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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.  Reducing Motor Vehicle-Related Injuries at an Arizona Indian Reservation: Ten Years of Application of Evidence-Based Strategies 
Motor vehicle crashes decreased and seat belt use, including car seat use, increased in an American Indian and Alaska Native community through a multidisciplinary approach using strong partnerships among public health and law enforcement agencies; community outreach; mass media campaigns; and enactment and high-visibility enforcement of key laws, such as lowering the legal blood alcohol concentration limit for drivers and mandating use of occupant restraints.
Motor vehicle crashes decreased and seat belt use, including car seat use, increased in an American Indian and Alaska Native community through a multidisciplinary approach using strong partnerships among public health and law enforcement agencies; community outreach; mass media campaigns; and enactment and high-visibility enforcement of key laws, such as lowering the legal blood alcohol concentration limit for drivers and mandating use of occupant restraints.
Unintentional injury is a significant public health burden for American Indians and Alaska Natives and was the leading cause of death among those aged 1 to 44 years between 1999 and 2004. Of those deaths, motor vehicle-related deaths cause the most mortality, justifying the need for intervention at an American Indian Reservation in Arizona (United States). We describe motor vehicle injury prevention program operations from 2004 through 2013. This community-based approach led by a multidisciplinary team primarily comprised of environmental public health and law enforcement personnel implemented evidence-based strategies to reduce the impact of motor vehicle-related injuries and deaths, focusing on reducing impaired driving and increasing occupant restraint use. Strategies included: mass media campaigns to enhance awareness and outreach; high-visibility sobriety checkpoints; passing and enforcing 0.08% blood alcohol concentration limits for drivers and primary occupant restraint laws; and child car seat distribution and education. Routine monitoring and evaluation data showed a significant 5% to 7% annual reduction of motor vehicle crashes (MVCs), nighttime MVCs, MVCs with injuries/fatalities, and nighttime MVCs with injuries/fatalities between 2004 and 2013, but the annual percent change in arrests for driving under the influence (DUI) was not significant. There was also a 144% increase in driver/front seat passenger seat belt use, from 19% in 2011 before the primary occupant restraint law was enacted to 47% during the first full year of enforcement (2013). Car seat checkpoint data also suggested a 160% increase in car seat use, from less than 20% to 52% in 2013. Implementation of evidence-based strategies in injury prevention, along with employment of key program approaches such as strong partnership building, community engagement, and consistent staffing and funding, can narrow the public health disparity gap experienced among American Indian and Alaska Native communities.
doi:10.9745/GHSP-D-15-00249
PMCID: PMC4682586  PMID: 26681708
8.  Drowning in Aboriginal and Torres Strait Islander children and adolescents in Queensland (Australia) 
BMC Public Health  2015;15:795.
Background
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1186/s12889-015-2137-z
PMCID: PMC4545709  PMID: 26286446
9.  Cancer Disparities Among Alaska Native People, 1970–2011 
Introduction
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.
Methods
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.
Results
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.
Conclusion
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.
doi:10.5888/pcd11.130369
PMCID: PMC4273544  PMID: 25523352
10.  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.
doi:10.3201/eid1009.030745
PMCID: PMC3320287  PMID: 15498163
botulism; surveillance; epidemiology; foodborne disease; Clostridium botulinum; research
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.
Objective
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.
Design
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.
Results
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.
Conclusions
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.
doi:10.1136/ip.2007.015677
PMCID: PMC2610620  PMID: 17916891
occupational safety; policy; evaluation; machine; manufacturing industry
12.  Abusive head trauma among children in Alaska: a population-based assessment 
International Journal of Circumpolar Health  2013;72:10.3402/ijch.v72i0.21216.
Background
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.
Objective
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.
Design
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.
Results
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.
Conclusions
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.
doi:10.3402/ijch.v72i0.21216
PMCID: PMC3754493  PMID: 23986886
child maltreatment; child abuse; abusive head trauma; traumatic brain injury; surveillance; epidemiology
13.  Is the Societal burden of fatal occupational injury different among NORA industry sectors? 
Problem
Since the implementation of the Occupational Safety and Health Act, safety and health in the work environment has seen marked improvement. Although these improvements are laudable, workplace hazards continue to plague the American worker. Understanding the economic burden of fatalities by industry sector is important to setting broad occupational safety and health research priorities. Cost estimates provide additional information about how fatal injuries affect society and hence can improve injury prevention program planning, policy analysis, evaluation, and advocacy.
