Ohio Department Of Health Research Articles

Massive Microbiological Groundwater Contamination Associated with a Waterborne Outbreak in Lake Erie, South Bass Island, Ohio

BackgroundA groundwater-associated outbreak affected approximately 1,450 residents and visitors of South Bass Island, Ohio, between July and September 2004.ObjectivesTo examine the microbiological quality of groundwater wells located on South Bass Island, we sampled 16 wells that provide potable water to public water systems 15–21 September 2004.MethodsWe tested groundwater wells for fecal indicators, enteric viruses and bacteria, and protozoa (Cryptosporidium and Giardia). The hydrodynamics of Lake Erie were examined to explore the possible surface water–groundwater interactions.ResultsAll wells were positive for both total coliform and Escherichia coli. Seven wells tested positive for enterococci and Arcobacter (an emerging bacterial pathogen), and F+-specific coliphage was present in four wells. Three wells were positive for all three bacterial indicators, coliphages, and Arcobacter; adenovirus DNA was recovered from two of these wells. We found a cluster of the most contaminated wells at the southeast side of the island.ConclusionsMassive groundwater contamination on the island was likely caused by transport of microbiological contaminants from wastewater treatment facilities and septic tanks to the lake and the subsurface, after extreme precipitation events in May–July 2004. This likely raised the water table, saturated the subsurface, and along with very strong Lake Erie currents on 24 July, forced a surge in water levels and rapid surface water–groundwater interchange throughout the island. Landsat images showed massive influx of organic material and turbidity surrounding the island before the peak of the outbreak. These combinations of factors and information can be used to examine vulnerabilities in other coastal systems. Both wastewater and drinking water issues are now being addressed by the Ohio Environmental Protection Agency and the Ohio Department of Health.

Death Data Have Researchers Searching for Answers

Back to table of contents Previous article Next article Clinical & Research NewsFull AccessDeath Data Have Researchers Searching for AnswersEve BenderEve BenderSearch for more papers by this authorPublished Online:17 Nov 2006https://doi.org/10.1176/pn.41.22.0026People with serious mental illness in one sample of psychiatric inpatients had more than three times the rate of death of those in the general population without mental illness and died an average of 32 years earlier.The leading causes of death among people in the sample, most of whom were diagnosed with a psychotic disorder, were heart disease, suicide, accidents, and cancer.The findings call for increased screening and monitoring of patients with serious mental illness for medical comorbidities, according to the authors of the study, published in the October Psychiatric Services.Researchers collected medical information on 20,018 patients hospitalized on at least one occasion at one of nine hospital sites associated with five behavioral health care organizations in Ohio's public mental health system between 1998 and 2002.They matched patients' hospital records with death records from the Ohio Department of Health and identified 608 patients who died during the four-year period (hospital deaths were included in the sample).The patients who died had been diagnosed with a number of mental disorders, including schizophrenia (134), schizoaffective disorder (128), alcohol abuse (101), bipolar disorder (87), alcohol dependence (85), major depressive disorder (80), cannibis abuse (59), other mixed or unspecified drug abuse (56), and cocaine abuse (35).The majority of patients in the sample died from heart disease (126), suicides (108), accidents (83), or cancer (44).Researchers also measured years per life lost for those who died, which is a measure of premature death based on the current mean survival age for a cohort matched by age and gender in the general population.Patients with serious mental illness died an average of 32 years earlier than patients in the general population, according to the findings. The average age of death for the people in the sample was 47.7 years. When researchers calculated the standard mortality ratio for patients in the sample who died, they found 3.2 times the rate of death as that of the general U.S. population.The most prevalent comorbid medical conditions for patients in the sample who died included obesity (144), hypertension (136), diabetes (70), chronic obstructive pulmonary disease (62), and injuries (39).Among the 126 patients who died of heart disease, leading comorbidities included hypertension, obesity, diabetes, chronic obstructive pulmonary disease, and disorders of lipid metabolism.Previous research has yielded similar results. For example, a report released by the federal Centers for Disease Control and Prevention in April said that patients with schizophrenia or bipolar disorder lose as much as 20 years off their average life expectancy compared withsimilar individuals in the general population without seriousmental illness and had elevated rates of heart disease (Psychiatric News, July 7).At a 2004 meeting convened by the American Diabetes Association and attended by several APA members, the organization issued a consensus statement confirming the risk of metabolic changes associated with second-generation anti-psychotics and calling for careful monitoring of patients on these medications.In the study of hospitalized patients with serious mental illness in Ohio, researchers could not draw conclusions about cause of death. They speculated, however, that underlying factors may have included medication-induced weight gain, poor personal hygiene, reduced physical activity, increased prevalence of smoking and substance use, and inadequate social support, according to C. Bayard Paschall III, Ph.D., chief of the Ohio Department of Mental Health's Office of Performance Improvement.“The question is how we tease some of these characteristics away” from others to be able to associate them with cause of death for patients with serious mental illness, Paschall told Psychiatric News.Study findings indicate a need for closer collaboration between psychiatry and primary care, according to lead author Brian Miller, M.D., M.P.H., a PGY-2 psychiatry resident at the Medical College of Georgia.In ideal circumstances, patients with serious mental illness could walk from their psychiatrist's office to an office across the hall to see a primary care physician “who might screen them for some of the comorbid medical conditions we observed in our study,” he said.In addition, he suggested that psychiatrists and other physicians treating patients who take second-generation antipsychotics carefully monitor these patients for side effects associated with metabolic dysfunction and also write orders for tests of fasting blood glucose, lipid profiles, and liver and thyroid function.Miller and Paschall are conducting further research on some of the factors that may be contributing to excess death rates among people with serious mental illness.“Mortality and Medical Comorbidity Among Patients With Serious Mental Illness” is posted at<http://psychservices.psychiatryonline.org/cgi/content/full/57/10/1474>.▪ ISSUES NewArchived

