• Home
• About ATSDR
• Press Room
• A-Z Index
• Glossary
• Employment
• Contact Us
• CDC

ATSDR en Español

Search:

Skip directly to: content | left navigation | search

---

Find a Publication

1. ATSDR > Public Health Assessments & Consultations

PUBLIC HEALTH ASSESSMENT

KELLY AIR FORCE BASE
SAN ANTONIO, BEXAR COUNTY, TEXAS

Appendix F

Community Health Reports

Community Health Reports

Two health surveys have recently been conducted in communities surrounding Kelly Air Force Base. One survey was conducted in the North Kelly Garden area which is adjacent to the northern part of the base, and the second was conducted in communities located in San Antonio City Council District 4. Information presented in this section came directly from documents provided to ATSDR for review.

Primary Health Care Review, 1994-1995, San Antonio City Council District 4

In 1994-1995, a Primary Health Care Review was carried out in San Antonio City Council District 4 (Figure F-1, page F-4). The review had three components: (1) an analysis of existing data about the area to give an objective framework; (2) focus groups and interviews with District 4 residents, community leaders, and health care providers; and (3) a formal household survey. A vast amount of information was collected for this review. A summary of each component, as it relates to overall conditions of the area and specific to Kelly Air Force Base, is addressed here.

Quintana Road and the Missouri Pacific Railroad line divide the San Antonio City Council District 4 into two parts. The area east of Quintana Road is referred to as the East sector, and the area west of Quintana Road is referred to the West sector. Lackland Air Force Base and Kelly Air Force Base are in the West sector.

The East and West sectors have very different characteristics. The East sector neighborhoods and subdivisions were developed about 50 years ago, and the West sector subdivisions about 25 years ago. Community infrastructure such as stores and churches are distributed throughout the East sector, while in the West sector long blocks of single family houses were built. There are few stores and churches in the West sector, and they are found clustered on the major streets.

Existing Data

In reviewing existing information concerning City Council District 4, data was gathered from several sources including the San Antonio Metropolitan Health District, other city agencies, state and federal agencies, and U.S. Census data for 1970, 1980, and 1990. Also reviewed was information from the San Antonio Chamber of Commerce, the San Antonio Express-News, and school districts in the area. In developing the review, needs assessments and reports were also used. Some of those were the Assessment of the Wesley Community Center Service Area, a report by the Columbia Heights Learning and Leadership Development Center, and a report published by the Partnership for Hope and San Antonio 2000.

As a whole, the area has a young population, with a higher proportion of children and young people under 19 years of age than the remainder of Bexar County, and a smaller proportion of people 65 and older. Many military retirees live in the West sector. In this district, people of Hispanic race/ethnicity form the largest proportion of the population (81%). There is a high proportion of single parent families in both the East and West sectors. The East sector has had a persistently high, and still increasing, number of people with annual household incomes less than the federal poverty level. The West sector has the most rapidly decreasing income levels, appearing more concentrated in the Sky Harbor area. Families with young children headed by single females are most likely to have household incomes which fall below the federal poverty level. More than one-third of the adults in the East sector have completed less than the ninth grade of education. Overall, twice as many adults in District 4 (27.4%) have less than a ninth grade education when compared to the number of adults with a ninth grade education in Bexar County as a whole (14.7%).

Almost all health care services are located in the East sector of District 4. Two Metropolitan Health District clinics are in the East sector. The University Hospital System has no clinic in District 4, although the new Southwest clinic serves the area. For potential clients in the West sector, however, Lackland and Kelly Air Force bases represent a physical barrier around which citizens must find transformation.

In general, most pregnant women in the area are seeking earlier prenatal care than in previous years. This is indicated by records of both the East sector and the county as a whole. The East sector improvement in first trimester prenatal care influences the overall improvement rate of District 4. In the West sector, however, the proportion of women seeking prenatal care in the first trimester in the West sector, however, has shown little change. Low birth weight is a major cause of infant death.

A large part of City Council District 4 lies immediately downhill of the Lackland and Kelly Air Force bases. These bases share a common boundary. Because access to the bases is restricted, the military installations in San Antonio pose a special problem for locating and identifying contaminated soil and water. Low-level radiation was detected from training munitions buried at the Lackland Training Annex between 1955 and 1964. In 1987, 13 inactive waste disposal sites and 6 abandoned storage sites were officially identified at Lackland. At the Kelly Logistics Center, industrial wastes and petroleum-based chemicals are used during the maintenance of military aircraft. Spills of chemicals and JP-4 jet fuel have been found in Leon Creek, in soil samples, and in groundwater. As of January 1992, 52 possible sites of contamination had been identified.

The nature of the work done at Lackland and Kelly introduced heavy metals, petroleum products, low-level radiation, and industrial solvents to southwest San Antonio at a time when there was little awareness of environmental impact issues. It is not known if people living in the area were exposed to hazardous chemicals or, if they were exposed, what the levels of exposure were.

Figure F-l. Map of San Antonio City Council District 4

Focus Groups and Interviews

Focus groups are small gatherings of from 4 to 10 people who agree to participate in a group session and answer questions about a particular subject. The focus groups used in the health care survey usually consisted of community residents and community health care providers. A focus group questionnaire was developed to obtain information on health problems in the community, health services used when residents were ill, access to health care, barriers to health care, and methods used to prevent illness. The focus groups were also given an opportunity to provide suggestions to improve community health services.

Focus groups from citizens of City Council District 4 reported concerns about personal and family safety and mentioned such things as crime, violence, gangs, and drugs. Alcoholism, dysfunctional families, and transportation difficulties were reported. Unpleasant neighborhood environments including problems with trash, dump sites, drainage, and stray animals were reported as common occurrences. In many cases, these community problems take precedence over individual health concerns, and each problem may have its own impact on an individual's health.

The community survey found that diabetes and the mental and emotional health of people of all ages were issues of concern for community members. Depression and emotional disturbances were frequently described. Dental disease, teen pregnancy, and hypertension and heart disease were also concerns reported by many. Although sick children are found in all neighborhoods, living conditions in some cases contribute to infant diarrhea, skin diseases, and infestations with scabies and lice. Factors of hygiene and nutrition, inadequate health-related knowledge, and the lack of health facilities and personnel contribute to these problems. School nurses have reported that children lose weight during school vacations, especially the long summer vacation. The nurses report that these children require several weeks after school reopens to regain the nutritional status that they had when they were last eating meals at school. How hunger and poor nutrition affect student learning in San Antonio is not known. Educational data, however, indicates that the school districts serving District 4 have a very low percentage of children passing the Texas Assessment of Academic Skills tests. The rate of passing corresponds to the proportion of economically disadvantaged students in the school districts.

The survey indicated that cost, convenience, and comfort level were the main factors people considered in choosing where to go for health care. Most of those questioned said that they go to doctors or clinics when they were sick, but said that the point at which they sought medical care was determined by how sick they felt. Generally, they reported that an illness severe enough to prevent work or other daily activity would cause them to go to the traditional medical care system. Until that time, they said that they would try home remedies, talk to a school nurse, ask relatives for advice, pray, and wait and hope they would get better. Some reported that they would go to Mexico for treatment. The survey indicated that community members considered school nurses, public health nurses, clinics, and relatives to be important sources of health information. Respondents indicated that the pain and severity of an illness balanced against the cost that might be involved (medical consultations, tests, and treatment including medications) were the primary things considered in making a decision to go to a doctor.

