Sick-Buildings-Transportation-Choices and Oxygen Levels
I rented an atmospheric oxygen calibrator, one that miners use now instead of some unlucky canary. I discovered that oxygen levels in different locales varied from one to six percentage points (21% to 15%) 20.8% of the air we breathe at sea level is normal. In a commercial jumbo jet it dipped approximately 24 percent to 15.8 percent of the air we were breathing. Added to jet-lag (which has been reduced by my Breathing Exercise #2 guided audio), do frequent flyers or airplane personnel get more colds or illness than the average? What is their life span these days? Germs, viruses and bacteria are anaerobic; they thrive in an oxygen poor atmosphere.
NASA pilots use ninety percent oxygen or more in their high altitude planes. The basement meeting room of a hotel decreased to 19.2 percent, an eight percent reduction. Theywanted me to teach breathing classes there. I refused. Another hotel read O2 at 20.8. Thats the hotel I would choose to stay or teach in. During a rain storm O2 % dropped from 20.8 to a 20.1; Water must displace a little oxygen. A stuffy car reduced it to 19.5 and with the heater on another percentage point to 18.2, or 12 percent. A room where I wrote some of this workbook dipped to 20.1 and it became uncomfortably stuffy. My positive attitude went down. I took a brisk walk in the fresh air and felt good again. Shouldnt that tell you something right then if you have to go to the trouble of going outside to get a breath of fresh air to feel better? For a good article on buildings and breathing. PDF should link get broken it did.
A study of welders working in closed environments in England showed that a 17 percent oxygen environment was the least researchers felt comfortable allowing a welder to work in. Id like to get those welders health and life span records. A lot of welders I know have serious lung problems in their later years. The torches burn up breathable oxygen as well as the torchs tanks of oxygen.
The Biosphere 2 team near Tucson, Arizona canceled the two year live-in residency requirement. This was due largely to the drop in oxygen levels within the bubble environment to 14%. They couldnt create an environment that would naturally produce more than 14%. Speaking with the physician in charge I learned that concerns were that residents were developing enlarged chests to capture more oxygen. Sounds like mutation to me.
Smoking (Stop Smoking Program) a cigarette will give one a lift or take their mind off our troubles and when they do that they spontaneously take a deep breath and feel better. It is often the breath that releases the tension and troubles. Try injecting the nicotine intravenously and Ill bet you get stimulation without any relaxation. On second thought, better not. It might kill you.
Mountain people live on less oxygen because the air is thinner. Their chests often enlarge. This is not mutation as their offspring do not have enlarged chests but for others not being a part of successive generations, the chest may well become rigid inviting reduced breathing dynamics and lung compression/expansion. Study the Kenyans or High mountain Ethiopians for more about this. Add sea level stresses, devitalized or overcooked foods, and pollution and I suspect they would suffer many maladies previously unknown to them. How would that affect their quality of life and longevity? Anyone studying Mexico City and Denver these days for breathing-related (practically every stress and air quality oriented disease is breathing related) disorders?
What might happen if atmospheric O2 in your locale (apartment of office building) was reduced just one percent. That is approximately a 5% oxygen supply reduction for years or even generations?
We have the capability of measuring these factors but few seem to care...Yet I understand people at the Scripps Institute are measuring atmospheric oxygen. Considering most blue green, red and brown algae are from the sea and produce approximately 80% of the earths oxygen supply, this makes a lot of sense.
Do you agree with Stephen Hawking when he stated that mankind will have to clone themselves to keep up with technology. I know he has a lot of reason to want to believe that, God bless him, but thats still really scary.
Cant we slow down and study what works instead of what might work or seems to work on rats and primates? Lets find out, does more oxygen serve mankind? Research hyperbaric oxygen chambers to get more clarity on that.
Get a Turbo Oxygen system
NASA's space medicine programs have of course been working with oxygen related to high altitude flying and space travel. My questions are:
Carbon dioxide (CO2) in soda drinks causes the lungs to have to work harder to eliminate the excess waste product.