Investigation of an Outbreak of Tuberculosis in a Small Community Setting

BACKGROUND/OBJECTIVES: Ashtabula County, Ohio has been a low-risk county for Tuberculosis (TB) based on the Centers for Disease Control and Prevention guidelines. Over the past ten years there has been an average of one or two cases of active TB a year in the county. METHODS: In 2005 over a three month period of time there were six cases of active TB identified in Ashtabula County. The index case presented to the health department in January 2005 with a pre-employment TB test (PPD) measuring 10 mm induration. The patient was asymptomatic at that time. A workup was completed and the patient was seen at the TB clinic and started on Isoniazid. Sputum smears for acid fast bacillus were negative. In February the patient was admitted to a local hospital with respiratory distress and a diagnosis of left plerual effusion. A DNA probe showed Mycobacterium Tuberculosis Complex. A contact investigation was started by the health department and the Ohio Department of Health was notified. The investigation and follow-up was complicated by the fact that the suspected source case likely had active disease for over three years and had some medical procedures performed at a healthcare facility in another county. This person was unaware of having TB and was identified through contact investigation and sent for testing. The investigation was further complicated because the index case did not reveal contact with the suspected source case although this was later confirmed throug investigation. RESULTS: After identification of each case, contacts were identified through interviews with the clients, physicians and healthcare facilities where clients were treated. The suspected source case was found through contact investigation of his mother. He was unaware of having TB although he was symptomatic and under the care of his primary care physician for chronic bronchitis. Fifty six contacts were PPD tested and there were eight conversions. Testing was repeated in three months on those testing negative and there were no further conversions. The Infection Control nurse at the out of county facility where the suspected source patient had been seen was notifed and she conducted TB testing at that facility. No conversions were found. CONCLUSIONS: Though the overall incidence of TB is declining in the U.S. increased awareness of TB, appropriate TB diagnostic work up and treatment, among healthcare professionals in low incidence areas is increasingly important. Tuberculosis can be difficult to diagnosis because the signs and symptoms are seen in other diseases. Primary Care physicians provide the critical first steps in reducing the incidence of active cases. Contact investigation of an active case of TB requires diligence and effective communication. Persistence is necessary when working with clients to gain adequate information regarding contacts.

