The following are pre-publication drafts of articles from the Morbidity and
Mortality Weekly Report 44(01) dated January 13, 1995.  Late-breaking
articles, and final editorial revisions are not included.  Therefore, these
articles should not be quoted without consulting the official printed copy
that is released to the public, as received from the CDC.--CDC.Also, please
refer to the printed copy for any charts or graphically represented data.

**********************************************************
   CONTENTS

   --  Injuries Associated With Use of Snowmobiles --
       New Hampshire, 1989-1992
   --  Physician Vaccination Referral Practices
       and Vaccines for Children -- New York, 1994
   --  Differences in Maternal Mortality Among
       Black and White Women -- United States, 1990
   --  Proportionate Mortality from Pulmonary Tuberculosis
       Associated With Occupations -- 28 States, 1979-1990
   --  Erratum: Vol. 43, No. 40
  
***********************************************************

Injuries Associated With Use of Snowmobiles --
New Hampshire, 1989-1992

     Recreational use of snowmobiles is popular in New Hampshire
during the winter months; from 1982 to 1992, the annual number of
registered snowmobiles ranged from approximately 21,200 to 42,500.
During this period, 26 deaths associated with use of snowmobiles in
New Hampshire accounted for 822 years of potential life lost before
age 65 years. To assist in the development and evaluation of
injury-prevention programs for users of off-highway recreational
vehicles (OHRVs) (e.g., all-terrain vehicles, trail bikes, and
snowmobiles), the State of New Hampshire Department of Fish and Game
(DFG) and the New Hampshire Department of Health and Human Services
examined reports of injuries resulting from OHRV use in New Hampshire
from January 1989 through February 1992*. This report summarizes
information about snowmobile-associated fatal and nonfatal injuries
during this period.

       Since 1981, New Hampshire has required reporting of OHRV
incidents resulting in injury. A standard report form must be
completed by a person involved in the event or by a law enforcement
agent and filed with DFG within 5 days of the incident. Information
collected on the form includes demographic characteristics of the
operator, type of vehicle, environmental conditions, date and time of
the incident, whether the operator reported having taken an OHRV
safety course, type of injury, excessive speed, and use of alcohol and
helmets.

       During January 1989-February 1992, DFG received reports of 164
snowmobile incidents resulting in injury. Of the 164 incidents, 155
involved 188 vehicles and resulted in 163 nonfatal injuries, and nine
involved 13 vehicles and resulted in 12 fatalities and two nonfatal
injuries (Table 1). All fatal incidents were reported by law
enforcement agents. Of the 155 reports of nonfatal incidents, 103
(66%) were completed by a law enforcement agent.

       All operators involved in fatal (13) and most involved in
nonfatal (161 [86%]) incidents were male. Seven (54%) operators
involved in fatal incidents and 75 (40%) operators involved in
nonfatal incidents were aged 20-29 years; no operators involved in
fatal incidents and 40 (21%) involved in nonfatal incidents were aged
less than 20 years. No operator involved in a fatal incident and 14
(7%) of those involved in a nonfatal incident were reported to have
taken an OHRV safety course.

       Of nine fatal events and 155 nonfatal events, seven (78%) and
64 (46%), respectively, occurred during darker periods (i.e., 4 p.m.-8
a.m., November-March). No fatal and 25 (16%) nonfatal events occurred
during periods of precipitation or other inclement weather (i.e., fog
or active snow, sleet, or rain). Operating on a frozen body of water
was reported for five of nine fatal and 36 (23%) of 155 nonfatal
events.

       Overall, 67% of fatal incidents were associated with alcohol
use and 67% with excessive speed. Of the 103 police-reported nonfatal
incidents, 16 (16%) involved alcohol use, and 36 (35%) involved
excessive speed; in comparison, of 52 incidents reported only by
persons involved in the incident, one (2%) and three (6%),
respectively, reported use of alcohol or excessive speed.

       Of eight deaths resulting from incidents occurring on a frozen
body of water, three resulted from hypothermia and five from either
head and neck injuries (three) or multiple trauma (two). Three other
deaths were attributed to head and neck trauma and one to multiple
trauma.

