References1. Communicable Diseases Prevention and Con-

trol: New, Emerging, and Re-emerging Infec-tious Diseases. Geneva, Switzerland: WorldHealth Organization; February 22, 1995. WHOdocument A48/15.

2. Cities and Emerging or Re-emerging Diseasesin the XXIst Century. Geneva, Switzerland:World Health Organization; June 1996. WHOfact sheet 122.

3. Manual ofthe International Statistical Classifi-cation ofDiseases, Injuries, and Causes ofDeath, Based on Recommendations ofthe NinthRevision Conference, 1975. Geneva, Switzer-land: World Health Organization; 1977.

4. Pinner RW, Teutsch SM, Simonsen L, et al.Trends in infectious diseases mortality in theUnited States. JAMA. 1996;275:189-193.

5. Physicians 'Handbook on Medical CertificationofDeath. Hyattsville, Md: National Center forHealth Statistics; 1994. DHHS publication PHS87-1108.

6. Green MS. The male predominance in the inci-dence of infectious diseases in children: a pos-tulated explanation for disparities in the litera-ture. IntJEpidemiol. 1992;21:381-386.

7. Health Status in Israel-1997. Tel Hashomer:Israel Center for Disease Control; 1997. Publi-cation 202.

Briefs

8. Leinsalu M. Time trends in cause-specific mor-tality in Estonia from 1965 to 1989. Int J Epi-demiol. 1995;24:106-1 13.

9. Becker TM, Wiggins C, Peek C, Key CR,Samet JM. Mortality from infectious diseasesamong New Mexico's American Indians, His-panic whites, and other whites, 1958-87. Am JPublic Health. 1990;80:320-323.

10. Modelmog D, Rahlenbeck S, Trichopoulos D.Accuracy of death certificates: a population-based, complete-coverage, one-year autopsystudy in East Germany. Cancer Causes Control.1992;3:541-546.

11. Wagner BM. Mortality statistics without autop-sies: Wonderland revisited. Hum Pathol. 1987;9:875-876.

Sonomorphologic Evaluation of Goiter inan Iodine Deficiency Area in the IvoryCoastDoris Franke, MD, Guido Filler, MD, Miroslav Zivicnjak, PhD, Paul Kouame', MD,Iris Ohde, Lars Eckhardt, Ekkehard Doehring, MD, and Jochen H. H. Ehrich, MD

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Iodine deficiency disorders remain aglobal public health problem ofmajor impor-tance. Worldwide, nearly 1 billion people areliving in iodine-deficient areas; of these indi-viduals, 190 million' to 655 million2 havegoiter, and 3 million to 20 million' are suffer-ing from severe thyroid disorders such as cre-tiniSM.36 Of all human beings affected byiodine deficiency disorders, 75% are living inless developed countries.7

In Africa, one third of the populationexperiences iodine deficiency. To this point,national iodine supplementation programsand programs supported by the World HealthOrganization (WHO) have not succeeded inpreventing related morbidity despite simpleand comparatively inexpensive prophylacticmeasures. In 1983, Hetzel5 stated that lack ofpolitical weight and geographic isolationwere the main factors responsible for the per-sistence ofthis major public health problem.

Our study sought to evaluate, via ultra-sonography, the extent of thyroid morbidityin a remote village in the Ivory Coast beforethe distribution ofiodized salt.

Methods

The study was conducted in November1996 in the village of Glanle, which islocated in the middle western region of the

Ivory Coast. Field research conducted byLatapie et al.8 and by Kouame et al.9 hadshown this area to be iodine deficient andendemic for goiter. There was limited migra-tion among the population studied owing tothe area's geographically isolated location,lacking electricity and running water. Food isacquired only from residents' own agricul-tural resources. The staple foods are rice and,to a lesser extent, manioc. Dried fish is avail-able only from a local lake. The water supplyis provided by a few local wells.

Subjects provided informed consent(orally) after an explanation ofthe study pro-tocol in the local language. Participation wasvoluntary. Forty-five percent of the popula-tion was studied. The study involved house-to-house demographic assessment; in themajority ofcases, subjects were identified via

Doris Franke, Guido Filler, Miroslav Zivicnjak, IrisOhde, Lars Eckhardt, and Jochen H. H. Ehrich arewith Charite Children's Hospital, Humboldt Uni-versity, Berlin, Germany. Paul Kouame is with theInstitut National de Sante Publique d'Abidjan,Ivory Coast. Ekkehard Doehring is with the Boardof Public Health, Neuruppin, Germany.