I visited Seattle recently and noticed how healthy the people looked, even with no noticeable tans; their skin and faces, seemed full of healthy color, their eyes alert, and seemingly unhurried. There is abundant rain-cleansed, oxygen rich air and water up there.
Meanwhile, do you live next to a freeway, or work in an oxygen short sick building, have CO2 and pollution displace the oxygen, develop a larger chest that also takes in more pollutants or invites reduction of alveoli resulting in reduced oxygen uptake as well as inhibit lung cleansing that doesnt allow taking in much of anything, including oxygen? Is there a relationship with breathing and diabetes; cancer; heart trouble; stress; cystic fibrosis; asthma; emphysema; and any other illness or state of wellness you can think of?
YES! Given the Framingham 30 year study that clarified breathings direct relationship with longevity and the fact that many will lose 75% of their breathing capacity by age 75 if they do not take action soon, are you "boiling a frog. Are you the frog?
There are easy and safe ways to learn to breathe better. Yoga, Tai Chi and Chi Gong are very beneficial but they may not appeal to everyone or have teachers that teach with enough depth of insight relevant to breathing. As beneficial as the Eastern Practices can be, they seem to need more attention given to the breath. Optimal Breathing techniques combine insights from several other perspectives. Study the breath and breathing.
OF PREVENTION IS WORTH A POUND OF CURE.
* "Our investigation provides evidence of the transmission of M. tuberculosis from passenger to passenger and from passenger to flight crew aboard commercial aircraft".
From mike: And any other germ that is transmitted via the air you breathe. Pneumonia, bronchitis, asthma inducing airborn particles, colds, flus ALL get to fly along with you ... or in you.
A dear friend of mine was a flight attendant 25 years ago. Back when you had to be traffic stopping gorgeous to get that job. They told her then that she should wear support hose because the work on the plane would age them faster. Whyzat? Standing a lot; bending a lot; poor diets; long hours and time zone stresses; high pressure altitude compromising venal flow; - low oxygen environment all add up to awesome health challenges.
*This statement was from a study
( http://airlinepilots.com/Aeromedicine/CDCTuberculosisPage2.htm - I saved it below in case it got unlinked - it did.)
including the staffs of more than 40 state and local health departments, the airline company, and the physicians of exposed passengers and crew; the staffs of the tuberculosis-control programs of the states of Hawaii and Maryland for sharing information about the index patient and the results of contact investigations; the representatives of the Federal Aviation Administration, the Council of State and Territorial Epidemiologists, the Airline Transport Association, the National Tuberculosis Controllers Association, and the airline companies for their participation in the development of recommendations for notifying passengers and crew after possible exposure to tuberculosis on aircraft.
What to do:
Keep the air vent open and breezing your face -most planes have HEPA filters, so get maximum benefit from that; notice if the person near you looks sick and move to another seat at least 20 feet away, especially if they are coughing or blowing their nose; drink lots of water, while on board and as often as practical; wear an anti allergen face mask; take immune booster supplements and antioxidants like vitamin E, Quercitin, vitamin C, and beta carotene; make sure you have enough - 40/50 grams of insoluble and soluble fiber in your daily diet to rid your body of debris and toxic waste thrown off by the kidneys, liver and immune system function -that means flax seeds, fresh veggies and fruits; reduce dairy foods, fried foods, prepared meats, red meats and saturated fats of all kinds; no bagels. Avoid salty, sugary and caffeine foods. Get enough sleep to wake up rested. Every day. Rest and recover in the PRP while you do Breathing Exercise #2. Walk, swim or run; "Standing" creates rigidity - remember why they "standing water" a breeding ground for unhealthy organisms. If you stand a lot, watch out for biking as it may add to varicose veins. Get health books like Linda Pages Healthy Healing or the latest Balch and Balchs Dietary Wellness. Develop your breathing to the max. The more you have the more oxygen you can grab from the air, the faster you will recover from a "day in hell", the easier your entire nervous system will have to work and the less tired you will get in the first place. Recommended breathing development program
Investigation of Index patient and Household Contacts Medical and laboratory records of the index patient were reviewed. State and local health departments investigated the contacts of the two households in the two states where the index patient had lived during her visit to the United States.