       Of 165 persons nonfatally injured, 104 (63%) were reported to
have been wearing helmets. Helmets were reported to have been worn by
31 (57%) of 54 persons with nonfatal head injuries, compared with four
of six persons with fatal head injuries.

Reported by: A Hewitt, State of New Hampshire Dept of Fish and Game;
Bureau of Vital Records and Health Statistics; D Solet, M Kiely,
Office of Chronic Disease and Health Data, New Hampshire Dept of
Health and Human Svcs. Div of Field Epidemiology, Epidemiology Program
Office, CDC.

Editorial Note: In New Hampshire, most fatal snowmobile incidents
involved male operators in their 20s, use of alcohol, or excessive
speed; half of persons killed sustained head injuries. In addition,
fatalities occurring as a result of operating on frozen bodies of
water were associated with either severe trauma or events related to
falling through the ice (i.e., hypothermia). These findings are
consistent with previous studies of fatalities associated with the use
of OHRVs (1,2). For example, contributing factors for nondrowning
deaths following incidents on frozen water surfaces have included high
speeds attained on such open surfaces and unexpected uneven terrain
(e.g., ice ridges) (1). The findings in this report also indicate that
some snowmobile drivers and passengers did not wear helmets. Although
this investigation could not assess the effectiveness of helmet use, a
previous study estimated that helmet use can reduce the risk for death
among all-terrain vehicle operators by approximately 42% and can
reduce the likelihood of head injury in a nonfatal incident by
approximately 64% (3).

       The findings in New Hampshire are subject to at least three
limitations. First, rates of injury and death could not be determined
because of the lack of an accurate denominator. Although previous
studies have used registered OHRVs as a denominator, this number may
vary in relation to season and other environmental factors (e.g.,
inclement weather). Second, because approximately one third of
nonfatal injury reports were completed only by persons involved in the
incident, some information reported may not be valid (e.g., helmet
use, speed, and alcohol use). Finally, these findings probably
underestimate the true incidence of snowmobile-associated injuries
because of underreporting. Review of hospital emergency and discharge
records could assist in evaluating the extent of underreporting.

       Information from the injury reporting system in New Hampshire
may be useful for public health surveillance and assessment of
snowmobile and other OHRV injuries (4). In addition, this data source
can be used by the New Hampshire Snowmobile Association and other
organizations to target high-risk groups for intervention programs.
Since 1975, DFG has operated a safety training course for OHRV users.
State law requires that any OHRV operator driving off their private
property either possess a valid driver's license (minimum age: 16
years) or have taken this course. Operators aged less than 30 years
should especially be targeted by any intervention strategy; in
particular, young operators with a valid driver's license are
encouraged to take the DFG safety course.

       References

       1. Rowe B, Milner R, Johnson C, Bota G. Snowmobile-related
deaths in Ontario: a 5-year review. Can Med Assoc J 1992;146:147-52.

       2. Hargarten SW. All-terrain vehicle mortality in Wisconsin: a
case study in injury control. Am J Emerg Med 1991;9:149-52.

       3. Rodgers GB. The effectiveness of helmets in reducing
all-terrain vehicle injuries and deaths. Accid Anal Prev
1990;22:47-58.

       4. Smith SM, Middaugh JP. An assessment of potential injury
surveillance data sources in Alaska using an emerging problem:
all-terrain vehicle-associated injuries. Public Health Rep 1989;
104:493-8.

       * Because the standard reporting form was changed in 1992,
         comparison with later years was not possible.


Physician Vaccination Referral Practices
and Vaccines for Children -- New York, 1994

       Although vaccinations are among the most effective preventive
public health measures available, many children are not vaccinated on
time (1). One identified barrier to timely vaccination is referral of
children by primary-care physicians to other medical settings for
vaccination (2). This report summarizes a survey by the New York State
Department of Health of vaccination referral practices among New York
physicians and describes the implementation in New York of Vaccines
for Children (VFC), a national program making federally purchased
vaccines available at no cost to health-care providers for
administration to eligible children (3).