Language differences appear to be a problem for individuals (for both those receiving health care and those providing it) rather than the system as a whole. Health care providers, however, need to be sensitive to non-English speaking clients, and staff members who are bilingual provide a vital service. Clinics and doctors are associated with sickness, and the association may prevent people from thinking of medical providers as health promoters. This is an extra hurdle to be overcome if medical facilities and clinics are chosen as locations for health promotion activities.

Transportation is seen as a major problem, especially for older people. There is no public transportation in the area, and cars are the preferred method of transportation. The survey indicated that people would find transportation for serious problems, but that for other health matters, transportation problems would prevent clinic visits.

Household Survey

Focus groups and interviews with community members help to identify specific problems, but other methods must be used to determine the extent of the problems and find out how many people are affected by them. A survey of households in City Council District 4 was conducted to more clearly define the extent of the health problems. A discussion of the survey methods is contained in the section on Primary Health Care Review.

One-fourth of the District 4 survey respondents think their health is excellent or very good, while half of the respondents say they have fair or poor health. One in three young adults (35-44 years) say their health is fair or poor.

One out of every three District 4 respondents reported that they have both high blood pressure and high cholesterol, making those conditions the most prevalent health problems in the area. Those with high blood pressure are most likely to be older adults with annual family incomes of less than $10,000. They are more likely than people without diagnosed high blood pressure to say they have fair or poor health, some sleep problems, high cholesterol, heart disease, and/or diabetes, and symptoms of both heart disease and diabetes. One in three respondents suffer from arthritis. Diabetes has been reportedly diagnosed in one in five respondents. Diabetes is a disease which should be viewed in a family context, because it is present in the parents and/or siblings of one of every two persons diagnosed with diabetes. Respondents with diabetes are more likely than those without diabetes to have a low family income, to say their health is fair or poor, to report limited activity, and to have heart disease. While about 33% of people with diabetes say they exercise regularly, less than 14% of the people with diabetes report exercise as part of their diabetic control program.

Almost 40% of District 4 respondents report symptoms that might indicate some type of cancer, and almost as many District 4 respondents report symptoms sometimes associated with heart disease. Over 60% of the respondents reported possible diabetes-related symptoms including blurred vision, frequent urination, leg cramps when walking, and poor circulation. An isolated symptom does not signify any disease, but needs medical evaluation. Between 70%-80% of the residents with symptoms said they had gone to a doctor or clinic. Of all symptoms reported, symptoms associated with heart disease were the most likely to be evaluated.

Almost three-fourths of the survey respondents said they have a regular family doctor or clinic. People with third party health insurance are most likely to have a regular source of care, and people with a regular source of health care are most likely to have had disease symptoms evaluated. Having a regular doctor or clinic did not make any difference in the frequency of use of the emergency room.

Getting medications or supplies was reported to be a problem by slightly more than 16% of those surveyed, while slightly more than 13% reported problems in getting needed medical services. Almost 25% of the respondents said that cost prevented them from going to the doctor. People reporting heart disease or diabetes were more than twice as likely as people without these diseases to say they had problems obtaining medications or other supplies or problems obtaining needed medical services. The most frequently reported barriers to care in District 4 are high cost, having to wait too long at a clinic or a doctor's office, lack of insurance, not having services available in the neighborhood, and fragmented medical care (including what was interpreted as lack of continuity in care resulting from seeing different doctors at each different clinic visit and not having one physician to follow up on previous visits).

In District 4, 25% of survey respondents reported that they smoke tobacco, mostly cigarettes. Men are more likely to smoke tobacco than women. There appears to be no correlation between smoking and having or not having a regular doctor or clinic. Smokers, however, are less likely than nonsmokers to exercise regularly, and they are more likely to have concerns about their use of drugs or alcohol.

Common preventive screening tests are reported at similar rates for both the East and West sectors of District 4 with the exception of prostate checks for men and dental checks. Slightly more than 73% of respondents have had a cholesterol test, 67% of women have had a mammogram at some time, and 90% of women have had a Pap smear at some time. Less than 50% of men in the District 4 survey reported having ever had a prostate check.

North Kelly Gardens Comprehensive Community Health Survey

Between February and June of 1996, members of the Committee for Environmental Justice Action and members of the Southwest Public Workers Union in San Antonio, along with consultants from the Foundation for a Compassionate Society, conducted a health survey in the North Kelly Gardens community. This survey was requested by the residents of North Kelly Gardens concerned about the possibility that of contamination in their area from hazardous substances originating at the Kelly Air Force Base. Their concerns were that a contaminated groundwater plume originating at the base had reached the North Kelly Gardens area and that the community's location--downwind of the base's fuel storage tanks--could put them at risk. Households in the immediate area of North Kelly Gardens were included in the survey: houses on Beech Street, Bay Street, the western part of Weir Avenue, Carnation Street, and households south of Athel, Barney, Dahlgreen, and Westcott Streets just north of the base (Figure F-2, page F-9). Of 143 households, 107 adults and 48 children were surveyed.

The Symptom Survey Questionnaire developed for the study is extremely comprehensive. It includes questions regarding demographic information, family medical history, and personal medical history including questions pertaining to the lung, cardiovascular system, blood disorders, digestive system, urinary tract, endocrine/glandular system, skin problems, immune system, head and neck problems, teeth and gums, nervous system, muscles, bones, and cancer. All questions pertained to symptoms that appeared after individuals moved into the area. Specific questions were also asked regarding possible occupational or recreational activities that might have caused or contributed to the reported adverse health effects.

Of the 107 adults who participated in this survey, nearly two-thirds were female (63%, n=67) and one-third were male (35%, n=37). The majority of the females were 20-49 years of age (61%, n=41) while half of the men were 30-49 years of age (49%, n=18). Table F-1 summarizes the survey results of adult participants.

Mothers were asked to answer questions about the health status of their children who were 18 years of age or less. Surveys for 48 children were included in the study. Of these children, approximately 40% (n=19) were males and 60% (n=29) were females. Most of the males (60%, n=11) were under 9 years of age, while approximately one-half (52%, n=15) of the females were 10-15 years of age. Only 3 children were 16 years of age or older. Table F-2 summarizes the survey results for children.

Supplemental Clinical Evaluations

Approximately 41% of the total respondents (44 adults and 20 children) in the North Kelly Gardens Community Health Survey reported respiratory symptoms. In order to evaluate the relationship of self-reported symptoms to objective measurements that could be verifiably defined, further study was needed. Therefore, a study of 22 children and 28 adults in the area was undertaken. The study consisted of two parts. The first part consisted of a supplemental respiratory symptom questionnaire that asked about the number of medications, doctor visits, and hospital stays. The questionnaire also asked about breathing difficulties affecting quality of life at home, school, sports, or work.

Figure F-2. North Kelly Gardens Community Survey Area.

In the second part of the supplemental study, survey participants received physician-administered lung function tests. Hand-held peak flow meters (ASSESS brand) were used, and the best of three forced expiratory efforts was recorded for each participant. These figures were compared to the expected normal values for persons of the same age, sex, and height.