Requests for reprints should be sent to DorisFranke, MD, Charite Children's Hospital, Schu-mannstr. 20-21, D-101 17 Berlin, Germany (e-mail:doris.franke@charite.de).

This brief was accepted June 3, 1999.

American Journal of Public Health 1857

Briefs

official documents. In only a few exceptionswere subjects identified by persons accompa-

nying the researchers.The subjects studied represented a conve-

nience sample consisting of individuals whoagreed to join the investigation on a voluntarybasis after the study had been announced at acommunity assembly. Basic medical care was

offered for everyone, because there was no

medical health care in a 30-km area surround-ing the village with the exceptions of a locallytrained midwife and a vaccination projectfunded by the United Nations Children's Fund.

We used a portable ultrasound machine(Picker CS 9100) equipped with a 7.5-MHzlinear scanner and a 3.5-MHz sector scanner.

A Mitsubishi P-66 thermal printer was usedfor photodocumentation. Only 2 examiners,who were present throughout the duration ofthe study, conducted ultrasonography. Theseexaminers exchanged documenting and scan-

ning roles so that every individual was seen

by both. Major discrepancies were doublechecked. Interindividual variation of singledimensions was 5%. Thyroid volumetry was

performed according to the method ofBrunnet al.'° Age-dependent reference limits forthyroid volume determined by Gutekunst etal., and recommended by WHO, were used."Focal abnormalities of the thyroid were clas-sified as cysts, nodules, and calcifications.

We used descriptive statistics in estimat-ing basic anthropometric characteristics andthyroid volume. We evaluated sex differencesin defined age cohorts via analysis of vari-ance, the Mann-Whitney test, and the Fisherexact test, using SPSS/PC for Windows (ver-sion 7.5) and Graph Pad Prism (version 2.0).

Results

We examined 11 16 persons (55.6%female) older than 6 years (nearly half of thepopulation of the village) by ultrasound ofthe thyroid gland. Thirty-eight percent ofsubjects were younger than 20 years, and 5%were older than 60 years; the median age was24 years. Thyroid volume increased steadilywith age. As a means of accounting for thisincreasing volume, z scores for thyroid vol-ume were calculated. An omnibus sex com-

parison using z scores derived from theGutekunst reference limits revealed a highlysignificant difference between females andmales (P <.0001, Mann-Whitney U test);the median female z score was 3.35 (range:1.36 to 324), and the median male z score

was 2.213 (range: 0.99 to 31.7). The slopes ofthe regression lines for both females(0.2411 t0.0421 1,P < .0001) and males(0.02551 i 0.007483, P = .0007) were signif-icantly nonzero (Figure 1).

Up to the age of 15 years, the thyroidvolume was not significantly different inmales and females; thereafter, it increasedmore in females than in males. There were

sex differences for the following age groups:21 to 30 years (P< .05), 41 to 50 years (P<.05), and above 60 years (P= .01).

In women and men older than 60 years,the median thyroid volumes were 50 mL and33 mL, respectively; in some patients, how-ever, volumes were up to 700 mL. There wasa significant difference between the volumeof the right and the left lobe, with that of theright lobe consistently being larger. Data are

summarized in Table 1.Females developed goiter more frequently

than males; prevalence rates were 64.7% and53.3%, respectively. The lowest frequency ofgoiter was observed in the 16- to 20-year agegroup (35.4% in females and 17.1% in males),and the highest frequency was observed in

those older than 60 years (100% in women and72.2% in men) (see Figure 2).

Frequencies of focal thyroid abnormal-ities are shown in Table 2. In children andadolescents, nearly no cysts, calcifications,or nodules were found until the age of15 years. From the age of 16 years onward,the frequency ofnodules, calcifications, andcysts increased with age and thyroid vol-ume. The prevalence of nodules in the totalpopulation was 28.4% (24.5% in personswithout goiter and 39.1% in persons withgoiter). Among the 451 persons without goi-ter, 1 to 3 nodules were found in 46 (10.2%),and more than 3 nodules were found in 11(2.4%). The corresponding numbers in the665 persons with goiter were 149 (22.4%)and 111 (16.7%). A statistically significantdifference in the presence of nodules bysex was found only in subjects aged 31 to50 years (P<.05).

