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1.  Alaska's model program for surveillance and prevention of occupational injury deaths. 
Public Health Reports  1999;114(6):550-558.
The National Institute for Occupational Safety and Health (NIOSH) established its Alaska Field Station in Anchorage in 1991 after identifying Alaska as the highest-risk state for traumatic worker fatalities. Since then, the Field Station, working in collaboration with other agencies, organizations, and individuals, has established a program for occupational injury surveillance in Alaska and formed interagency working groups to address the risk factors leading to occupational death and injury in the state. Collaborative efforts have contributed to reducing crash rates and mortality in Alaska's rapidly expanding helicopter logging industry and have played an important supportive role in the substantial progress made in reducing the mortality rate in Alaska's commercial fishing industry (historically Alaska's and America's most dangerous industry). Alaska experienced a 46% overall decline in work-related acute traumatic injury deaths from 1991 to 1998, a 64% decline in commercial fishing deaths, and a very sharp decline in helicopter logging-related deaths. Extending this regional approach to other parts of the country and applying these strategies to the entire spectrum of occupational injury and disease hazards could have a broad effect on reducing occupational injuries.
PMCID: PMC1308539  PMID: 10670623
2.  Traumatic occupational fatalities in South Carolina, 1989-90. 
Public Health Reports  1993;108(4):483-488.
Death certificates for South Carolina for 1989 and 1990 were examined to identify deaths resulting from injury incurred in the workplace. There were 277 deaths in that category in the 2-year period, an average yearly rate for traumatic occupational fatalities of 8.84 per 100,000 workers. The groups of industries with the highest fatality rates were transportation-communication-utilities, construction, and agriculture-fishing-forestry. The leading causes of death were injuries from motor vehicle crash, homicide, and falls. The traumatic occupational fatality rate for men was about 13 times greater than that for women; however, a much higher proportion of women died from homicide on the job. The findings in general reflect trends reported in other studies. The death rates for workers in South Carolina for 1989-90, however, were higher than national averages for 1980-88. National data for 1989-90 were not available for comparison. The data suggest that more effective injury prevention efforts need to be applied to such causes of on-the-job injury as motor vehicle crash, homicide, and falls. Those three categories accounted for more than 56 percent of all traumatic occupational fatalities in South Carolina in 1989 and 1990. Motor vehicle crash prevention efforts particularly are needed in the transportation-communication-utilities industries. The findings show that particular efforts need to be directed to the retail trade category for prevention of homicide and to the construction industry for prevention of falls.
PMCID: PMC1403413  PMID: 8341784
3.  Fatal work-related farm injuries in Canada, 1991-1995. Canadian Agricultural Injury Surveillance Program 
BACKGROUND: Studies from other developed countries have shown that agriculture is among the most dangerous occupational sectors in terms of work-related deaths. The authors describe the occurrence of fatal work-related farm injuries in Canada and compare these rates with those in other Canadian industries. METHODS: The authors present a descriptive, epidemiological analysis of data from the recently established Canadian Agricultural Injury Surveillance Program. The study population comprised Canadians who died from work-related farm injuries between 1991 and 1995. Crude, age-standardized, age-specific and provincial rates of such injuries are presented, as are overall death rates in other Canadian industries. Other factors examined were the people involved, the mechanism of injury, and the place and time of injury. RESULTS: There were 503 deaths from work-related farm injuries during the study period, for an overall annual rate of 11.6 deaths per 100,000 farm population. Modest excesses in this rate were observed in Ontario, Quebec and the Atlantic provinces. High rates were observed among men of all ages and among elderly people. Among the cases that listed the person involved, farm owner-operators accounted for 60.2% of the people killed. There was no substantial increase or decrease in the annual number of deaths over the 5 years of study. The leading mechanisms of fatal injury included tractor rollovers, blind runovers (person not visible by driver), extra-rider runovers, and entanglements in machinery. Compared with other industries, agriculture appears to be the fourth most dangerous in Canada in terms of fatal injury, behind mining, logging and forestry, and construction. INTERPRETATION: Canada now has a national registry for the surveillance of fatal farm injuries. Farming clearly is among the most dangerous occupations in Canada in terms of fatal work-related injuries. Secondary analyses of data from this registry suggest priorities for prevention, continued surveillance and in-depth research.
PMCID: PMC1230438  PMID: 10405669
4.  Preventing commercial fishing deaths in Alaska 
OBJECTIVES: To evaluate the effectiveness of the United States Commercial Fishing Industry Vessel Safety Act of 1988 in reducing the high occupational death rate (200/100,000/year in 1991-2) among Alaska's commercial fishermen. METHODS: Comprehensive surveillance of deaths in commercial fishing was established by our office during 1991 and 1992 for Alaska. Demographic data and data on risk factors and incidents were compiled and analysed for trend. RESULTS: During 1991-8, there was a significant (p < 0.001) decrease in deaths in Alaska related to commercial fishing. Although drownings from fishermen falling overboard and events related to crab fishing vessels (often conducted far offshore and in winter) have continued to occur, marked progress (significant downward trend, p < 0.001) has been made in saving the lives of people involved in vessels capsizing and sinking. CONCLUSIONS: Specific measures tailored to prevent drowning associated with vessels capsizing and sinking in Alaska's commercial fishing industry have been successful. However, these events continue to occur, and place fishermen and rescue personnel at substantial risk. Additional strategies must be identified to reduce the frequency of vessels capsizing and sinking, to enable parallel improvements in the mortality among crab fishermen, and to prevent fishermen falling overboard and drownings associated with them.