       During April 1993, a random sample of 1137 licensed
pediatricians and family-practice physicians (from a total n=5392) in
New York were surveyed by mail about vaccination practices. Of 752
(66%) responses, 502 (67%) were from actively practicing primary-care
physicians. Of these, 250 (50%) referred all or some of their patients
elsewhere for vaccinations. Of referring physicians, 228 (91%)
referred patients to a local health department clinic; 109 (44%) had
increased the number of patient referrals during 1983-1993, while
seven (3%) had decreased referrals. In addition, 63 (25%) reported
that the number of well-child-care visits had decreased during
1983-1993, while five (2%) reported increases during that time. Of the
250 referring physicians, 246 provided reasons for referral and rated
those reasons as "very important," "somewhat important," or "not
important" (Table 1). Financial hardship was a "very important" reason
for referral for 217 (88%) of those surveyed; the lack of vaccination
coverage by private insurance was "very important" for 132 (54%).
Physicians also were asked whether the government should underwrite
the cost of mandatory vaccinations. Overall, 409 (54%) respondents
indicated that some or all of the costs of childhood vaccination
should be underwritten.

       Since October 1, 1994, free vaccine has been available to VFC
participating providers in New York. Categories of federally eligible
children aged less than 19 years include those on Medicaid, those who
are uninsured, those who are underinsured who visit federally
qualified health centers, and American Indians/Alaskan Natives. New
York also provided free vaccine to underinsured children who receive
care in any medical setting and any child served at a local health
department.

       Medical-care providers were recruited for VFC through articles
published in professional organization newsletters and by mailing of
registration packets to licensed pediatricians, family physicians,
osteopathic physicians, and medical facilities. As of December 27,
1994, a total of 1378 physician practices in New York (including at
least 1972 individual physicians and at least 362 health-care
facilities) were participating in VFC.

       To determine the extent of enrollment by Medicaid providers,
the list of VFC enrollees was compared to a list of providers who
billed Medicaid for childhood vaccines during federal fiscal year
1993. Of 2169 physicians who billed Medicaid for childhood vaccines in
1993, a total of 1213 (56%) had enrolled. Among the 166 physicians who
submitted a minimum of 1000 claims for individual vaccines, 143 (86%)
had enrolled, while 653 (68%) of 956 physicians not yet enrolled had
submitted fewer than 50 claims.

       In September 1994, the New York State Department of Health
conducted a telephone survey of health-care providers who had returned
registration forms and declined participation in the program to
determine reasons for nonparticipation and to guide future recruitment
efforts. Of the 41 physicians who had declined, 29 (71%) were
contacted. Of these, five (17%) were retired, five (17%) did not
accept patients aged less than 19 years, six (21%) were subspecialists
or in academic medicine and did not provide vaccinations, six (21%)
indicated that most of their patients would not be eligible, one (2%)
had multiple reasons for not registering, and the six (21%) with
patients who could benefit from VFC agreed to register as a result of
the phone call.

       From September 15, 1994 (the first date vaccines could be
ordered), through December 27, 1994, a minimum of 2,496,000 doses of
vaccine had been ordered and approximately 2,456,000 doses were
shipped to VFC participants. The average time between placement of
orders and receipt of vaccine by providers was 1 week.

Reported by: HG Cicirello, MD, GA Bunn, DR Lynch, SC Meldrum, MS, GS
Birkhead, MD, D Morse, MD, State Epidemiologist, New York State Dept
of Health. S Freidman, MD, N Jenkusky, MPH, New York City Dept of
Health. EE Schulte, MD, Albany Medical Center, Albany, New York.
National Immunization Program, CDC.

Editorial Note: In the United States, approximately 2 million children
need one or more doses of recommended vaccines (4). In a 1993
retrospective survey of children entering kindergarten in New York,
only 53% had been appropriately vaccinated with the recommended
vaccines by age 2 years (5). Important barriers to timely vaccination
include missed opportunities to vaccinate at each health-care visit,
inconvenient clinic hours, inadequate parental awareness of the need
for timely vaccination, inadequate vaccination tracking, the costs of
vaccines, and the referral of children from the private sector to the
public sector. This report demonstrates that vaccination referrals, in
part attributable to vaccine costs, are common among New York
primary-care providers. Implementation of VFC is expected to reduce
these financial barriers.

