Exposures to Discarded Sulfur Mustard Munitions - Mid-Atlantic and New England States 2004-2012

Abstract

Before the 1970s, the United States sometimes disposed of at sea excess, obsolete, or unserviceable munitions, including chemical munitions (1). Chemical munitions known to have been disposed of at sea included munitions filled with sulfur mustard, a vesicant (i.e., an agent that causes chemical burns or blisters of the skin and mucous membranes) (2). Signs and symptoms of exposure to a mustard agent can include redness and blistering of the skin, eye irritation, rhinorrhea, hoarseness, shortness of breath, and (rarely) diarrhea and abdominal discomfort. Since 2004, CDC has received notification of three separate incidents of exposure to sulfur mustard munitions. In one incident, a munition was found with ocean-dredged marine shells used to pave a driveway. The other two incidents involved commercial clam fishing operations. This report highlights the importance of considering exposure to sulfur mustard in the differential diagnosis of signs and symptoms compatible with exposure to a vesicant agent, especially among persons involved with clam fishing or sea dredging operations.

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INSIDE
305 Obliterative Bronchiolitis in Workers in a Coffee-
Processing Facility — Texas, 2008–2012
308 Progress in Introduction of Pneumococcal
Conjugate Vaccine — Worldwide, 2000–2012
312 National Shortage of Purified-Protein Derivative
Tuberculin Products
313 Notes from the Field: Acute Pesticide-Related
Illness Resulting from Occupational Exposure to
Acrolein — Washington and California, 1993–2009
315 Notes from the Field: Exposures to Discarded
Sulfur Mustard Munitions — Mid-Atlantic and
New England States 2004–2012
317 Announcements
319 QuickStats
Continuing Education examination available at
http://www.cdc.gov/mmwr/cme/conted_info.html#weekly.
U.S. Department of Health and Human Services
Centers for Disease Control and Prevention
Morbidity and Mortality Weekly Report
Weekly / Vol. 62 / No. 16 April 26, 2013
Workers’ Memorial Day —
April 28, 2013
Workers’ Memorial Day recognizes workers who died or
suffered from exposures to hazards at work. In 2011, a total
of 4,069 U.S. workers died from work-related injuries (1).
Most fatalities from work-related illness are not captured
by national surveillance systems, but an estimate for 2007
was 53,445 deaths (2). Several national surveillance systems
report new cases of nonfatal work-related injuries and ill-
nesses, although no system captures all cases. In 2011, nearly
3 million injuries and illnesses to private industry workers
and 821,000 to state and local government workers were
reported by employers (3). In the same year, an estimated
2.9 million work-related injuries were treated in emergency
departments, resulting in 150,000 hospitalizations (CDC,
unpublished data, 2013).
Based on methods that focus on medical costs and
productivity losses, the societal cost of work-related fatali-
ties, injuries, and illnesses was estimated at $250 billion
in 2007 (2). Methods that include consideration of pain
and suffering would result in a higher estimated societal
cost (4). CDC is working to better describe the burden
of fatalities, injuries, and illnesses suffered by workers;
additional information is available at http://www.cdc.gov/
niosh/programs/econ/risks.html.
References
1. Bureau of Labor Statistics. Economic news release: table 2: fatal
occupational injuries by industry and selected event or exposure,
2011 (preliminary). Washington, DC: US Department of Labor,
Bureau of Labor Statistics; 2012.
2. Leigh JP. Economic burden of occupational injury and illness in the
United States. Millbank Q 2011;89:728–72.
3. Bureau of Labor Statistics. Economic news release: workplace injury
and illness summary. Washington, DC: US Department of Labor,
Bureau of Labor Statistics; 2012.
4. Haddix AC, Teutsch SM, Corso PS, eds. Prevention effectiveness:
a guide to decision analysis and economic evaluation. New York,
NY: Oxford University Press;2003:74.
During 2003–2010, the U.S. oil and gas extraction industry
(onshore and offshore, combined) had a collective fatality rate
seven times higher than for all U.S. workers (27.1 versus 3.8
deaths per 100,000 workers). The 11 lives lost in the 2010
Deepwater Horizon explosion provide a reminder of the haz-
ards involved in offshore drilling. To identify risk factors to
offshore oil and gas extraction workers, CDC analyzed data
from the Bureau of Labor Statistics (BLS) Census of Fatal
Occupational Injuries (CFOI), a comprehensive database of
fatal work injuries, for the period 2003–2010. This report
describes the results of that analysis, which found that 128
fatalities in activities related to offshore oil and gas operations
occurred during this period. Transportation events were the
leading cause (65 [51%]); the majority of these involved aircraft
(49 [75%]). Nearly one fourth (31 [24%]) of the fatalities
Fatal Injuries in Offshore Oil
and Gas Operations —
United States, 2003–2010
Please note: An erratum has been published for this issue. To view the erratum, please click here.

Morbidity and Mortality Weekly Report
302 MMWR / April 26, 2013 / Vol. 62 / No. 16
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U.S. Department of Health and Human Services, Atlanta, GA 30333.
Suggested citation: Centers for Disease Control and Prevention. [Article title]. MMWR 2013;62:[inclusive page numbers].
Centers for Disease Control and Prevention
Thomas R. Frieden, MD, MPH, Director
Harold W. Jaffe, MD, MA, Associate Director for Science
James W. Stephens, PhD, Director, Office of Science Quality
Denise M. Cardo, MD, Acting Deputy Director for Surveillance, Epidemiology, and Laboratory Services
Stephanie Zaza, MD, MPH, Director, Epidemiology and Analysis Program Office
MMWR Editorial and Production Staff
Ronald L. Moolenaar, MD, MPH, Editor, MMWR Series
John S. Moran, MD, MPH, Deputy Editor, MMWR Series
Teresa F. Rutledge, Managing Editor, MMWR Series
Douglas W. Weatherwax, Lead Technical Writer-Editor
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Stephen R. Spriggs, Terraye M. Starr
Visual Information Specialists
Quang M. Doan, MBA, Phyllis H. King
Information Technology Specialists
MMWR Editorial Board
William L. Roper, MD, MPH, Chapel Hill, NC, Chairman
Matthew L. Boulton, MD, MPH, Ann Arbor, MI
Virginia A. Caine, MD, Indianapolis, IN
Barbara A. Ellis, PhD, MS, Atlanta, GA
Jonathan E. Fielding, MD, MPH, MBA, Los Angeles, CA
David W. Fleming, MD, Seattle, WA
William E. Halperin, MD, DrPH, MPH, Newark, NJ
King K. Holmes, MD, PhD, Seattle, WA
Timothy F. Jones, MD, Nashville, TN
Rima F. Khabbaz, MD, Atlanta, GA
Dennis G. Maki, MD, Madison, WI
Patricia Quinlisk, MD, MPH, Des Moines, IA
Patrick L. Remington, MD, MPH, Madison, WI
John V. Rullan, MD, MPH, San Juan, PR
William Schaffner, MD, Nashville, TN
occurred among workers whose occupations were classified as
“transportation and material moving.” To reduce fatalities in
offshore oil and gas operations, employers should ensure that
the most stringent applicable transportation safety guidelines
are followed.
CFOI, a cooperative program between the BLS and state
governments, is the most comprehensive national surveillance
system for work-related fatalities in the United States. Multiple
data sources are used to collect information on each fatality.
A fatal injury is considered work-related if the event leading
to the injury occurred while the employee was working, based
on confirmation by two independent sources.
The oil and gas extraction industry includes three types of
companies, defined according to the North American Industry
Classification System (NAICS): oil and gas operators who
control and manage leased areas (NAICS 211), drilling contrac-
tors who drill the wells (NAICS 213111), and well-servicing
companies who provide all other types of support operations
that prepare a well for production and completion (NAICS
213112). Offshore oil and gas operations include all activities
involved in the extraction of crude oil and natural gas from
reservoirs found beneath the seafloor. CFOI does not include
a variable to specifically identify offshore fatalities. Further,
not all workers involved in offshore operations are directly
employed in the oil and gas extraction industry, and therefore
would not be captured in one of the three NAICS codes above.
To accurately identify all workers killed during offshore oil
and gas operations, CDC and BLS identified cases two ways:
1) the fatality was included in one of the industry’s three
NAICS codes, and the CFOI variable denoting the location
was coded as a body of water, or 2) the fatality contained
any one of the following key words in the CFOI narrative:
“offshore,” “off shore,” “platform,” “boat,” “ship,” “barge,” or
“helicopter,” and further examination of the case revealed that
the incident was related to offshore oil and gas operations.
Cases identified during 2003–2010 were analyzed by year,
age, race/ethnicity, event type, nature and source of injury, and
NAICS code. CFOI narrative data were reviewed to identify
factors involved in helicopter events. Annual fatality rates
were calculated using a count of active offshore drilling rigs as
the denominator, which included fixed and semisubmersible
drilling rigs, mobile offshore drilling units, and drillships.
A Poisson regression model was used to measure trends.
During 2003–2010, a total of 128 fatalities occurred in
activities related to offshore oil and gas operations in the United
States, an average of 16 per year. All but one fatality occurred
in Gulf of Mexico operations. All decedents were male with
a mean age of 41.4 years. The majority were non-Hispanic
whites (101 [79%]). Despite a 63% decrease in the number
of active offshore drilling rigs during 2003–2010, the number
of annual fatalities during offshore operations remained stable,
resulting in a statistically significant increase in the number of
fatalities per rig rate (Figure).
Transportation events were the leading cause of fatalities
(65 [51%]), followed by contact with objects or equipment
(21 [16%]), fires and explosions (17 [13%]), and exposure