Investigation of the Flight Crew and Passengers
The passenger manifest and lists of flight-crew members for the four flights were obtained from the airline company. Information from the manifest and from frequent-flyer records was used to locate passengers and identify seat assignments. Persons who were not residents of the United States or Canada were excluded from the investigation. The passengers and members of the flight crews (contacts) were notified by certified letter of their potential exposure to tuberculosis, advised to have a Mantoux tuberculin skin test, and asked to complete a questionnaire. Data collected included demographic and epidemiologic information. Except for those of contacts with evidence of previous tuberculosis or previous positive tuberculin skin tests, skin-test results reported in this study are based on written records provided by health departments or by personal physicians.
Contacts with negative results on tuberculin skin tests performed less than 12 weeks after the flight were mailed a second letter advising them of the need for a final test at least 12 weeks after their exposure. A positive tuberculin skin test was defined as involving an induration of 10 mm or larger. A skin-test conversion was defined as an increase of 10 mm or move in induration within the previous two years. Contacts with positive tuberculin skin tests or conversions were interviewed about other risk factors for tuberculosis. Results of tuberculin skin tests and interviews were reviewed independently by three tuberculosis experts, who assessed whether positive results were due to new infection or the booster effect. (3-5)
Results of tuberculin skin tests were analyzed according to age, sex, race or ethnic group, flight, flight duration, and seat proximity to the index patient. Categorical variables were compared with the use of the chi-square or Fisher's exact test. Continuous variables were compared with the use of Student's t-test. (6)
Information about the type of aircraft flown on each flight was obtained from airline records. Airline-industry diagrams were used to map seat assignments and manufacturers' specifications of airflow, and air-distribution systems were reviewed for each type of aircraft. Aircraft-ventilation systems were not otherwise evaluated.
The index patient was a 32-year old Korean woman, who according to relatives was taking no antituberculous medication but had previously been treated for tuberculosis -- twice as an adolescent in Korea and once within the past two years in Japan -- with unknown medication. She arrived in Honolulu in April on a tourist visa and was reportedly coughing and lethargic while staying with friends (Household 1) for five days. She then flew from Honolulu to Chicago and from Chicago to Baltimore, where she remained with friends (Household 2) for one month. Members of Household 2 reported a worsening of her symptoms, including progressive cough, lethargy, shortness of breath, fever, night sweats, and the eventual onset of scant hemoptysis. In May she returned to Honolulu, flying from Baltimore to Chicago and from Chicago to Honolulu. Eight days after returning to Household 1, she had an acute episode of hemoptysis, described as consisting of approximately 1 liter of bright red blood. Hospital evaluation revealed extensive pulmonary disease.), and her sputum was highly positive (3+) for acid-fast bacilli and was culture-positive for M. tuberculosis. The patient died from pulmonary hemorrhage and respiratory failure five days after being hospitalized.
Household Contacts of Index Patient Both Korean-born adults in Household 1 had positive tuberculin skin tests in June 1994. Their two children, three and seven years of age, had negative skin tests 14 weeks after exposure. The mother in Household 2 had had a positive skin test in 1977, and her chest film was normal in May 1994. The father's test showed 12 mm of induration at the end of May, and his chest film was normal. Their 21-month-old, U.S.-born child had a skin-test conversion from 0 mm of induration in May and early July (2 and 8 weeks after the index patient departed, respectively) to 22 mm of induration 17 weeks after her departure. As of December 1995, the child remained free of signs and symptoms of active tuberculosis.