Method
This study estimated the total, mean, and median societal costs by worker and case characteristic in 2003–2006 for the industry sectors identified in the National Institute for Occupational Safety and Health National Occupational Research Agenda (NORA). Analyses were conducted with restricted access to the Bureau of Labor Statistics Census of Fatal Occupational Injuries data. These data exclude military personnel, decedents with unknown age or sex, and fatalities occurring in New York City. Societal costs were estimated using the cost-of-illness approach, which combines direct and indirect costs to yield an overall cost of an fatal occupational injury.
Results
During this period, the cost of the 22,197 fatal occupational injuries exceeded $21 billion. The mean and median costs of these fatalities were $960,000 and $944,000 respectively. Total societal costs by NORA sector ranged from a high of $5.8 billion in Services to a low of $530 million in Healthcare and Social Assistance with mean costs ranging from the nearly $800,000 in Agriculture, Forestry, and Fishing to almost $1.1 million in Mining.
Discussion
The societal costs—total, mean, and median costs—of case and worker characteristics for occupational fatal injuries varied within each NORA sector.
Impact on Industry
To have the greatest societal impact, these costs can be used to target resources for public and private sector research by industry.
doi:10.1016/j.jsr.2012.09.005
PMCID: PMC4732276  PMID: 23398699
fatal occupational injury; occupational injury cost; NORA; burden of injury; occupational safety
14.  Examining Occupational Health and Safety Disparities Using National Data: A Cause for Continuing Concern 
Background
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.
Methods
Bureau of Labor Statistics workplace data were used to characterize high-risk occupations and examine relationships between demographic and work-related variables and fatality.
Results
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.
Conclusions
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.
doi:10.1002/ajim.22297
PMCID: PMC4556419  PMID: 24436156
occupational health disparities; injury; fatality; occupation; industry; race; ethnicity; nativity; SOII; CFOI; CPS
15.  Mortality trends among Alaska Native people: successes and challenges 
International Journal of Circumpolar Health  2013;72:10.3402/ijch.v72i0.21185.
Background
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.
Objective
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.
Design
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.
Results
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.
Conclusion
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.
doi:10.3402/ijch.v72i0.21185
PMCID: PMC3751233  PMID: 23977643
Native American; unintentional injury; suicide; death; vital statistics
16.  Reported traumatic injuries among West Coast Dungeness crab fishermen, 2002–2014 
International maritime health  2015;66(4):207-210.
Background
Commercial fishing is a high-risk occupation. The West Coast Dungeness crab fishery has a high fatality rate; however, nonfatal injuries have not been previously studied. The purpose of this report was to describe the characteristics of fatal and nonfatal traumatic occupational injuries and associated hazards in this fleet during 2002–2014.
Materials and methods
Data on fatal injuries were obtained from a surveillance system managed by the National Institute for Occupational Safety and Health. Data on nonfatal injuries were manually abstracted from Coast Guard investigation reports and entered into a study database. Descriptive statistics were used to characterise demographics, injury characteristics, and work processes performed.
Results
Twenty-eight fatal and 45 nonfatal injuries were reported between 2002 and 2014 in the Dungeness crab fleet. Most fatalities were due to vessel disasters, and many nonfatal injuries occurred on-deck when fishermen were working with gear, particularly when hauling the gear (47%). The most frequently reported injuries affected the upper extremities (48%), and fractures were the most commonly reported injury type (40%). The overall fatality rate during this time period was 209 per 100,000 full-time equivalent workers and the rate of nonfatal injury was 3.4 per 1,000 full-time equivalent workers.
Conclusions
Dungeness crab fishermen are at relatively high risk for fatal injuries. Nonfatal injuries were limited to reported information, which hampers efforts to accurately estimate nonfatal injury risk and understand fishing hazards. Further research is needed to identify work tasks and other hazards that cause nonfatal injuries in this fleet. Engaging fishermen directly may help develop approaches for injury prevention.
doi:10.5603/IMH.2015.0041
PMCID: PMC4704689  PMID: 26726891
commercial fishing; occupational safety; injuries
17.  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.
doi:10.1136/ip.7.1.22
PMCID: PMC1730691  PMID: 11289530
18.  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
19.  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.
doi:10.1016/j.phr.2004.07.006
PMCID: PMC1497660  PMID: 15313112
20.  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.
Introduction
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.
Methods
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.
Results
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).
Conclusions
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.
doi:10.1186/cc7733
PMCID: PMC2688146  PMID: 19250547
21.  Inequalities in Alcohol-Related Mortality in 17 European Countries: A Retrospective Analysis of Mortality Registers 
PLoS Medicine  2015;12(12):e1001909.