Morbidity and Mortality Weekly Report
MMWR / April 26, 2013 / Vol. 62 / No. 16 303
to harmful substances/environments (16 [13%]) (Table).
Seventy-five percent of transportation events were associated
with aircraft, all of which were helicopters (49 fatalities).
Seventeen helicopter events occurred; 11 of these resulted in 43
(88%) of the fatalities. CFOI narratives noted that mechanical
failure or loss of engine power was associated with five events
(eight fatalities), and bad weather played a role in three of the
events (seven fatalities). In five events, a total of nine fatalities
involved occupants who survived the initial impact but later
drowned. All of the helicopter events occurred in Gulf of
Mexico offshore operations.
Two thirds of the fatalities involved workers employed in
the oil and gas extraction industry (87 [68%]). Of those, half
involved workers employed by well servicing companies (43
[49%]), followed by drilling contractors (26 [30%]), and oil
and gas operators (18 [21%]). The remainder involved work-
ers in offshore oil and gas operations who were classified as
employees in another industry, including transportation and
warehousing (23 [18%]), construction (10 [8%]), and all other
industries (eight [6%]). Nearly one fourth (31 [24%]) of the
decedents worked in occupations classified as “transportation
and material moving” that transported workers and their equip-
ment to and from offshore drilling platforms.
Reported by
Matthew M. Gunter, MA, Office of Safety, Health, and Working
Conditions, Bureau of Labor Statistics, US Dept of Labor.
Ryan Hill, MPH, Western States Office, Mary B. O’Connor, MS,
Kyla D. Retzer, MPH, Jennifer M. Lincoln, PhD, Alaska Pacific
Office, National Institute for Occupational Safety and Health,
CDC. Corresponding contributor: Ryan Hill, gii9@cdc.gov,
303-236-0502.
Editorial Note
Catastrophic events like the Deepwater Horizon explosion
attract intense media attention but do not account for the
majority of work-related fatalities during offshore operations.
This report found that transportation events (specifically
helicopter crashes) were the most frequent fatal event in
this industry.
The findings in this report are consistent with previously
reported data. Mechanical failures and bad weather were identi-
fied as the most common factors in helicopter crashes related
to offshore oil and gas operations in the Gulf of Mexico during
1983–2009 (1). That study also found that two thirds of all
forced or precautionary landings resulting from mechanical
failures occurred in water; aircraft floatation devices either
failed to deploy or malfunctioned in 20% of nonfatal crashes
(1). Another study analyzed Canadian civilian helicopter
crashes into water and found that lack of warning time, sink-
ing, and helicopter inversion were major contributing factors
in fatalities (2). The same study found that drowning was
the primary cause of death in helicopter crashes over water
and, even when available, use of life jackets among pilots and
passengers was inconsistent (2). Other studies also indicate
drowning and exposure as post-impact hazards to survival (3,4).
To increase pilots’ situational awareness and improve safety,
the Federal Aviation Administration (FAA) worked with the oil
and gas industry and aircraft operators in the Gulf of Mexico
to implement Automatic Dependent Surveillance-Broadcast
(ADS-B) technology, which uses satellites to transmit informa-
tion to air traffic controllers and to other aircraft equipped with
ADS-B avionics (5). This technology provides flight tracking,
improved communications capabilities, enhanced weather
information, and terrain and traffic information. Before the
implementation of this technology, radar coverage did not pick
TABLE. Number and percentage of fatal injuries among workers
involved in offshore oil and gas operations, by event — United States,
2003–2010
Event No. (%)
Transportation events 65 (50.8)
Aircraft events* 49 (38.3)
Water vehicle events 16 (12.5)
Contact with objects and equipment 21 (16.4)
Fires and explosions 17 (13.3)
Exposure to harmful substances/environments 16 (12.5)
Other event types 9 (7.0)
Total 128 (100.0)
Source: U.S. Department of Labor, Bureau of Labor Statistics, Census of Fatal
Occupational Injuries.
* All involved helicopters.
0
5
10
15
20
25
30
35
40
0
5
10
15
20
25
2003 2004 2005 2006 2007 2008 2009 2010
Rate per 100 rigs
No. of fatalities
Year
No. of fatalities
Rate per 100 rigs
FIGURE. Number and rate of fatal injuries among workers involved
in offshore oil and gas operations (N = 128), by year — United States,
2003–2010*
Sources: U.S. Department of Labor, Bureau of Labor Statistics, Census of Fatal
Occupational Injuries. Baker Hughes, Inc., North America Rotary Rig Count.
* Significant increase in fatality rate during 2003–2010 (linear regression χ² = 20.66;
p<0.01). Fatality rate calculated per 100 active drilling rigs, which include fixed
semisubmersible drilling rigs, mobile offshore drilling units, and drillships, but
exclude producing platforms.

Morbidity and Mortality Weekly Report
304 MMWR / April 26, 2013 / Vol. 62 / No. 16
up low-flying aircraft and traditional radio communications
had limited capability, and therefore were not effective in warn-
ing pilots of rapidly changing weather conditions. Since late
2009, when ADS-B was implemented in the Gulf of Mexico,
no weather-related fatal helicopter crashes during oil and gas
operations have occurred as of the end of 2012 (6).
The findings in this report are subject to at least two limita-
tions. First, the level of detail and quality of narrative source
information in CFOI used to identify one third of the fatalities
in this report and identify factors related to helicopter events
might vary from case-to-case. A narrative might exclude impor-
tant information if it was not included in the source documents
used to develop the CFOI case record. Conversely, mention
of a given factor in the CFOI case record does not necessarily
mean that the factor caused or contributed to the incident.
Second, occupational fatality rates based on the number of
offshore workers or the number of offshore flight hours could
not be calculated because those data were not available. As a
result, the number of active offshore drilling rigs, an estimate
of industry activity that does not include offshore producing
platforms, was used to calculate occupational fatality rates.
To reduce fatalities in the offshore oil and gas industry,
employers should ensure that the most stringent applicable
transportation safety guidelines are followed. The International
Association of Oil and Gas Producers (OGP) has developed
guidelines for aircraft operations in the oil and gas industry
that exceed FAA safety regulations (7). According to the OGP
guidelines, pilots and passengers should complete helicopter
underwater escape training and wear life jackets during flights
over water. Floatation gear fitted to the helicopter should auto-
matically inflate on impact with water and be capable of sup-
porting the helicopter on the surface of the water. Companies
should provide personal locator beacons for pilots, passengers,
and life rafts. Life rafts should be externally mounted on the
helicopters. Where appropriate, engine and vibration monitor-
ing equipment should be installed to detect incipient failure.
Acknowledgments
Census of Fatal Occupational Injuries Program, Bureau of Labor
Statistics, US Dept of Labor; Devin Lucas, Alaska Pacific Office, Jason
Burton, Western States Office, National Institute for Occupational
Safety and Health, CDC.
References
1. Baker SP, Shanahan DF, Haaland W, Brady JE, Li G. Helicopter crashes
related to oil and gas operations in the Gulf of Mexico. Aviat Space Environ
Med 2011;82:885–9.
2. Brooks CJ, MacDonald CV, Donati L, Taber MJ. Civilian helicopter
accidents into water: analysis of 46 cases, 1979–2006. Aviat Space Environ
Med 2008;79:935–40.
3. Chen CT, Muller M, Fogarty KM. Rotorcraft ditchings and water-related
impacts that occurred from 1982 to 1989, Phase I. Atlantic City, NJ:
US Department of Transportation, Federal Aviation Administration
Technical Center; 1993. Available at http://www.dtic.mil/cgi-bin/
GetTRDoc?AD=ADA279164.
4. Muller M, Bark LW. Rotorcraft ditchings and water-related impacts that
occurred from 1982 to 1989, Phase II. Atlantic City, NJ: US Department of
Transportation, Federal Aviation Administration Technical Center; 1993.
Available at http://www.dtic.mil/cgi-bin/GetTRDoc?AD=ADA276473.
5. Federal Aviation Administration. Fact sheet: automatic dependent
surveillance-broadcast (ADS-B). Washington DC: US Department of
Transportation, Federal Aviation Administration; 2010. Available at http://
www.faa.gov/news/fact_sheets/news_story.cfm?newsid=7131.
6. National Transportation Safety Board. National Transportation Safety
Board aviation accident database and synopses. Available at http://www.
ntsb.gov/aviationquery/index.aspx.
7. International Association of Oil and Gas Producers. Aircraft management
guidelines. London, United Kingdom: International Association of Oil and
Gas Producers; 2011. Available at http://www.ogp.org.uk/pubs/390.pdf.
What is already known on this topic?
The oil and gas extraction industry has an elevated occupa-
tional fatality rate that is consistently among the highest of
any U.S. industry. The causes of the most frequent fatalities
among onshore oil and gas extraction workers are well known.
However, little is known about the unique risk factors faced by
workers during offshore oil and gas operations.
What is added by this report?
During 2003–2010, a total of 128 fatalities occurred among
offshore oil and gas workers. Transportation fatalities (65 [51%])
were the most common. A total of 49 (75%) transportation
fatalities were associated with helicopters. All of the helicopter
fatalities occurred in Gulf of Mexico operations.
What are the implications for public health practice?
Employers should ensure that the transportation safety
guidelines developed by the International Association of Oil and
Gas Producers are followed. Pilots and passengers should wear
life jackets during flights over water and complete helicopter
underwater escape training, and helicopters should be equipped
with survival equipment specific to their operating environment.

