Association. RESULTS: Overall, 32,619 males and 21,835 females were considered to have structural congenital malformations, with prevalences of 2.52% and 1.76%, respectively. Thus, males demonstrated a malformation prevalence that was 22% higher than that in females. Using a criterion of a 40% increase or decrease in the relative risk for males, increased risks for 15 and decreased risks for 17 specific malformation categories were observed. Increased risks were associated with most organ systems, with the notable exception of the nervous system (increased risks for nervous system malformations were observed among female births). Risks were not substantially influenced by adjusting for maternal age, race/ethnicity, parity, or education. CONCLUSIONS: Our observations extend the relatively few studies that have investigated differential prevalences of a large number of specific structural malformations between male and female births.
BACKGROUND: There is a paucity of epidemiologic information about the external ear malformations anotia and microtia. METHODS: Using data from a large population-based registry, we explored prevalences and maternal/infant characteristics associated with anotia and microtia. Data were derived from the California Birth Defects Monitoring Program, a population-based active surveillance system for collecting information on infants and fetuses with congenital malformations using multiple source ascertainment. Approximately 2.5 million births (live-born and stillborn) occurred during the ascertainment period, 1989-1997. Information on maternal and infant/fetal characteristics was obtained from California birth certificate and fetal death files. RESULTS: The prevalence of anotia/microtia was 2.50 per 10,000 live births and stillbirths. Isolated cases, i.e., those live births and stillbirths with no other accompanying anomaly diagnoses, revealed a prevalence of 0.63 per 10,000, whereas among nonisolated cases, the prevalence was 1.53 per 10,000 live births and stillbirths. Prevalences of isolated anotia/microtia were substantially higher among U.S.-born Hispanics, foreign-born Hispanics, and Asians compared to non-Hispanic whites, with relative risks ranging from three- to seven-fold. Similar prevalences for maternal race/ethnicity (except for Asians) were observed for live births and stillbirths with nonisolated cases of anotia/microtia, but the magnitude of risks were lower than those observed for isolated cases. Prevalence of nonisolated anotia/microtia was substantially lower among women whose education was 12 years or more. CONCLUSIONS: These data reveal descriptive epidemiologic features of anotia/microtia most notably substantial risks associated with race/ethnic groups and lower maternal education. Additional study for factors associated with these characteristics could reveal clues for the etiology of these ear anomalies.
Asian Americans and Pacific Islanders (AAPI) have the fastest growing rate of overweight and obese children. Aggressive programs are urgently needed to prevent unhealthy acculturation-related changes in diet and physical activity and to promote the healthier aspects of traditional lifestyle habits. We conducted focus groups and key informant interviews to explore knowledge, attitudes, dietary practices, and physical activity levels among three low-income Asian American ethnic groups, Chinese, Vietnamese, and Hmong, in California. Content analysis was used to identify similarities and differences among the groups. Several common health beliefs clearly emerged. Participants noted the importance of fresh (not frozen) fruit and vegetable consumption and physical activity for general health. The concept of good health included having a harmonious family, balance, and mental and emotional stability. All groups also expressed the general belief that specific foods have hot or cold properties and are part of the Yin/Yang belief system common to Asian cultures. The lure of fast food, children's adoption of American eating habits, and long work hours were identified as barriers to a healthy, more traditional lifestyle. A California campaign for Asian Americans using multilevel strategies is recommended to counter the alarming rise of obesity among AAPI youth. Strategies directed to individual, community, and policy levels should emphasize maintenance of healthy traditional diets, informed selection of mainstream U.S. foods, and promotion of active lifestyles to prevent an impending burden from cancer and nutrition-related chronic diseases in AAPI populations.
BACKGROUND: Rural residence has been associated with increased risk of late stage cancer diagnosis, but it is unknown if this is related to lower socioeconomic status (SES) of rural residents or to other factors. This study examined the impacts of SES and urban/rural status on colorectal cancer (CRC) stage at diagnosis in California. METHODS: Cases of CRC among persons >or=50 years of age diagnosed from 1988-2000 were obtained from the California Cancer Registry. A composite census based SES measure was used in the analysis, and the RUCA (Rural Urban Commuting Areas) classification scheme was used to categorize the residence at diagnosis as urban, large town, or small town. Multivariate logistic regression was used to examine the association between SES, urban/rural status, and late stage at diagnosis. RESULTS: In multivariate models, SES had the strongest association with stage at diagnosis among individuals living in urban areas. As SES level increased, odds of late stage at diagnosis decreased. Individuals in the highest SES category had lower odds of being diagnosed at late stage when compared with those in the lowest SES category (O.R. = 0.91, 95% C.I. = 0.87, 0.94). For individuals who lived in large towns and small rural towns, SES was not significantly associated with stage at diagnosis. We found no significant differences in stage at diagnosis by urban/rural status within SES categories. CONCLUSIONS: These data suggest that the relationship between SES and the risk of late stage colorectal cancer varies among rural and urban populations. Further research into the factors that influence access to and utilization of colorectal cancer screening in rural areas is needed.