       The actual number of VFC participants in New York probably is
underestimated by VFC enrollment figures because many physicians work
in facilities or in group practices where only the physician-in-chief
is registered in the program. In addition, the impact of the program
on vaccination coverage and overall occurrence of vaccine-preventable
diseases cannot be determined yet. However, VFC has allowed New York
to increase provision of vaccine to more children in primary-care
settings where they first seek care. In states where vaccines have
been made available for all children, vaccination rates of
preschoolers are approximately 10% higher than the national average
(AG Holtmann, University of Miami, unpublished data, 1993).

       The Childhood Immunization Initiative (CII) has designated
vaccination of preschool-aged children a national priority and has
established 1996 and year 2000 goals of vaccinating at least 90% of
children by age 2 years with the recommended number of doses of
diphtheria and tetanus toxoids and pertussis, polio, Haemophilus
influenzae type b, hepatitis B, measles, mumps, and rubella vaccines.
The five strategies of CII, which address both financial and
nonfinancial barriers to vaccination, are to 1) improve the delivery
of vaccines; 2) reduce the cost of vaccines for parents (VFC); 3)
enhance awareness, partnerships, and community participation; 4)
monitor vaccination coverage and disease; and 5) improve vaccines and
their use. VFC, as an integral part of this initiative, will assist
physicians and other health-care providers in reaching these national
goals.

References

       1. NCHS. Health, United States, 1993. Hyattsville, Maryland: US
Department of Health and Human Services, Public Health Service, CDC,
1994; DHHS publication no. (PHS)94-1232.

       2. Bordley WC, Freed GL, Garrett JM, Byrd CA, Meriwether R.
Factors responsible for immunization referrals to health departments
in North Carolina. Pediatrics 1994;94:376-80.

       3. CDC. Vaccines for Children program, 1994. MMWR 1994;43:705.

       4. CDC. Vaccination coverage of 2-year-old children--United
States, 1993. MMWR 1994;43:705-9.

       5. Hamburg BG, Dowling TP, Kramer JI, Randles RH, Rodewald LE.
Immunization of pre-school children. New York: New York State Public
Health Council, Ad Hoc Immunization Committee, March 1993.


Differences in Maternal Mortality Among
Black and White Women -- United States, 1990

       The risk for maternal mortality has consistently been higher
among black women than white women. The 1990 national health objective
of reducing maternal mortality to no more than five deaths per 100,000
live births for any racial/ethnic group was nearly achieved for white
women, for whom the maternal mortality ratio* was 5.7 in 1990 (1); for
black women, however, the ratio was 18.6. The year 2000 national
health objectives include reducing the overall maternal mortality
ratio to no more than 3.3 deaths per 100,000 live births and to no
more than five for blacks (objective 14.3) (2). This report summarizes
race-specific differences in maternal mortality among black and white
women for 1990 and compares these with trends in mortality from
1940-1990.

       Maternal mortality ratios were calculated at 10-year intervals
from 1940 to 1990 using data contained on death certificates filed in
state vital statistics offices and compiled by CDC in a national
database (3,4). Maternal deaths were defined as those for which a
maternal condition was designated as the underlying cause of death, as
recorded on the death certificate by the attending physician, medical
examiner, or coroner.** This report compares maternal mortality only
for black and white women because data for other racial/ethnic groups
were not available for all years; data for Hispanic women are included
in the totals for both blacks and whites.

       In 1990, the overall maternal mortality ratio was 8.0 deaths
per 100,000 live births, a 98% decline from 363.9 in 1940. From 1940
to 1990, race-specific ratios declined substantially, from 319.8 to
5.7 for white women and from 781.7 to 18.6 for black women. Although
the percentage decline was similar for black women and white women
(97.6% and 98.2%, respectively), the ratios for black women were
consistently two to four times higher than those for white women. For
example, compared with that for white women, the maternal mortality
ratio for black women was 2.4 times greater in 1940, 3.6 times greater
in 1950, 4.1 times greater in 1960, 3.9 times greater in 1970, 3.4
times greater in 1980, and 3.3 times greater in 1990 (Figure 1, page
13).