Results

Adults

The 28 adults participating in the survey ranged in age from 20-69 years. All had lived in the neighborhood for their entire adult lives, and many of them were life-long residents. Nearly two-thirds of these individuals (n=18) reported that breathing problems interfered with work, sports, or other activities around the house. Half also reported visiting a doctor for breathing problems in the past year; four reported hospital visits. Ten said that they were on medication, usually multiple prescriptions for the control of reactive airway disease. Results of the peak flow testing indicated abnormally low capacity in 18 out of the 28 individuals. For 16 of the participants, results were at least 30 liters per minute less than the flow rate expected for individuals of their age, sex, and height. Seven of those with poor test results were exposed to cigarette smoke.

Children

The children in the survey ranged in age from 2 to 16 years. All of the children live in the North Kelly Gardens neighborhood and attend school there. The answers to the questionnaires indicated that 8 of the 22 children had seen a doctor frequently because of breathing problems, and 5 had been to the emergency room or stayed overnight in a hospital because of breathing problems. Lung function tests indicated abnormal results in almost half of the children (n=10). Test results indicated that 8 children had flow rates that were more than 30 liters per minute less than rates that would have been expected for children of the same age, sex, and height. Most of the abnormal test results were for children on multiple medications for asthma. None of the children with abnormal test results live in households with smokers or receive child care from a smoker.

Discussion

A copy of the questionnaire that was used in the North Kelly Gardens health survey was given to ATSDR for review. The questionnaire was very comprehensive. The results of the questionnaire provided to ATSDR, however, included only descriptive analyses of the number of people reporting specific outcomes. The questionnaire included other types of information that would be useful in obtaining a more complete picture of the health of people in the community. For example, it would be useful to compare length of residence in the area to the type or number of symptoms reported. Also, certain information not used in the analysis was available (such as occupational history, family health history, smoking status, and other characteristics that could be associated with health conditions).

The supplemental respiratory symptom questionnaire used for this evaluation was not available for ATSDR to review; therefore, the results that have been reported here are from materials prepared by the persons who administered the survey. The tables that were presented along with the summary information do not provide the height of the individuals with abnormal lung function test results, and therefore a comparison of individual results to expected ranges could not be conducted.

Symptom-and-disease prevalence studies, such as the one that was done in North Kelly Gardens, are often conducted if there is a high level of concern in a community but little information available to satisfactorily determine exposure. A health survey is usually conducted in a community that is concerned about a particular source of exposure. The community being studied is called the "subject community." The subject community is then compared to a community that is as similar to it as possible except for the exposure of concern. The ideal comparison community would have demographic features similar to those of the subject community such as size of the population, types of housing and businesses in the area, and income levels. Although there are difficulties in conducting and interpreting findings from studies that compare two communities, difficulties are much greater if a comparison community is not used.

The public health care review that was conducted in City Council District 4 1994-1995 was very comprehensive and included information from multiple sources. All results reported here came from the public health care review document.

Existing data sources used in the health care review included several federal, state, and local agencies. Collection of data by these agencies typically follows defined quality assurance and quality control measures that allow these results to be validated. It is not clear whether information provided by local newspapers was validated, and it is also not clear exactly how much information was provided by the newspapers. Needs assessments and reports were also used as existing data sources for this review. Needs assessments are conducted to determine the needs and concerns of a community, professional group, or program/project. They provide the basis for determining the goals and objectives of an activity and determining the health education activity most appropriate to meet identified needs. It is unclear which community members or professional groups were involved in this process and whether their views are representative of the community.

Other than what has been mentioned previously, it is unknown how the focus group members were selected, how long they lived or worked in the area, who they were, or--for the medical providers in the group--what types of medical providers they were. It is difficult to ascertain, therefore, whether the opinions of the focus groups are representative of the community as a whole. Also, the methodology used to select households to complete the household survey of District 4 was not available. It is unknown if the opinions expressed in the survey are representative of the opinions of the whole community.

Summary

The survey conducted in the North Kelly Garden area provides information regarding a number of symptoms or adverse health effects being reported by area residents while the Primary Health Care Review conducted in City Council District 4 gives an overview of the conditions and issues confronting residents on a daily basis. Both surveys aid in our understanding of the communities surrounding Kelly Air Force Base.

Community health surveys such as the two described are rarely available in areas where a public health assessment is being conducted. These documents provide valuable information--both about the overall health and well-being of the residents of the community and about the concerns that community residents have expressed about living in the area.

Appendix G

Health Outcome Data

Health Outcome Data

The evaluation of health outcome data helps to provide a general picture of the health of a community, and it may help to identify or confirm the presence of excess disease or illness in a community. However, elevated rates of a particular disease may not necessarily be caused by hazardous substances in the environment. Other factors, such as socioeconomic status, occupation, and lifestyle, also may influence the development of disease. In contrast, a contaminant can contribute to illness or disease without this being reflected in the available health outcome data.

Health outcomes selected for evaluation are based on community concerns and biological plausibility. During several site visits, ATSDR staff members discussed health concerns with community residents. Many residents expressed concern about elevated cancer rates and birth defects. Citizens around Kelly Air Force Base also expressed concerned about reports of lead found in soil samples taken from the neighborhood and the effects that exposure to lead may have on their children. The Health Outcome Data section of this public health assessment addresses these concerns.

Health outcome data is evaluated if a completed exposure pathway exists for the chemical or chemicals suspected of causing the health outcome of concern. When a contaminant of concern has been identified as a carcinogen, specific types of cancers which may be related to the contaminant are usually selected for evaluation. At Kelly, we have identified air as a exposure pathway with hexavalent chromium and volatile organic compounds (VOCs) such as tetrachloroethylene and benzene as primary contaminants of concern. For cancer, the health outcomes we considered included cancer of the kidney, liver, lung, cervix, bladder, and leukemia. We also examined all reportable birth defects and low birth weight babies. The majority of the health outcome data analyses focused on zip code areas 78211, 78228, and 78237.

Interpreting Health Outcome Data

To determine if there is an excess of a particular disease or health condition we compare the observed number of cases in the population living in the area of concern to an "expected" number of cases determined from a standard population. For cancer, we examined the ratio of observed-to-expected number of cases (incidence) or deaths (mortality), and the information was further standardized to eliminate possible effects due to race, sex, and age. These ratios are referred to as the standardized incidence ratio (SIR) or standardized mortality ratio (SMR). The type of ratio used depends on the type of health data to which one is referring. For birth defects and low birth weight babies, we divided the number of observed cases by the number expected, producing an observed-to-expected ratio (O:E ratio).

An O:E ratio of 1.0 indicates that the number of cases observed in the population being evaluated is equal to the number of cases expected based on the rate of disease in the comparison population. A ratio greater than 1.0 indicates that more cases occurred than expected; and a ratio less than 1.0 indicates that fewer cases occurred than expected. Accordingly, a ratio of 1.5 is interpreted as 50% more cases than expected; and a ratio of 0.9 indicates 10% fewer cases than would be expected.

Caution should be exercised, however, when interpreting these ratios. The interpretation of a ratio depends on both the value of the ratio and the numbers used to compute the ratio. Two ratios can have the same size but be interpreted differently. For example, a ratio of 1.5 based on 2 expected cases and 3 observed cases indicates a 50% excess in cancer, but the excess is actually only 1 case. However, a ratio of 1.5 based on 200 expected cases and 300 observed cases represents the same 50% excess in cancer, but because the ratio is based upon a greater number of cases, the estimate is less likely to be attributable to chance. It is very unlikely that 100 excess cases of cancer would occur by chance alone. However, a single excess case very easily could be due to chance occurrence.