Arthritis And Physical Functioning Among Nursing Home Residents - Ohio, 1999

To evaluate association between arthritis and activity of daily living (ADL) disability among nursing home residents, we examined 1999 Ohio nursing home assessment data. Multivariate logistic regression analysis was performed to obtain adjusted odds ratios. A total of 152,882 (93%) were aged 21 years or older, had information on their arthritis status, sex, race, and were included in the study; 31% were assessed as having arthritis. Residents had the greatest difficulty with bathing, transferring, dressing, personal hygiene, and toilet use and the least difficulty with eating. Among and within each ADL, those with arthritis typically had more disability and need for assistance in performing ADLs than those without arthritis. The association between arthritis and ADL disability varied by ADL and subgroups defined by demographic characteristics, body mass index, and the presence of comorbid conditions. Clinicians might prevent or decrease disability levels through intervention regarding arthritis among these subgroups. This study has been supported by the Ohio Department of Health.

Health Department Collaboration with Emergency Departments as a Model for Public Health Programs among at-Risk Populations

Accessing at-risk and underserved populations for intervention remains a major obstacle for public health programs. Emergency departments (EDs) care for patients not otherwise interacting with the health care system, and represent a venue for such programs. A variety of perceived and actual barriers inhibit widespread implementation of ED-based public health programs. Collaboration between local health departments and EDs may overcome such barriers. The goal of this study was to assess the effectiveness of a health department-funded, ED-based public health program in comparison with other similar community-based programs through analysis of data reported by health department-funded HIV counseling and testing centers in one Ohio county. Data for HIV counseling and testing at publicly funded sites in southwestern Ohio from January 1999 through December 2002 were obtained from the Ohio Department of Health. Demographic and risk-factor profiles were compared between the counseling and testing program located in the ED of a large, urban teaching hospital and the other publicly funded centers in the same county. A total of 26,382 patients were counseled and tested; 5,232 were ED patients, and 21,150 were from community sites. HIV positivity was 0.86% (95% confidence interval [CI] 0.64%, 1.15%) in the ED and 0.65% (95% CI 0.55%, 0.77%) elsewhere. The ED program accounted for 19.8% of all tests and 24.7% of all positive results. The ED notified 77.3% of individuals testing positive and 84.4% of individuals testing negative. At community program centers, 88.3% of patients testing positive and 63.8% of patients testing negative were notified of results. All ED patients notified of positive status were successfully referred to infectious disease specialists. Public health programs can operate effectively in the ED. EDs should have a rapidly expanding role in the national public health system.

A Multistate Outbreak of Salmonella enterica Serotype Typhimurium Infection Linked to Raw Milk Consumption—Ohio, 2003

In December 2002, the Ohio Department of Health was notified of two children with Salmonella infection. Both had a history of drinking raw milk from a combination dairy-restaurant-petting zoo (dairy). The dairy was the only establishment in Ohio licensed to sell raw milk and reported 1.35 million visitors annually. We investigated to determine the extent of the outbreak and identify illness risk factors. A case patient was any person with pulsed-field gel electrophoresis–matched Salmonella enterica serotype Typhimurium from 30 November 2002 to 18 February 2003. Sixty-two met the confirmed case definition. Forty dairy case patient patrons were included in a case-control study; 56 controls were their well meal companions. Consumption of raw milk was found to be associated with illness (odds ratio, 45.1; 95% confidence interval, 8.8 to 311.9). The dairy discontinued selling raw milk. Because 27 other states still allow the sale of raw milk, awareness of the hazards of its consumption should be raised and relevant regulations carefully reviewed.

