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Chronic Disease Control Continued Association (JAMA) has published background papers and recommendations issued by the U.S. Preventive Services Task Force on components of the periodic health examination. Smoking Cessation

AAFP has developed for its members a package of smoking cessation materials, the Stop Smoking Kit, which includes medical records forms, waiting room posters, and information on smoking cessation counseling techniques. AAFP has produced a self-help booklet and audiotape for patients who wish to quit smoking. The dangers of smoking in pregnancy have been emphasized by ACOG in The Standards for Obstetric-Gynecologic Services and in its Technical Bulletin entitled "Cigarette Smoking and Pregnancy." The Clinical Efficacy Assessment Program of ACP has evaluated office-based smoking cessation methods. The American Medical Association (AMA) has worked for the creation of smoke-free public environments, and the American Dental Association (ADA) has sponsored professional and public education on the use of smokeless tobacco. Smoking cessation techniques have also been taught in continuing medical education programs of the American Osteopathic Association (AOA). Injury Control

The Injury Prevention Program of AAP provides pediatricians with safety surveys, information sheets, and other materials to inform parents about childhood injury prevention. The American College of Preventive Medicine (ACPM) has produced continuing education materials on the prevention of motor-vehicle trauma. An AMA monograph, Medical Conditions Affecting Drivers, and a JAMA review by AMA staff on medical standards for civilian pilots (1) both focus on the prevention of injuries. AMA has held several conferences on injury prevention since 1983. Immunizations

The Report of the Committee on Infectious Diseases (popularly known as the "Red Book"), published by AAP, and the Guide for Adult Immunization ("Green Book"), published by ACP, offer recommendations on pediatric and adult immunizations, respectively. ACPM has been part of a national initiative to promote adult immunization and, in particular, reimbursement through Medicare for pneumococcal vaccine. Oral Health

ADA promotes the use of dental sealants, fluoridation of water systems, the prevention of caries associated with nursing bottles (in collaboration with AAP), and the prevention of dental complications from medical illness, including human immunodeficiency virus infection. Other Areas

ACOG has developed Adolescent Sexuality: Guides for Professional Involvement, a manual for physicians working with schools and public education programs on unwanted teenage pregnancy. ACOG has also prepared technical bulletins on the prevention of osteoporosis. Other educational programs include the National High Blood Pressure Education Program and the National Cholesterol.Education Program. Implementation

Medical and dental organizations have also taken steps to facilitate the implementation of clinical preventive services. These efforts include professional education, patient and public education, and public policy changes, as follows:

Chronic Disease Control Continued

Professional education. Education of health professionals at the undergraduate, graduate, and postgraduate levels is an important component of organizational initiatives in chronic disease prevention and control. AOA requires training in prevention beginning with the first year of undergraduate training and continuing through residency. AOA's continuing medical education courses have featured a number of prevention-related topics. Recent courses offered by AMA have included environmental risk assessment and the diagnosis and management of hyperlipidemia. ACPM cosponsors the PREVENTION conference series and also markets the "Dietary Inventory of Nutritional Experience," a computer software program that teaches physicians about nutrition and how to improve nutritional behavior. Both AAFP and AAP have organized numerous continuing medical education courses in prevention and regularly feature articles about health promotion and disease prevention in their respective journals, American Family Physician and Pediatrics.

Patient and public education. Many organizational chronic disease prevention and control projects include components on patient or public education. AAP's injury prevention program, for example, includes educational materials for patients. ACOG's efforts to prevent osteoporosis and unwanted teenage pregnancy include patient education pamphlets and television advertising. Patient education materials also have been produced by ACP, ADA, and AAFP.