A certain amount of chance variation can be expected when looking at the occurrence of different health conditions in communities and statisticians have developed methods to take this into account. One method is to calculate a 95% confidence interval (95% CI) for the O:E ratio. The 95% CI is the range of estimated ratio values that has a 95% probability of including the true ratio for the population. The confidence interval is a statistical measure of the precision of the risk estimate.

"Statistically significant" means there is less than 5% chance that the observed difference is merely the result of random fluctuation in the number of observed cancer cases. For example, if the confidence interval does not include 1.0 and the interval is below 1.0, then the number of cases is significantly lower than expected. Similarly, if a confidence interval does not include 1.0 and the interval is above 1.0, then there is a significant excess in the number of cases. If the confidence interval includes 1.0, then the true ratio may be 1.0, and it cannot be concluded with sufficient confidence that the observed number of cases reflects a real excess or deficit. As long as the 95% confidence interval contains 1.0, that indicates that the ratio is still within the range one might expect based on the disease experience of the comparison population. However, if either the upper or lower bound of the confidence interval is 1.0, it is considered of borderline statistical significance. This means that the ratio is close to being statistically significant and that the number of cases was either higher or lower than expected.

In addition to the number of cases, the width of the confidence interval also reflects the precision of the ratio estimate. For example, a narrow confidence interval (e.g. 1.03-1.15) indicates that the population's size was sufficiently large to generate a fairly precise estimate of the ratio. A wide interval (e.g. 0.85-4.50) indicates far less precision, and more uncertainty, in the calculated ratio.

Cancer Data

All cancer data were provided by the Cancer Registry Division (CRD) of the Texas Department of Health. The CRD maintains cancer incidence and mortality data for the state of Texas. Cancer incidence data are acquired under the Texas Cancer Incidence Reporting Act (Chapter 82, Health and Safety Code), which requires every general and special hospital, clinical laboratory, and cancer treatment center to report all cases of cancer to the CRD. Every inpatient or outpatient case diagnosed with or treated for cancer must be reported to the CRD. Although the CRD is a passive registry that relies on facilities to supply the information, it monitors the number of expected reports from each institution and contacts those facilities that fail to report. To ensure that reported data are complete and accurate, CRD staff members perform case-finding and other quality control checks at these institutions. The CRD has determined that for Public Health Region 8, which includes San Antonio, cancer incidence reporting is 90% - 95% complete for the years 1990-1994. Cancer mortality data is obtained by CRD from death certificate information maintained by the Bureau of Vital Statistics. The CRD conducted an analysis of both cancer incidence (1990-1994) and cancer mortality data (1991-1995) for three zip code areas around Kelly Air Force Base (78211, 78228, and 78237).

Initial Cancer Request

After receiving the petition to perform a public health assessment on neighborhoods north and southeast of Kelly Air Force Base, ATSDR requested that the CRD evaluate rates of cancers of the colon, pancreas, lung, prostate, breast, and leukemia in zip code areas 78211 and 78237. This information was used only to give a general idea of the rates of cancer in these communities and the results from this evaluation are presented in Attachment A.

Incidence Data

The CRD evaluated cancer incidence data for the period 1990-1994 for San Antonio zip code areas 78211, 78237, and 78228 for the following cancer sites: liver, lung, cervix, bladder, kidney, and leukemia. Data were initially evaluated using race-, sex-, and age-specific cancer incidence rates published by the California Cancer Registry. Statewide cancer incidence data for Texas were not available and the California Cancer Registry had Hispanic cancer rates which could be used for comparison. During the course of the analyses statewide cancer incidence data became available for Texas and the analyses were updated to include the Texas comparison population. These results are presented in this section. The results from the initial analysis using California rates as the comparison population are included in Attachment B.

During the period 1990-1994, the number of cases observed for cancer of the liver, lung, bladder, kidney, and leukemia were close to the number expected among males and females in zip code 78211 (Table 1). The number of cases observed for cervical cancer among females was also close to the number expected during this time period. In zip code 78228, the number of observed cases of bladder cancer and leukemia among males and females were close to the number expected, as were the number of cases observed for lung, cervical, and kidney cancer among females (Table 2). A significant excess of liver cancer among males was observed. Of borderline statistical significance, a higher than expected number of kidney cancer cases and a lower than expected number of lung cancer cases. In zip code 78237, the number of cases observed for lung, bladder and kidney cancer, as well as leukemia, was close to the number expected among males (Table 3). However, a significant excess of liver cancer was observed among males in this zip code area. The number of cases observed for cancer of the liver, lung and bladder were close to the number expected among females in zip code 78237. A significant excess of liver cancer among females was observed as was a higher than expected number of kidney and cervical cancer cases, although the elevations were of borderline statistical significance.

Mortality Data

ATSDR compares mortality and incidence data for indications of reporting consistency. Using death certificate information, the CRD also evaluated cancer mortality for the same cancer sites for the three zip code areas of concern for the period 1991-1995 (Tables 4-6). During this period, a significant excess of liver cancer deaths was observed among males in zip codes 78228 and 78237. During the same period of time, a significant excess of liver cancer deaths was observed among females in zip codes 78211 and 78237. In zip code 78228, the number of lung cancer cases in males was significantly lower than expected. A higher than expected number of leukemia cases was observed among males in zip code 78237, although the elevation was of borderline statistical significance.

Additional Liver Cancer Analysis

Because of the increased occurrence of liver cancer in the initial three zip code areas, ATSDR requested that the CRD evaluate the incidence and mortality data for liver cancer in ten additional zip code areas surrounding Kelly Air Force Base to determine if there were an excess of liver cancer cases. Incidence data were initially evaluated using race-, sex-, and age-specific cancer incidence rates published by the California Cancer Registry since statewide cancer incidence data for Texas was not available at the time this analysis was conducted. Once statewide cancer incidence data became available, the analyses were conducted using Texas incidence rates. The results from the analysis using California as the comparison population are included in Attachment B.

An additional five zip code areas were evaluated when conducting the analysis of liver cancer rates in the area using Texas incidence data but not evaluated when conducting the analysis of liver cancer mortality. For the sake of consistency, Tables 7 and 8 include the results from the same zip code areas. The results from the five additional zip code areas are included in Attachment C.

The analysis of incidence data using Texas as the comparison population for the ten additional zip code areas during the period 1990-1994 indicates a statistically significant excess of liver cancer among males in the 78201, 78205 and 78227 zip code areas (Table 7). A higher than expected number of liver cancer cases was observed among males in zip code 78207, although this excess was of borderline statistical significance. Among females in the study area during the same time period, no statistically significant excess of liver cancer was observed. However, a higher than expected number of liver cancer cases was observed among females in zip code 78207 and 78221, although these excesses were of borderline statistical significance.

The analysis of mortality data for this area during the period 1991-1995 also indicates a statistically significant excess of liver cancer among the males in the 78201, 78204 and 78207 zip code areas and females in the 78242 zip code (Table 8). A higher than expected number of liver cancer deaths in males was observed in zip code 78227 and in females in zip code areas 78207, 78221 and 78226, although the elevations were of borderline statistical significance.

Additional Cancer Analysis

In order to examine cancer incidence in other areas surrounding Kelly Air Force Base, ATSDR requested that the CRD evaluate incidence data for cancer of the liver, lung, cervix, bladder, kidney, and leukemia in the zip code areas 78201, 78204, 78205, 78207, 78221, 78224, 78225, 78226, 78227 and 78242 during the period 1990-1994. The results from these analyses are presented in Attachment D.