The association of chronic endometritis with preterm birth

ObjectiveTo determine if chronic endometritis (CE) diagnosed by endometrial biopsy (EMB) is associated with preterm birth (PTB) <37 & <35 weeks.Study designA case control design involving three local pathology departments. EMB reports (1992-2002) of women aged 18-45 were identified using SNOMED codes. Reports were dichotomized into those with and those without CE. CE was diagnosed by the presence of plasma cells. Results were forwarded and birth certificates (BC) were linked at the Ohio Department of Health (ODH). Included were women who delivered singletons (1992-2002) within three years of biopsy. Conditions associated with indicated PTB were excluded: cardiac & renal disease, diabetes, preeclampsia, placental abruption and previa. Statistical analysis included logistic regression, Student's t-test, Fisher's Exact, & Chi-square testing where appropriate. P<.05 were significant.Results1603 EMB reports were identified. The ODH linked BC data to 193 reports, 157 of which met inclusion criteria. 26 of the 157 women had CE. Table 1 shows that when compared to normal EMB results, women with CE were more likely to deliver at <35, but not <37 weeks. Testing for confounders and effect modifiers showed these groups to be similar. Infants born <37 weeks were more likely to be African-American (p<0.001), have intrapartum fever, meconium, or fetal distress (p = 0.026), and to require assisted ventilation (p = 0.016).Table 1≥37 weeks N = 137<37 weeks N = 20OR (95% CI)P-valueNo CE11789.3%1410.7%CE2076.6%623.1%2.51 (.86-7.29)0.091≥35 weeks N = 149<35 weeks N = 8No CE12796.9%43.1%CE2284.6%415.4%5.77 (1.3-24.8)0.026 Open table in a new tab ConclusionWhen compared to women with normal biopsy results, women with CE were more likely to deliver at<35, but not<37 weeks. ObjectiveTo determine if chronic endometritis (CE) diagnosed by endometrial biopsy (EMB) is associated with preterm birth (PTB) <37 & <35 weeks. To determine if chronic endometritis (CE) diagnosed by endometrial biopsy (EMB) is associated with preterm birth (PTB) <37 & <35 weeks. Study designA case control design involving three local pathology departments. EMB reports (1992-2002) of women aged 18-45 were identified using SNOMED codes. Reports were dichotomized into those with and those without CE. CE was diagnosed by the presence of plasma cells. Results were forwarded and birth certificates (BC) were linked at the Ohio Department of Health (ODH). Included were women who delivered singletons (1992-2002) within three years of biopsy. Conditions associated with indicated PTB were excluded: cardiac & renal disease, diabetes, preeclampsia, placental abruption and previa. Statistical analysis included logistic regression, Student's t-test, Fisher's Exact, & Chi-square testing where appropriate. P<.05 were significant. A case control design involving three local pathology departments. EMB reports (1992-2002) of women aged 18-45 were identified using SNOMED codes. Reports were dichotomized into those with and those without CE. CE was diagnosed by the presence of plasma cells. Results were forwarded and birth certificates (BC) were linked at the Ohio Department of Health (ODH). Included were women who delivered singletons (1992-2002) within three years of biopsy. Conditions associated with indicated PTB were excluded: cardiac & renal disease, diabetes, preeclampsia, placental abruption and previa. Statistical analysis included logistic regression, Student's t-test, Fisher's Exact, & Chi-square testing where appropriate. P<.05 were significant. Results1603 EMB reports were identified. The ODH linked BC data to 193 reports, 157 of which met inclusion criteria. 26 of the 157 women had CE. Table 1 shows that when compared to normal EMB results, women with CE were more likely to deliver at <35, but not <37 weeks. Testing for confounders and effect modifiers showed these groups to be similar. Infants born <37 weeks were more likely to be African-American (p<0.001), have intrapartum fever, meconium, or fetal distress (p = 0.026), and to require assisted ventilation (p = 0.016).Table 1≥37 weeks N = 137<37 weeks N = 20OR (95% CI)P-valueNo CE11789.3%1410.7%CE2076.6%623.1%2.51 (.86-7.29)0.091≥35 weeks N = 149<35 weeks N = 8No CE12796.9%43.1%CE2284.6%415.4%5.77 (1.3-24.8)0.026 Open table in a new tab 1603 EMB reports were identified. The ODH linked BC data to 193 reports, 157 of which met inclusion criteria. 26 of the 157 women had CE. Table 1 shows that when compared to normal EMB results, women with CE were more likely to deliver at <35, but not <37 weeks. Testing for confounders and effect modifiers showed these groups to be similar. Infants born <37 weeks were more likely to be African-American (p<0.001), have intrapartum fever, meconium, or fetal distress (p = 0.026), and to require assisted ventilation (p = 0.016). ConclusionWhen compared to women with normal biopsy results, women with CE were more likely to deliver at<35, but not<37 weeks. When compared to women with normal biopsy results, women with CE were more likely to deliver at<35, but not<37 weeks.