PMCID: PMC1757672  PMID: 10658549
5.  Occupational injury deaths of 16 and 17 year olds in the US: trends and comparisons with older workers. 
Injury Prevention  1997;3(4):277-281.
OBJECTIVE: To examine patterns of occupational injury deaths of 16 and 17 year olds in the United States for the three year period 1990-2, examine trends since the 1980s, and compare fatality rates with those of older workers. METHODS: Occupational injury deaths were analyzed using the death certificate based National Traumatic Occupational Fatalities (NTOF) surveillance system. Fatality rates were calculated using estimates of full time equivalent (FTE) workers based on data from the Current Population Survey, a monthly household survey. RESULTS: There were 111 deaths of 16 and 17 year olds for the years 1990-2. The average yearly rate was 3.5 deaths/100,000 FTE. The leading causes of death were motor vehicle related, homicide, and machinery related. All causes occupational injury fatality rates for 16 and 17 year olds were lower than for adults for 1990-2. Rates for the leading causes of death (motor vehicle related, homicide, and machinery related) were comparable or slightly higher than the rates for young and middle aged adult workers. Although rates decreased dramatically from 1980 to 1983, the decreasing trend attenuated in later years. CONCLUSIONS: Comparisons of youth fatality rates to those of adult workers should address differences in patterns of employment, most importantly hours of work. Comparisons to narrow age groupings of adults is preferable to a single category of all workers 18 years and older. Increasing compliance with federal child labor regulations could help reduce work related deaths of youth. Other measures are needed, however, as there are many work hazards, including those associated with homicides, that are not addressed by United States federal child labor law regulations.
PMCID: PMC1067854  PMID: 9493624
6.  Drowning in Alaskan waters. 
Public Health Reports  1996;111(6):531-535.
OBJECTIVE: To enumerate drowning fatalities in Alaska in order to identify risk factors and areas for intervention. METHODS: Information from death certificates, state troopers' reports, and medical examiner reports were abstracted and analyzed. Rates were calculated using 1990 census figures as denominator data. RESULTS: There were 542 drowning fatalities in Alaska for the years 1988 to 1992. The 20-29 age group had the highest frequency and rate of drownings. The incidence rate for the state was 20 drownings per 100,000 population per year, almost 10 times higher than the overall U.S. rate of 2.11 per 100,000 per year. Incidence rates were highest among adolescent males (10-19), young adult males (20-29). Alaska Natives, and rural residents. Alaska Native males, ages 30-39 averaged 159 drownings per 100,000 per year, the highest drowning rates in the state. CONCLUSIONS: Drowning is a major public health concern in Alaska. People who fish commercially and young Native males are groups at high risk for drowning. Intervention efforts should be concentrated on these two populations.
PMCID: PMC1381902  PMID: 8955701
7.  Drowning in Aboriginal and Torres Strait Islander children and adolescents in Queensland (Australia) 
BMC Public Health  2015;15:795.
Aboriginal and Torres Strait Islander (Indigenous) children are at greater risk of drowning than other children, however little is known about drowning of Indigenous children. This study identifies the previously unpublished incidence and characteristics of fatal and non-fatal drowning in Indigenous children and adolescents.
Retrospective data (Jan 2002-Dec 2008) on fatal and non-fatal drowning events among Indigenous and Non-Indigenous Queensland residents aged 0-19 years were obtained from multiple sources across the continuum of care (pre-hospital; emergency department; admitted patients; fatality) and manually linked. Crude incidence rates for fatal and non-fatal events were calculated using population data from the Australian Bureau of Statistics.
There were 87 (6.7 % of all events) fatal and non-fatal (combined) Indigenous drowning events yielding a crude Incidence Rate of 16.8/100,000/annum. This is 44 % higher than the incidence rate for Non-Indigenous children. For every fatality, nine others were rescued and sought medical treatment (average 12 per year). There were no significant changes in Indigenous drowning incidents over the study period. Drowning rates were higher for Indigenous females than males. Overall incidence was higher among Indigenous children and adolescents than Non-Indigenous children for every calendar year and age-group (0-4 years; 5-9 years; 10-14 years) except those aged 15-19 years where no drowning events were recorded for males.
Location of drowning sites was similar in both populations 0-19 years, however there were slight differences in frequency at each of the locations. The three leading drowning locations for Indigenous 0-19 years olds were pool (48 %), bath (21 %) and natural water (16 %), and for non-Indigenous 0-19 years the leading locations were pool (66 %), natural water (13 %) and bath (12 %) (p < .01). Except for pool drowning, Indigenous drowning occurred more often in geographic areas of relative disadvantage. Among Indigenous children drowning location varied with age (p < .001). Most frequent locations by age were: <1 year bath (71 %); 1-4 years pools (80 %); 5-9 years pools (75 %) and 10-19 years beach/ocean (36 %). Severity of event differed statistically with Indigenous status and by remoteness with all fatal drowning events occurring in Regional or Remote areas, and none in Major Cities.