1858 American Journal of Public Health

400-

300-

E 200-

o 100-I

O (A 15-

o Females* Males

0

0 0 0 ocO o 0° 0 CC

-Females- -- Males

+2SD- 2SD

10 20 30 40 50 60 70Age, y

Note. Values are expressed as standard deviation z scores. For both males andfemales, the slope of the regression line was significantly nonzero, with a muchsteeper slope in females.

FIGURE 1-Thyroid volume, by age: Ivory Coast, 1996.

TABLE 1-Sonographically Determined Thyroid Volume (mL) in Adults: Ivory Coast,1996

Women MenLeft Lobe Right Lobe Left Lobe Right Lobe

Minimum 1.0 2.5 1.7 1.225th percentile 6.8 7.9 7.9 6.9Median 13.0 11.2 9.9 12.075th percentile 20.2 22.0 16.0 18.3Maximum 342 378 108.6 186.8

Note. Data were not normally distributed, and therefore minimum, 25th percentile, median,75th percentile, and maximum are given. There was a significant difference between leftand right lobe (Wilcoxon matched pairs test) for both males and females (P<.0001).

0

December 1999, Vol. 89, No. 12

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Females1.0-

0.8* No goiter

0.6- Goiter

a 0.4-0L

0.2-

0.0 6-10 11-15 16-20 21-30 31-40 41-50 51-60 >60

Age Cohort, y

Males* ** *** ** **

1.0

0.8-MENo goiter

0X 606 DGoitera)

o) 0.4-

0.2-

0.0 6-10 11-15 16-20 21-30 31-40 41-50 51-60 >60

Age Cohort, y

Note. Prevalence rates in females increased significantly with increasing age. *P<.05;**P<.01; ***P<.001.

FIGURE 2-Prevalence of goiter in females and males of different age cohorts:Ivory Coast, 1996.

Cysts were found in 7.7% of the studypopulation (86/1116). Among these individ-uals, cysts were found in 14 (1.3%) withoutgoiter and 72 (6.5%) with goiter. There wasno statistically significant difference in thepresence of cysts by sex.

Calcifications were found in 39.7% ofthe study population. Their first manifesta-tion was in the 1 1- to 15-year age group, andthey were found more often in females thanin males (64.6% vs 35.4%); however, this dif-ference was statistically significant only inthe 41- to 50-year age group.

Among persons older than 60 years withenlarged thyroid glands, nodules were evi-

dent in 68.2% of women and 52.8% of men,calcifications were evident in 50% ofwomenand 33% of men, and cysts were evident in23% ofwomen and 20% ofmen.

Discussion

The aim of this study was to describe theactual extent of thyroid morbidity in the pop-ulation of a remote, severely iodine-deficientarea in the Ivory Coast before the distributionof iodized salt. In a study conducted in thisregion in 1981, Latapie et al.8 found a globalprevalence of goiter diagnosed by palpation

of 54%. Marked iodine deficiency wasdemonstrated by low urinary iodine excre-tion, increased levels of thyrotropin, and lowlevels of levorotatory thyroxine (T4). Mea-surements of iodine concentrations in foodsamples and water of this village performedat the same time as our survey showed thatconcentrations were still very low, and free T4thyroid hormone levels were subnormal.9

Subjects were chosen as a conveniencesample after announcement of the study at acommunity assembly. The cohort consisted of45% of the total village population. Althoughsuch a sampling method may introduce bias,'2the large proportion of45% of the total popu-lation is likely to provide a representative pic-ture. However, some of the worst-affectedindividuals may have been missed. In general,the community sought to hide severely illmembers, and, if any bias was introduced atall, the already-shocking prevalence of severegoiter may have been underestimated.

We found prevalence rates of ultrasono-graphically determined goiter of 64.7% infemales and 53.3% in males. Thyroid vol-ume, degree of goiter, and frequency andtotal number of nodules increased with age.Similar findings were reported by Berghoutet al. in a cross-sectional survey in theNetherlands'3 and by Struwe and Hinrichs inGermany.'4 Among an adult population liv-ing in an area with borderline to mild iodinedeficiency, Struwe and Hinrichs found focalabnormalities in 21%, with a higher fre-quency in women aged 36 to 50 years. Calci-fications, cysts, and nodules were found inonly 2%, 11%, and 10% ofprobands, respec-tively; the corresponding percentages in ourstudy were 39.7%, 7.7%, and 28.4%.