Flight Crew and Passengers Of 1042 passenger and crew contacts identified on the four flights, 117 (11.2 percent) were not notified: 24 were residents of foreign countries, and for 93 no information on their whereabouts was available. The remaining 925 (88.8 percent) resided in 41 states, Puerto Rico, the District of Columbia, and Canada and were notified of their potential exposure. Of these, 802 (86.7 percent) provided results of a final tuberculin skin test (at least 12 weeks after exposure). Forty-two contacts were excluded from the analysis: 40 had had tuberculosis previously or had evidence of a previous positive tuberculin skin test, 1 died of cancer, and 1 died of the acquired immunodeficiency syndrome (AIDS) with documented anergy. Neither contact who died had signs or symptoms compatible with tuberculosis. The passenger with AIDS was already receiving rifabutin prophylaxis and had smears and cultures negative for acid-fast bacilli after exposure.
Of the 760 contacts for whom data were analyzed, 95 percent were passengers and 5 percent were crew members. Only 10 contacts (1.3 percent) were exposed on two connecting flights. Fifty-five percent of the contacts were male, 94 percent were U.S.-born, 86 percent were white, and the median age was 43 years (range, 6 months to 86 years). There were no statistically significant differences in the demographic characteristics of contacts among the four flights. Previous vaccination with bacille Calmette-Guerin (BCG) was reported by 2.6 percent of all the contacts, and exposure to a family member or friend with tuberculosis by 7.5 percent.
The results of tuberculin skin tests of the contacts are shown in.. In the six contacts on flight 4 who had conversions to positive skin tests, the first test was performed a median of 8 weeks after exposure (range, 34 weeks before exposure to 10 weeks after exposure), and the second test was administered a median of 23 weeks after exposure (range, 8 to 29. All the contacts with negative tuberculin skin tests had final tests performed at least 12 weeks after exposure (median, 16; range, 13 to 32).
All 11 contacts on flights 1 and 2 who had positive tuberculin skin tests had other risk factors, including birth in a country where tuberculosis is highly endemic (reference 7) or receipt of BCG (5 contacts), exposure to tuberculosis in a family member (3), residence overseas (2), and occupational exposure (1). Passengers on flights 1 and 2 who had positive tuberculin skin tests had not been seated near the index patient. On flight 3, three people had positive tuberculin skin tests, but none had conversion. Of these, two were born in countries where tuberculosis is highly endemic and had received BCG. The third person with a positive test, who had been seated three rows away from the index patient, reported having no other risk factors for tuberculosis.
The characteristics of the 15 contacts on flight 4 who had positive tuberculin skin tests are shown and their seat assignments in relation to that of the index patient are shown.. The index patient had been seated next to the aisle in the next-to-last row of the rear cabin section of the aircraft. Nine contacts with positive tuberculin skin tests, who had been seated throughout the aircraft, had other risk factors for tuberculosis. Six contacts with positive tuberculin skin tests, including four with conversions, had no other identified factors.
THIS REPORTsummarizes the association between the results of tuberculin skin tests and seating proximity to the index patient for contacts on flight 4 who had no other identified risk factors. Contacts with positive tests, including four with conversions, were more likely to have been seated in the same cabin section of the aircraft as the index patient than contacts who with negative tests (P=0.001). In fact, all six contacts with positive tuberculin skin tests and no risk factors, including all four with conversions, had been seated in the same cabin section of the aircraft as the index patient. Those seated within two rows of her were 8.5 times more likely to have positive tuberculin skin tests or conversions than those seated elsewhere in the same cabin section. Among the six persons with positive tuberculin skin tests, four had been seated within two rows of the index patient, and the two seated toward the front of the rear cabin section reported having frequently visited friends seated very near the index patient and having used the lavatory close to her seat. As of February 1996, all six remained free of signs and symptoms of active tuberculosis.