For every fatal drowning among Indigenous children in Queensland aged 0-19 years there are nine non-fatal events. This previously unreported survival ratio of 9:1 indicates the non-fatal injury burden in Indigenous children aged 0-19 years. Although higher Indigenous drowning rates prevailed, no significant changes over time are concerning. Equally the apparent over-representation of Indigenous adolescent females should be weighed against the absence of drowning among Indigenous male adolescents in the same age group in consecutive years of the study. Further investigation around behaviour and culture may highlight protective factors. Culturally specific prevention strategies which take into account social and demographic indicators identified in this study should be delivered to carers and peers of vulnerable age groups who frequent specific locations. Females, swimming ability, supervision and the young are areas which need to be incorporated into Indigenous-specific interventions for drowning prevention.
PMCID: PMC4545709  PMID: 26286446
8.  Cancer Disparities Among Alaska Native People, 1970–2011 
Cancer is the leading cause of death among Alaska Native people. The objective of this study was to examine cancer incidence data for 2007–2011, age-specific rates for a 15-year period, incidence trends for 1970–2011, and mortality trends for 1990–2011.
US data were from the Surveillance, Epidemiology, and End Results (SEER) Program SEER*Stat database and from the SEER Alaska Native Tumor Registry. Age-adjusted cancer incidence rates among Alaska Native people and US whites were compared using rate ratios. Trend analyses were performed using the Joinpoint Regression Program. Mortality data were from National Center for Health Statistics.
During 2007–2011 the cancer incidence rate among Alaska Native women was 16% higher than the rate among US white women and was similar among Alaska Native men and US white men. Incidence rates among Alaska Native people exceeded rates among US whites for nasopharyngeal, stomach, colorectal, lung, and kidney cancer. A downward trend in colorectal cancer incidence among Alaska Native people occurred from 1999 to 2011. Significant declines in rates were not observed for other frequently diagnosed cancers or for all sites combined. Cancer mortality rates among Alaska Native people during 2 periods, 1990–2000 and 2001–2011, did not decline. Cancer mortality rates among Alaska Native people exceeded rates among US whites for all cancers combined; for cancers of the lung, stomach, pancreas, kidney, and cervix; and for colorectal cancer.
Increases in colorectal screening among Alaska Native people may be responsible for current declines in colorectal cancer incidence; however; improvements in treatment of colon and rectal cancers may also be contributing factors.
PMCID: PMC4273544  PMID: 25523352
9.  Foodborne Botulism in the United States, 1990–2000 
Emerging Infectious Diseases  2004;10(9):1606-1611.
Home-canned foods and Alaska Native foods are leading causes of U.S. foodborne botulism; botulism’s epidemic potential renders each case a public health emergency.
Foodborne botulism, a potentially lethal neuroparalytic disease, is caused by ingesting preformed Clostridium botulinum neurotoxin. We reviewed surveillance data and reports from 1990 to 2000. Of 263 cases from 160 foodborne botulism events (episode of one or more related cases) in the United States, 103 (39%) cases and 58 events occurred in Alaska. Patients' median age was 48 years; 154 (59%) were female; the case-fatality rate was 4%. The median number of cases per event was 1 (range 1–17). Toxin type A caused 51% of all cases; toxin type E caused 90% of Alaska cases. A particular food was implicated in 126 (79%) events. In the lower 49 states, a noncommercial food item was implicated in 70 (91%) events, most commonly home-canned vegetables (44%). Two restaurant-associated outbreaks affected 25 persons. All Alaska cases were attributable to traditional Alaska Native foods. Botulism prevention efforts should be focused on those who preserve food at home, Alaska Natives, and restaurant workers.
PMCID: PMC3320287  PMID: 15498163
botulism; surveillance; epidemiology; foodborne disease; Clostridium botulinum; research
10.  Abusive head trauma among children in Alaska: a population-based assessment 
International Journal of Circumpolar Health  2013;72:10.3402/ijch.v72i0.21216.
Serious physical abuse resulting in a traumatic brain injury (TBI) has been implicated as an underreported cause of infant mortality. Nearly 80% of all abusive head trauma (AHT) occurs among children <2 years of age, with infants experiencing an incidence nearly 8 times that of 2-year olds.
This study describes the validation of the CDC Pediatric Abusive Head Trauma (PAHT) definitions when applied to a multi-source database at the state level and provides a robust annual incidence estimate of AHT among children <2 years of age in Alaska.
AHT cases among children residing in Alaska during 2005–2010 were identified by applying the PAHT coding schema to a multi-source database which included vital death records, the Violent Death Reporting System (AK-VDRS), the Maternal Infant Mortality Review – Child Death Review (MIMR-CDR), the Alaska Trauma Registry (ATR), the inpatient Hospital Discharge Database (HDD) and Medicaid claims. Using these data, we calculated statewide AHT annual incidence rates.