Morbidity and Mortality Weekly Report
MMWR / April 26, 2013 / Vol. 62 / No. 16 305
Obliterative bronchiolitis, a rare, irreversible form of fixed
obstructive lung disease, has been identified in workers exposed
to flavoring chemicals while working in the microwave-popcorn
and flavoring-manufacturing industries (1); the occupational risk
to workers outside these industries is largely unknown. This report
describes two cases of obliterative bronchiolitis identified in work-
ers employed in a small coffee-processing facility. Both patients’
illness was misdiagnosed before they received a diagnosis of work-
related obliterative bronchiolitis, which had not been identified
previously in the coffee-processing industry. These cases reinforce
the need for exposure evaluation in all industries in which work-
ers are exposed to flavoring chemicals. Additionally, a high index
of suspicion is required when these potentially exposed workers
have progressive shortness of breath. If obliterative bronchiolitis is
suspected, immediate protection from further exposure is crucial
to prevent further deterioration of lung function.
Case Reports
Patient 1. In October 2007, a nonsmoking, previously
healthy Hispanic woman aged 34 years began work at the
coffee-processing facility. Initially hired to work in the quality
control laboratory, after 3 months she moved briefly to house-
keeping, and then to the flavoring room. There, whole roasted
coffee beans were mixed with liquid flavorings in an open
process, ground, and packaged. Her primary tasks included
operating the grinding and packing machines for these flavored
coffee beans. After 1 year in this room, in January 2009, she
transferred to a similar job in the unflavored coffee area, and
in October 2011, she was dismissed.
The woman first sought care in November 2008, approxi-
mately 1 year after beginning work at the facility. She reported
cough, shortness of breath on exertion, and occasional wheez-
ing, which did not improve when away from work. Additional
concerns included fatigue, throat dryness, constant thirst, and
vertigo. Initial lung function testing showed severe obstruction
responsive to bronchodilators (Table). She was hospitalized,
and upon discharge was placed on antihistamines, inhaled
steroids, and bronchodilators for possible asthma.
Despite initial improvement, 1 year later the woman visited
a pulmonologist, describing worsening symptoms. Workup
included repeat lung function testing, which demonstrated a
worsening obstructive defect. Inspiratory and expiratory high-
resolution computed tomography (HRCT) of the chest showed
diffuse bronchial wall thickening, a prominent mosaic pattern,
mild cylindrical bronchiectasis, and a small amount of fibrotic
upper lobe scarring. Although inhaled steroids and mucus
clearance therapy improved her cough, her dyspnea continued
to worsen; an open lung biopsy was performed, which revealed
constrictive bronchiolitis (the histopathologic correlate of
obliterative bronchiolitis) with both narrowed and obliterated
airways with surrounding fibrous tissue and a variable mixed
chronic inflammatory cell infiltrate. Based on this result, she
received a diagnosis of obliterative bronchiolitis.
At the patient’s most recent evaluation in April 2012, she
continued to describe symptoms of severe shortness of breath
with even light exertion, paroxysmal cough, and an inability
to tolerate smells. Lung function testing at that time showed
continued air trapping and severe obstruction marginally
responsive to bronchodilators, and HRCT demonstrated disease
progression. The patient currently is awaiting a lung transplant.
Patient 2. In October 2009, a previously healthy, nonsmok-
ing, Hispanic man aged 39 years went to work at the coffee-
processing facility as an unloader, removing sacks of green
coffee beans from trucks. Over the next 3 months he moved
to maintenance, and then to the flavoring room, where he
worked as a mixer. His job involved open bench-top weighing
of liquid flavorings, which he poured into barrels of roasted
coffee beans. A machine rotated these open barrels while he
stood nearby to monitor the process. He worked there for about
19 months before moving to become a packer for unflavored
coffee until placed on medical leave in 2012.
The man first noticed symptoms in April 2011, after work-
ing at the company for about 18 months. Although his initial
concern was dyspnea with heavy exertion, he soon became
short of breath with moderate activity. He received a diagnosis
of bronchitis and was treated with steroids without significant
improvement. He was subsequently placed on nasal and oral
steroids, his workup failed to identify an allergic etiology, and
he was referred to a pulmonologist in December 2011.
Although no longer working with flavorings, the man
continued to describe cough, weight loss, and irritated eyes.
Spirometry revealed severe obstruction. After 3 weeks of treat-
ment with inhaled steroids, further testing confirmed this find-
ing, and additionally demonstrated air trapping and a lack of
bronchodilator response. HRCT of the chest showed a subtle
mosaic abnormality with marked and diffuse air trapping, a
few scattered centrilobular nodules, bronchial wall thickening,
and mild bilateral cylindrical bronchiectasis. Consequent open
lung biopsy revealed chronic and subacute small airways injury
morphologically consistent with constrictive bronchiolitis.
His doctors diagnosed his illness as obliterative bronchiolitis.
At follow-up in May 2012, the patient said that although his
Obliterative Bronchiolitis in Workers in a Coffee-Processing Facility —
Texas, 2008–2012

Morbidity and Mortality Weekly Report
306 MMWR / April 26, 2013 / Vol. 62 / No. 16
cough had improved, his shortness of breath with exertion was
worsening, and he was troubled by fatigue in the evenings.
In addition to their youth and shared work environment,
these patients have much in common. Both initially had cough
and dyspnea on exertion; their illness initially was misdiag-
nosed, and they were unsuccessfully treated with steroids and
bronchodilators. In each case, a diagnosis of work-related oblit-
erative bronchiolitis was made on the basis of lung function
testing showing obstruction and hyperinflation, supportive
HRCT and lung biopsy findings, and the temporal relation-
ship between symptom onset and work exposure.
Reported by
Sharon Huff, MD, James M. Stocks, MD, Rena Saito, PhD, Patty
Bilhartz, MD, Jeffrey Levin, MD, Depts of Occupational Health
Sciences and Medicine, Univ of Texas Health Science Center at
Tyler; Craig Glazer, MD, Dept of Internal Medicine, Univ of
Texas Southwestern Medical Center at Dallas. Rachel Bailey, DO,
Kristin Cummings, MD, Kathleen Kreiss, MD, Div of Respiratory
Disease Studies, National Institute for Occupational Safety and
Health; Anna-Binney McCague, MD, EIS Officer, CDC.
Corresponding contributor: Anna-Binney McCague,
wja6@cdc.gov, 304-285-6078.
Editorial Note
These two cases of obliterative bronchiolitis in a coffee-
processing facility suggest expansion of the number of workers
potentially at risk for flavoring-chemical related disease. They
raise concerns about the current adequacy of identification
of at-risk workers and workplace controls, and about pos-
sible underreporting of disease. Especially of note is the short
employment tenure of affected workers and their apparent
rapid decline in lung function. Although these patients
were symptomatic within <18 months of work, their illness
initially was unrecognized, leading to a diagnostic delay of
8–14 months. This is consistent with the natural history of
obliterative bronchiolitis, which differs significantly from much
chronic obstructive lung disease, where decline is slow and risk
factors more apparent. Despite these differences, obliterative
bronchiolitis often is misdiagnosed in such workers as asthma
or chronic obstructive pulmonary disease, and therefore might
be underreported.
CDC currently is evaluating health hazards at this facility
to identify other potential cases, understand occupational
exposures, and prevent new cases. Diacetyl, implicated as the
cause of obliterative bronchiolitis in workers exposed to flavor-
ings (2,3), was present in this workplace, according to some
material safety data sheets accompanying flavoring materials
to which affected workers were exposed. Yet other flavorings
might have contained undeclared diacetyl because material
safety data sheets only must mention recognized hazards of
components comprising ≥1% of a product (4). Therefore,
exposure assessment is necessary in this plant. Additionally, one
substitute for diacetyl used in this facility has shown toxicity
similar to diacetyl in laboratory animals (5).
Currently, no specific federal regulations govern workers
exposed to diacetyl or its substitutes. CDC has drafted a rec-
ommended standard for occupational exposure that provides
a quantitative risk assessment (6). One of the crucial recom-
mendations, in addition to limitation of exposure, is regular
hazard assessment in industries that use flavorings. Whereas
most studies have focused on the microwave popcorn and
flavoring industries, this report shows that other industries
might benefit from the recommendations.
The findings in this report are subject to at least three limita-
tions. First, the exposure of the two patients was not quantified;
data on exposure of workers at the facility currently are being
collected as part of the CDC health hazard evaluation. Second,
diacetyl is produced by many foods, including coffee during the
roasting process (7,8). Volatile organic compounds, including
diacetyl, can be released during grinding (9). The relative con-
tribution of diacetyl from flavorings and roasting or grinding to
these two cases is unknown. Finally, production practices vary
throughout the industry; therefore, it is possible this facility is
not representative of other coffee-processing facilities.
Patients with a potential occupational exposure to flavoring
chemicals should be considered at risk for obliterative bron-
chiolitis, and a high index of suspicion should be maintained.
TABLE. Lung function test results for two coffee-processing workers
with obliterative bronchiolitis, by month and year of test —
Texas, 2008–2012
Test
Patient 1 Patient 2
Nov
2008
Dec
2009*
Feb
2010
Apr
2012
Dec
2011
Dec
2011
FVC %
predicted
51 66 82 79 45 64
FEV1 %
predicted
20 32 35 35 20 28
FEV1/FVC % 49 42 38 37 36 35
Bronchodilator
response†Yes —§No Ye s — No
TLC %
predicted
117 134 — — — 111
RV %
predicted
236 289 — 225 — 212
ERV %
predicted
56 48 — 74 — 22
DLCO %
predicted
Normal Normal — Normal — Normal
Abbreviations: FVC = forced vital capacity; FEV1 = forced expiratory volume in
1 second; TLC = total lung capacity; RV = residual volume; ERV = expiratory
reserve volume; DLCO = diffusing capacity of the lung for carbon monoxide.
* DLCO and lung volumes were performed 1 week after spirometry.
† Bronchodilator response was defined as a ≥12% change in FEV1 or FVC after
bronchodilator administration.
§ Not reported.