Aircraft and Ventilation Systems
For both transoceanic flights, flights 1 and 4, Boeing 747-100 aircraft were used. Flight 1 took place in April and lasted 8 hours; flight 4 was in May and lasted 8.75 hours. The Chicago-to-Baltimore and Baltimore-to- Chicago flights, flights 2 and 3, were both on Airbus 320-200 aircraft and were 1.75 and 2 hours long, respectively. No flight delays were reported to have occurred on any of the flights. Both the B747-100 and A320-200 aircraft had air-recirculation systems with high-efficiency particulate air (HEPA) filtration. The B747-100 aircraft recirculates air through one common reservoir for the entire aircraft. Approximately 50 percent of the air is recirculated, and rates of air exchange reported by the manufacturers of these types of aircraft range from 6 to 20 times per hour. Smoking was prohibited on all four flights.
This incident provided a unique opportunity to investigate the transmission of M. tuberculosis on aircraft. A high proportion of U.S. residents among the passengers, repeated notification, and national media attention let to a high response rate among contacts. Prompt notification by a state tuberculosis-control program allowed us to assess the development of tuberculous infection among the May 1994 passengers and flight crew prospectively.
Our investigation provides evidence of the transmission of M. tuberculosis from passenger to passenger and from passenger to flight crew aboard commercial aircraft. Although the possibility of transmission from the index patient to other passengers on flights 1, 2, and 3 cannot be excluded, the evidence is most compelling for flight 4. This includes evidence of recent transmission (i.e., skin test conversions), an association between transmission and proximity to the index patient, and a dose-response effect. All but one of the contacts who had no risk factors for tuberculosis and had positive skin tests, including all those with conversions, were seated in the same section as the index patient. Those seated within two rows were at greatest risk. The skin-test conversions on flight 4 but not on flight 3, although the flights took place on the same day, suggest that prolonged exposure to aerosol droplets from the index patient played a part. The apparent absence of transmission on flight 1 may have been due to the varying infectiousness of the index patient, who had long-standing disease. She was more symptomatic in May than in April. The timing of the skin-test conversion in the child in Household 2 suggests that transmission occurred just before flights 3 and 4. The children in Household 1 may have escaped infection because the index patient was less infectious in April, they were not in close proximity to her when she returned in May, or because of chance alone, since many household contacts of people with infectious tuberculosis are known to remain uninfected. (8,9) Since there are no clinical data on the risks and benefits of preventive therapy that does not include isoniazid and rifampin, clinicians of infected contacts had two options: to administer no preventive therapy and watch carefully for the appearance of signs and symptoms of tuberculosis, (10) or to consider six months of preventive therapy with rifabutin, to which the isolate was fully susceptible.
These findings are consistent with previous reports of the transmission of other airborne pathogens on commercial aircraft, such as measles, influenza, and smallpox. (11-13) Our results are also consistent with the previous finding that the risk of transmission of M. tuberculosis from a flight-crew member with infectious tuberculosis to other crew members increased with the duration of in-flight exposure. (1) Previous investigations involving closed environments, including naval ships, also showed an association between proximity to a person with infectious tuberculosis and transmission of M. tuberculosis. (14) In our investigation, the absence of passengers with skin-test conversions in other cabin sections of the aircraft on flight 4 is further evidence that M. tuberculosis was not transmitted through the aircraft's air-recirculation system.