The databases with the highest case capture rates were the ATR and Medicaid systems, both at 51%, followed by HDD at 38%. Combined, the ATR, HDD and Medicaid systems captured 91% of all AHT cases. The linkage and use of the PAHT definitions yielded an estimated sensitivity of 91% and specificity of 98%. During the study period, we detected an annual average incidence of 34.4 cases per 100,000 children aged <2 years (95% CI 25.1, 46.1) and a case fatality proportion of 22% (10/45). Among the AHT cases, 82% were infants. Significant differences (p < 0.05) in AHT were noted by age and race, but not by sex.
In Alaska, applying the CDC PAHT definition to the multi-source database enabled us to capture 49% more AHT cases than any of the individual database used in this analysis alone.
PMCID: PMC3754493  PMID: 23986886
child maltreatment; child abuse; abusive head trauma; traumatic brain injury; surveillance; epidemiology
11.  Effects of the Occupational Safety and Health Administration's control of hazardous energy (lockout/tagout) standard on rates of machinery‐related fatal occupational injury 
Injury Prevention  2007;13(5):334-338.
To evaluate the impact of the United States' federal Occupational Safety and Health Administration's control of hazardous energy (lockout/tagout) standard on rates of machinery‐related fatal occupational injury. The standard, which took effect in 1990, requires employers in certain industries to establish an energy control program and sets minimum criteria for energy control procedures, training, inspections, and hardware.
An interrupted time‐series design was used to determine the standard's effect on fatality rates. Machinery‐related fatalities, obtained from the National Traumatic Occupational Fatalities surveillance system for 1980 through 2001, were used as a proxy for lockout/tagout‐related fatalities. Linear regression was used to control for changes in demographic and economic factors.
The average annual crude rate of machinery‐related fatalities in manufacturing changed little from 1980 to 1989, but declined by 4.59% per year from 1990 to 2001. However, when controlling for demographic and economic factors, the regression model estimate of the standard's effect is a small, non‐significant increase of 0.05 deaths per 100 000 production worker full‐time equivalents (95% CI −0.14 to 0.25). When fatality rates in comparison groups that should not have been affected by the standard are incorporated into the analysis, there is still no significant change in the rate of machinery‐related fatalities in manufacturing.
There is no evidence that the lockout/tagout standard decreased fatality rates relative to other trends in occupational safety over the study period. A possible explanation is voluntary use of lockout/tagout by some employers before introduction of the standard and low compliance by other employers after.
PMCID: PMC2610620  PMID: 17916891
occupational safety; policy; evaluation; machine; manufacturing industry
12.  Examining Occupational Health and Safety Disparities Using National Data: A Cause for Continuing Concern 
Occupational status, a core component of socioeconomic status, plays a critical role in the well-being of U.S. workers. Identifying work-related disparities can help target prevention efforts.
Bureau of Labor Statistics workplace data were used to characterize high-risk occupations and examine relationships between demographic and work-related variables and fatality.
Employment in high-injury/illness occupations was independently associated with being male, Black, ≤high school degree, foreign-birth, and low-wages. Adjusted fatal occupational injury rate ratios for 2005–2009 were elevated for males, older workers, and several industries and occupations. Agriculture/forestry/fishing and mining industries and transportation and materials moving occupations had the highest rate ratios. Homicide rate ratios were elevated for Black, American Indian/Alaska Native/Asian/Pacific Islanders, and foreign-born workers.
These findings highlight the importance of understanding patterns of disparities of workplace injuries, illnesses and fatalities. Results can improve intervention efforts by developing programs that better meet the needs of the increasingly diverse U.S. workforce.
PMCID: PMC4556419  PMID: 24436156
occupational health disparities; injury; fatality; occupation; industry; race; ethnicity; nativity; SOII; CFOI; CPS
13.  Mortality trends among Alaska Native people: successes and challenges 
International Journal of Circumpolar Health  2013;72:10.3402/ijch.v72i0.21185.
Current mortality rates are essential for monitoring, understanding and developing policy for a population's health. Disease-specific Alaska Native mortality rates have been undergoing change.
This article reports recent mortality data (2004–2008) for Alaska Native/American Indian (AN/AI) people, comparing mortality rates to US white rates and examines changes in mortality patterns since 1980.
We used death record data from the state of Alaska, Department of Vital Statistics and SEER*Stat software from the National Cancer Institute to calculate age-adjusted mortality rates.
Annual age-adjusted mortality from all-causes for AN/AI persons during the period 2004–2008 was 33% higher than the rate for US whites (RR=1.33, 95% CI 1.29–1.38). Mortality rates were higher among AN/AI males than AN/AI females (1212/100,000 vs. 886/100,000). Cancer remained the leading cause of death among AN/AI people, as it has in recent previous periods, with an age-adjusted rate of 226/100,000, yielding a rate ratio (RR) of 1.24 compared to US whites (95% CI 1.14–1.33). Statistically significant higher mortality compared to US white mortality rates was observed for nine of the ten leading causes of AN/AI mortality (cancer, unintentional injury, suicide, alcohol abuse, chronic obstructive pulmonary disease [COPD], cerebrovascular disease, chronic liver disease, pneumonia/influenza, homicide). Mortality rates were significantly lower among AN/AI people compared to US whites for heart disease (RR=0.82), the second leading cause of death. Among leading causes of death for AN/AI people, the greatest disparities in mortality rates with US whites were observed in unintentional injuries (RR=2.45) and suicide (RR=3.53). All-cause AN/AI mortality has declined 16% since 1980–1983, compared to a 21% decline over a similar period among US whites.