Discussion

Overall, liver cancer rates are elevated in many zip code areas surrounding Kelly Air Force Base; however the reason for these elevations is unknown. The data available to the Texas Cancer Registry regarding individuals who have been diagnosed with liver cancer is limited. Information is not available concerning known risk factors associated with liver cancer, or if occupations had exposed individuals to chemicals that are known liver carcinogens.

The analysis of liver cancer mortality found a significant excess among males and females in two zip code areas. Only one zip code area had a significant excess of liver cancer deaths for both males and females. While the number of liver cancer deaths was elevated, mortality can be affected by several factors including socioeconomic status, access to medical care, and stage of disease at diagnosis. Additionally, the liver is a common site of metastasis for tumors originating in other organs. Metastasis is the spread of disease from one part of the body to another unrelated to it. Death certificates and hospital charts cannot always be relied on to accurately distinguish primary from secondary (metastatic) tumors, making the interpretation of these results difficult.

General Facts about Cancer

Almost everyone alive today will be affected by cancer, either personally or because friends and family members contract the disease. Approximately two out of every five persons will develop some type of cancer in their lifetime. Furthermore, cancer is not one disease, but many different diseases. Different types of cancer are generally thought to have different causes. In Texas, as in the United States, cancer is the second leading cause of death, exceeded only by heart disease. In 1996, 31,969 Texans died of cancer. Sixty-five percent of these deaths were in persons 65 years of age or older.

The incidence of cancer varies by race/ethnicity, gender, the type of cancer, geographic distribution, population under study, and a variety of other factors. Scientific studies have identified a number of factors for various cancers which may increase an individual's risk of developing a specific type of cancer. General cancer risk factors include heredity, geographic area, diet, environmental causes, tobacco smoke, sexual practices, and alcohol consumption.

Liver Cancer¹

The term "primary liver cancer" refers to any malignant tumor arising in the liver itself, not to refer to a cancer that originates elsewhere and spreads, or metastasizes, to the liver. Hepatitis B infection is the most important risk factor in the occurrence of liver cancer worldwide. However, it is usually necessary for infection with hepatitis B to occur early in life in order for liver cancer to develop; it rarely develops in individuals who become infected in adulthood. Males are at much greater risk (twofold to sevenfold higher) for developing liver cancer than females. Also, individuals with cirrhosis of the liver resulting from hepatitis B are at much higher risk of developing liver cancer than those with less severe liver disease. Cirrhosis is the extensive scarring of the liver in which the scar tissue surrounds "nodules" of regenerating liver tissue and is a consequence of chronic liver injury. Some of the causes of cirrhosis are alcohol abuse, chronic hepatitis, prolonged obstruction to the outflow of the bile from the liver, and some viral forms of autoimmune liver disease. Recently, infection with the hepatitis C virus has been strongly linked with liver cancer.

Exposure to some chemicals and toxins can lead to liver cancer. Perhaps the best known and extensively studied is aflatoxin. Aflatoxin, a common mold found in poorly stored peanuts and other foods, readily causes liver cancer in laboratory animals and, in humans, may potentiate the cancer-causing effects of hepatitis B infection.

Some forms of inherited metabolic diseases may predispose individuals to liver cancer. The most common of these is hemochromatosis or "iron overload", a disorder of iron metabolism that results in an excessive iron accumulation in the body. If untreated, iron accumulation leads to cirrhosis and the development of liver cancer.

Other risk factors thought to be associated with liver cancer include alcohol intake, smoking, use of anabolic steroids, and the use of oral contraceptives.

Kidney Cancer²

Kidney cancer accounts for 2% of all new cancers each year in the United States. Studies have shown that cigarette smoking increases the risk of kidney cancer as does high relative weight or obesity. Early studies noted the association of obesity and kidney cancer among women; however, more recent studies have also found an increased risk among overweight men. Some studies have found death from kidney cancer to be elevated among asbestos-exposed workers and among coke-oven workers in steel plants.

Leukemia^3,4

Leukemia is cancer of the blood-forming cells. It occurs when immature or mature cells multiply in an uncontrolled manner in the bone marrow. There are four types of leukemia: acute lymphocytic leukemia (ALL), acute myeloid leukemia (AML), chronic lymphocytic leukemia (CLL), and chronic myeloid leukemia (CML). Each type of leukemia can have different etiologies and different prognoses.

In 1993, about 29,000 new cases of leukemia were diagnosed in the United States, representing about 2.4% of all new cancer cases in that year. Leukemia occurs slightly more often in whites than in blacks and in males more often than females. The incidence of leukemia also varies by age. Leukemia accounts for nearly one-third of all children's cancers, but it actually affects far more adults than children. Acute lymphocytic leukemia occurs predominantly in young children and in adults age 65 and older; acute myeloid leukemia occurs in infants, adolescents, and older people, but is unusual in young children (ages 2 to 10). Only 5% of childhood leukemia cases are chronic, and virtually all of these are chronic myeloid leukemia. Chronic lymphocytic leukemia almost never occurs in children and is rare before age 30; 60 years is the average age at diagnosis. Chronic myeloid leukemia is uncommon below the age of 20; half of all CML patients are over age 67.

Certain factors are known to increase the risk of developing the disease. Among these are exposure to radiation, heredity, congenital factors, chemicals (benzene), drugs (chloramphenicol, phenylbutazone), and viruses (human T-lymphotrophic virus type I or HTLV-I).

Cervical Cancer⁵

The two major risk factors for cancer of the cervix are sexual intercourse at an early age and multiple sex partners. More than 90% of all cervical cancer cases are due to a sexually transmitted human papilloma virus infection of the cervix.

In a number of studies, cigarette smoking has been found to increase the risk of cervical cancer; especially among long-term or high-intensity smokers. Choice of contraceptive method also appears to affect the risk of cervical cancer. There is increasing evidence that nutritional factors may play a role in cervical disease. Several studies suggest that low intake of either vitamin C or beta carotene may be associated with elevations in risk, although this has not always been found. Deficiency in folacin (one of the B complex vitamins) has also been proposed as a risk factor, especially among oral contraceptive users whose stores of this vitamin are depleted.

Birth Outcomes

Birth Defects Data

All data relating to birth defects were provided by the Texas Department of Health (TDH) Birth Defects Monitoring Division (TBDMD) and the TDH Bureau of Vital Statistics. Birth defects were identified by examining three types of vital record certificates: live birth certificates, fetal death certificates, and infant death certificates. Each type of vital record contains information on birth defects, and the fetal and infant death certificates also contain information on the cause(s) of death. The TBDMD began active surveillance for birth defects in the San Antonio in January 1997.

Texas requires that birth certificates be filled out for all live births and that the certificates be filed with the state within 5 days of the birth. Birth defects are reported on birth certificates through the use of check boxes. The physician has the choice of 24 boxes. Twenty-two boxes list specific categories of birth defects, there is one check box for "other" defects, and one check box for "none".

A fetal death certificate must be filed for any stillborn infant of 20 weeks or more gestation. Birth defects are also reported on fetal death certificates through the use of check boxes. The physician has the choice of the same 24 boxes.