       From 1960 through 1990 (years for which more detailed data were
available), the maternal mortality ratio was higher for black women in
all age groups and for each of the major causes of death. The
black-white differential was greatest for pregnancies that did not end
in a live birth, such as ectopic pregnancy, spontaneous abortion,
induced abortion, and gestational trophoblastic disease.***

Reported by: Div of Reproductive Health, National Center for Chronic
Disease Prevention and Health Promotion; Div of Vital Statistics,
National Center for Health Statistics, CDC. Editorial Note: Despite
overall improved maternal survival during 1940-1990, black women were
more than three times more likely than white women to die from
complications of pregnancy, childbirth, and the puerperium. Although
the reasons for this disparity are unclear, possible explanations
include differences in pregnancy-related morbidity, access to and use
of health-care services, and content and quality of care.

       Maternal hospitalization, except when associated with delivery,
can serve as a marker for severe maternal morbidity. For example,
during 1987-1988, a study of pregnancy-related hospitalizations
indicated the ratio for black women was 1.4 times that for white women
(6); during the same period, the black-white maternal mortality ratio
was 3.1. However, in a study of women in the military--who have
unrestricted access to prenatal care--there was virtually no
difference between black and white women in the overall prevalence of
antenatal hospitalization and in the indications for hospitalization
(7).

       Early entry into prenatal care (i.e., during the first
trimester)--one indicator of access to and use of pregnancy-related
health care--has been assessed for women whose pregnancies ended in a
live birth. During 1980-1990, although 76% of all mothers received
early prenatal care, the percentage of black women who did not receive
early prenatal care was nearly twice that for white women (8). In
1990, 39.4% of black mothers did not receive early prenatal care,
compared with 20.8% of white mothers. Once women enter prenatal care,
studies indicate differences between black and white women in the
advice given to them and use of technology (9,10).

       Data describing access to pregnancy-related health care other
than prenatal care (e.g., gynecologic services) or the content and
quality of health care once women obtain these services are limited.
Narrowing discrepancies in maternal mortality between black and white
women will require evaluating and addressing race-specific differences
in morbidity and in access to and use and content of pregnancy-related
care. Addressing discrepancies in maternal mortality also may improve
maternal morbidity and infant survival.

       References

       1. Public Health Service. Promoting health/preventing disease:
objectives for the nation. Washington, DC: US Department of Health and
Human Services, Public Health Service, 1980.

       2. Public Health Service. Healthy people 2000: national health
promotion and disease prevention objectives. Washington, DC: US
Department of Health and Human Services, Public Health Service, 1991;
DHHS publication no. (PHS)91-50213.

       3. NCHS. Vital statistics of the United States, for years 1939-
1991. Vol I-natality. Hyattsville, Maryland: US Department of Health
and Human Services, Public Health Service, CDC.

       4. NCHS. Vital statistics of the United States, for years 1939-
1991. Vol II-mortality, part A. Hyattsville, Maryland: US Department
of Health and Human Services, Public Health Service, CDC.

       5. NCHS. Estimates of selected comparability ratios based on
dual coding of 1976 death certificates by the eighth and ninth
revisions of the International Classification of Diseases.
Hyattsville, Maryland: US Department of Health and Human Services,
Public Health Service, CDC, 1980. (Monthly vital statistics report;
vol 28, no. 11, suppl).

       6. Franks AL, Kendrick JS, Olson DR, Atrash HK, Saftlas AF,
Moein M. Hospitalization for pregnancy complications, United States,
1986-1987. Am J Obstet Gynecol 1992;166:1339-44.

       7. Adams MM, Harlass FE, Sarno AP, Read JA, Rawlings JS.
Antenatal hospitalization among enlisted servicewomen, 1987-1990.
Obstet Gynecol 1994;84:35-9.

       8. NCHS. Health, United States, 1993. Hyattsville, Maryland: US
Department of Health and Human Services, Public Health Service, CDC,
1994; DHHS publication no. (PHS)94-1232.

       9. Kogan MD, Kotelchuck M, Alexander GR, Johnson WE. Racial
disparities in reported prenatal care advice from health care
providers. Am J Public Health 1994;84:82-8.

