ATW1H%ASUACAD.BITNET@oac.ucla.edu (Dr David Dodell) (06/21/89)
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Health InfoCom Network News Page 9
Volume 2, Number 25 June 20, 1989
counts higher, were apparently able to suppress the AIDS virus and suppress
tumors called Kaposi's sarcoma as well.
AIDS Spawns An Epidemic Of Unconcern
Several thousand doctors, medical researchers and health administrators have
gathered in Montreal this week for the fifth international AIDS conference,
against a background of a rapidly increasing number of worldwide AIDS cases -
and rapidly declining public interest in the disease, at least in Europe and
North America. Despite intense research, no cure for the disease or vaccine
to prevent it is yet in sight.
Politicians, journalists and the general public are currently showing less
concern about AIDS than at any point since the first interantional conference
in Atlanta in 1985, when the world was shocked into realising that the disease
was a serious threat to public health.
"In the US there's now a familiarity with the disease which has bred an
undisguised contempt for it," says Dr June Osborn, Dean of the School of
Public Health at the University of Michigan. "I even have people saying to me:
'Your life must becoming easier now that the epidemic is on the wane.'
"Unfortunately society is not dealing successfully with AIDS, but sweeping
it under the carpet. The people whose business is to deal with the epidemic
remain in awe of the looming problems."
Experts are becoming more confident about estimating the size of the
epidemic and predicting its future growth, as governments, particularly in
Africa, stop pretending that AIDS hardly exists and begin to welcome medical
assistance from outside. The World Health Organisation, which expects to
spend Dollars 90 m this year on its Global Programme on AIDS, estimates that
between 5 m and 10 m people are now carrying HIV, the virus that causes AIDS;
20 m are likely to be infected by the year 2000. According to the present
medical knowledge, most of them will eventually die of AIDS.
The number of AIDS cases reported to the WHO reached 152,000 last month,
but the true total is believed to be at least three times as great. WHO
projections show the number of cases reaching 1 m by the end of 1991 and 3-4 m
by the end of the century.
Although the US has much the largest number of official AIDS cases -90,000
of whom about half have died - the epidemic there is still confined largely to
homosexual men and people who inject themselves with illegal drugs. In
Africa, where the 23,000 reported cases probably represent lkess than one
tenth of the real total, the vast majority have been infected by heterosexual
contact or by their mother in the womb.
According to the Organisation Pan-Africaine de Lutte contre Sida (Opals),
based in Paris, up to 30 per cent of young adults and 15 per cent of children
are now infected in some cities in central Africa. Dr Michel Rosenheim, Opals
vice president, says the social effect will be devastating.
"AIDS is affecting the most healthy and productive members of society," Dr
Rosenheim says. "It is not a disease of the poor like tuberculosis and
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Volume 2, Number 25 June 20, 1989
malaria. The future leaders of these African countries are going to die of
AIDS."
In most of Europe and North America the much feared "break out" of AIDS
into the non-drug-using heterosexual population has not occurred. Although
Europe as a whole remains about three years behind the US in the progress of
the epidemic, different patterns are emerging in southern Europe, where the
disease is concentrated among intravenous drug users, and northern Europe,
where most victims are homsexuals.
AIDS is beginning to spread through the Caribbean region as a heterosexual
epidemic on the African model. But perhaps the most disturbing new evidence
comes from Asia, the continent so far least touched by AIDS. Tests on illegal
drug users in Bangkok show that the propotion infected by HIV has risen from
just 1 per cent in January 1988 to more than 50 per cent now.
Dr James Chin, head of the WHO's AIDS surveillance unit, says that the
Bangkok figures should finally destroy the myth that Asians have largely
escaped infection because they are genetically less susceptible to the virus.
Since Bangkok is a centre for "sexual tourism," infection of the city's 50,000
drug users could spread AIDS rapidly through the region.
Nations are divided as to what social policies should be adopted to deal
with the disease. So are employers and trade union officials, who are having
to deal with AIDS as a labour relations issue.
Cuba stands out as the only country where the government forces AIDS
patients to live apart from their families and friends in special sanatoria
until they die. China last year strengthened local legislation making
homosexuality, drug addiction, and prostitution punishable by lengthy labour
re-education, as a way of combating AIDS. And mandatory testing is practised
in a growing number of states and countries including Bavaria, Bulgaria, South
Africa, Argentina, and the Soviet Union.