Surveillance of Infectious Disease Occurrences in the Community: An Analysis of Symptom Presentation in the Emergency Department

Objectives: To determine the effectiveness of a simulated emergency department (ED)‐based surveillance system to detect infectious disease (ID) occurrences in the community. Methods: Medical records of patients presenting to an urban ED between January 1, 1999, and December 31, 2000, were retrospectively reviewed for ICD‐9 codes related to ID symptomatology. ICD‐9 codes, categorized into viral, gastrointestinal, skin, fever, central nervous system (CNS), or pulmonary symptom clusters, were correlated with reportable infectious diseases identified by the local health department (HD). These reportable infectious diseases are designated class A diseases (CADs) by the Ohio Department of Health. Cross‐correlation functions (CCFs) tested the temporal relationship between ED symptom presentation and HD identification of CADs. The 95% confidence interval for lack of trend correlation was 0.0 ± 0.074; thus CCFs &gt; 0.074 were considered significant for trend correlation. Further cross‐correlation analysis was performed after chronic and non‐community‐acquirable infectious diseases were removed from the HD database as a model for bioterrorism surveillance. Results: Fifteen thousand five hundred sixty‐nine ED patients and 6,489 HD patients were identified. Six thousand two hundred eight occurrences of true CADs were identified. Only 87 (1.33%) HD cases were processed on weekends. During the study period, increased ED symptom presentation preceded increased HD identification of respective CADs by 24 hours for all symptom clusters combined (CCF = 0.112), gastrointestinal symptoms (CCF = 0.084), pulmonary symptoms (CCF = 0.110), and CNS symptoms (CCF = 0.125). The bioterrorism surveillance model revealed increased ED symptom presentation continued to precede increased HD identification of the respective CADs by 24 hours for all symptom clusters combined (CCF = 0.080), pulmonary symptoms (CCF = 0.100), and CNS symptoms (CCF = 0.120). Conclusions: Surveillance of ED symptom presentation has the potential to identify clinically important ID occurrences in the community 24 hours prior to HD identification. Lack of weekend HD data collection suggests that the ED is a more appropriate setting for real‐time ID surveillance.

Evaluation of a Rape Protocol; A Five Year Follow‐up with Nurse Managers

To evaluate the use and effectiveness of a protocol developed for emergency nurses and other medical personnel to use with survivors of sexual assault. The Ohio Department of Health (ODH) Protocol for the Treatment of Adult Sexual Assault Survivors was developed by a multi-disciplinary team in 1991-92 as a written guide to provide comprehensive, standardized, non-judgmental, and equitable treatment for survivors. In 1993, this 118-page manual was sent to all Ohio hospitals. In 1994, a follow-up video and training guide were also delivered. In 1997, Victims Rights Advocacy, a non-profit agency in Ohio, and the Center for Social Work Research at The University of Texas at Austin collaboratively conducted an evaluation of the utilization and effectiveness of this protocol at Ohio hospitals. Emergency departments at Ohio hospitals were asked to complete a mailed survey regarding their policies and procedures for treating sexual assault patients. Telephone calls were made to the hospitals that did not return a survey, and site visits were conducted at 20 hospitals in diverse areas of Ohio. Overall, respondents concurred that hospitals can benefit from using a standardized protocol, such as the ODH Protocol, for treating victims of sexual assault. Survey participants also indicated that training is needed on several topics, especially testifying in court, cultural awareness, and the needs of special populations, such as male, gay, lesbian, and bisexual survivors. In addition, findings indicate that survivors need more follow-up services, and written information about these services should be provided to them. Nurse practitioners can improve the treatment of sexual assault survivors in their communities through a variety of actions, such as gathering information about available protocols and training opportunities for personnel, and becoming familiar with resources that can help victims.

Ohio Early Start

In 1995, the Ohio Department of Health, in conjunction with the Ohio Family and Children First Initiative, designed and implemented an initiative called “Ohio Early Start” that was designed to prevent later developmental problems in infants and toddlers. Ohio Early Start was coordinated with the existing part C early intervention program and other birth-to-three efforts to ensure a comprehensive, community-based, and family-friendly network of child development, health, and self-sufficiency resources. Successful experiences of this large-scale program implementation and evaluation, as well as the challenges faced at the state and local level, are described.