Infant deaths are defined as the death of a baby less than one year of age. The same death certificate is used to record all deaths in Texas, regardless of the age at death. Death certificates list the International Classification of Disease 9^th Revision (ICD-9) code for all causes of death, both the immediate cause and the underlying cause(s). The ICD-9 codes are a system of numerical codes for specific diseases and health conditions. Birth defects listed among the cause(s) of death are found coded by specific ICD-9 codes.

Case Definitions

For this health assessment, we defined a case as an infant or fetus who:

1) was delivered between January 1, 1990, and December 31, 1995;
2) had a mother residing in zip code 78211, 79237, or 78228 at the time of the birth; and
3) had a birth defect indicated on a vital record (birth, death, or fetal death certificate)

1990 is considered to be the first year for which reliable data on specific birth defects are available. The last year for which complete data are available is 1995.

To determine if there was a possible "excess" of birth defects in the three zip codes of concern, we compared the number of "observed" cases for each category of birth defect to the number of cases we would have "expected," based on rates for specific birth defects for the entire state. As with the cancer information, we determined the observed-to-expected ratio (O:E) and calculated the 95% confidence interval for each birth defect category. We examined the number of birth defects for each type of vital record: birth, death, and fetal death certificates. The results are presented in the following sections, according to the type of vital record used for the analysis. Tables 9 through 19 list the specific number of cases and O:E ratios.

Birth Certificates

TDH calculated the O:E ratio for each category of birth defects. The number of expected cases is based on the rate for specific birth defects for Texas. The ratios were not adjusted for race or maternal age.

Tables 9-11 list information on 1990-1995 birth defects recorded on birth certificate check boxes for each of the zip codes 78211, 78228, and 78237. The tables list the 22 specific birth defect categories and a nonspecific "other" category, the observed number of cases for each defect, the expected number, and the O:E ratio with the 95% confidence interval.

The only statistically significant findings from the birth certificate data are for the category "other" defects in zip codes 78211 and 78237. This category is a nonspecific category, a "catch-all" category for birth defects that are not attributed to one of the 22 categories of specific defects. The defects listed in the "other" category may include a wide variety of defects of different structural systems, some of which may be very serious or merely cosmetic, and whose cause(s) may be very diverse. A nonspecific category such as "other" is difficult to interpret because it is not possible to tell if the elevated O:E ratios are due to a slight elevation in many different defects listed in the "other" category or if it is due to larger increases in one or two kinds of defects listed in the category.

Fetal Death Certificates

There were no statistically significant elevations of any O:E ratios for conditions listed on fetal death certificates for any zip code. Tables 12-14 list the number of observed and expected cases for each birth defect category and the O:E ratios with 95% confidence intervals for the individual zip codes for the time period 1990-1995.

Infant Death Certificates

Death certificates for children less than one year old were also reviewed (Tables 15-17), and 17 specific categories of birth defects were evaluated for 1990-1995. No statistically significant elevations in the O:E ratios were seen for any of the defects in zip codes 78211 and 78228. The O:E ratios for three categories of heart and circulatory system-related defects were significantly elevated for zip code 78237. The elevated ratios were for the categories "bulbus cordis anomalies and anomalies of cardiac septal closure" (ICD9 745), "other congenital anomalies of the heart" (ICD9 746), and "other congenital anomalies of the circulatory system" (ICD9 747). Several children had more than one heart or circulatory system defect listed on their death certificate (19 defects reported for 14 infants).

Discussion

The review of the 1990-1995 birth certificate and fetal death certificate data for zip codes 78211, 78228, and 78237 did not indicate an excess number of birth defects for any specific category of defect examined. The O:E ratios for the nonspecific "other" category on birth certificates were elevated for zip codes 78211 and 78237, but due to the nonspecific nature of the category, do not warrant additional analysis at this time. The infant death certificate data for zip code 78237, however, indicate an excess of reported cases for three categories of heart and circulatory system-related defects for 1990-1995.

Because of the increased occurrence of heart and circulatory-related defects in zip code 78237, additional analyses were performed to further examine the elevated O:E ratios for these categories. To determine if race/ethnicity may have accounted for or contributed to the elevated number of cases reported, the O:E ratios based on infant death certificate data for zip code 78237 were statistically adjusted for race and ethnicity (Table 18). Adjustment for race/ethnicity was performed because the race/ethnicity distribution of the San Antonio population differs from the population distribution of the state of Texas, our comparison population. During 1990-1995, 96.4% of all live births in San Antonio were Hispanic, while only 39.7% of all live births in the state of Texas were of Hispanic origin. If the comparison population does not reflect the race/ethnicity distribution of the study population (the San Antonio area), then the expected number of cases used for comparison may be over or underestimated.

After adjusting for race/ethnicity, the O:E ratios for each of the three birth defect categories changed only slightly. The O:E ratios for "bulbus cordis anomalies and anomalies of cardiac septal closure" (ICD9 745) and "other congenital anomalies of the heart" (ICD9 746) remained significantly elevated for zip code 78327. The O:E ratio for "other congenital anomalies of circulatory system" decreased slightly, and although it remained elevated, it is no longer statistically significant.

TDH also examined the information available on the birth and death certificates for the infants reported with these defects in zip code 78237. The age range of the mothers was 16-40 years with an average age of 24 (median age = 23). Nine of the 14 children (64%) were girls. As previously noted, several children had multiple heart and circulatory system-related defects. One child had a diagnosed chromosomal defect.

TDH also calculated the O:E ratios for the three heart and circulatory system-related defects, adjusting for maternal age. Table 19 lists the observed and expected number of cases, the O:E ratio, and the 95% confidence interval for each birth defect. Adjusting for mother's age increases the O:E ratios for each defect and all O:E ratios remained statistically significant.

The cause(s) for the apparent excess of heart and circulatory system-related defects for zip code 78237 are not immediately evident. We know that for specific heart and circulatory system defects, several risk factors (factors that may increase the risk of a mother delivering a baby with a heart or circulatory system defect) have been identified. These risk factors include maternal diabetes, drinking alcohol, taking large amounts of vitamin A, and taking certain medications such as valproic acid or amphetamines. We do not have information which would allow us to evaluate the possible effect of these risk factors on the cases of heart and circulatory system defects for zip code 78237. We are recommending, however, continued monitoring of heart and circulatory system defects in zip code 78237 using vital statistic information and data from the Texas Birth Defects Monitoring Division (TBDMD) as it becomes available.

Low Birth Weight

Information on low birth weight is obtained from birth certificates from the Texas Department of Health's Bureau of Vital Statistics. A low birth weight infant is defined as an infant who is born weighing less that 2,500 grams (5.5 pounds). For this health assessment, a case was defined as an infant weighing less than 2,500 grams (5.5 pounds) at birth who was born from 1990-1995 to a mother residing in one of the three zip code areas studied.

To determine if there were an excess number of low birth weight babies born in the three zip codes in 1990-1995, the number of low birth weight babies born in each zip code was compared to the number expected based on low birth weight rates for the entire state of Texas for the same time period. For each zip code area, Table 20 lists the number of low birth weight babies, the number expected, and the O:E ratio with 95% confidence intervals. Zip codes 78211 and 78228 did not have a significantly elevated number of low birth weight babies reported. The O:E ratio for zip code 78237 was statistically significant.