Background
Socioeconomic inequalities in alcohol-related mortality have been documented in several European countries, but it is unknown whether the magnitude of these inequalities differs between countries and whether these inequalities increase or decrease over time.
Methods and Findings
We collected and harmonized data on mortality from four alcohol-related causes (alcoholic psychosis, dependence, and abuse; alcoholic cardiomyopathy; alcoholic liver cirrhosis; and accidental poisoning by alcohol) by age, sex, education level, and occupational class in 20 European populations from 17 different countries, both for a recent period and for previous points in time, using data from mortality registers. Mortality was age-standardized using the European Standard Population, and measures for both relative and absolute inequality between low and high socioeconomic groups (as measured by educational level and occupational class) were calculated.
Rates of alcohol-related mortality are higher in lower educational and occupational groups in all countries. Both relative and absolute inequalities are largest in Eastern Europe, and Finland and Denmark also have very large absolute inequalities in alcohol-related mortality. For example, for educational inequality among Finnish men, the relative index of inequality is 3.6 (95% CI 3.3–4.0) and the slope index of inequality is 112.5 (95% CI 106.2–118.8) deaths per 100,000 person-years. Over time, the relative inequality in alcohol-related mortality has increased in many countries, but the main change is a strong rise of absolute inequality in several countries in Eastern Europe (Hungary, Lithuania, Estonia) and Northern Europe (Finland, Denmark) because of a rapid rise in alcohol-related mortality in lower socioeconomic groups. In some of these countries, alcohol-related causes now account for 10% or more of the socioeconomic inequality in total mortality.
Because our study relies on routinely collected underlying causes of death, it is likely that our results underestimate the true extent of the problem.
Conclusions
Alcohol-related conditions play an important role in generating inequalities in total mortality in many European countries. Countering increases in alcohol-related mortality in lower socioeconomic groups is essential for reducing inequalities in mortality. Studies of why such increases have not occurred in countries like France, Switzerland, Spain, and Italy can help in developing evidence-based policies in other European countries.
In a harmonized analysis of regional data, Johan Mackenbach and colleagues characterize three decades of alcohol-related mortality across socioeconomic groups in Europe.
Editors' Summary
Background
People have consumed alcoholic beverages throughout history, but, globally, about three million people die from alcohol-related causes every year. Alcohol consumption, particularly in higher amounts, is a risk factor for cardiovascular disease (diseases of the heart and/or blood vessels), liver cirrhosis (scarring of the liver), injuries, and many other fatal and nonfatal health problems. Alcohol also affects the well-being and health of people around those who drink, through alcohol-related crime and road traffic crashes. The impact of alcohol use on health depends on the amount of alcohol consumed and on the pattern of drinking. Most guidelines on alcohol consumption recommend that men should regularly consume no more than two alcoholic drinks per day and that women should regularly consume no more than one drink per day (a “drink” is, roughly speaking, a can of beer or a small glass of wine). The guidelines also advise people to avoid binge drinking—the consumption of five or more drinks on a single occasion for men or four or more drinks on a single occasion for women.
Why Was This Study Done?
Like many other behaviors that affect health, alcohol consumption is affected by socioeconomic status (an individual’s economic and social position in relation to others based on income, level of education, and occupation). Thus, in many European countries, the frequency of drinking and the levels of alcohol consumption are greater in higher socioeconomic groups than in lower socioeconomic groups, whereas binge drinking and other problematic forms of alcohol consumption occur more frequently in lower socioeconomic groups. Importantly, higher levels of mortality (death) from alcohol-related conditions have been documented in lower socioeconomic groups than in higher socioeconomic groups in several European countries. Here, the researchers analyze mortality registers to find out whether the magnitude of socioeconomic inequalities in alcohol-related mortality differs among European countries and whether these inequalities have changed over time. Documenting these differences and changes is important because it may help to explain socioeconomic inequalities in alcohol-related mortality and thus inform policies and interventions designed to reduce alcohol-related harm and socioeconomic inequalities in mortality.
What Did the Researchers Do and Find?