Mortality rates and trends are essential to understanding the health of a population and guiding policy decisions. The overall AN/AI mortality rate is higher than that of US whites, although encouraging declines in mortality have occurred for many cause specific deaths, as well as for the overall rate. The second leading cause of AN/AI mortality, heart disease, remains lower than that of US whites.
PMCID: PMC3751233  PMID: 23977643
Native American; unintentional injury; suicide; death; vital statistics
14.  Comparison of work related fatal injuries in the United States, Australia, and New Zealand: method and overall findings 
Injury Prevention  2001;7(1):22-28.
Objectives—To compare the extent, distribution, and nature of fatal occupational injury in New Zealand, Australia, and the United States.
Setting—Workplaces in New Zealand, Australia, and the United States.
Methods—Data collections based on vital records were used to compare overall rates and distribution of fatal injuries covering the period 1989–92 in Australia and the United States, and 1985–94 in New Zealand. Household labour force data (Australia and the United States) and census data (New Zealand) provided denominator data for calculation of rates. Case definition, case inclusion criteria, and classification of occupation and industry were harmonised across the three datasets.
Results—New Zealand had the highest average annual rate (4.9/100 000), Australia an intermediate rate (3.8/100 000), and the United States the lowest rate (3.2/100 000) of fatal occupational injury. Much of the difference between countries was accounted for by differences in industry distribution. In each country, male workers, older workers, and those working in agriculture, forestry and fishing, in mining and in construction, were consistently at higher risk. Intentional fatal injury was more common in the United States, being rare in both Australia and New Zealand. This difference is likely to be reflected in the more common incidence of work related fatal injuries for sales workers in the United States compared with Australia and New Zealand.
Conclusions—The present results contrasted with those obtained by a recent study that used published omnibus statistics, both in terms of absolute rates and relative ranking of the three countries. Such differences underscore the importance of using like datasets for international comparisons. The consistency of high risk areas across comparable data from comparable nations provides clear targets for further attention. At this stage, however, it is unclear whether the same specific occupations and/or hazards are contributing to the aggregated industry and occupation group rates reported here.
PMCID: PMC1730691  PMID: 11289530
15.  Trends in rates of occupational fatal injuries in the United States (1983-92) 
OBJECTIVES: An updated version of a national surveillance system of traumatic occupational fatalities was used to explore adjusted and unadjusted trends in rates of fatal injury. METHODS: Data from the national traumatic occupational fatalities surveillance system were combined with data on employment from the United States Bureau of Labor Statistics. Poisson regression was then used to examine trends in rates of occupational fatality injuries while controlling for demographic and workplace characteristics. RESULTS: Adjusted annual changes in rates of fatal injuries ranged from a decline of 6.2% for workers in technical and administrative support occupations--for example, health, science, and engineering technicians, pilots, computer programmers--to an increase of 1.6% in machine operators, assemblers, and inspectors. For industries, annual changes ranged from a decline of 5.3% for workers in public administration--for example, justice, public order, and safety workers--to an increase of 2.6% for workers in the wholesale trade. By comparison, the annual decline over all industries and occupations was 3.1%. In many industries and occupations, an effect modification of annual trends by the age of the worker was also found with the oldest workers experiencing either no decline or a significant increase in rates of fatal injuries. CONCLUSIONS: This general pattern of decline, adjusted for the effects of demographic characteristics of the worker population, is encouraging; however, increases in rates of fatal injuries found in particular industries and occupations, suggest appropriate targets for increased injury prevention efforts.
PMCID: PMC1757606  PMID: 9816383
16.  The burden of sepsis-associated mortality in the United States from 1999 to 2005: an analysis of multiple-cause-of-death data 
Critical Care  2009;13(1):R28.
Sepsis is the 10th leading cause of death in the United States. The National Center for Health Statistics' multiple-cause-of-death (MCOD) dataset is a large, publicly available, population-based source of information on disease burden in the United States. We have analysed MCOD data from 1999 to 2005 to investigate trends, assess disparities and provide population-based estimates of sepsis-associated mortality during this period.
Sepsis-associated deaths occurring in the United States from 1999 to 2005 were identified in MCOD data using International Classification of Disease, 10th Revision (ICD-10) codes. Population-based mortality rates were calculated using bridged-race population estimates from the National Center for Health Statistics. Comparisons across age, sex and racial/ethnic groups were achieved by calculating mortality rate ratios.