Morbidity and Mortality Weekly Report
MMWR / April 26, 2013 / Vol. 62 / No. 16 307
Because risk was not recognized previously in this industry,
these two cases support the need for widespread hazard assess-
ment in all industries using flavoring chemicals or generating
diacetyl. For those patients suspected of having obliterative
bronchiolitis, immediate intervention by removal from expo-
sure is crucial to reducing respiratory morbidity and mortality.
What is already known on this topic?
Obliterative bronchiolitis is a severe, irreversible lung disease
that can be caused by diacetyl in flavorings, as seen previously
among workers in the microwave popcorn and flavoring
production industries. The extent of obliterative bronchiolitis
in other areas of the food industry is not known.
What is added by this report?
This report describes two cases of obliterative bronchiolitis in
workers in a coffee-processing facility, an industry in which
obliterative bronchiolitis had not been identified previously.
Both patients experienced symptoms within <18 months
exposure. Both have severe illness that was misdiagnosed for
>8 months, and one is awaiting a lung transplant.
What are the implications for public health?
Obliterative bronchiolitis might be underdiagnosed in workers
in the food and flavoring industries. The absence of recognized
cases at facilities that use or produce flavoring chemicals does
not mean absence of risk. Diagnosis requires a high index of
suspicion, and early removal from the exposure is crucial to
reducing respiratory morbidity and mortality from this
irreversible disease.
Acknowledgments
Mike Hazel, Dept of Cardiology Svcs, Univ of Texas Health Science
Center at Tyler.
References
1. Kanwal R. Bronchiolitis obliterans in workers exposed to flavoring
chemicals. Curr Opin Pulm Med 2008;14:141–6.
2. CDC. Fixed obstructive lung disease in workers at a microwave popcorn
factory—Missouri, 2000–2002. MMWR 2002;51:345–7.
3. CDC. Fixed obstructive lung disease among workers in the flavor-
manufacturing industry—California, 2004–2007. MMWR 2007;56:389–93.
4. Day G, LeBouf R, Grote A, et al. Identification and measurement of
diacetyl substitutes in dry bakery mix production. J Occup Environ Hyg
2011;8:93–103.
5. Hubbs AF, Cumpston AM, Goldsmith WT, et al. Respiratory and olfactor y
cytotoxicity of inhaled 2,3-pentanedione in Sprague-Dawley rats. Am J
Pathol 2012;181:829–44.
6. National Institute for Occupational Safety and Health. Draft criteria for
a recommended standard: occupational exposure to diacetyl and
2,3-pentanedione. Cincinnati, OH: US Department of Health and Human
Services, CDC, National Institute for Occupational Safety and Health;
2011. Available at http://www.cdc.gov/niosh/docket/archive/docket245.html.
7. Occupational Safety and Health Administration. Sampling and analytical
methods: acetoin and diacetyl. Washington, DC: US Department of
Labor, Occupational Safety and Health Administration; 2008. Available
at http://www.osha.gov/dts/sltc/methods/validated/1012/1012.html.
8. Daglia M, Papetti A, Aceti C, Sordelli B, Spini V, Gazzani G. Isolation
and determination of alpha-dicarbonyl compounds by RP-HPLC-DAD
in green and roasted coffee. J Agric Food Chem 2007;55:8877–82.
9. Akiyama M, Murakami K, Ohtani N, et al. Analysis of volatile compounds
released during the grinding of roasted coffee beans using solid-phase
microextraction. J Agric Food Chem 2003;51:1961–9.

Morbidity and Mortality Weekly Report
308 MMWR / April 26, 2013 / Vol. 62 / No. 16
Pneumococcal conjugate vaccines (PCVs) are safe and effec-
tive for reducing illness and deaths caused by Streptococcus
pneumoniae (1). Recommendations for PCV use from the
World Health Organization (WHO) (1,2) and funding from
the GAVI Alliance have resulted in an increase in PCV intro-
ductions into national immunization programs, especially in
lower-income countries. Additionally, new formulations that
cover more serotypes commonly causing disease in lower- and
middle-income countries have become available. This report
uses WHO data from 2000–2012, stratified by country dis-
ease burden characteristics and World Bank country income
groups, to describe global progress in PCV introduction. As
of December 2012, a total of 86 (44%) WHO member states
have added PCV to the routine infant immunization sched-
ule of their national immunization programs; among those,
23 have introduced PCV with GAVI Alliance support. PCV
introduction among WHO member states was most common
in the Americas Region (60% of member states), followed by
the Eastern Mediterranean Region (50%), European Region
(49%), African Region (41%), and Western Pacific Region
(33%); none of 11 WHO member states in the South-East
Asia Region have introduced PCV. Proportions of low- and
middle-income countries with PCV introductions were similar.
The proportion of the world’s birth cohort living in countries
with PCV in national immunization programs increased from
1% in 2000 to 31% in 2012. These findings suggest that efforts
to increase PCV introduction and use globally are succeeding;
however, gaps in PCV use remain in Asia and countries with
large birth cohorts, where concerted efforts should be focused.
Worldwide, an estimated 14.5 million episodes of serious
pneumococcal disease (including pneumonia, meningitis, and
sepsis) occur each year in children aged <5 years, resulting in
approximately 500,000 deaths, almost all of which occur in
low- and middle-income countries (3). PCV was first licensed
in 2000 as a formulation that provided protection against seven
of the most common pneumococcal serotypes. In 2006, WHO
recommended that PCV be included in all routine immuniza-
tion programs, especially in countries with high pneumococcal
disease burden, defined as >10% of deaths in children aged
<5 years attributed to pneumonia or pneumonia mortality
rate of >50 deaths per 1,000 live births among children aged
<5 years (1). Beginning in 2010, new PCV formulations pro-
tecting against 10 and 13 serotypes have become available for
use, offering better coverage for serotypes commonly causing
disease in low- and middle-income countries (4).
To assess the status of global PCV introduction, a WHO
database tracking vaccine introductions was used to identify
countries that included PCV in routine infant immunization
schedules as of December 2012. PCV introductions were
characterized by WHO region (5), eligibility for GAVI Alliance
financial support,* World Bank income classification,† and
pneumonia disease burden (6). The proportion of the global
birth cohort living in countries that had introduced PCV was
calculated using United Nations 2010 birth cohort estimates
(6). For countries that introduced PCV during 2000–2009,
WHO–United Nations Children’s Fund (UNICEF) estimated
coverage for the full 3-dose series of PCV was used, if avail-
able (5). Operational issues related to PCV introduction were
identified through WHO post-introduction evaluations.
As of December 2012, 86 (44%) of 194 WHO member
states had introduced PCV into national immunization pro-
grams, up from one (1%) in 2000 (Figure 1), representing
31% of all children born in WHO member states. PCV was
introduced in national immunization programs in 21 (60%)
of 35 member states in the Americas Region, 11 (50%) of 22
member states in the Eastern Mediterranean Region, 26 (49%)
of 53 member states in the European Region, 19 (41%) of 46
member states in the African Region, nine (33%) of 27 member
states in the Western Pacific Region, and none of 11 member
states in the South-East Asia Region (Figure 2). By income
level, 36 (73%) of 50 high-income countries introduced PCV;
proportions were lower for remaining income strata: 13 (37%)
of 36 low-income, 18 (35%) of 52 lower-middle income, and
18 (34%) of 53 upper-middle income countries. Among 72
countries that were eligible for phase II (2007–2010) finan-
cial support from the GAVI Alliance for PCV introduction,
23 (32%) introduced PCV and all low-income introductions
occurred with GAVI Alliance support. By 2012, 21 (36%) of
59 high-mortality countries and 38 (37%) of 102 countries in
which >10% of deaths in children aged <5 years were attrib-
utable to pneumonia had introduced PCV. Among countries
Progress in Introduction of Pneumococcal Conjugate Vaccine —
Worldwide, 2000–2012
* Eligibility for phase II GAVI Alliance support (2007–2010) was based on having
a gross national income (GNI), in U.S. dollars, of ≤$1,000 in 2003 and
diphtheria-tetanus-pertussis vaccination coverage >50%.
† World Bank income groups, in U.S. dollars, are defined as follows: high-income
countries: countries with a 2011 GNI per capita ≥$12,476; upper-middle
income countries: countries with a 2011 GNI <$12,476 and ≥$4,036; lower-
middle income countries: countries with a 2011 GNI <$4,035 and ≥$1,027;
and low-income countries: countries with a 2011 GNI ≤$1,026. Countries
with no income status: Cook Islands, Nauru, Niue. Additional information is
available at http://data.worldbank.org/indicator/ny.gnp.pcap.cd.