       10. Brett KM, Schoendorf KC, Kiely JK. Differences between
black and white women in the use of prenatal care technologies. Am J
Obstet Gynecol 1994;170:41-6.

        * The maternal mortality ratio is the number of maternal
          deaths per 100,000 live births. CDC's National Center for
          Health Statistics (NCHS) uses the term maternal mortality
          rate as required by the World Health Organization. In this
          report, the term "ratio" is used because the numerator
          includes some maternal deaths that were not related to live
          births, and thus were not included in the denominator. For
          this analysis, 3 years of data were combined to calculate
          maternal mortality ratios to promote statistical reliability
          and stability in the estimates. For example, 1990 ratios are
          based on data from 1989 through 1991. In addition, beginning
          with the 1989 data year, NCHS began using race of mother
          instead of race of child to tabulate live birth and fetal
          death data by race. In this analysis, race for live births
          is tabulated by the race of the child for maternal mortality
          to maintain comparability of ratios.

       ** An underlying cause of death is defined by the International
          Classification of Diseases, Ninth Revision (ICD-9), as "a)
          the disease or injury which initiated the train of morbid
          events leading directly to death, or b) the circumstances of
          the accident or violence which produced the fatal injury."
          In 1979, the ICD-9 provided the first formal definition of
          maternal mortality, defining maternal death as the death of
          a woman while pregnant or within 42 days of termination of
          pregnancy. This definition differed from that used
          previously by NCHS, which included deaths up to 1 year after
          termination of pregnancy. However, the change from the
          1-year limit used in the eighth revision to the 42-day limit
          used in the ninth revision did not greatly affect the
          comparability of maternal mortality statistics (4). *** The
          ICD code is revised approximately every 10 years. In the
          ninth revision, ectopic pregnancy (ICDA code 631) was
          transferred from complications of pregnancy (ICDA codes
          630--634) to pregnancy with abortive outcomes (ICD codes
          630--638) (5). In this report, maternal deaths from ectopic
          pregnancy are included with abortive outcomes for all time
          periods.


Proportionate Mortality from Pulmonary Tuberculosis
Associated With Occupations -- 28 States, 1979-1990

       The risk for occupational exposure to tuberculosis (TB) is
increased among health-care and other workers exposed to persons with
active TB, workers exposed to silica or other agents that increase the
risk of progression from latent infection to active TB, and workers in
occupations associated with low socioeconomic status (SES). Accurate
estimates of and surveillance for occupationally associated TB are
limited because reports of incident TB cases lack comprehensive
occupational data (1). Although occupation is routinely recorded on
death certificates, this information is not routinely coded and
entered into vital statistics data files. To identify occupations
associated with increased risk for TB mortality, CDC's National
Institute for Occupational Safety and Health (NIOSH) used data from
the National Occupational Mortality Surveillance (NOMS) database* to
conduct a proportionate mortality study of persons with pulmonary TB
by occupation for 1979-1990 (the most recent year for which data were
available). This report presents the findings of the study.

       Data collected in the NOMS database include each decedent's
usual industry and occupation, coded using 1980 U.S. census codes (2).
During 1979-1990, approximately 3.4 million mortality records that
included a usual occupation (excluding "housewife") were reported to
NOMS. For this study, data for blacks and whites were analyzed
separately because of substantial differences in race-specific rates
of pulmonary TB (1,3); numbers of deaths for other racial groups were
too small to calculate stable estimates. Ethnicity was not routinely
coded on death certificates until 1989 and could not be analyzed.

       Indirectly age-standardized, race- and sex-specific
proportionate mortality ratios (PMRs) were calculated by comparing the
proportion of pulmonary TB deaths (International Classification of
Diseases, Ninth Revision, code 011) among decedents in each
occupational group to the proportion of pulmonary TB deaths among all
decedents with a coded occupation (4). Confidence intervals (CIs) were
calculated using the Mantel-Haenszel chi-square test or, when less
than 1000 deaths were observed, the variance from a Poisson
distribution. This analysis examined a total of 458 separate or
combined occupational groups, comprising all 503 census occupational
codes; of these 458 groups, 329 (71.8%) had one or more deaths
attributed to pulmonary TB. Data are presented for the 21 occupational
groups in which at least one of the race- and sex-specific categories
had both 1) four or more pulmonary TB deaths and 2) either a PMR
greater than 200 or a PMR with a 95% CI that did not include 100.