From 1999 to 2005 there were 16,948,482 deaths in the United States. Of these, 1,017,616 were associated with sepsis (6.0% of all deaths). The age-adjusted rate of sepsis-associated mortality was 50.37 deaths per 100,000 (95% confidence interval (CI) = 50.28 to 50.47). There were significant disparities in sepsis-associated mortality in race/ethnicity and sex groups (P < 0.0001). After controlling for age, Asians were less likely than whites to experience sepsis-related death (rate ratio (RR) = 0.78, 95% CI = 0.77 to 0.78), while Blacks (RR = 2.24, 95% CI = 2.23 to 2.24), American Indians/Alaska Natives (RR = 1.24, 95% CI = 1.24 to 1.25) and Hispanics (RR = 1.14, 95% CI = 1.13 to 1.14) were more likely than whites to experience sepsis-related death. Men were at increased risk for sepsis-associated death in all race/ethnicity categories (RR = 1.27, 95% CI = 1.27 to 1.28), but the degree of increased susceptibility associated with being male differed among racial/ethnic groups (P < 0.0001). Although crude sepsis-associated mortality increased by 0.67% per year during the study period (P < 0.0001), the age-adjusted mortality rate decreased by 0.18% per year (P < 0.01).
The rapid rise in sepsis mortality seen in previous decades has slowed, but population ageing continues to drive the growth of sepsis-associated mortality in the United States. Disparities in sepsis-associated mortality mirror those previously reported for sepsis incidence. Sepsis in Asians, Hispanics and American Indian/Alaska Natives should be studied separately because aggregate measures may obscure important differences among these groups.
PMCID: PMC2688146  PMID: 19250547
17.  Fatal traumatic brain injury, West Virginia, 1989-1998. 
Public Health Reports  2004;119(5):486-492.
OBJECTIVE: The objective of this study was to describe fatal cases of traumatic brain injury (TBI) among West Virginia residents. METHODS: The authors analyzed data from the National Center for Health Statistics Multiple Cause of Death tapes for the period 1989-1998. They compared West Virginia's annualized average TBI death rate with the rates of other states and with the rate among U.S. residents for the same period. U.S. Bureau of Census population estimates were used as denominators. RESULTS: A total of 4,416 TBI deaths occurred in West Virginia in 1989-1998, for an annual average death rate of 23.6 per 100,000 population. From 1989 to 1998, TBI death rates declined 5% (p=0.4042). Seventy-five percent (n=3,315) of fatalities occurred among men. Adults > or =65 years of age accounted for the highest percentage of fatal injuries (n=1,135). The leading external causes of fatal TBI were: firearm-related (39% of reported fatalities), motor vehicles-related (34%), and fall-related (10%). Firearm-related TBI became the leading cause of TBI fatalities in 1991, surpassing motor vehicle-related TBI. Seventy-five percent of firearm-related TBI deaths were suicides (n=1,302). West Virginia's TBI death rate (23.6 per 100,000) was higher than the national rate (20.6 per 100,000). In 23 states, the average TBI death rates over the 10-year period were higher than West Virginia's. Whereas modest declines in TBI death rates occurred for motor vehicle-related and firearm-related causes in West Virginia, a concomitant 38% increase occurred in the fall-related TBI death rate during the decade. CONCLUSION: Data presented in this report can be used to develop targeted prevention programs in West Virginia.
PMCID: PMC1497660  PMID: 15313112
18.  Fatal Occupational Injuries among Non-governmental Employees in Malaysia 
In Malaysia, surveillance of fatal occupational injuries is fragmented. We therefore analyzed an alternative data source from Malaysia’s Social Security organization, the PERKESO.
We conducted a secondary data analysis of the PERKESO database comprised of 7 million employees from 2002 to 2006.
Overall, the average annual incidence was 9.2 fatal occupational injuries per 100,000 workers. During the five-year period, there was a decrease in the absolute number of fatal injuries by 16% and the incidence by 34%. The transportation sector reported the highest incidence of fatal injuries (35.1/100,000), followed by agriculture (30.5/100,000) and construction (19.3/100,000) sectors. Persons of Indian ethnicity were more likely to sustain fatal injuries compared to other ethnic groups.
Government and industry should develop rigorous strategies to detect hazards in the workplace, especially in sectors that continuously record high injury rates. Targeted interventions emphasizing worker empowerment coupled with systematic monitoring and evaluation is critical to ensure success in prevention and control measures.
PMCID: PMC3505558  PMID: 22544443
occupational injuries; fatal; transportation; agriculture; Malaysia
19.  Hospitalised and Fatal Head Injuries in Viti Levu, Fiji: Findings from an Island-Wide Trauma Registry (TRIP 4) 
Neuroepidemiology  2012;38(3):179-185.
Globally, head injury is a substantial cause of mortality and morbidity. A disproportionately greater burden is borne by low- and middle-income countries. The incidence and characteristics of fatal and hospitalised head injuries in Fiji are unknown.
Using prospective data from the Fiji Injury Surveillance in Hospital system, the epidemiology of fatal and hospitalised head injuries was investigated (2004–2005).