Morbidity and Mortality Weekly Report
MMWR / April 26, 2013 / Vol. 62 / No. 16 309
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
0
10
20
30
40
50
60
70
80
90
100
Percentage
Year of PCV introduction
WHO recommends
PCV be included
in routine infant
immunization
programs
First country
(Rwanda)
introduces
PCV with GAVI
Alliance support
WHO
prequalies
PCV7 and PCV10
WHO
prequalies
PCV13
WHO recommends
use of PCV10 or
PCV13 using a
3-dose schedule
% of countries that introduced PCV
% of birth cohort living in countries
that have introduced PCV
Abbreviations: PCV7 = 7-valent PCV; PCV10 = 10-valent PCV; PCV13 = 13-valent PCV.
FIGURE 1. Progress of pneumococcal conjugate vaccine (PCV) introductions and proportions of birth cohorts living in countries that have
introduced PCV into routine infant immunization schedules, by year — World Health Organization (WHO), worldwide, 2000–2012
High income
Upper-middle income
Lower-middle income
Low income
Not applicable
PCV not introduced, introduced in high-risk groups only,
or data not available
Data sources: World Health Organization/Immunization Vaccines and Biologicals/Expanded Programme on Immunization 2013 database, and World Bank list of
economies (July 2012).
* World Bank income groups are defined (in U.S. dollars) as follows: high-income countries = countries with a 2011 gross national income (GNI) per capita ≥$12,476;
upper-middle income countries = countries with a 2011 GNI <$12,476 and ≥$4,036; lower-middle income countries = countries with a 2011 GNI <$4,035 and ≥$1,027;
and low-income countries = countries with a 2011 GNI ≤$1,026. No income status was reported for Niue. Additional information is available at http://data.worldbank.
org/indicator/ny.gnp.pcap.cd.
FIGURE 2. Countries that have introduced pneumococcal conjugate vaccines in their national Immunization programs, by income status* —
worldwide, 2012

Morbidity and Mortality Weekly Report
310 MMWR / April 26, 2013 / Vol. 62 / No. 16
using PCV, coverage with 3 doses of PCV assessed at age
12–24 months was highest among high- and low-income
countries (median: 92% and 95%, respectively); less among
upper-middle income countries (median: 76%), and lowest
among lower-middle income countries (median: 44%) (Table).
Reports from 11 postintroduction evaluations conducted dur-
ing 2010–2012 in low- and middle-income African countries
described programmatic issues related to PCV introductions. First,
programs need accurate data to define target populations, accom-
panied by clear messages to health workers and the community to
prioritize target populations. In several countries, children outside
the target infant age group also were brought for vaccination and,
in most cases, were vaccinated, creating shortages of PCV for the
target age group. Second, health worker knowledge that PCV
provides protection against only one cause of pneumonia was
crucial to ensure that they educated caretakers about other options
for prevention and treatment of pneumonia. Third, weaknesses
were identified in the underlying capacity of the immunization
systems, including needs for 1) innovative training approaches
to address the complexity of messages relating to use of new vac-
cines, 2) improvement of supportive supervision, and 3) further
enhancement of injection safety, injection waste management,
and monitoring of adverse events after immunization.
Reported by
Susan A. Wang, MD, Carsten F. Mantel, MD, Marta Gacic-
Dobo, MSc, Laure Dumolard, PhD, Thomas Cherian, MD, Dept
of Immunizations, Vaccines, and Biologicals, World Health
Organization, Geneva, Switzerland. Brendan Flannery, PhD,
Global Immunization Div, Center for Global Health; Jennifer D.
Loo, MPH, Jennifer R. Verani, MD, Cynthia G. Whitney, MD,
Div of Bacterial Diseases, National Center for Immunization and
Respiratory Diseases, CDC. Corresponding contributor:
Jennifer D. Loo, jloo@cdc.gov, 404-639-4735.
Editorial Note
Use of PCV has increased substantially since 2000, especially
in low- and middle- income countries, where the burden of
pneumococcal disease and deaths is high. A critical factor
enabling vaccine introductions in low-income countries has
been support from the GAVI Alliance. As of the first quarter of
2013, 24 countries have introduced PCV with GAVI Alliance
support, and 27 additional countries have been approved for
GAVI Alliance–supported PCV introductions (7). However,
important gaps in PCV introduction remain, notably in the
WHO South-East Asia Region and in countries with large
birth cohorts. The lack of PCV introduction in several large
countries is reflected in the gap between the proportion of
TABLE. Numbers of countries with pneumococcal conjugate vaccine (PCV) introductions and PCV coverage, by World Bank income group* and
characteristics associated with high burden of pneumococcal disease — worldwide, 2012
PCV introduction status/coverage
High income
(n = 50)
Upper-middle
income
(n = 53)
Lower-middle
income
(n = 52)
Low income
(n = 36)
No income
status†
(n = 3)
Total
(N = 194)
No. (%) No. (%) No. (%) N o. (%) No. (%) No. (%)
Number of countries with PCV introductions
Added PCV to the routine infant immunization schedule 36 (73) 18 (34) 18 (35) 13 (37) 1 (33) 86 (44)
Offering PCV for high-risk populations only 3 (6) 2 (4) 0 — 0 — 0 — 5 (3)
No PCV introduction to date 11 (22) 33 (62) 34 (65) 23 (64) 2 (67) 103 (53)
Number of countries with PCV introductions
among countries with high burden of pneumococcal disease
Phase II GAVI Alliance–eligible countries 0 — 3 (6) 33 (63) 36 (100) 0 — 72 (38)
PCV introductions with GAVI Alliance support NA — 0 — 10 (30) 13 (36) NA — 23 (32)
Countries with mortality >50 per 1,000 live births among
children aged <5 years (i.e., high child mortality rate)
1 (2) 4 (8) 22 (42) 32 (89) 0 — 59 (31)
PCV introductions in high child mortality rate countries 0 — 1 (25) 7 (32) 13 (41) NA — 21 (36)
Countries with >10% deaths attributed to pneumonia among
children <5 years
2 (4) 20 (38) 43 (83) 35 (97) 2 (67) 102 (53)
PCV introductions in countries with high rates of
child pneumonia deaths
1 (50) 7 (35) 16 (37) 13 (37) 1 (50) 38 (37)
PCV coverage
Number of countries reporting 2011 coverage for 3 doses
of PCV
21 12 4 2 1 40
Median coverage for 3 doses of PCV in 2011 (92) (76) (44) (95) (99) (90)
Range (1–99) (46–98) (23–67) (93–97) (1–99)
Abbreviation: NA = not applicable.
* World Bank income groups are defined (in U.S. dollars) as follows: high-income countries = countries with a 2011 gross national income (GNI) per capita ≥$12,476;
upper-middle income countries = countries with a 2011 GNI <$12,476 and ≥$4,036; lower-middle income countries = countries with a 2011 GNI <$4,035 and ≥$1,027;
and low-income countries = countries with a 2011 GNI ≤$1,026. Additional information is available at http://data.worldbank.org/indicator/ny.gnp.pcap.cd.
† Countries with no income status: Cook Islands, Nauru, and Niue.

Morbidity and Mortality Weekly Report
MMWR / April 26, 2013 / Vol. 62 / No. 16 311
countries having introduced PCV (44%) and the propor-
tion of the world’s birth cohort living in countries that have
introduced PCV (31%). Low- and middle-income countries
lagged behind high-income countries, with all low-income
introductions attributed to GAVI Alliance support. Middle-
income countries are not eligible for GAVI Alliance support
and need to weigh vaccine procurement and operational costs
against costs of other health priorities. Additionally, only two
companies (Pfizer and GlaxoSmithKline) manufacture any
of the three PCV formulations; each formulation is supplied
by one company and insufficient supply has led to delays in
planned introductions in some countries. Although pneumonia
is a leading killer of children in the majority of countries, the
disease burden preventable by PCV might be unrecognized,
decreasing local demand for the vaccine. Improved data on the
impact of PCV vaccination in reducing and preventing disease
caused by Streptococcus pneumoniae will help guide policy deci-
sions about PCV introduction and sustained use (1).
The findings of this report are subject to at least two limi-
tations. First, the vaccination coverage estimates might differ
from actual coverage because of inaccurate reporting of target
population size or number of doses administered. Additionally,
coverage estimates were only from countries using PCV for at
least 2 years and might not be reflective of coverage achieved
in all settings.
In spite of these challenges, the rate at which PCV has been
introduced into childhood immunization programs worldwide
has been faster than that of other new vaccines in the past (8).
In addition to WHO recommendations and GAVI Alliance
support, other measures are encouraging PCV use around
the world. WHO and UNICEF promote PCV use in the
integrated Global Action Plan for Pneumonia and Diarrhoea
(GAPPD) as a comprehensive approach to reducing pneumo-
nia morbidity and mortality and as an important strategy for
achieving United Nations Millennium Development Goal 4
to reduce child mortality (9). Further information on the mag-
nitude of PCV benefits in low- and middle-income countries
might encourage more policy makers to introduce PCV into
immunization programs; studies are ongoing and data on the
impact and effectiveness of PCV in reducing disease caused by
Streptococcus pneumoniae in these settings is being prepared for
publication. A WHO manual for measuring the impact of the
Haemophilus influenzae type b conjugate vaccine and PCV can
assist with designing studies to determine how PCV performs
in a variety of settings.§ The progress of PCV introductions
noted in this report and anticipated PCV introductions in
coming years will help reduce the burden of pneumonia and
pneumococcal disease worldwide.
References
1. World Health Organization. Pneumococcal vaccines; WHO position
paper—2012. Wkly Epidemiol Rec 2012;87:129–44.
2. World Health Organization. Pneumococcal conjugate vaccine for
childhood immunization—WHO position paper. Wkly Epidemiol Rec
2007;82:93–104.
3. O’Brien KL, Wolfson LJ, Watt JP, et al. Burden of disease caused by
Streptococcus pneumoniae in children younger than 5 years: global estimates.
Lancet 2009;374:893–902.
4. Johnson HL, Deloria-Knoll M, Levine OS, et al. Systematic evaluation
of serotypes causing invasive pneumococcal disease among children
under five: the pneumococcal global serotype project. PLoS Med
2010;7(10):pii:e1000348.
5. World Health Organization. Immunization surveillance, assessment and
monitoring: data, statistics and graphics. Geneva, Switzerland: World
Health Organization; 2012. Available at http://www.who.int/
immunization_monitoring/data/en.
6. United Nations Children’s Fund. The state of the world’s children 2012:
children in an urban world. New York, New York: United Nations Children’s
Fund; 2012. Available at http://www.unicef.org/sowc2012/index.php.
7. GAVI Alliance. Countries approved for support. Geneva, Switzerland:
GAVI Alliance; 2013. Available at http://www.gavialliance.org/results/
countries-approved-for-support.
8. Levine OS, Knoll MD, Jones A, Walker DG, Risko N, Gilani Z. Global
status of Haemophilus influenzae type b and pneumococcal conjugate
vaccines: evidence, policies, and introductions. Curr Opin Infect Dis
2010;23:236–41.
9. World Health Organization, United Nations Children’s Fund. Ending
preventable child deaths from pneumonia and diarrhoea by 2025: the
integrated Global Action Plan for Pneumonia and Diarrhoea (GAPPD).
Geneva, Switzerland: World Health Organization; 2013. Available at
http://www.who.int/maternal_child_adolescent/documents/global_
action_plan_pneumonia_diarrhoea/en/index.html.
What is already known on this topic?
Globally, Streptococcus pneumoniae is a significant cause of
pneumonia, meningitis, and sepsis in children aged <5 years
and leads to an estimated 14.5 million episodes of serious
disease and approximately 500,000 deaths annually.
Pneumococcal conjugate vaccines (PCVs) are safe and effective
for prevention of this disease, and the World Health
Organization (WHO) recommends that PCV be included in all
routine immunization programs.
What is added by this report?
PCV use increased from one (1%) WHO member state in 2000 to
86 (44%) in 2012. Gaps in PCV introductions were noted in Asia
and in countries with large birth cohorts; only 31% of the
world’s birth cohort currently has access to PCV. WHO recom-
mendations for use, financial support through the GAVI Alliance
for PCV introduction in lower-income countries, and newer PCV
formulations that protect against additional serotypes likely
contributed to the increased use of PCV.
What are the implications for public health practice?
Increased use of PCV will help reduce the incidence of pneumo-
nia and pneumococcal disease worldwide. The success of PCV
introductions and the lessons learned from countries that have
added PCV to their immunization programs will help guide
decisions about future PCV introductions and sustained use.
§ Available at http://www.who.int/immunization/documents/WHO_IVB_12.08/
en/index.html.