The ohio solid organ transplantation consortium: A 15-year experience

The Ohio Solid Organ Transplantation Consortium (OSOTC) was established by the Ohio Department of Health in 1984 for the purpose of providing a means for regulating the practice of nonrenal organ transplantation in the State of Ohio. The OSOTC comprises all transplant centers in Ohio that provide these services including The Cleveland Clinic Foundation, the University of Cincinnati Hospitals/ Children's Hospital Medical Center, the Medical College of Ohio Hospitals, The Ohio State University Hospitals/Children's Hospital, and the University Hospitals of Cleveland. The mission of the OSOTC is to ensure equitable access to quality organ transplantation services in Ohio for those in need of a heart, lung, liver, pancreas, or small bowel transplant; to manage transplantation costs; and, in general, to support organ transplantation and organ donation in the state. These goals are achieved, in part, by mandatory pretransplant patient candidate reviews, adherence to strict patient listing criteria, submission of yearly transplant volume and outcomes data, and yearly program outcomes reviews. Since its inception, the OSOTC has performed almost 5000 transplant candidate reviews and more than 2300 patients in Ohio have received a nonrenal transplant. In this article, we describe these activities and review the data accumulated to date. In addition, the impact that the OSOTC has had on organ transplantation in Ohio will be discussed. It is the opinion of all of the member institutions and their respective transplant staffs that participation in the OSOTC has been beneficial to their patients and has fostered a collegial interaction among the transplant professionals in Ohio.

The Accuracy of Hospital Reports of Organ Donation Eligibility, Requests, and Consent: A Cross-Validation Study

Many states require hospitals to complete a form for each patient who dies, reporting the patient's organ and tissue donation eligibility status, whether a request was made, and the outcome of the request. A study was conducted to determine the accuracy of state-required forms in documenting organ eligibility and procurement activities. Four Level 1 trauma hospitals in northeast Ohio were sampled by using a weekly review of all deaths. Detailed chart reviews were conducted on a total of 2,270 deaths occurring during a six-month period in 1997, interviews with health care providers and staff members at organ procurement organizations were held, and records of the local Ohio Department of Health (ODH) were reviewed. Agreement between these data sources and the ODH form were compared to evaluate whether the ODH form correctly documented patients' eligibility status, occurrence of a donation request, and donation request outcome. Descriptive statistics and sensitivity and specificity analyses were completed. The quality of the information provided through these forms was variable. Problems included missing, inaccurate, and contradictory data. State reporting forms overrepresented the size of the organ donor pool by about four times, and requests for donation and consent to donation were inaccurately reported. Hospital form completion rates ranged from 12% to 82.6%. Basing the evaluation of hospital or statewide organ procurement performance on summary information provided by these forms would lead to an inaccurate picture of organ procurement activities in the state.

Occupational Silicosis—Ohio, 1989-1994

Silicosis is a chronic lung disease associated with the inhalation and pulmonary deposition of dust that contains crystalline silica. Through the Sentinel Event Notification System for Occupational Risks (SENSOR)* program, CDC's National Institute for Occupational Safety and Health (NIOSH) is assessing practical models for implementing state-based surveillance of silicosis and linking follow-up intervention activities to surveillance reports. From 1989 through 1992, the Ohio Department of Health (ODH) SENSOR program identified silicosis cases through reports of Bureau of Workers' Compensation (BWC) claims, physician reports, and death certificates. The addition in 1993 of hospital discharge reports as an ascertainment source resulted in a substantial increase in the number of silicosis case reports identified annually (Table 1). This report describes the investigation of a case of occupational silicosis in Ohio and summarizes the impact of hospital-based reporting on surveillance for silicosis in Ohio during 1993-1994.

Determination of Mirex in Human Blood Serum Containing Poiychiorinated Biphenyis by Using Packed Column Gas Chromatography

An analytical method has been developed that uses electron capture/gas-liquid chromatography to determine Mirex in serum containing polychlorinated biphenyls (PCBs) (Aroclor 1260). With this method, 0.2 ppb Mirex can be determined in 4 mL serum that also contains 10 ppb PCBs. The method provides approximately 70% recovery of Mirex at 1.0 and 3.5 ppb. The coefficients of variation are 4.5 and 4.6% at 1.0 and 3.5 ppb, respectively. In a cooperative study with the Ohio Department of Health, the Centers for Disease Control used this method to determine the extent of exposure of Salem, OH, residents to Mirex. Confirmation of Mirex was obtained by using high resolution gas chromatography and high resolution mass spectrometry.