So far, the US and most west European governments have resisted draconian
measures because of the political, social and legal implications, quite apart
from the unproven medical effectiveness of compulsory testing.
Companies which openly declare that they screen potential recruits are the
exception rather than the rule. Testing is for jobs in which AIDs could
arguably affect performance and put public safety at risk. Examples are
British Airways and Texaco, which have introduced screening for pilots and
truck drivers respectively.
US employers who tried to solve the problem of AIDS at the workplace by
firing those with the disease are now finding themselves on the wrong side of
the law. Since 1986 an increasing number of states and several cities in the
US have made AIDS a "protected handicap" so that a large measure of protection
now surrounds the victim.
The issue of AIDS dscrimination at the workplace has yet to be fully tested
in European courts. However a report written by the international jurist, the
late Mr Paul Sieghart, argues that a company which refuses a job applicant
because he or she is suspected of carrying the AIDS virus could be liable
under international human rights law.
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Volume 2, Number 25 June 20, 1989
Last year in one of the first cases of its kind in the UK, a homosexual who
was sacked because his colleagues feared he would give them AIDS won 2,000
Pounds (pds) damages in an out-of-court settlement, even though a court had
earlier ruled against him.
On balance, however, most companies in Europe and the US are adopting a
conciliatory approach which avoids such legal minefields and minimises
disruption in industrial relations. This concentrates on providing
information about the facts as far as they are known and laying to rest
irrational fears about "catching AIDS" from contact at work.
Life insurance companies, on the other hand, argue that their financial
health depends on discriminating against clients who are risk from AIDS.
Their attitude - and in particularly the way they have asked applicants about
HIV tests - has put the insurance industry in conflict with the organised
medical profession.
The only drug so far licensed by government authorities to treat AIDS
directly is AZT (also known as Retrovir) made by Wellcome, a UK pharmaceutical
company. But AZT, which is used by about 30,000 people around the world, is
far from perfect. It causes unpleasant side effects, such as severe anaemia,
in many AIDS patients and it does not claim to cure the disease but only to
relieve some symptoms and prolong life.
For the 70 bn pds-a-year world drug industry, therefore, the challenge is
to come up with a product that will improve on AZT. According to the
Pharmaceutical Manufacturers Association of the US, a total of 56 medicines
designed to treat AIDS and the secondary infections which accompany it are now
going through the various stages of the Food and Drug Administration's
approvals process.
Designing an effective treatment for any virus is a formidable scientific
challenge. Viruses work by infiltrating themsleves inside human cells and
hijacking the host cells' metabolic machinery to grow and reproduce. They are
much more difficult targets than bacteria, which are independent cells and can
be killed by antibiotics without destroying the human cells around them.
The way HIV can bury itself in the genetic material of the cell and then
suddenly burst into lethal action after a delay of several years makes it hard
to attack, even in comparison with other viruses such as influenza and the
common cold for which no cures exist. A "cure" for HIV, in the sense of
eradicating the virus from the genes of AIDS patients, may not be achieved for
several decades; but most researchers believe that they can develop a drug
which is free of side effects and whch suppresses all symptons of the disease.
Several anti-viral drugs now proceeding through the final stages of
clinical trials look as though they might have fewer side effects than AZT.
One of the most promising is dideoxyinosine (DDI), under development by
Bristol-Myers of the US. Both AZT and DDI work because they mimic the
chemical building blocks of the genetic material DNA.
The new anti-virals are likely to be used in a "drug cocktail" containing
other medicines designed to stimulate the immune system and to fight the
secondary infections such as pneumonia which afflict AIDS patients.
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Volume 2, Number 25 June 20, 1989
Developing a vaccine to prevent HIV infection may be even more difficult
than finding an effective treatment. Some AIDS specialists say that the
nature of the virus makes the quest for a vaccine hopeless.
But 12 pharmaceutical companies are trying to develop an HIV vaccine in the
US. And in the current issue of the journal Nature, a UK team led by
Professor Jeffrey Almond of Reading University reports encouraging laboratory
tests of a prototype vaccine based on a hybrid HIV-Polio virus.