Morbidity and Mortality Weekly Report
312 MMWR / April 26, 2013 / Vol. 62 / No. 16
Tubersol, a product of Sanofi Pasteur Limited, is in short sup-
ply nationwide until at least the end of May 2013. Tubersol is
one of two purified-protein derivative (PPD) tuberculin products
licensed by the Food and Drug Administration (FDA). The
manufacturer has notified CDC that 50-dose vials of Tubersol
will remain unavailable until the end of May 2013 and that
supplies of 10-dose vials are still being reestablished: the product
is available only by contacting Sanofi directly (at https://www.
vaccineshoppe.com/index.cfm? or telephone, 800-822-2463).
JHP Pharmaceuticals, LLC, the manufacturer of Aplisol, the
other PPD tuberculin product licensed by FDA, has notified
FDA that the product is available in restricted quantity. Acute
local shortages of Aplisol also have been reported to CDC by TB
control officials, as health-care providers switch from Tubersol
to Aplisol. The shortages of Aplisol probably will diminish as
Tubersol supplies are restored to their preshortage availability
in the normal distribution networks. This report advises public
health officials, clinicians, and workers in occupational health
and infection control about how to adapt to the shortage.
Two kinds of immunologic methods are used for detecting
Mycobacterium tuberculosis infection: tuberculin skin tests (TSTs)
and interferon-γ release assay (IGRA) blood tests. The indications
for use of these tests are the same, although one or the other
method is preferred for certain populations (1), and this could
play a role in setting priorities when one of the methods is unavail-
able. Together, these tests are the only means for detecting latent
M. tuberculosis infection, and they contribute to diagnosing tuber-
culosis (TB) disease. When findings such as chest radiography,
nucleic acid amplification test of sputum, and/or mycobacterial
cultures are sufficient for confirming or excluding TB, the results
from a TST or an IGRA blood test might not be needed (2).
A negative TST or IGRA result does not exclude the possibility
of TB infection because some persons can have a compromised
ability to react to tests for TB infection. However, most persons
diagnosed with TB in the United States have had a positive TST
or IGRA blood test that has contributed to that diagnosis. When
TB disease is strongly suspected, specific treatment should be
started regardless of results of a TST or an IGRA blood test (1,3).
In controlled studies, the agreement between TST results
from Tubersol and Aplisol is high. The agreement between
results from a TST and an IGRA blood test or between results
from the two commercial IGRA blood tests is lower (1).
CDC recommends any of the following three general
approaches for addressing the shortages of TST antigens:
1. Substitute IGRA blood tests for TSTs. Although the costs
associated with the blood tests themselves can be greater
than the cost of TSTs, the use of the blood tests might
be more cost-effective in certain settings because their
improved specificity in persons who have had previous
Bacille Calmette-Guérin (BCG) immunization or exposure
to nontuberculous mycobacteria might allow for better
targeting of preventive therapy. The blood tests require
phlebotomy, preparation of blood specimens, and specific
laboratory services for analysis; these tests are not available
in all practice settings. Clinicians who use the IGRA blood
tests should be aware that the criteria for test interpretation
are different from criteria for interpreting TSTs (1).
2. Allocate TSTs to priority indications, such as TB contact
investigations, as determined by public health authori-
ties. This might require deferment of testing some per-
sons. CDC does not recommend testing persons who
are not at risk for TB (4).
3. Substitute Aplisol for Tubersol for skin testing. In cross-
sectional studies, the two products give similar results
for most patients. Shortages of Aplisol are expected to
become more widespread, limiting the feasibility of
this approach.
Some surveillance programs for TB infection control rely
on routine serial TSTs. Switching products or methods might
make changes in serial results difficult to interpret: the apparent
conversions of results from negative to positive or reversions
from positive to negative could be caused by inherent inter-
product or intermethod discordance (1,5). In settings with a
low likelihood of TB exposure, the deferment of routine serial
testing should be considered in consultation with public health
and occupational health authorities.
Reported by
John Jereb, MD, Sundari Mase, MD, Terence Chorba, MD,
Kenneth Castro, MD, Div of Tuberculosis Elimination,
National Center for HIV, Hepatitis, STDs, and Tuberculosis
Prevention, CDC. Corresponding contributor: John Jereb,
MD, jjereb@cdc.gov, 404-639-5316.
References
1. CDC. Updated guidelines for using interferon gamma release assays to
detect Mycobacterium tuberculosis infection—United States, 2010.
MMWR 2010;59(No. RR-5).
2. American Thoracic Society. Diagnostic standards and classification of
tuberculosis in adults and children. Am J Respir Crit Care Med 2000;
161(4 Pt 1):1376–95. Available at http://www.cdc.gov/tb/publications/
pdf/1376.pdf.
3. CDC. Treatment of tuberculosis. MMWR 2003;52(No. RR-11).
4. CDC. Targeted tuberculin testing and treatment of latent tuberculosis
infection. MMWR 2000;49(No. RR-6).
5. CDC. Guidelines for preventing the transmission of Mycobacterium
tuberculosis in health-care settings, 2005. MMWR 2005;54(No. RR-17).
National Shortage of Purified-Protein Derivative Tuberculin Products