       From 1979 through 1990, a total of 2206 deaths was attributed
to pulmonary TB. Of these deaths, 1024 (46.4%) occurred among workers
in the 21 occupational groups that met the selection criteria. The 21
occupational groups were categorized into four risk groups (Table 1):
1) high potential for exposure to persons with TB (based on published
reports and NIOSH health hazard evaluations [HHEs]**); 2) potential
for substantial exposure to silica (determined using unpublished data
from the National Occupational Exposure Survey [5] and the National
Occupational Health Survey of Mining [6]); 3) low SES occupation
(defined as a Nam-Powers socioeconomic index score less than 30 [where
1 signifies the lowest possible SES occupation and 100 the highest])
(7) without other recognized risk factors; and 4) unknown risk
factors.

       Of the 21 occupational groups that met the selection criteria,
two race- and sex- specific groups were associated with potential
workplace exposure to persons with TB: white male health services
workers (health and nursing aides, orderlies, and attendants)
(PMR=350; seven deaths)*** and white male funeral directors (PMR=299;
four deaths) (Table 1). Six of the 21 occupational groups were
associated with potential for high silica exposure. For white males,
these groups comprised mining machine operators; operators of
machinery used to grind, abrade, buff, or polish; nonconstruction
laborers; and construction workers (particularly brick and stone
masons, construction laborers, carpenters, and roofers); PMRs ranged
from 134 (169 deaths) to 290 (six deaths). For black males, these
groups comprised construction workers (particularly construction
laborers); mixing and blending machine operators; and furnace, kiln,
and oven operators, except food; PMRs ranged from 128 (105 deaths) to
376 (five deaths).

       For two of the occupations associated with low SES that met the
selection criteria (food preparation and service workers [particularly
bartenders and cooks] and farm workers), previous reports have
documented increased risk for TB (8). The other low SES occupations
that met the selection criteria (e.g., housekeepers and butlers and
nonfarm animal caretakers) have not previously been associated with
increased risk for TB.

Reported by: Surveillance Br, Div of Surveillance, Hazard Evaluations
and Field Studies, and Epidemiological Investigations Br, Div of
Respiratory Disease Studies, National Institute for Occupational
Safety and Health, CDC.

Editorial Note: In comparison with surveillance for TB based on
incident symptomatic cases or TB skin-test conversions,
mortality-based surveillance may be a relatively insensitive indicator
of current occupational risks. However, except for studies of selected
occupations, the findings in this report comprise the only available
information about possible associations between occupation and TB
infection. Furthermore, these findings identify several additional
occupations associated with increased risk for TB, for which there are
biologically plausible explanations. For example, the increased risk
for funeral directors may reflect increased likelihood of exposure to
infection from cadavers, and for mining machine operators, may reflect
exposure to silica, which increases the risk of progression from
latent infection to active TB. For occupational groups categorized
"unknown risk," reasons for their elevated PMRs cannot be explained.
These groups may be at increased risk through factors other than the
three recognized in this analysis or may show elevated PMRs by chance
alone.

       The findings in this report are subject to at least four
limitations. First, mortality-based surveillance data are not
sensitive indicators of risk for disease because mortality is affected
by a combination of several interacting factors. In particular,
mortality from TB reflects exposure, infection, SES, access to and
adequacy of medical care, and underlying medical conditions. Overall,
such factors probably contributed to the approximately threefold
greater proportion of pulmonary TB-related mortality among blacks than
among whites in this study (0.18% and 0.05%, respectively). Second,
the method of death certificate-based PMR analysis described in this
report is subject to possible misclassification of usual occupation
and cause of death and to potential biases inherent in the use of the
PMR statistic as a risk estimator (4) and fails to compensate
statistically for multiple comparisons. Third, death certificates lack
information about lifestyle and other risk factors; therefore, no
adjustment was made for possible confounding. Fourth, the timeliness
of death certificates as a source of data is constrained by processing
delays. Despite these limitations, these findings are important
because of the strength and biological plausibility of many of the
reported associations.