Although AIDS victims are understandably impatient that new drugs are not
emerging more rapidly from the billions of dollars spent on AIDS research, the
progress made since HIV was discovered six years ago has been astonishing.
And, because of the cross-fertilisation with other areas of medical research,
future beneficiaries could include anyone who suffers from a viral illness or
even cancer.
The mood in Montreal, however, is far from triumphant. In the absence of a
cure or vaccine, the only viable policy for containing the AIDS epidemic is to
persuade the public to avoid risky sexual behaviour and stop sharing drug
needles. That depends on a high level of media and political interest in the
disease, and AIDS specialists who complained that journalists overwhelmed
previous international AIDS meetings are worried that there may not be enough
coverage this time.
HEALTH: AIDS CONFERENCE ENDS
MONTREAL, June 9 (IPS) -- "There is light at the end of the tunnel," U.S.
researcher Dr. Jonas Salk told 10,000 delegates attending the fifth
International Conference on the Acquired Immune Deficiency Syndrome (AIDS),
which ended here today.
Though Salk stressed that no breakthrough was imminent, he insisted that
headway was being made in the search for a vaccine against the Human
Immunodeficiency Virus (HIV), which scientists believe causes AIDS.
Salk is the U.S. researcher who in 1955 developed the poliomyelite vaccine.
In recent years he has been working with two other researchers toward an HIV
vaccine.
"HIV infection is not necessarily a death sentence," Salk told delegates
from over 70 countries gathered at the "Palais des Congres" since June 4.
At last year's fourth International AIDS Conference in Stockholm, Salk also
reported encouraging test finds.
Throughout the meeting here, the largest of its kind on AIDS, researchers -
- especially from the U.S. -- stressed that research on AIDS vaccines is
promising.
But as Dr. Mervyn Silverman, president of the U.S. Federation of AIDS
Research, put it, "We're not there yet."
In fact, said Dr. Robert Gallo of the U.S. National Cancer Institute, the
public should not expect any more major scientific headway against the
syndrome and the virus.
"There will be new findings, but the major things we need are done... It's
a problem of technology and time, and testing this or that in certain numbers
of ways," Gallo said.
Dr. Gallo and Luc Montagnier of Paris' Pasteur Institute are credited with
the 1984 discovery of HIV.
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Volume 2, Number 25 June 20, 1989
Organized by the "International AIDS Society" (IAS) and the World Health
Organization (WHO), the five-day Montreal meeting mainly focused on new AIDS
drugs.
Besides "AZT," and "Zidovudine" for combating AIDS virus infections, there
are an estimated 60 new drugs in or near clinical testing in AIDS patients.
As the fifth International Conference on AIDS was winding down today and
delegates began checking-out of hotels, many echoed the opinion of a
Senegalese researcher.
"Very few new things were revealed here," noted Dr. Alpha Sy, of Senegal's
Epidemiology and Statistical Research Unit.
The next AIDS conference is scheduled for June 20-24, 1990 in San Francisco
where the fatal disease was first reported in 1981.
INFANT MORTALITY IN UGANDA
More than half of all deaths in Uganda each year are among children under five
years, according to a recent UNICEF study.
Entitled "Health Situation on Children in Uganda," the draft situation analysi
says that a 1988 survey found one fourth of the deaths among families
interviewed in 1987, occurred in children below one.
In 1987, national figures show that infant mortality in this age group was 104
per 1,000. However, the death rate for children below two years of age was 12
per 1,000, according to the study.
The major causes of death for all ages are diarrhoea, tetanus, measles and
acute respiratory diseases. The Ugandan government spends some four million
U.S. dollars each year on immunization and primary health care programmes.
While deaths of children older than one month are mostly related to measles,
diphtheria, tuberculosis, polio, whooping cough and tetanus, the causes of hig
perinatal and neonatal mortality rates are primarily the result of poor health
and nutritional status of mothers, complicated deliveries and neo-natal
tetanus.
UNICEF's Information and Communications Officer in Kampala Sheba Rukikaire say
that although measles has been responsible for more infant and child deaths
over the past 10 years, statistics show that mortality has been reduced by
immunization. Vaccination coverage for measles has increased from 17 per cent
in 1985 to over 50 per cent by 1988, she adds.