Morbidity and Mortality Weekly Report
MMWR / April 26, 2013 / Vol. 62 / No. 16 313
Acute Pesticide-Related Illness Resulting from
Occupational Exposure to Acrolein — Washington
and California, 1993–2009
Acrolein is an aquatic herbicide used in the western United
States to prevent impaired water flow in irrigation canals.
Despite its toxicity, few cases of acrolein-related illness have
been reported in the literature. On August 15, 2012, an
irrigation district notified the Washington State Department
of Labor & Industries (L&I) of acrolein-related illness in
one of its pesticide applicators. L&I inspected the site and
interviewed the exposed worker, coworkers, and employer.
The Washington State Department of Health assisted by
obtaining medical records, interviewing the patient and hos-
pital staff, and reviewing information obtained from L&I.
To look for additional cases, CDC reviewed data from the
SENSOR-Pesticides program* and the California Department
of Pesticide Regulation for 1993–2009, the most recent years
of data availability, and identified seven additional cases of
acute acrolein-related illness.
A licensed aquatic pesticide applicator aged 57 years, previ-
ously healthy and employed for 15 years by an irrigation district
in Washington, was exposed to acrolein while monitoring an
application† to an irrigation canal in the Quincy-Columbia
Basin. The man was not wearing the label-required respiratory
protection, gloves, or a long-sleeved shirt§ when he investigated
a leak in the connection between the acrolein tank and the
metal assembly through which acrolein flows.
Almost immediately after exposure to the leak the worker had
burning, watery eyes. Within 2 hours he experienced throat
tightness, difficulty breathing, inability to swallow, moderate
phlegm production, vomiting, and inability to talk because
of dyspnea. He was admitted to the intensive-care unit and
approximately 6 hours after exposure developed right facial
droop but no other weakness or paresthesias. Supportive treat-
ment was provided, including administration of epinephrine.
Approximately 48 hours after exposure, the patient went into
ventricular fibrillation and concomitantly experienced a grand
mal seizure. His condition was ultimately stabilized, and he was
discharged to home after a 3-week hospitalization. He received
a diagnosis of lateral medullary syndrome and continued to
have dysphagia, right-sided facial droop, and left-sided altered
thermal skin sensitivity. He returned to work at the irritation
district for 1 month in January 2013 but is not currently work-
ing because of ongoing medical conditions.
CDC identified seven additional cases of acute acrolein-
related illness in the United States during 1993–2009, all
in California. Five cases were among workers employed by
irrigation districts, of whom four were pesticide applicators
and one maintained pesticide application equipment. Six of
the workers were men, and the mean age was 41 years (range:
24–53 years). Four workers had low severity illness, and three
had illness of moderate severity.¶ Common symptoms were
eye irritation (five workers), headache (three), dyspnea (two),
and skin irritation or burns (two). No worker was hospitalized,
but two lost time from work.
Acrolein is highly volatile, producing an extremely irritat-
ing vapor that is highly reactive and acts by degrading cellular
structures by cross-linking proteins (1). Acrolein also can
produce inflammation of the heart, and ventricular fibrilla-
tion can occur in the setting of epinephrine administration
combined with an acrolein-induced catecholamine release
(2). Although acrolein is measureable in blood and urine,
these tests are not commonly available and are not useful in
assessing exposure (3).
Because of its toxicity, acrolein is applied only through closed
systems, which prevents its release into the air. Such systems are
not closed during set up and break down, and visual inspection
of application equipment can involve exposure to leaks; there-
fore, applicators must comply with stringent requirements for
personal protective equipment (PPE) when performing these
activities (1). Use of a closed application system combined
with annual training, applicator certification,** adherence
to the manufacturer’s other operating procedures for acrolein
(4), and compliance with PPE requirements are expected to
Notes from the Field
* Additional information available at http://www.cdc.gov/niosh/topics/pesticides/
overview.html.
† Magnacide H Herbicide, Baker Petrolite Corporation, EPA registration number
10707-9.
§
Label-required PPE includes a long-sleeved shirt and long pants, shoes, and
socks, chemical-resistant gloves made of butyl rubber, and a National Institute
of Occupational Safety and Health–approved full-face respirator with either
an organic-vapor-removing cartridge with a prefilter approved for pesticides or
a canister approved for pesticides.
¶ Severity of illness and injury of cases can be categorized into four groups using
standardized criteria for state-based surveillance programs: low, moderate,
high, and death. In low severity cases, illness/injury usually resolves without
treatment and <3 days are lost from work. Moderate severity cases involve
non–life-threatening health effects that are generally systemic and require
medical treatment. No residual disability is detected, and time lost from work
is ≤5 days. Additional information available at http://www.cdc.gov/niosh/
topics/pesticides/pdfs/pest-sevindexv6.pdf.
** Additional information available at http://www.epa.gov/oppfead1/safety/
applicators/applicators.htm.

Morbidity and Mortality Weekly Report
314 MMWR / April 26, 2013 / Vol. 62 / No. 16
effectively prevent exposures of concern to workers (1). Use
of nonchemical means to prevent clogging of irrigation canals
with weeds and algae (e.g., mechanical harvesting, sediment
removal, canal lining, and replacing the canal with piping)
have been considered by irrigation districts in Washington
but found not feasible because of cost and the potential for
increased risk for injury to workers (5).
Reported by
Luis Rodriguez, Joanne Prado, Washington State Dept of
Health. April Holland, California Dept of Pesticide Regulation;
John Beckman, California Dept of Public Health. Geoffrey M.
Calvert, MD, Div of Surveillance, Hazard Evaluations, and
Field Studies, National Institute for Occupational Safety and
Health, CDC. Corresponding contributor: Geoffrey M. Calvert,
gcalvert@cdc.gov, 513-841-4448.
References
1. US Environmental Protection Agency. Reregistration eligibility decision
document for acrolein. Washington DC: US Environmental Protection
Agency; 2008. Available at http://www.epa.gov/oppsrrd1/REDs/
acrolein_red.pdf.
2. Beauchamp RO Jr, Andjelkovich DA, Kligerman AD, Morgan KT, Heck
HD. A critical review of the literature on acrolein toxicity. Crit Rev Toxicol
1985;14:309–80.
3. Agency for Toxic Substances and Disease Registry. Toxicological profile
for acrolein. Atlanta, GA: US Department of Health and Human Services,
Public Health Service, Agency for Toxic Substances and Disease Registry;
2007. Available at http://www.atsdr.cdc.gov/toxprofiles/tp124.pdf.
4. Baker Petrolite. Magnacide H herbicide application and safety manual.
Bakersfield, CA: Baker Petrolite Corporation; 2005.
5. Washington State Department of Ecology. Fact sheet for the irrigation
system aquatic weed control National Pollutant Discharge Elimination
System (NPDES) and state waste discharge general permit. Olympia,
WA: Washington State Department of Ecology; 2012. Available
at http://www.ecy.wa.gov/programs/wq/pesticides/irrigation/docs/
irrigationfsrtc051612.pdf.

Morbidity and Mortality Weekly Report
MMWR / April 26, 2013 / Vol. 62 / No. 16 315
Exposures to Discarded Sulfur Mustard Munitions
— Mid-Atlantic and New England States
2004–2012
Before the 1970s, the United States sometimes disposed of
at sea excess, obsolete, or unserviceable munitions, including
chemical munitions (1). Chemical munitions known to have
been disposed of at sea included munitions filled with sulfur
mustard, a vesicant (i.e., an agent that causes chemical burns
or blisters of the skin and mucous membranes) (2). Signs and
symptoms of exposure to a mustard agent can include redness
and blistering of the skin, eye irritation, rhinorrhea, hoarse-
ness, shortness of breath, and (rarely) diarrhea and abdominal
discomfort. Since 2004, CDC has received notification of three
separate incidents of exposure to sulfur mustard munitions.
In one incident, a munition was found with ocean-dredged
marine shells used to pave a driveway. The other two incidents
involved commercial clam fishing operations. This report
highlights the importance of considering exposure to sulfur
mustard in the differential diagnosis of signs and symptoms
compatible with exposure to a vesicant agent, especially among
persons involved with clam fishing or sea dredging operations.
Case Reports
Case 1. In 2004, U.S. Air Force Explosive Ordnance
Disposal (EOD) personnel responded to discovery of an artil-
lery shell protruding from a Delaware driveway paved with
crushed clamshells (3). They recovered the shell and moved it
to Dover Air Force Base for destruction using standard EOD
procedures. During handling a “black, tar-like substance”
began to drip, and two members required treatment for chemi-
cal burns after large pus-filled blisters developed on their hands
and arms. One EOD team member required hospitalization as
a result of the exposure. Sulfur mustard exposure was confirmed
by chemical analysis. After this incident, the Department of
Defense made the Army’s policy and procedures for address-
ing liquid-filled munitions applicable to the Air Force and all
other military services.
Case 2. In 2010, commercial fishermen recovered an
unknown number of munitions during dredging for clams
off the coast of Long Island, New York (4). During the effort
to dump the munitions back in the ocean, a munition was
dropped on the deck of the boat, resulting in the release of
a black liquid substance. Drops of the substance also landed
on the clothing covering the leg and arm of a crew member,
and another crew member was exposed to fumes. After sev-
eral hours, both crew members felt ill and were subsequently
transported to a local hospital for evaluation. One crew
member was evaluated and released. The other crew member
developed small blisters on his forearm and upper thigh. These
injuries were recognized by a nurse trained in chemical agent
injuries as compatible with exposure to sulfur mustard. Sulfur
mustard exposure was confirmed by chemical analysis.
Case 3. In 2012, a 75-mm projectile was recovered at a
clam processing plant in Delaware. Reportedly, it had been
brought to the plant accidentally during dredging operations
for clams in Delaware Bay. An EOD team removed the muni-
tion for disposal (5). The munition involved was determined
to contain mustard agent. None of the potentially exposed
persons developed signs or symptoms of exposure to mustard.
Clam fishermen told investigators that they routinely recover
munitions that often “smell like garlic,” a potential indication
of the presence of a chemical agent.
Diagnosis and Management of Suspected Cases
Mustard agent is listed in the Chemical Weapons Convention
as an agent used in chemical munitions. Clinicians suspect-
ing mustard exposure should consult with their state or local
health department and poison control center regarding the
need for follow-up and investigation of potential exposures.
CDC’s Chemical Weapons Elimination Program can provide
technical consultation and laboratory services to assist clini-
cians with testing, diagnosis, and management of suspected
cases. Program staff members can be contacted through the
duty officer at the CDC Emergency Operations Center at
770-488-7100.
Additional information regarding the U.S. Army Chemical
Material Activity programs is available by contacting the Public
Affairs Office by telephone, 800-488-0648. Additional infor-
mation regarding CDC programs associated with chemical
weapons is available by telephone at 800-CDC-INFO.
Reported by
Russell Fendick, Non-Stockpile Chemical Material, US Army
Chemical Material Activity. JC King, Office of the Deputy
Assistant Secretary of the Army for Environment Safety and
Occupational Health. Terry Tincher, MS, Marilyn Radke, MD,
Gino Begluitti, Chemical Weapons Elimination Program, Miguel
Cruz, MPH, Mark Keim, MD, Michael Schwartz, MD, Office
of Environmental Health Emergencies, National Center for
Environmental Health/Agency for Toxic Substances and Disease
Registry; Lisa Delaney, MPH, National Institute for Occupational
Safety and Health. CDC. Corresponding contributor: Terry
Tincher, ttincher@cdc.gov, 770-488-0700.
Notes from the Field

Morbidity and Mortality Weekly Report
316 MMWR / April 26, 2013 / Vol. 62 / No. 16
References
1. US Army Technical Center for Explosives Safety. Munitions at sea: a guide
for commercial maritime industries. McAlester, OK: Defense Ammunition
Center, US Army Technical Center for Explosives Safety. Available at
http://www.history.navy.mil/library/online/munitionsatsea.htm.
2. Agency for Toxic Substances and Disease Registry. Toxic substances portal:
sulfur mustard. Atlanta, GA: Available at Agency for Toxic Substances
and Disease Registry; 2011. Available at http://www.atsdr.cdc.gov/toxfaqs/
TF.asp?id=904&tid=184.
3. Carroll LS. Sulfur mustard: cutaneous exposure. Clin Toxicol 2005;43:55.
4. Weibrecht K, Rhyee S, Manuell ME, Longo C, Boyer EW, Brush E. Sulfur
mustard exposure presenting to a community emergency department.
Ann Emerg Med 2012;59:70–4.
5. WBOC 16. Delaware seafood facility evacuated after military ordnance
found. July 2, 2012. Available at http://www.wboc.com/story/18915482/
unexploded-ordnance-uncovered-at-del-clam-processing-facility.