In the population we studied, the agegroup older than 60 years was most severelyaffected in regard to goiter prevalence, thy-roid volume, and frequency of focal abnor-malities. Hintze et al. '5 studied 569 unse-lected subjects older than 60 years in aniodine-deficient area in Germany and foundsonographically determined goiter preva-lence rates of 54.2% in women and 22.5% inmen (overall rate: 49.7%). The prevalence ofnodules was 17.6% (58.6% in our study),and the prevalence of cystic lesions was7.6% (21.1% in our study). In the entiregroup described by Hintze et al., median thy-roid volumes were 19.2 mL in women and16.6 mL in men; the corresponding volumesin our population above 60 years were50 mL and 33 mL. The more severe morbid-ity in our population might be due to ahigher degree of long-standing iodine defi-ciency in the Ivory Coast. Consumption ofmanioc may have an additional effect.

Thyroid volume, as well as prevalenceand degree of goiter, was significantly higher

American Journal of Public Health 1859

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December 1999, Vol. 89, No. 12

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TABLE 2-Prevalence of Focal Abnormalities of the Thyroid Gland, by Age Cohort: Ivory Coast, 1996

Age Groups, y

6-10 11-15 16-20 21-30 31-40 41-50 51-60 >60

Nodules: females 0 0 15.2 27.9 50.0 63.6 65.5 68.2Nodules: males 0 4.4 14.3 18.4 34.4 33.3 56.8 52.8Calcifications: females 0 0 0 4.3 7.6 28.6 27.3 50.0Calcifications: males 0 2.2 0 2.3 7.8 7.7 29.7 33.3Cysts: females 0 2.3 10.1 5.0 13.6 18.2 12.7 22.7Cysts: males 0.9 1.1 8.6 2.3 6.3 10.3 10.8 20.0

in women older than 20 years as a result ofthe higher iodine demands during pregnancyand lactation.16 As have other authors,'3 17-19we found a higher right lobe than left lobevolume.

The prevalence of focal abnormalitiessuch as nodules, cysts, and calcificationsincreased with age, but there were few sex-related differences. This is in contrast toobservations from Struwe et al.,'7 who founda higher prevalence of thyroid nodules, butnot of goiter, in women with previous preg-nancies living in a borderline iodine-deficientarea in Germany.

The overall prevalence of goiter in chil-dren and in adults was not significantly dif-ferent (62% in children aged 6-15 years and64% in adults). Unlike observations inEurope that showed a higher prevalence ofincreased thyroid volume during puberty,20we found the lowest frequency of goiter inthis age group. The reason for this findingremains unclear. A statistical problem may bein part responsible, because there was a sud-den jump in the Gutekunst reference valuesfrom adolescents aged 17 years (16 mL forboth sexes) to adults (18 mL in women and25 mL in men).

We found no difference in thyroid vol-ume by sex up to the age of 15 years. It isinteresting that Menken et al.21 also found nosex difference in thyroid volume in Germanchildren aged 2 to 16 years, with the excep-tion of significantly higher volumes in girlsaged 10 and 11 years. This may reflect afaster increase in thyroid volume at the begin-ning of puberty in girls. In contrast, a studyconducted in an endemic region in Guinearevealed the presence of goiter in 55% ofschoolchildren, with a sex difference only atpuberty.22

The main finding of the present studywas the severe extent of goiter and thyroidmorbidity in the population investigated.Because we used ultrasound evaluation ratherthan palpation, we were able to gather moredetailed information. It is likely that our wor-rying findings are not confined to remote vil-lages in the Ivory Coast but, rather, reflect asevere global problem. This is the case

despite the relatively inexpensive iodine sup-plementation measures that could be appliedto overcome the problem. In fact, such sup-plementation was initiated in the study vil-lage soon after this investigation had beencompleted. In addition to socioeconomic dif-ficulties and lack ofpolitical will, geographicisolation may be the most important reasonfor the unsolved problem of diseases associ-ated with iodine deficiency.

In summary, no improvement in iodine-deficiency disorders has occurred in the areastudied over the last few decades. Becauseof the substantial morbidity involved, it isvital that prophylaxis of iodine deficiency beimproved. D:

ContributorsD. Franke, M. Zivicnjak, P. Kouame, L. Eckhardt,and J. H.H Ehrich organized the study and collectedthe data in the Ivory Coast. All of the authors partic-ipated in the conception of the study as well as theanalysis and interpretation of the data.