Source: UNICEF, Kampala
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Volume 2, Number 25 June 20, 1989
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Center for Disease Control Reports
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Morbidity and Mortality Weekly Report
Thursday June 15, 1989
Epidemiologic Notes and Reports
Common-Source Outbreak of Giardiasis -- New Mexico
In April 1988, the Albuquerque Environmental Health Department and the New
Mexico Health and Environment Department investigated reports of giardiasis
among members of a church youth group in Albuquerque. The first two members to
be affected had onset of diarrhea on March 3 and 4, respectively; stool
specimens from both were positive for Giardia lamblia cysts. These two persons
had only church youth group activities in common. Routine surveillance
identified no other cases associated with the church youth group.
The youth group had dinner once a week at the church; food was prepared by
parents of group members. The number of attendees at each meal varied, and no
record of who attended was kept. A survey of all families attending the church
sought to identify any family members who had eaten at any youth group dinners
in March and any who had had diarrhea since February 1, 1988. One hundred
forty-eight persons who attended at least one youth group dinner in March were
interviewed about food they had eaten at the meal(s); the 42 persons reporting
diarrheal illness were interviewed about details of their illness.
A case was defined as diarrhea and/or abdominal cramping with onset after
February 1, 1988, lasting greater than 7 days and/or a stool specimen positive
for Giardia cysts. Twenty-two (15%) persons met the case definition. Onset of
illness occurred from March 3 to March 30 (Figure 1), and illness lasted 1-32
days (median: 20 days). Twenty-one (19%) of 108 persons who ate the youth
group dinner on March 2 developed an illness meeting the case definition,
compared with one (3%) of 40 who did not eat that meal (relative risk
(RR)=7.8, 95% confidence interval (CI)=1.1-55.9, p=0.02).
For the 21 ill persons who had eaten the March 2 dinner, the most frequent
symptoms reported were fatigue (95%), diarrhea (91%), abdominal cramps (57%),
bloating (57%), and weight loss (67%). Patients ranged in age from 11 to 58
years (median: 39 years); 14 (67%) were female; 15 (71%) sought care from a
physician. Fourteen (67%) patients submitted stool specimens for ova and
parasite examination; 10 (71%) specimens were positive for Giardia cysts.
Seven of the stool specimens were also tested for Shigella, Salmonella,
Campylobacter, and Yersinia, and all were negative. One ill person attended a
day-care center, one had household contact with a day-care center attendee,
and none had consumed surface water.
The foods served at the dinner on March 2 included tacos (with meat,
onions, tomatoes, lettuce, cheese, salsa, sour cream, and tortillas), corn,
peaches, cupcakes, soft drinks, coffee, and tea. No food samples were
available for microbiologic testing. Persons who became ill were more likely
to have reported eating lettuce (RR=8.1, CI=1.1-57.3), salsa (p less than
0.01), onions (RR=4.2, CI=1.9-9.1), or tomatoes (RR=3.5, CI=1.4-8.8) or
drinking tea/coffee (RR=5.5, CI=2.3-13.4). Water consumption was not
associated with illness. Lettuce, onions, and tea/coffee were most strongly
associated with illness by logistic regression analysis.
Except for the commercially prepared salsa, the implicated foods were
prepared in the church kitchen. The lettuce and tomatoes were rinsed at the
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Volume 2, Number 25 June 20, 1989
kitchen's main sink; the outer leaves of the lettuce were removed; and the
lettuce, tomatoes, and onions were chopped on the same cutting board, which
was not washed between items. The dinner was prepared by eight women whose
children were in the youth group; all ate the meal. Although the woman who
prepared the lettuce and tomatoes taught preschool and had a child in
preschool, neither she nor her child was ill when the meal was prepared. None
of the eight food preparers reported symptoms at the time of meal preparation;
however, five became ill with diarrhea after March 8. Three had stool
specimens positive for Giardia cysts.