Morbidity and Mortality Weekly Report
MMWR / April 26, 2013 / Vol. 62 / No. 16 317
National Campaign to Prevent Falls in
Construction — United States, 2013
Each day, on average, two construction workers die in
the United States (1). In 2010, the 9.1 million construction
workers (including self-employed workers) in the United
States accounted for 7% of the national workforce (2), yet
experienced 17.1% of fatal work-related injuries (2). In
2011, the rate of fatal injuries in construction was the second
highest of any U.S. industry (3). Within the industry, falls at
construction sites are the leading cause of death, accounting
for 35% of deaths among private sector construction work-
ers (not including government or self-employed workers) in
2011 (1); most of these deaths were attributed to falls from
roofs, scaffolds, and ladders (2). Deaths and injuries from falls
represent a major, persistent, yet preventable public health
problem. Safe construction requires both skilled workers and
responsible employers.
CDC’s National Institute for Occupational Safety and Health
has engaged the construction sector through a government/
labor/management partnership, representing state and federal
government agencies, professional organizations, trade asso-
ciations, labor organizations, and private industry. The goal,
in part, is to develop a national campaign aimed at construc-
tion contractors, onsite supervisors, and workers to address
and reduce falls, fall-related injuries, and fall-related fatalities
among construction workers. On Workers’ Memorial Day,
April 28, 2013, a national information and media campaign
will be launched again through this partnership.
References
1. Bureau of Labor Statistics. Census of Fatal Occupational Injuries
(CFOI)—current and revised data. Washington, DC: US Department
of Labor, Bureau of Labor Statistics; 2012. Available at http://www.bls.
gov/iif/oshcfoi1.htm#2011.
2. CPWR—The Center for Construction Research and Training. The
construction chartbook. 5th ed. Silver Spring, MD: CPWR; 2013. Available
at http://www.cpwr.com.
3. Bureau of Labor Statistics. Economic news release: census of fatal
occupational injuries summary, 2011 (preliminary results). Washington, DC:
US Department of Labor, Bureau of Labor Statistics; 2012. Available at
http://bls.gov/news.release/cfoi.nr0.htm.
Announcements
Amyotrophic Lateral Sclerosis (ALS) Awareness
Month — May 2013
May is Amyotrophic Lateral Sclerosis (ALS) Awareness
Month. ALS, also known as Lou Gehrig’s disease, is a progres-
sive, fatal, neurodegenerative disorder of both the upper and
lower motor neurons. Persons with ALS usually die within
2–5 years of diagnosis. The etiology of ALS is not well under-
stood, and currently there is no cure.
In October 2010, the federal Agency for Toxic Substances
and Disease Registry (ATSDR) launched the National ALS
Registry to collect and analyze data regarding persons with
ALS in the United States. The main goals of the registry are
to determine the incidence and prevalence of ALS within the
United States, characterize the demographics of those living
with ALS, and examine the potential risk factors for the disease.
The registry uses data from existing national databases, includ-
ing the Centers for Medicare and Medicaid Services and the
U.S. Department of Veterans Affairs, as well as information
provided by persons with ALS through a secure online web
portal, available at http://www.cdc.gov/als. At the web portal,
registrants can take brief online surveys regarding potential risk
factors for the disease.
To achieve the registry’s goals, ATSDR is collaborating
with the ALS Association (http://www.alsa.org), Muscular
Dystrophy Association (http://www.als-mda.org), Les Turner
Foundation (http://www.lesturnerals.org), and other organiza-
tions to make all persons with ALS and their families aware of
the opportunity to register in the National ALS Registry. When
sufficient data have been gathered to provide a representative
picture of persons with ALS, ATSDR will begin analyzing the
data and providing deidentified information so that researchers
can gain a better understanding of the disease.
In addition to enrolling persons with ALS, ATSDR also has
undertaken various initiatives to help strengthen the registry.
These include implementing active surveillance activities to
help evaluate the completeness of the registry in three states
and eight metropolitan areas, funding a bioregistry feasibility
study to link potential specimen data collected (e.g., blood,
saliva, and tissue) with existing registry surveys, and funding
external research on ALS risk factors and burden of disease.
Additionally, ATSDR has launched a new research notifica-
tion mechanism that puts researchers directly in contact with
registry enrollees who are interested in taking part in new
clinical trials and epidemiologic studies. Additional informa-
tion regarding these initiatives and the National ALS Registry
is available at http://www.cdc.gov/als.

Morbidity and Mortality Weekly Report
318 MMWR / April 26, 2013 / Vol. 62 / No. 16
Healthy Vision Month — May 2013
The May 2013 theme for Healthy Vision Month is “Healthy
Vision: Make It Last a Lifetime.” CDC’s Vision Health
Initiative joins with the National Institutes of Health’s National
Eye Institute in encouraging everyone to make vision and eye
health a lifetime priority.
In 2010, approximately 4 million persons in the United
States aged ≥40 years had vision impairment (including low
vision and blindness); by 2050, this number is projected to
reach 13 million (1). Vision impairment is associated with
inability to perform daily activities such as reading, driving a
car, and preparing meals. Vision impairment also is associated
with an increased risk for falls, fall-related injuries, depression,
and reduced overall health (2–4). Millions of persons in the
United States have undetected vision problems and eye dis-
eases. Vision disorders are the seventh most common chronic
condition for persons aged ≥65 years, the ninth most common
for those aged 50–64 years, and the third most common for
those aged ≤17 years (5,6).
Early detection, timely treatment, and the use of proper eye
safety practices can prevent or delay vision impairment. The
American Optometric Association and the American Academy
Announcements
of Ophthalmology recommend a regular, comprehensive
dilated eye examination to potentially detect and treat vision
problems early. Additional information about activities that
promote prevention, early detection, and treatment of eye
diseases leading to vision impairment is available at http://www.
cdc.gov/visionhealth and http://www.nei.nih.gov/healthyeyes.
References
1. National Eye Institute. Projections for vision impairment (2010–2030–
2050). Bethesda, MD: National Institutes of Health, National Eye
Institute; 2010. Available at http://www.nei.nih.gov/eyedata/vision_
impaired.asp#4.
2. Li Y, Crews JE, Elam-Evans LD, et al. Visual impairment and health-
related quality of life among elderly adults with age-related eye disease.
Qual Life Res 2011;20:845–52.
3. Wood JM, Lacherez P, Black AA, Cole MH, Boon MY, Kerr GK. Risk
of falls, injurious falls, and other injuries resulting from visual impairment
among older adults with age-related macular degeneration. Invest
Opththalmol Vis Sci 2011;52:5088–92.
4. Zhang X, Bullard KM, Cotch MF, et al. Association between depression
and functional vision loss in persons 20 years of age or older in the United
States, NHANES 2005–2008. JAMA Ophthalmol 2013 Mar 7:1–9.
5. Anderson G. Chronic care: making the case for ongoing care. Princeton,
NJ: Robert Wood Johnson Foundation; 2010. Available at http://www.
rwjf.org/files/research/50968chronic.care.chartbook.pdf.
6. Martin LG, Freeman VA, Schoeni RF, Andreski PM. Trends in disability
and related chronic conditions among people ages fifty to sixty-four.
Health Aff (Millwood) 2010:29:725–31.

Morbidity and Mortality Weekly Report
MMWR / April 26, 2013 / Vol. 62 / No. 16 319
* Per 1,000 population, based on 6-year annual average. Assault was determined if any one of the following
was the first-listed E-code: 960–969, homicide and injury purposely inflicted by other persons; 979, terrorism;
999.1, late effect of injury due to terrorism.
† 95% confidence interval.
During 2005–2010, approximately 388,000 emergency department visits were made each year by persons aged ≤18 years who
had been injured by assault, an overall rate of 5.0 visits per 1,000 persons per year. The visit rate for assault for non-Hispanic
blacks aged 13–18 years was 25.3 per 1,000 population, which was higher than the 8.4 rate for non-Hispanic whites and the 9.7
rate for Hispanics. Among children aged 0–12 years, the visit rate also was higher among non-Hispanic blacks (5.7) than among
non-Hispanic whites (1.6) or Hispanics (1.6).
Source: National Hospital Ambulatory Medical Care Survey 2005–2010. Available at http://www.cdc.gov/nchs/ahcd.htm.
Reported by: Linda F. McCaig, MPH, lmccaig@cdc.gov, 301-458-4365; Michael Albert, MD, wmy1@cdc.gov.
0
0–12 13–18
5
10
15
20
25
30
35
Rate
Age group (yrs)
†
White, non-Hispanic
Black, non-Hispanic
Hispanic
QuickStats
FROM THE NATIONAL CENTER FOR HEALTH STATISTICS
Average Annual Rate of Emergency Department Visits for Assault* Among
Persons Aged ≤18 Years, by Age Group and Race/Ethnicity —
United States, 2005–2010

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