The Distribution and Dynamics of Rickettsia in the Tick Population of Ohio

A five-year survey of ticks and associated rickettsia in Ohio shows a partitioning of spotted fever group rickettsia (namely, Rickettsia montana and R. rickettsii) into three areas of the state where the majority of human spotted fever cases occur. The percentage of ticks infected, even in areas with a high incidence of disease, is remarkably low, less than 1%. The statewide infection rate for R. bellii approaches 3%, and this organism appears to be more evenly distributed throughout the state. Dermacentor variabilis, which accounts for 97% of Ohio ticks received for testing, is the only species which has been found to harbor rickettsia. Ohio's tick testing program is not an effective surveillance tool and is of no use in diagnosing tick-borne disease. However, the program does function as an excellent means of increasing public awareness of tick-borne disease.

Effectiveness of four school health education projects upon substance use, self-esteem, and adolescent stress.

The purpose of this investigation was to evaluate the effectiveness of school health education projects on substance use, self-esteem, and stress. The subjects were 161 adolescents in fifth through eighth grades in four school health education projects funded through the Ohio Department of Health. Data collection included pretest/posttest questionnaires on self-report use of tobacco products, alcohol, marijuana, and other drugs. In addition, the Hare Self-Esteem and the Adolescent Stress Symptomology Scales were utilized. There was a six-week interval between pretest and posttest administration. MANCOVA, with age as a covariate, was used to compare pretest/posttest scores for self-esteem and stress symptomology. Furthermore, interviews were conducted with project staff about the educational methodology of their intervention. The results revealed that the predominate educational method used by the projects was lecture/discussion. There were no significant differences between pretest/posttest questionnaires for frequency of substance use, self-esteem, or stress symptomology. Effective school health education programs need sufficient quantity and quality in order to have an impact on health behaviors and the intermediate health-enhancing variable of self-esteem.

Reye's Syndrome

Patients with Reye's syndrome (RS) whose degree of severity was classified as stage 0 (alert and awake) were compared with patients with a severity classification of stage 1 or greater. The Centers for Disease Control case definition and staging criteria were used. Two hundred twenty-seven patients with RS were investigated by the Ohio Department of Health from Dec 1, 1978, through March 31, 1980. There were 67 identified patients who never exceeded stage 0 and 160 patients classified as stage 1 or greater. Both groups of patients were compared according to demographic features, symptomatology, medication use during the antecedent illness, and laboratory findings during the RS illness. Stage 0 patients were similar to patients at stage 1 or greater in their demographic features, illnesses, medications preceding RS, and results of liver function tests; however, values of serum ammonia, creatine phosphokinase, prothrombin time, and bilirubin increased with RS severity.

Aspirin and Reye's Syndrome-Reply

In Reply.— The Ohio Department of Health received only two reports of Reye's syndrome cases from the Cleveland Clinic during the study period (December 1978 through March 1980). The first of the two cases reported to us was not included in the study because our nurse coordinator could not get timely access to the child's record to verify fulfillment of the case definition. This child was reported by Dr Orlowski to have received aspirin. The other patient who was included in our study did not have a history of aspirin ingestion. Thirty-three hospitals reported cases to the Ohio Department of Health. With the exception of Dr Orlowski, there is no evidence of similar reporting problems at the other 32 hospitals. The vast majority of cases (85% ) of the 227 cases were reported from the state's six major pediatric referral centers. In Cleveland, this was Rainbow Babies and Children's Hospital (affiliated

Aspirin and Reye's Syndrome

To the Editor.— As one of the institutions that participated in the Ohio State study on Reye's syndrome and medication use, I am somewhat confused about the results of the study by Dr Thomas Halpin and co-workers in the Aug 13 issue of The Journal (1982;248:687). During the study period of December 1978 through March 1980, we reported to the Ohio Department of Health five cases of patients with Reye's syndrome, two of whom had no history of aspirin ingestion. The article stated that during this study period, of the 97 patients with Reye's syndrome, only three had no history of aspirin ingestion. I find it somewhat difficult to believe that two of the three patients with Reye's syndrome who had no history of aspirin ingestion were from a single institution, namely, the Cleveland Clinic. Likewise, the article states that during the period of December 1978 through March 1980, all

Staff development in local hypertension control programs: Frank S. Bright, Ohio Department of Health, P.O. Box 118, Columbus, Ohio 43216; Esther Lenhert; Patricia Thielen

Staff development in local hypertension control programs: Frank S. Bright, Ohio Department of Health, P.O. Box 118, Columbus, Ohio 43216; Esther Lenhert; Patricia Thielen