In total, 226 hospital admissions and 50 fatalities (66% died prior to admission) with a principal diagnosis of head injury were identified (crude annual rates of 34.7 and 7.7/100,000, respectively). Males were more likely to die and be hospitalised as a result of head injury than females. The highest fatality rate was among those in the 30–44-year age group. Road traffic crashes were the leading causes of injuries resulting in death (70%), followed by ‘hit by person or object’ and falls (14% each). Among people admitted to hospital, road traffic crashes (34.5%) and falls (33.2%) were the leading causes of injury. The leading cause of head injuries in children was falls, in 15–29-year-olds road traffic crashes, and in adults aged 30–44 years or 45 years and older ‘hit by person or object’. Among the two major ethnic groups, Fijians had higher rates of falls and ‘hit by person or object’ and Indians higher rates for road traffic crashes. There were no statistically significant differences between the overall rates of head injuries or the fatal and non-fatal rates among Fijians or Indians by gender following age standardisation to the total Fijian national population.
Despite underestimating the overall burden, this study identified head injury to be a major cause of death and hospitalisation in Fiji. The predominance of males and road traffic-related injuries is consistent with studies on head injuries conducted in other low- and middle-income countries. The high fatality rate among those aged 30–44 years in this study has not been noted previously. The high case fatality rate prior to admission to the hospital requires urgent attention.
PMCID: PMC3375116  PMID: 22472517
Head injuries; Epidemiology; Traumatic brain injury; Surveillance; Fiji
20.  Comparison of unintentional fatal occupational injuries in the Republic of Korea and the United States 
Injury Prevention  2004;10(4):199-205.
Objectives: To compare the profile of unintentional fatal occupational injuries in the Republic of Korea and the United States to help establish prevention strategies for Korea and to understand country specific differences in fatality risks in different industries.
Methods: Occupational fatal injury data from 1998–2001 were collected from Korea's Occupational Safety and Health Agency's Survey of Causes of Occupational Injuries (identified by the Korea Labor Welfare Corporation) and from the United States Census of Fatal Occupational Injuries. Employment estimates were obtained in both countries. Industry coding and external cause of death coding were standardized. Descriptive analyses of injury rates and Poisson regression models to examine time trends were conducted.
Results: Korea exhibited a significantly higher fatal injury rate, at least two times higher than the United States, after accounting for different employment patterns. The ordering of industries with respect to risk is the same in the two countries, with mining, agriculture/forestry/fishing, and construction being the most dangerous. Fatal injury rates are decreasing in these two countries, although at a faster rate in Korea.
Conclusions: Understanding industrial practices within different countries is critical for fully understanding country specific occupational injury statistics. However, differences in surveillance systems and employment estimation methods serve as caveats to any transnational comparison, and need to be harmonized to the fullest extent possible.
PMCID: PMC1730127  PMID: 15314045
21.  Diversity of trends in occupational injury mortality in the United States, 1980–96 
Injury Prevention  2003;9(1):9-14.
Objectives: Although the United States has generally enjoyed declining rates of fatal occupational injury, the rate of decline has not been uniform. To examine the heterogeneity of trends, changes in fatal occupational injury rates from 1980 to 1996 were estimated by occupation, industry, geographic region, and demographic group.
Methods: Deaths due to injury at work during 1980–96 were identified from the US National Traumatic Occupational Fatality database and populations at risk were estimated from the census of population. Mortality rates were computed for unintentional injuries, homicides, and all injuries combined. The annual rate of change was estimated using Poisson regression to model the death rate as a function of time.
Results: The estimated average rates for all fatal occupational injuries and for unintentional injuries declined by 3% per year, while the estimated rate of homicide declined <1% per year. The improvement was faster for men (3% per year) than for women (<1% per year) and for younger relative to older workers (7% per year v 2%–3% per year). Trends were also geographically heterogeneous, with the most rapid declines (7%–8% per year) in the South and West. Injury rates for most occupations and industries declined at near the average rate, but some experienced no change or an increase. The rate of homicide also increased in a number of occupations and industries.
Conclusions: Broad downward trends in occupational fatality rates may be explained by several factors, including organized safety efforts, product and process changes, and the ongoing shift of employment toward safer sectors. Disparities in fatal injury trends draw attention to potential opportunities to reduce risk: work settings with increasing injury rates are of particular concern.
PMCID: PMC1730941  PMID: 12642551
22.  Paradoxical increase in stroke mortality among Asian Indians in the United States 
To better characterize the stroke mortality and risk factors among Asian Indians by using U.S. multiple-cause-of-death and National Health and Interview Survey data.
Age-adjusted fatal stroke incidence, stroke rate ratio with 95% confidence interval, and average annual percentage change (APC) over 10 years were calculated.
The annual incidence of stroke mortality in 2000 was lowest among Asian Indians (88 per 100,000) followed by American Indians and Alaska Natives (112 per 100,000), whites (301 per 100,000) and African Americans (312 per 100,000). Significantly lower rates of hypertension and cigarette smoking in Asian Indians in 2000–2001 (compared with whites) explained the lower rates of stroke mortality. The APC increase over subsequent 10 years was 13.5%, 0.9%, −2.5%, and −2.9% for Asian Indians, American Indians and Alaska Natives, whites, and African Americans, respectively.
There is a paradoxical increase in stroke mortality among Asian Indians over the last 10 years in contrast to other population subsets.