Discussion

The review of the 1990-1995 low birth weight data from infant birth certificates for zip codes 78211, 78228, and 78237 indicated an excess number of low birth weight babies born in zip code area 78237. There are a number of risk factors which may increase a woman's chance of delivering a low birth weight baby. Women who smoke, drink alcohol, have poor nutritional habits, or who use illicit drugs have an increased risk for low birth weight babies. Lack of access to early prenatal care has also been associated with an increased risk of delivering a low birth weight baby. TDH did not have information available which would allow them to look at the role these risk factors may have played in the reported excess of low birth weight babies for zip code 78237.

In short, there are a number of factors that play an important role in the health of the mother and developing fetus and may affect birth weight. Some of these factors can be controlled by the mother, others cannot. However, given the community concerns and the fact that the number of low birth weight babies was elevated for zip code 78237 for 1990-1995, we recommend continued monitoring as additional data becomes available.

Lead Statistics System

In order to address concerns regarding lead levels, we looked at information provided by the Texas Department of Health's Bureau of Women and Children on blood lead levels in children less than 5 years of age who were tested in 1993-1995 in three zip code areas: 78228, 78237, and 78211. This information is collected only for children who were tested under the Medicaid program. Blood lead levels are considered to be elevated if they are greater than or equal to 10 micrograms per deciliter (> 10 ug/dL). The U.S. Centers for Disease Control and Prevention (CDC) has defined blood lead levels of > 10 ug/dL in children to be a level at which action or intervention is warranted. Tables 21 - 23 detail the results of blood lead tests in children for the three zip codes.

Zip Code Area 78211

In 1993, 574 blood lead tests were conducted on children less than 5 years of age to determine their blood lead levels in zip code 78211. In 1994 and 1995, 285 and 296 children were tested each year (Table 21). The percentage of tests with elevated blood lead levels greater 10 ug/dL was 10% in 1993, 4% in 1994, and 8% in 1995. Less than 2% of the test results reported were greater than 20 ug/dL each year.

Zip Code Area 78228

In 1993, 577 blood lead tests were conducted on children less than 5 years of age to determine their blood lead levels in zip code 78228. In 1994 and 1995, 459 and 519 children were tested (Table 22). The percentage of tests with elevated blood lead levels greater 10 ug/dL was 5% in 1993, 3% in 1994, and 4% in 1995. Less than 2% of the test results reported were greater than 20 ug/dL each year.

Zip Code Area 78237

In 1993, 635 blood lead tests were conducted on children less than 5 years of age to determine their blood lead levels in zip code 78237. In 1994 and 1995, 503 and 530 children were tested (Table 23). The percentage of tests with elevated blood lead levels greater 10 ug/dL was 7% in 1993, 4% in 1994, and 7% in 1995. Less than 1% of the test results reported were greater than 20 ug/dL each year.

Discussion

Between 1993 and 1995, cases of elevated blood lead levels were reported in 90% of the zip code areas in Bexar County. However, this information is limited in that it only includes children who were tested under the Medicaid program. This information also does not provide information on the number of children who may have been tested more than once.

Statewide in 1994 and 1995, the percentage of children less than 5 years of age who had their first blood lead screening tests and were found to have elevated blood leads (> 10 ug/dL) was 6% in 1994 and 5.5% in 1995. The Centers for Disease Control, the Texas Department of Health, and many local health departments have established protocols for intervention with children with elevated blood lead levels. For children with elevated blood lead levels (> 10 ug/dL), medical care providers are asked to retest the child. If a child's second test shows an elevated blood level ( > 10 ug/dL, but less than 20 ug/dL), it is recommended that the medical care provider talk with the parent about possible sources of lead exposure and that the child be retested in 3-4 months. If the child's second test shows a blood lead level >20 ug/dL, follow-up and counseling should be conducted by the medical care provider and the Texas Department of Health or local health department will send a packet of information to the child's parents about lead poisoning. The packet, available in English and Spanish, explains what lead poisoning is, lists potential sources of lead in the home and environment, and recommends specific activities parents can do to limit exposure. In addition, the medical care provider may request a public health nurse to visit the home to talk with the parents in person. If necessary, an environmental investigator may also be asked to visit the child's house to help identify specific sources of lead exposure. The investigator may also test various items such as paint, water, soil, and dishes for possible lead contamination. Children with elevated blood lead levels will be followed, including additional blood lead tests, until the blood lead level is below 10 ug/dL. The local, regional, and state health departments may all be involved in various aspects of the follow-up.

Conclusions

1. In zip code area 78211, an elevation of liver cancer deaths was observed among females.

2. In zip code area 78228, an elevation of liver and kidney cases was observed among males, as well as an elevation of liver cancer deaths among males.

3. In zip code area 78237, an elevation of liver cancer cases was observed among males and elevations of cancer of the cervix, kidney and leukemia was observed among females. Elevations of liver cancer and leukemia deaths were observed among males, as well as an elevation of liver cancer deaths among females.

4. Additional analysis of liver cancer rates in ten other zip code areas indicated elevations of liver cancer among males in four of the zip code areas evaluated (78201, 78205, 78207, 78227) and among females in two of the zip code areas (78207, 78221). Elevations in liver cancer mortality were observed among males in four of the ten zip code areas evaluated (78201, 78204, 78207, 78227) and among females in four of the ten zip code areas evaluated (78207, 78221, 78226, 78242).

5. Analysis of birth defects found an excess of reported cases of heart and circulatory system-related defects for zip code area 78237.

6. Analysis found an elevated number of low birth weight babies reported for zip code area 78237.

Table 1: Number of Observed and Expected Cancer Cases and Race-Adjusted Standardized Incidence Ratios, Selected Sites, San Antonio, Texas Zip Code 78211, 1990-1994

Note: The SIR (standardized incidence ratio) is defined as the number of observed cases divided by the number of expected cases. The latter is based on race-, sex-, and age-specific cancer incidence rates for Texas for the period 1992. The SIR has been rounded to the first decimal place.

Table 2: Number of Observed and Expected Cancer Cases and Race-Adjusted Standardized Incidence Ratios, Selected Sites, San Antonio, Texas Zip Code 78228, 1990-1994

Note: The SIR (standardized incidence ratio) is defined as the number of observed cases divided by the number of expected cases. The latter is based on race-, sex-, and age-specific cancer incidence rates for Texas for the period 1992. The SIR has been rounded to the first decimal place.

Bold type indicates an excess of borderline statistical significance
* Significantly higher ( at the 5% level) than expected.

Table 3: Number of Observed and Expected Cancer Cases and Race-Adjusted Standardized Incidence Ratios, Selected Sites, San Antonio, Texas Zip Code 78237, 1990-1994

Note: The SIR (standardized incidence ratio) is defined as the number of observed cases divided by the number of expected cases. The latter is based on race-, sex-, and age-specific cancer incidence rates for Texas for the period 1992. The SIR has been rounded to the first decimal place.

Bold type indicates an excess of borderline statistical significance
* Significantly higher ( at the 5% level) than expected.

Table 4: Number of Observed and Expected Cancer Deaths and Race Adjusted Standardized Mortality Ratios, Selected Sites, San Antonio, Texas, Zip Code 78211, 1991-1995

Note: The SMR (standardized mortality ratio) is defined as the number of observed deaths divided by the number of expected deaths. The latter is based on race-, sex-, and age-specific cancer mortality rates for Texas during the period 1990-1995.

* Significantly higher (at the 5% level) than expected.