Public policy. Numerous organizations have played an active role in advocating health-related changes in public policy. Child safety-seat laws were a focus of legislative action by AAP, and members of that association have testified before Congress on bills relevant to child health, have lobbied for improved access to health care for children, and have helped organize a child health advocacy coalition. ACOG has mounted policy initiatives on improved access to prenatal care and on contraceptive advertising. The expansion of community water fluoridation is a continuing concern of ADA. Several medical and dental organizations have worked together on various immunization policy questions. Reported by: American Academy of Family Physicians, Kansas City, Missouri. American Academy of Pediatrics, Elk Grove Village, Illinois. American College of Obstetricians and Gynecologists, Washington, DC. American College of Physicians, Philadelphia, Pennsylvania. American College of Preventive Medicine, Washington, DC. American Dental Association, Chicago, Illinois. American Medical Association, Chicago, Illinois. American Osteopathic Association, Chicago, Illinois. Office of Disease Prevention and Health Promotion, Public Health Svc, Dept of Health and Human Svcs. Editorial Note: The clinical setting offers an important opportunity for health professionals to provide services designed to control chronic disease (2). Clinicians, through their frequent contact with patients, have many opportunities to initiate disease prevention activities. In 1985, for example, the average American had contact with a physician 5.2 times (3). In addition to offering clinical preventive services such as screening tests, physicians can promote behavioral risk reduction through patient education and counseling (4). Clearly, the delivery of these preventive services during the clinical encounter serves an important public health role in the national strategy to prevent and control chronic disease (5,6).

At the same time, there are barriers to implementing preventive services in the clinical setting. There is evidence, for example, that physicians do not perform cancer screening and other preventive services in accordance with published recommendations (7,8). Despite these difficulties, however, physicians are beginning to adopt Chronic Disease Control Continued primary and secondary prevention as legitimate concerns (9) and appear to have a better understanding of how to change medical practices to comply with recommendations (10). This report suggests that, at the organizational level, physicians and dentists are developing programs for professional education and support, educational materials for patients, public education campaigns, and various policy initiatives to promote the implementation of disease prevention activities on a national scale.

For additional information, contact: American Academy of Family Physicians American College of Preventive Medicine Scientific Activities Division

1015 15th Street, NW, Suite 403 P.O. Box 8723

Washington, DC 20005 Kansas City, MO 64114-0723

American Dental Association American Academy of Pediatrics

Division of Education and Health Affairs Division of Maternal, Child, and

211 E. Chicago Avenue Adolescent Health

Chicago, IL 60611 141 Northwest Point Boulevard

American Medical Association P.O. Box 927

Department of Public Health Elk Grove Village, IL 60009-0927

535 N. Dearborn Street American College of Obstetricians and

Chicago, IL 60610 Gynecologists

American Osteopathic Association Resource Center

142 E. Ontario Street 600 Maryland Avenue, SW

Chicago, IL 60611
Washington, DC 20024-2588
American College of Physicians
Publications Department
4200 Pine Street
Philadelphia, PA 19104

References 1. Engelberg AL, Gibbons HL, Doege TC. A review of the medical standards for civilian airmen:

synopsis of a two-year study. JAMA 1986;255:1589–99. 2. Stott NC, Davis RH. The exceptional potential in each primary care consultation. JR Coll Gen

Pract 1979;29:201-5. 3. National Center for Health Statistics. Health, United States, 1986. Hyattsville, Maryland: US

Department of Health and Human Services, Public Health Service, 1986:137; DHHS publication no.

(PHS)87-1232. 4. Louis Harris and Associates. Health maintenance: a nationwide survey of the barriers

toward better health and ways of overcoming them, conducted among representative samples of the American public, business and labor leaders. Newport Beach, California:

Pacific Mutual Life Insurance, 1978. 5. Last JM, Adelaid MB. The iceberg: "completing the clinical picture" in general practice.

Lancet 1963;2:28–31. 6. Centers for Disease Control, Association of State and Territorial Health Officials. First

National Conference on Chronic Disease Prevention and Control: identifying effective strategies - conference summary. Atlanta: US Department of Health and Human Services,

Public Health Service, 1987:9–10. 7. McPhee SJ, Richard RJ, Solkowitz SN. Performance of cancer screening in a university

general internal medicine practice: comparison with the 1980 American Cancer Society

guidelines. J Gen Intern Med 1986;1:275–81. 8. Battista RN, Spitzer WO. Adult cancer prevention in primary care: contrasts among primary

care practice settings in Quebec. Am J Public Health 1983;73:1040_1. 9. Goldstein B, Fischer PM, Richards JW Jr, Goldstein A, Shank JC. Smoking counseling

practices of recently trained family physicians. J Fam Pract 1987;24:195–7. 10. Greer AL. The two cultures of biomedicine: can there be consensus? JAMA 1987;