Domestic air travel in the United States increased by 62 percent from 1980 through 1993 -- from 275 million to 445 million passengers per year. (15) Air travel from foreign countries to the United States increased by 182 percent, from 12.6 million passenger arrivals during 1975 to 35.5 million in 1991. (15) The projections of the World Health Organization for the worldwide tuberculosis epidemic include 90 million new cases during the present decade. (16) Increased air travel, the presence of tuberculosis worldwide, and immigration to the United States from countries with high rates of tuberculosis increase the probability passengers on commercial aircraft will be exposed to persons with tuberculosis. (15-17)
After the national media reported this incident in July 1994, the CDC received unsolicited reports of another 30 airline passengers with tuberculosis, including 10 whose diagnosis was already known at the time of travel, who were on commercial flights from July through December 1994. Assuming approximately 260 million airline passengers during that period, the 30 passengers with tuberculosis are estimated to represent approximately 1 of every 9 million passengers. (15) This probably underestimates the risk of exposure to tuberculosis on aircraft, since the reporting was unsolicited and probably incomplete. Assuming 300 passengers per international flight and 150 per domestic flight, however, as many as 10,000 passengers may have been exposed to M. tuberculosis on these flights, or approximately 1 of every 26,000 passengers who flew during that period. Furthermore, in our investigation less than 1 percent of all the contacts had skin-test conversions as a result of exposure to the index patient on the aircraft. Although limited by underreporting, these data suggest that passengers and flight crews have a relatively low risk of exposure to and transmission of M. tuberculosis on commercial aircraft in the United States.
In this investigation, the passenger with tuberculosis was a tourist from a region of the world where tuberculosis is highly endemic. (7,16) Screening for active tuberculosis is required for immigrants and refugees applying for legal residency in the United States but not for tourists, visitors on business, and students. (18) During 1993, 79 percent of the 21.4 million nonimmigrants who arrived in the United States were tourists. (19) Screening of such large numbers of nonimmigrants, even from selected countries with high rates of tuberculosis, would be impractical and very costly and, unless performed just before their flights, would not necessarily prevent exposure to persons with active tuberculosis.
To develop recommendations based on the available scientific evidence, in February 1995 officials of the CDC met with representatives from the Federal Aviation Administration, Air Transport Association, the Council of State and Territorial Epidemiologists, and the National Tuberculosis Controllers Association, as well as medical consultants from major airline companies. In March 1995, the CDC summarized six investigations of possible transmission of M. tuberculosis on aircraft and provided guidance for notifying passengers and flight crews in the event of exposure to tuberculosis during travel on commercial aircraft. (2) Four investigations found no conclusive evidence of the transmission of M. tuberculosis to other passengers. (2,20,21)Error! Bookmark not defined. shows suggested criteria and procedures for the notification of contacts that were distributed nationally to airline companies, state health departments, and tuberculosis-control programs in March 1995. The decision to notify passengers and crew members potentially exposed to tuberculosis should be guided by three criteria: the flight duration, the infectiousness of the index patient (e.g., whether he or she has smear-positive, cavitary pulmonary tuberculosis or laryngeal tuberculosis and whether there has been documented transmission to contacts), and seating proximity to the index patient, depending on the aircraft design. (2) In cases in which the airline is informed first, it should provide the name of the passenger's physician to the state health department in the state where the patient resides or is being treated for tuberculosis so that the health department can make a determination of infectiousness. Applying these criteria to instances of exposure to tuberculosis on aircraft will make it easier to decide when to inform those who may potentially benefit from preventive therapy, while averting the expenditure of resources in circumstances in which the transmission of M. tuberculosis is highly unlikely. The top priority of tuberculosis-control programs is still to identify and ensure the complete treatment of all patients with active tuberculosis. (23)
These suggested procedures apply to all domestic and foreign airlines. They were developed in the context of tuberculosis control in the United States, however, and may not be directly applicable to countries where strategies of tuberculosis prevention and control are different. The Global Tuberculosis Program of the World Health Organization, in collaboration with the CDC, has suggested these procedures to carriers that are not U.S.-based through the International Airline Transportation Association.
We are indebted to the staffs of more than 40 state and local health departments, the airline company, and the physicians of exposed passengers and crew for their assistance and support in conducting the investigation; to the staffs of the tuberculosis-control programs of the states of Hawaii and Maryland for sharing information about the index patient and the results of contact investigations; and to the representatives of the Federal Aviation Administration, the Council of State and Territorial Epidemiologists, the Airline Transport Association, the National Tuberculosis Controllers Association, and the airline companies for their participation in the development of recommendations for notifying passengers and crew after possible exposure to tuberculosis on aircraft.