The church is on the municipal water system. A survey of possible
connections between the church's potable water system and the sanitary sewer
system identified five potential cross-connections. However, water samples
taken at the time of the cross-connection survey had adequate chlorine levels
and were negative for coliform bacteria. On April 4, after the investigation
began, the church stopped using municipal water for consumption and began
catering meals. After elimination of all cross-connections, every outlet was
flushed simultaneously for 3 hours. No new cases occurred after the
remediation measures were completed.
Reported by: DJ Grabowski, MS, KJ Tiggs, JD Hall, DrPH, HW Senke, AJ Salas,
Albuquerque Environmental Health Department; CM Powers, JA Knott, Bernalillo
County District Health Office; LJ Nims, Scientific Laboratory Div; CM Sewell,
DrPH, Acting State Epidemiologist, New Mexico Health and Environment Dept. Div
of Field Svcs, Epidemiology Program Office, CDC.
Editorial Note: In this apparent point-source outbreak of giardiasis, the most
likely vehicle of transmission was taco ingredients. Although all the ill
persons ate the commercially prepared salsa, salsa was unlikely to have
transmitted Giardia cysts because the cysts would not remain viable after the
pasteurization and canning processes.
Two explanations for the contamination are possible. First, if the potable
water was contaminated, the lettuce and tomatoes could have been contaminated
when washed. Because the lettuce, tomatoes, and onions were all cut on the
same board, cross-contamination could have occurred. However, because
plumbing changes were made before completion of the epidemiologic
investigation, this hypothesis could not be tested. Second, if the woman who
prepared the lettuce and tomatoes was infected and excreting Giardia cysts,
she could have contaminated the vegetables during preparation. However, this
mode is less likely because this woman had acute onset of diarrhea 10 days
after the meal, suggesting a new infection at that time.
Only two reported outbreaks of giardiasis have been associated with food:
canned salmon (1) and noodle salad (2). In both outbreaks, contamination
occurred when food was mixed with bare hands. Waterborne outbreaks of Giardia
are well documented, and persons consuming untreated surface water are at
increased risk for developing giardiasis (3). Person-to-person transmission is
also well known in day-care and institutional settings (4). Public health
officials should consider foodborne transmission when investigating outbreaks
of giardiasis.
References
1. Osterholm MT, Forfang JC, Ristenen TL, et al. An outbreak of foodborne
giardiasis. N Engl J Med 1981;304:24-8.
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Volume 2, Number 25 June 20, 1989
2. Petersen LR, Cartter ML, Hadler JL. A food-borne outbreak of Giardia
lamblia. J Infect Dis 1988;157:846-8.
3. Craun GF. Waterborne giardiasis in the United States: a review. Am J Pub
Health 1979;69:817-9.
4. Pickering LK, Woodward WE. Diarrhea in day care centers. Pediatr Infect Dis
1982;1:47-52.
Health InfoCom Network News Page 17
Volume 2, Number 25 June 20, 1989
Current Trends Problems Created by Heat-Inactivation of Serum Specimens Before
HIV-1 Antibody Testing
Among laboratories testing for human immunodeficiency virus type 1 (HIV-1)
and participating in CDC's Model Performance Evaluation Program (1,2),
responses from May and September 1988 survey questionnaires show that 40
(3.9%) of 1034 and 41 (3.9%) of 1052 respondents, respectively, heat-
inactivate serum specimens before testing for HIV-1. Heat-inactivation is an
effective means of destroying HIV-1 (3) and is used both to prepare
therapeutic blood products and to produce certain laboratory quality-control
testing materials; however, this method is not recommended as a routine means
of protecting the safety of laboratory workers exposed to blood and other body
fluids while performing their jobs. Instead, laboratorians are urged to follow
universal precautions recommending that all blood be considered potentially
infective (4,5).
Heat-inactivation of serum specimens before they are screened by enzyme
immunoassay (EIA) for HIV antibody can give false-positive results (6,7).
Thus, laboratories that continue heat-inactivating serum are likely to obtain
false-positive results with some EIA kits (6,7). Heat-inactivation can also
interfere with Western blot analysis (8). Universal precautions preclude the
necessity of selective treatment such as heat-inactivation for specimens from
persons considered to be at increased risk for infection with HIV-1, hepatitis
B virus, or other diseases caused by bloodborne pathogens. Therefore, CDC
recommends that laboratories emphasize the practice of universal precautions
(4,5) rather than heat-inactivation of serum to prevent occupational
transmission of HIV.