AcknowledgmentsWe thank all inhabitants of Glanle for their coopera-tion and hospitality. The kind support of the localmidwife, Eugenie Kamara, in translation and organi-zation was especially helpful.

The support of Koffi Dje and Andre Chaventreis also gratefully acknowledged.

References1. Hetzel BS, Dunn JT, Stanbury JB. The Preven-

tion and Control ofIodine Deficiency Disor-ders. Amsterdam, the Netherlands: ElsevierScience Publishing Co; 1987:1-354.

2. Global Prevalence ofIodine Deficiency Disor-ders: Micronutrient Deficiency Information Sys-tem (MDIS). Geneva, Switzerland: World HealthOrganization; 1993:5. WHO/UNICEF/ICCIDDworking paper 1.

3. Hetzel BS, Potter BJ, Dulberg EM. The iodinedeficiency disorders: nature, pathogenesis andepidemiology. World Rev Nutr Diet. 1990;62:59-119.

4. Hetzel BS, ed. The Story ofIodine Deficiency.NewYork, NY: Oxford University Press Inc; 1989.

5. Hetzel BS. Iodine deficiency disorders (IDD) andtheir eradication. Lancet. 1983;12:1126-1129.

6. Delange F. The disorders induced by iodinedeficiency. Thyroid. 1994;4:107-128.

7. Gaitan E, Nelson NC, Poole GV. Endemicgoitre and endemic thyroid disorders. World JSurg. 1991;15:205-215.

8. Latapie JL, Clerc M, Beda B, et al. Aspect clin-ique et biologique du goitre endemique dans laregion de Man (C6te d'Ivoire). Ann Endocrinol(Paris). 1981 ;42:517-530.

9. Kouame P, Bellis G, Tebbi A, et al. The preva-lence of goitre and cretinism in a population ofthe West Ivory Coast. Colleg Antropol. 1998;22:31-41.

10. Brunn J, Block U, RufG, Kunze WP, Scriba PC.Volumetrie der Schilddriisenlappen mittelsReal-time-Sonographie [Volumetry of thyroidgland lobes using real-time sonography]. DtschMed Wochenschr 1981;106:1338-1340.

11. Gutekunst R, ed. Guidelines for the Control ofIodine Deficiency Disorders. Recommenda-tions ofWHO, UNICEF, and ICCIDD. Geneva,Switzerland: World Health Organization; 1993.

12. Piper MC, Lippman-Hand A. The conveniencesample as a source of data in the study ofDownsyndrome. JMent Defic Res. 1981 ;25:217-223.

13. Berghout A, Wiersinga WM, Smits NJ, TouberJL. Interrelationships between age, thyroid vol-ume, thyroid nodularity, and thyroid function inpatients with sporadic nontoxic goiter. Am JMed. 1990;89:602-608.

14. Struwe C, Hinrichs J. Schilddriisenvoluminaund Haufigkeit herdfdrmiger Veranderungenbei schilddriisengesunden Mannern und Frauenverschiedener Altersklassen [Thyroid volumesand frequency of focal abnormalities in healthymen and women of different age groups]. DtschMed Wochenschr. 1989;1 14:283-287.

15. Hintze G, Windeler J, Baumert J, Stein H, Kob-berling J. Thyroid volume and goitre prevalencein the elderly and their relationship to labora-tory indices. Acta Endocrinol (Copenhagen).1991;124:12-18.

16. Struwe C, Ohlen S. EinfluJ3 friiherer Schwanger-schaften auf Struma- und Knotenhaufigkeit beischilddriusengesunden Frauen [Influence of pre-vious pregnancies on the frequency of goiter andnodules in healthy women]. Dtsch Med Wochen-schr 1990;1 15:1050-1053.

17. Struwe CW, Haupt S, Ohlen S. Influence of pre-vious pregnancies on the prevalence of thyroidalnodules in women without clinical evidence ofthyroidal disease. Thyroid. 1993;3:7-9.

18. Olbricht T, Schmidtka T, Mellinghoff U, BenkerG, Reinwein D. Sonographische Bestimmungvon Schilddriusenvolumina bei Schilddriisenge-sunden [Sonographical determination of thy-roid volume in thyroid disease-free subjects].Dtsch Med Wochenschr. 1983;108:1355-1358.