Table 5: Number of Observed and Expected Cancer Deaths and Race Adjusted Standardized Mortality Ratios, Selected Sites, San Antonio, Texas, Zip Code 78228, 1991-1995

Note: The SMR (standardized mortality ratio) is defined as the number of observed deaths divided by the number of expected deaths. The latter is based on race-, sex-, and age-specific cancer mortality rates for Texas during the period 1990-1995.

* Significantly higher (at the 5% level) than expected.
+ Significantly lower (at the 5% level) than expected.

Table 6: Number of Observed and Expected Cancer Deaths and Race Adjusted Standardized Mortality Ratios, Selected Sites, San Antonio, Texas, Zip Code 78237, 1991-1995

Note: The SMR (standardized mortality ratio) is defined as the number of observed deaths divided by the number of expected deaths. The latter is based on race-, sex-, and age-specific cancer mortality rates for Texas during the period 1990-1995.

Bold type indicates an excess of borderline statistical significance
* Significantly higher (at the 5% level) than expected.

Table 7: Number of Observed and Expected Liver Cancer Cases and Race-Adjusted Standardized Incidence Ratios, San Antonio, Texas, 1990-1994

Note: The SIR (standardized incidence ratio) is defined as the number of observed cases divided by the number of expected cases. The latter is based on race-, sex-, and age-specific cancer incidence rates for Texas for the period 1992. The SIR has been rounded to the first decimal place.

Bold type indicates an excess of borderline statistical significance
* Significantly higher ( at the 5% level) than expected.

Table 8 Number of Observed and Expected Liver Cancer Deaths and Race-Adjusted Standardized Mortality Ratios, San Antonio, Texas, 1991-1995

Note: The SMR (standardized mortality ratio) is defined as the number of observed deaths divided by the number of expected deaths. The latter is based on race-, sex-, and age-specific cancer mortality rates for Texas during the period 1990-1995.

Bold type indicates an excess of borderline statistical significance
* Significantly higher (at the 5% level) than expected.

Table 9: Comparison of Observed Cases to Expected Based on Congenital Anomalies as Listed on Birth Certificates, San Antonio, Texas, Zip Code 78211, 1991-1995

^a Based on rates for the entire state of Texas.
^b Observed to expected ratio (observed number of cases divided by the expected number of cases).
^* Significant at the 5% level.

Table 10: Comparison of Observed Cases to Expected Based on Congenital Anomalies as Listed on Birth Certificates, San Antonio, Texas, Zip Code 78228, 1991-1995

^a Based on rates for the entire state of Texas.
^b Observed to expected ratio (observed number of cases divided by the expected number of cases).

Table 11: Comparison of Observed Cases to Expected Based on Congenital Anomalies as Listed on Birth Certificates, San Antonio, Texas, Zip Code 78237, 1990-1995

^a Based on rates for the entire state of Texas.
^b Observed to expected ratio (observed number of cases divided by the expected number of cases).
^* Significant at the 5% level.

Table 12: Comparison of Observed Cases to Expected Based on Congenital Anomalies as Listed on Fetal Death Certificates, San Antonio, Texas, Zip Code 78211, 1990-1995

^a Based on rates for the entire state of Texas.
^b Observed to expected ratio (observed number of cases divided by the expected number of cases).
^c Significant at the 5% level.

Table 13: Comparison of Observed Cases to Expected Based on Congenital Anomalies as Listed on Fetal Death Certificates, San Antonio, Texas, Zip Code 78228, 1990-1995

^a Based on rates for the entire state of Texas.
^b Observed to expected ratio (observed number of cases divided by the expected number of cases).

Table 14: Comparison of Observed Cases to Expected Based on Congenital Anomalies as Listed on Fetal Death Certificates, San Antonio, Texas, Zip Code 78237, 1990-1995

^a Based on rates for the entire state of Texas.
^b Observed to expected ratio (observed number of cases divided by the expected number of cases).

Table 15: Comparison of Observed Cases to Expected Based on Congenital Anomalies as Listed on Infant Death Certificates, San Antonio, Texas, Zip Code 78211, 1990-1995

^a International Classification of Disease - 9^th Edition
^b Based on rates for the entire state of Texas
^c Observed to expected ratio (observed number of cases divided by the expected number of cases)

Table 16: Comparison of Observed Cases to Expected Based on Congenital Anomalies as Listed on Infant Death Certificates, San Antonio, Texas, Zip Code 78228, 1990-1995

^a International Classification of Disease - 9^th Edition
^b Based on rates for the entire state of Texas
^c Observed to expected ratio (observed number of cases divided by the expected number of cases)

Table 17: Comparison of Observed Cases to Expected Based on Congenital Anomalies as Listed on Infant Death Certificates, San Antonio, Texas, 78237, 1990-1995

^a International Classification of Disease - 9^th Edition
^b Based on rates for the entire state of Texas
^c Observed to expected ratio (observed number of cases divided by the expected number of cases)
^* Significant at the 5% level

Table 18: Comparison of Observed Cases to Expected Adjusted for Selected Congenital Anomalies as Listed on Infant Death Certificates, San Antonio, Texas, Zip Code 78237, 1990-1995

^a International Classification of Disease - 9^th Edition
^b Based on rates for the entire state of Texas
^c Observed to expected ratio (observed number of cases divided by the expected number of cases)
Bold type indicates an excess of borderline statistical significance
^* Significant at the 5% level

Table 19: Comparison of Observed Cases to Expected Adjusted for Maternal Age for Selected Congenital Anomalies as Listed on Infant Death Certificates, San Antonio, Texas, Zip Code 78237, 1990-1995

^a International Classification of Disease - 9^th Edition
^b Based on rates for the entire state of Texas
^c Observed to expected ratio (observed number of cases divided by the expected number of cases)
^* Significant at the 5% level

Table 20: Comparison of Observed to Expected Cases of Low Birth Weight as Listed on Infant Birth Certificates, Zip Codes 78211, 78228, and 78237, San Antonio, Texas, 1990-1995

^a Based on rates for the entire state of Texas
^b Observed to expected ratio (observed number of cases divided by the expected number of cases)
^* Significant at the 5% level

Table 21: Blood Lead Levels of Children 0-72 Months of Age in San Antonio, Texas, Zip Code 78211

Table 22: Blood Lead Levels of Children 0-72 Months of Age in San Antonio, Texas, Zip Code 78228

Table 23: Blood Lead Levels of Children 0-72 Months of Age in San Antonio, Texas, Zip Code 78237

References:

1. Di Bisceglie A and Tabor E. Cancer Rates and Risks, National Institutes of Health, National Cancer Institute, 4th Edition, May 1996. NIH publication number 96-691.

2. McLaughlin JK. Cancer Rates and Risks, National Institutes of Health, National Cancer Institute, 4th Edition, May 1996. NIH publication number 96-691.

3. Linet MS. Cancer Rates and Risks, National Institutes of Health, National Cancer Institute, 4th Edition, 1996. NIH publication number 96-691.

4. Leukemia Research Report. National Institutes of Health, National Cancer Institute, November 1993. NIH Publication Number 94-329.

5. Brinton LA. Cancer Rates and Risks, National Institutes of Health, National Cancer Institute, 4th Edition, 1996. NIH publication number 96-691.

Next Section          Table of Contents

Agency for Toxic Substances and Disease Registry, 1825 Century Blvd, Atlanta, GA 30345
Contact CDC: 800-232-4636 / TTY: 888-232-6348 

Department of Health and Human Services