Epidemiologic Notes and Reports

Organophosphate Toxicity Associated
With Flea-Dip Products – California

Flea-control products, particularly flea dips for pet animals, may contain potent cholinesterase-inhibiting organophosphate pesticides. In 1986 and 1987, two cases of human illness associated with the use of flea-dip products were reported to the California Department of Health Services (CDHS) and the California Department of Industrial Relations (CDIR). One patient was a pet groomer who requested advice from the state's Hazard Evaluation System and Information Service (HESIS). The other patient was also a pet groomer. She had had a long-term illness that was discovered by HESIS through a telephone survey. Case 1

In early September 1986, a 33-year-old female pet groomer complained of periodic headache, nausea, dizziness, tiredness, and blurred vision and of sweating and feeling "confused" and "spaced out." For over a year, these episodes had occurred more frequently, and the symptoms had become more severe each time. According to her friends, her pupils were often pinpoint-sized during these episodes. At first, she thought her symptoms were due to stress at work, and she did not seek medical care.

For the preceding 18 months, she had been treating dogs with an organophosphate pesticide. During the summer months, she had treated an average of 10 dogs per day. The flea-dip product she used is a liquid concentrate containing 11.6% phosmet* (a cholinesterase-inhibiting organophosphate insecticide known to cause acute irritation of the mouth, eyes, and skin) as the active ingredient. While diluting the concentrate in water, she frequently had spilled some of the concentrate on her skin.

After consulting with HESIS, the woman's physician diagnosed her illness as organophosphate intoxication. Her red cell cholinesterase activity (0.84 ApH) was well within the usual range (0.56–1.01 ApH) found by the testing laboratory. The woman was treated with oral atropine, and her symptoms diminished. For 2 weeks after returning to work, she avoided contact with flea-dip solutions and remained asymptomatic; however, within an hour after she treated a dog with a product containing chlorpyrifos," a mild-to-moderate cholinesterase-inhibiting agent, her symptoms recurred. After that, she avoided contact with all organophosphate pesticides. Seven months later, her level of red cell cholinesterase, measured by the same laboratory, was within 20% (0.67 ApH) of the first value. Telephone Survey

Later in September 1986, HESIS conducted a telephone survey. Twenty-four pet groomers in the San Francisco Bay area and Los Angeles were selected at random from listings in telephone directories. Through telephone interviews, 12 persons reported that they frequently used flea-dip products and usually had symptoms when they worked with the products. The symptoms most commonly reported were headache, dizziness, nausea, fatigue, and dermatitis. Two persons reported having symptoms of sweating, tearing, and confusion, all of which are consistent with cholinesterase inhibition. Flea-control products containing phosmet were most often *N-(Mercaptomethyl)phthalimide S-10,0-dimethylphosphorodithioate). *0,0-Diethyl O-(3,5,6-trichloro-2-pyridyl)-phosphorothioate.

Toxicity Continued reported as being related to the symptoms. One person complained of symptoms while working with a product containing chlorfenvinphos,' an organophosphate classified by the Environmental Protection Agency (EPA) as Toxicity Class 1(1).'

Most of the pet groomers reported that they did not wear aprons or gloves and did not use the pesticides according to directions on the product labels. They often applied the undiluted concentrates with bare hands, and their skin and eyes were frequently exposed to the flea-control products. Chloro-1-(2,4-dichlorophenyl)-vinyl diethylphosphate. “The most toxic chemicals are assigned to Class I.

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TABLE II. Notifiable diseases of low frequency, United States

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*Because AIDS cases are not received weekly from all reporting areas, comparison of weekly figures may be misleading.

Nine of the 96 reported cases for this week were imported from a foreign country or can be directly traceable to a known internationally imported case within two generations.

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