1860 American Journal of Public Health December 1999, Vol. 89, No. 12

19. Miiller-Leisse C, Troger J, Khabirpour F, PocklerC. Schilddriisenvolumen-Normwerte: Sono-graphische Messungen an 7-20 jahrigen Schii-lern [Thyroid volume reference values: sono-graphic measurements in pupils aged 7-20years]. Dtsch Med Wochenschr. 1988;1 13:1872-1875.

20. TajtAkova M, Haneicova D, Langer P, TajtAk J,Malinovsky E, Varga J. Thyroid volume of EastSlovakian adolescents determined by ultra-sound 40 years after the introduction of iodizedsalt. Klin Wochenschr. 1988;66:749-751.

21. Menken KU, Engelhardt S, Olbricht T. Schildd-riisenvolumina und Jodurie bei Kindern im

Briefs

Alter von 2-16 Jahren [Thyroid volumeand iodine excretion in children aged 2-16years]. Dtsch Med Wochenschr. 1992;1 17:1047-1051.

22. Konde M, Inglenbleek Y, Daffe M, Sylla B,Barry 0, Diallo S. Goitrous endemic in Guinea.Lancet. 1994;344: 1675-1678.

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Effectiveness of a ComprehensiveMultisector Campaign to IncreaseSeat Belt Use in the Greater AthensArea, GreeceEleni Petridou, MD, MPH, Dimitrios Trichopoulos, MD, PhD, Matina Stappa, DDS,Yannis Tsoufis, MEC, Alkistis Skalkidou, and the Hellenic Road Traffic PoliceDepartment

Among the European Union memberstates, Greece has one of the highest deathrates from motor vehicle crashes." 2 Of theseveral factors that may contribute to this dis-crepancy, variability in seat belt use is likely tobe important.-6 Indeed, the prevalence of seatbelt use among car occupants in Greece isreported to be one of the lowest in the Euro-pean Union.6'7 The rising mortality frommotor vehicle accidents and a series of sensa-tional fatal car crashes in Greece have createda favorable climate among opinion leaders forthe launching of a comprehensive program toincrease seat belt use in Greece.8

Most efforts to increase seat belt use arebased on raising awareness as well as enforc-ing laws.9'2 This program eventually focusedon an education and information campaign,because the Road Traffic Police Departmentdid not intensify enforcement ofexisting legis-lation for mandatory seat belt use. Indeed, thenumber of citations for seat belt law violationsdeclined slightly in the Greater Athens areaduring the 9-month implementation period, incomparison with the same period during theprevious year. Therefore, the only componentof the program that could have had an impacton changes in seat belt use in mid-1998 wasthe education and information campaign.After a long preparatory period, the campaignwas launched in October 1997. It lasted untilJune 1998, with residual activities thereafter.

Methods

The program was coordinated by theCenter for Research and Prevention of

Injuries, Athens University Medical School,and was contributed to by 6 ministries andmore than 50 other governmental and non-governmental organizations. Each institutionalmember of this coalition had its own indepen-dent budget. The total cost of the campaignamounted to about US $3 million.

The activities of this campaign wereheavily concentrated in, although not limitedto, the Greater Athens area, where 40% ofthe10 million persons living in Greece reside.Specific actions comprised production anddistribution of televised and radio messages;Internet postings; more than 5000 copies ofa multiple venues video provided to roadtraffic police officials, school teachers, hos-pital administrators, TV stations, and privatephysicians; and a variety of eye-catchingadvertising materials. Miscellaneous events,such as painting and poster competitions for

Eleni Petridou and Dimitrios Trichopoulos are withthe Center for Research and Prevention of Injuries,Athens University Medical School, Athens, Greece,and the Department of Epidemiology, HarvardSchool of Public Health, Boston, Mass. MatinaStappa is with the Department of Health Education,Ministry of Education, Athens, Greece. YannisTsoufis is with the Ministry of Transportation,Athens, Greece. Alkistis Skalkidou is with the Cen-ter for Research and Prevention of Injuries, AthensUniversity Medical School, Athens, Greece, andTROHOPEDIA (Greek Youth for Road Safety).

Requests for reprints should be sent to EleniPetridou, MD, MPH, Department of Hygiene andEpidemiology, Athens University Medical School,75 M Asias St, TK 115 27, Athens, Greece (e-mail:epetrid@atlas.uoa.gr).

This briefwas accepted May 20, 1999.

American Journal of Public Health 1861