PMCID: PMC4051898  PMID: 24920980
Stroke; National Health and Interview Survey (NHIS); Asian Indians; Mortality; Incidence
23.  The Characteristics of Road Traffic Fatalities in Kazakhstan’s Semey Region, 2006-2010: A Descriptive Retrospective Study 
Iranian Journal of Public Health  2014;43(6):760-768.
Kazakhstan, a developing middle-income country, has the highest road traffic collision (RTC) mortality in the European Region. The aims of this study were to determine main characteristics of road traffic fatalities in Semey region, Kazakhstan and to compare findings with National data and middle-income European countries.
This descriptive surveillance study assesses RTC mortality rates and epidemiology in the Semey Region of East Kazakhstan Oblast. Data of all 318 road traffic fatalities form the Semey Regional Center for Forensic Medicine were analyzed for the 5-year period of January 1, 2006 through December 31, 2010.
Over the study period, the average road traffic mortality in the Semey Region was 12.1 per 100,000 population with downward trend by 35.1% (p=0.002). The victims mean age was 37.1 (SD=17) years. Males predominated at 74.5%. Vehicle fatality was the most common mode of fatality at 61.3%. The majority of collisions, 53.1%, occurred on highways. Most victims, 67.3%, have died at the scene of collision; in 67.3% of fatalities, autopsies identified multiple injuries as cause of death. The high number of fatal collisions took place in “no snow” season (P<0.001), with an overall 5-years downward dynamic.
High proportion of males, pedestrians and car occupants among road traffic fatalities; high proportion of death on scene in case of highway collisions are specifics for Semey region, Kazakhstan. These findings can be used to formulate preventive strategies to reduce fatalities and to improve the medical care system for road traffic fatalities.
PMCID: PMC4475594  PMID: 26110146
Road traffic fatality; Epidemiology; Accident; Kazakhstan
24.  Colorectal Cancer in Alaska Native People, 2005–2009 
Colorectal cancer (CRC) is the most frequently diagnosed cancer among Alaska Native (AN) people, and the second leading cause of cancer death. The incidence rate for the combined years 1999 through 2003 was 30% higher than the rate among U.S. whites (USWs) for the same period. Current incidence rates may serve to monitor the impact of screening programs in reducing CRC in the AN population.
Incidence data are from the Alaska Native Tumor Registry and the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) Program. We compared AN CRC incidence, survival rates, and stage at diagnosis with rates in USWs for cases diagnosed from 2005 through 2009. Relative survival calculations were produced in SEER*Stat by the actuarial method.
The CRC age-adjusted incidence rate among AN men and women combined was higher than those in USW men and women (84 vs. 43/100,000; P < .05; AN:USW rate ratio [RR] = 2.0). The greatest differences between rates in AN people and USWs were for tumors in the hepatic flexure (RR = 3.1) and in the transverse (RR = 2.9) and sigmoid (RR = 2.5) regions of the colon. Rectal cancer rates among AN people were significantly higher than rates in USWs (21 vs.12/100,000). Five-year relative survival proportions by stage at diagnosis indicate that the CRC 5-year relative survival was similar in AN people and USWs for the period 2004 through 2009.
The high rate of CRC in AN people emphasizes the need for screening programs and interventions to reduce known modifiable risks. Research in methods to promote healthy behaviors among AN people is greatly needed.
PMCID: PMC3481146  PMID: 23112882
25.  Aviation-Related Injury Morbidity and Mortality: Data from U.S. Health Information Systems 
Information about injuries sustained by survivors of airplane crashes is scant, although some information is available on fatal aviation-related injuries. Objectives of this study were to explore the patterns of aviation-related injuries admitted to U.S. hospitals and relate them to aviation deaths in the same period.
The Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) contains information for approximately 20% of all hospital admissions in the United States each year. We identified patients in the HCUP NIS who were hospitalized during 2000–2005 for aviation-related injuries based on the International Classification of Diseases, 9th Revision, codes E840–E844. Injury patterns were also examined in relation to information from multiple-cause-of-death public-use data files 2000–2005.
Nationally, an estimated 6080 patients in 6 yr, or 1013 admissions annually (95% confidence interval 894–1133), were hospitalized for aviation-related injuries, based on 1246 patients in the sample. The average hospital stay was 6.3 d and 2% died in hospital. Occupants of noncommercial aircraft accounted for 32% of patients, parachutists for 29%; occupants of commercial aircraft and of unpowered aircraft each constituted 11%. Lower-limb fracture was the most common injury in each category, constituting 27% of the total, followed by head injury (11%), open wound (10%), upper extremity fracture, and internal injury (9%). Among fatalities, head injury (38%) was most prominent. An average of 753 deaths occurred annually; for each death there were 1.3 hospitalizations.
Aviation-related injuries result in approximately 1000 hospitalizations each year in the United States, with an in-hospital mortality rate of 2%. The most common injury sustained by aviation crash survivors is lower-limb fracture.
PMCID: PMC2810202  PMID: 20027845
accident; aviation; fracture; injury; lower limb; mortality; parachuting; survivors

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