Driver CR, Valway SE, Morgan WM, Onorato IM, Castro KG. Transmission of Mycobacterium tuberculosis associated with air travel. JAMA 1994;272: 1031-5.
Exposure of passengers and flight crew to Mycobacterium tuberculosis on commercial aircraft, 1992-1995. MMWR Morb Mortal Wkly Rep 1995;44: 137-40.
Thompson NJ, Glassroth JL, Snider DE Jr, Farer LS. The booster phenomenon in serial tuberculin testing. Am Rev Respir Dis 1979;119: 587-97.
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Dean AG, Dean JA, Coulombier D, et al. Epi Info, Version 6: a word processing, database, and statistics program for epidemiology on microcomputers. Atlanta: Centers for Disease Control and Prevention, 1994.
Tuberculosis morbidity -- United States, 1994. MMWR Morb Mortal Wkly Rep 1995;44:387-95.
Rose CE Jr, Zerbe GO, Lantz SO, Bailey WC. Establishing priority during investigation of tuberculosis contacts. Am Rev Resp Dis 1979;119:603-9.
Tuberculosis in the United States, 1985-1986. Atlanta: Centers for Disease Control, 1987:95. (DHHS publication no. (CDC) 88-8322.)
Management of persons exposed to multidrug-resistant tuberculosis. MMWR Morb Mortal Wkly Rep 1992;41(RR-11):59-71.
Amler RW, Bloch AB, Orenstein WA, Bart KJ, Turner PM Jr, Hinman AR. Imported measles in the United States. JAMA 1982;248:2129-33.
Moser MR, Bender TR, Margolis HS, Noble GR, Kendal AP, Ritter DG. An outbreak of influenza aboard a commercial airliner. Am J Epidemiol 1979;110:1-6.
Ritzinger FR. Disease transmission by aircraft. Aeromed Rev 1965;4: 1-10.
Houk VN, Baker JH, Sorensen K, Kent DC. The epidemiology of tuberculosis infection in a closed environment. Arch Environ Health 1968;16:26-35.
Wilson RA. Transportation in America: statistical analysis of transportation in the United States. 12th ed. Lansdowne, Va.: Eno Transportation Foundation, 1994.
Raviglione MC, Snider DE Jr, Kochi A. Global epidemiology of tuberculosis: morbidity and mortality of a worldwide epidemic. JAMA 1995;273:220-6.
McKenna MT, McCray E, Onorato I. The epidemiology of tuberculosis in foreign-born persons in the United States, 1986 to 1993. N Eng J Med 1995;332:1071-76.
Public Health Service. Technical instructions for medical examination of aliens. Atlanta: Centers for Disease Control, 1991.
Immigration and Naturalization Service. Statistical yearbook of the Immigration and Naturalization Service, 1993. Washington, D.C.: Government Printing Office, 1994.
Miller MA, Valway SE, Onorato IM. Assessing tuberculin skin test (TST) conversion after exposure to tuberculosis on airplanes. Presented at the Meeting of the American Public Health Association Epidemiology Exchange, San Francisco, October 27, 1993. abstract.
McFarland JW, Hickman C, Osterholm MT, MacDonald KL. Exposure to Mycobacterium tuberculosis during air travel. Lancet 1993;342:112-3.
Braden CR, Valway SE, Onorato IM, et al. Infectiousness of a university student with laryngeal and cavitary tuberculosis. Clin Infect Dis 1995;21: 565-70.
American Thoracic Society. Control of tuberculosis in the United States. Am Rev Resp Dis 1992;146:1623-33.
From the Epidemic Intelligence Service, Epidemiology Program Office (T.A.K.) and the Division of Tuberculosis Elimination (T.A.K., S.E.V., W.W.I., I.M.O., K.G.C.), National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention. Address reprint requests to Dr. Kenyon, 1600 Clifton Rd., Mailstop E-10, Atlanta, GA 30333.
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