       The recent increase in TB incidence and the occurrence of
multidrug-resistant TB have focused attention on particular
populations at high risk for disease and on the potential for
transmission of infection to health-care workers. Occupation-based
surveillance for TB can assist in identifying groups at high risk and
indicate trends in the occurrence of infection in these workers. These
surveillance findings also can assist in evaluating the effectiveness
of prevention measures for groups previously established to be at
risk, such as miners and agricultural workers.

       To improve the detection and control of TB among occupational
groups, CDC has proposed two surveillance activities (9): 1)
collection and analysis of occupational information from TB case
reports and 2) serial cross-sectional surveys of known high-risk
populations (including selected occupations) to determine the
prevalence of TB skin-test positivity. These data, in combination with
ongoing collection and analysis of occupational information from death
certificates, will enable comprehensive surveillance for monitoring
recognized high-risk populations and identifying new at-risk groups.

References

       1. CDC. Tuberculosis morbidity--United States, 1992. MMWR
1993;42:696-7,703-4.

       2. Bureau of the Census. 1980 Census of population:
alphabetical index of industries and occupations--final edition.
Washington, DC: US Department of Commerce, Bureau of the Census, 1982;
publication no. PHC80-R3.

       3. CDC. Prevention and control of tuberculosis in U.S.
communities with at-risk minority populations: recommendations of the
Advisory Council for the Elimination of Tuberculosis. MMWR 1992;41(no.
RR-5):1-11.

       4. Decoufle P, Thomas T, Pickle L. Comparison of the
proportionate mortality ratio and standardized mortality ratio risk
measures. Am J Epidemiol 1980;111:263-9.

       5. Seta JA, Sundin DS, Pedersen DH. National Occupational
Exposure Survey, Vol 1. Cincinnati: US Department of Health and Human
Services, Public Health Service, CDC, NIOSH, 1988; DHHS publication
no. (NIOSH)88-106.

       6. Groce DW, Carr WG, Hearl FJ. The National Occupational
Health Survey of Mining. In: CDC surveillance summaries (August). MMWR
1986;35(no. SS-2):17.

       7. Nam CB, Terrie EW. Comparing the Nam-Powers and Duncan SEI
occupational scores. Tallahassee, Florida: Florida State University,
Center for the Study of Population, 1986.

       8. Weeks JL, Levy BS, Wagner GN, eds. Tuberculosis. In:
Preventing occupational disease and injury. Washington, DC: American
Public Health Association, 1991:572-81.

       9. CDC. National action plan to combat multidrug-resistant
tuberculosis. MMWR 1992;41(no. RR-11):1-48.

         * Through a collaborative project with CDC (specifically
           NIOSH and the National Center for Health Statistics) and
           the National Cancer Institute, the following 28 states
           contributed occupation-coded death certificate data to NOMS
           for 1 year or more during 1979-- 1990: Alaska, California,
           Colorado, Georgia, Idaho, Indiana, Kansas, Kentucky, Maine,
           Missouri, Nebraska, Nevada, New Hampshire, New Jersey, New
           Mexico, New York, North Carolina, Ohio, Oklahoma,
           Pennsylvania, Rhode Island, South Carolina, Tennessee,
           Utah, Vermont, Washington, West Virginia, and Wisconsin.

        ** The NIOSH HHE program is a federally mandated program for
           investigation of suspected hazardous exposures or disease
           outbreaks in the workplace. As of March 1994, a total of 50
           HHE requests related to TB had been received by NIOSH and
           25 completed (NIOSH, unpublished data, 1994).

       *** Based on the criteria used in this analysis, no other
           health-care workers had elevated PMRs.


Erratum: Vol. 43, No. 40

       In "Adult Blood Lead Epidemiology and Surveillance--United
States, Second Quarter, 1994," on page 741, the first sentence of the
second paragraph should read "The cumulative number of BLL reports for
the first and second quarters of 1994 increased 48% over the
comparable time period for 1993 (Table 1)." On pages 741- 742, the
last sentence of the third paragraph should be deleted. The following
table contains the corrected numbers and footnotes and replaces Table
1 on page 742. *

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