Reported by: Div of Laboratory Systems, Public Health Practice Program Office,
CDC.
References
1. Taylor RN, Przybyszewski VA. Summary of the Centers for Disease Control
human immunodeficiency virus (HIV) performance evaluation surveys for 1985 and
1986. Am J Clin Pathol 1988;89:1-13.
2. Schalla WO, Hearn TL, Griffin CW, Taylor RN. Role of the Centers for
Disease Control in monitoring the quality of laboratory testing for human
immunodeficiency virus infection. Clin Microbiol Newsletter 1988;10:156-9.
3. Martin LS, McDougal JS, Loskoski SL. Disinfection and inactivation of the
human T lymphotropic virus type III/lymphadenopathy-associated virus. J Infect
Dis 1985;152:400-3.
4. CDC. Recommendations for prevention of HIV transmission in health-care
settings. MMWR 1987;36(suppl 2S):3S-18S.
5. CDC. Update: universal precautions for prevention of transmission of human
immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens in
health-care settings. MMWR 1988;37:377-82, 387-8.
6. Evans RP, Shanson DC, Mortimer PP. Clinical evaluation of Abbott and
Wellcome enzyme linked immunosorbent assays for detection of serum antibodies
to human immunodeficiency virus (HIV). J Clin Pathol 1987;40:552-5.
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Volume 2, Number 25 June 20, 1989
7. McBride JH, Howanitz PJ, Rodgerson DO, Miles J, Peter JB. Influence of
specimen treatment on nonreactive HTLV-III sera. AIDS Res Hum Retroviruses
1987;3:333-40.
8. Goldfarb MF. Effect of heat-inactivation on results of HIV antibody
detection by Western blot assay. Clin Chem 1988;34:1661-2.
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Volume 2, Number 25 June 20, 1989
Epidemiologic Notes and Reports Work-Related Injuries and Illnesses in an
Automotive Parts Manufacturing Company -- Chicago
In 1985, 146 work-related injuries and illnesses occurred among the 349
full-time workers in an automotive parts manufacturing company in Chicago. The
company's injury/illness rate of 41.8 cases per 100 full-time workers per year
was more than four times greater than the 1985 industry average of 10.1 cases
per 100 workers, as reported by the Bureau of Labor Statistics (BLS), for
companies manufacturing motor vehicle parts (1).
In March 1986, the company requested that the Rush-Presbyterian-St.
Luke's Occupational Health Centers in Chicago evaluate its 1985 injury
experience. Examination of workers' compensation records, Occupational Safety
and Health Administration (OSHA) records, medical reports, and insurance
records showed high rates of musculoskeletal and dermatologic injuries,
including sprains/strains (11.2 per 100 full-time workers), contusions (10.0),
and cuts/lacerations (5.4). The most commonly affected body parts were the
finger (10.3 per 100 full-time workers), back (6.3), and hand (4.6).
The most prevalent nature-of-injury categories (e.g., sprains/strains,
contusions, cuts/lacerations) were further evaluated for the most common
sources (e.g., boxes, metal items, machines) and types (e.g., overexertion,
being struck by an object) of injury. Fifty-four percent of sprains/strains
were associated with boxes; 87%, with overexertion (i.e., excessive physical
effort associated with the lifting, pushing, or pulling of an external
object). Forty percent of contusions were associated with boxes; 46% resulted
from having been struck by an object. Fifty-eight percent of cuts/lacerations
were associated with contact with metal items.
In March 1986, simultaneous with the analysis of its 1985 injuries, the
company modified its procedures for handling materials. These changes included
1) a decrease in the size of the boxes used to transport automotive parts, 2)
a decrease in the average weight of the boxes from 50 to 25 pounds, and 3) the
installation of manual conveyors and lift assists designed to decrease manual
lifting requirements. The company also sponsored regular plant inspections,
safety films, lectures, and various safety contests.
In April 1988, the company's 1986 injury experience was analyzed to
evaluate the effectiveness of the interventions. From workers' compensation
forms, OSHA records, and medical reports, 44 work-related injuries and
illnesses were identified among the company's 321 full-time workers. Even
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