The researchers obtained data on deaths from alcoholic psychosis, dependence, and abuse; alcoholic cardiomyopathy (a type of heart disease); alcoholic liver cirrhosis; and accidental alcohol poisoning from the mortality registers of 17 European countries. Using available data on educational level and occupational class, they calculated relative and absolute socioeconomic inequalities in alcohol-related mortality (relative inequality reflects mortality differences between socioeconomic groups in terms of a proportion or percentage; absolute inequality reflects mortality differences between groups in terms of deaths per 100,000 person-years). Rates of alcohol-related mortality were higher in individuals with less education or with manual (as opposed to non-manual) occupations in all 17 countries. Both relative and absolute inequalities were largest in Eastern Europe but Finland and Denmark also had very large absolute inequalities in alcohol-related mortality. For example, among Finnish men, those with the lowest level of education were 3.6 times more likely to die from an alcohol-related cause than those with the highest level of education, and there were 112.5 more deaths per 100,000 person-years among those with the lowest level of education than among those with the highest level of education. The relative inequality in alcohol-related mortality increased over time in many countries. Moreover, the absolute inequality increased markedly in Hungary, Lithuania, Estonia, Finland, and Denmark because of a rapid rise in alcohol-related mortality in lower socioeconomic groups. By contrast, mortality from alcohol-related causes among lower educated men was stable in France, Switzerland, Spain, and Italy.
What Do These Findings Mean?
These findings suggest that alcohol-related conditions are an important contributing factor to the socioeconomic inequality in total mortality in many European countries. Indeed, in some countries (for example, Finland), alcohol-related causes account for 10% or more of the socioeconomic inequality in total mortality among men. The accuracy of these findings is likely to be affected by the use of routinely collected underlying causes of death and by other aspects of the study design. Importantly, however, these findings indicate that to reduce socioeconomic inequalities in mortality, health professionals and governments need to introduce interventions and policies designed to counter recent increases in alcohol-related mortality in lower socioeconomic groups. Further investigation of why such increases have not occurred in some countries may help in the design of these important public health initiatives.
Additional Information
This list of resources contains links that can be accessed when viewing the PDF on a device or via the online version of the article at http://dx.doi.org/10.1371/journal.pmed.1001909.
The World Health Organization provides detailed information about alcohol, including a fact sheet on the harmful use of alcohol; its Global Status Report on Alcohol and Health 2014 provides country profiles for alcohol consumption, information on the impact of alcohol use on health, and policy responses; the Global Information System on Alcohol and Health provides further information about alcohol, including information on control policies around the world
The US National Institute on Alcohol Abuse and Alcoholism has information about alcohol and its effects on health; it provides interactive worksheets to help people evaluate their drinking and decide whether and how to make a change
The US Centers for Disease Control and Prevention provides information on alcohol and public health
The UK National Health Service Choices website provides detailed information about drinking and alcohol, including information on the risks of drinking too much, tools for calculating alcohol consumption, and personal stories about alcohol use problems
MedlinePlus provides links to many other resources on alcohol
doi:10.1371/journal.pmed.1001909
PMCID: PMC4666661  PMID: 26625134
22.  Long-Term Exposure to Silica Dust and Risk of Total and Cause-Specific Mortality in Chinese Workers: A Cohort Study 
PLoS Medicine  2012;9(4):e1001206.
A retro-prospective cohort study by Weihong Chen and colleagues provides new estimates for the risk of total and cause-specific mortality due to long-term silica dust exposure among Chinese workers.
Background
Human exposure to silica dust is very common in both working and living environments. However, the potential long-term health effects have not been well established across different exposure situations.
Methods and Findings
We studied 74,040 workers who worked at 29 metal mines and pottery factories in China for 1 y or more between January 1, 1960, and December 31, 1974, with follow-up until December 31, 2003 (median follow-up of 33 y). We estimated the cumulative silica dust exposure (CDE) for each worker by linking work history to a job–exposure matrix. We calculated standardized mortality ratios for underlying causes of death based on Chinese national mortality rates. Hazard ratios (HRs) for selected causes of death associated with CDE were estimated using the Cox proportional hazards model. The population attributable risks were estimated based on the prevalence of workers with silica dust exposure and HRs. The number of deaths attributable to silica dust exposure among Chinese workers was then calculated using the population attributable risk and the national mortality rate. We observed 19,516 deaths during 2,306,428 person-years of follow-up. Mortality from all causes was higher among workers exposed to silica dust than among non-exposed workers (993 versus 551 per 100,000 person-years). We observed significant positive exposure–response relationships between CDE (measured in milligrams/cubic meter–years, i.e., the sum of silica dust concentrations multiplied by the years of silica exposure) and mortality from all causes (HR 1.026, 95% confidence interval 1.023–1.029), respiratory diseases (1.069, 1.064–1.074), respiratory tuberculosis (1.065, 1.059–1.071), and cardiovascular disease (1.031, 1.025–1.036). Significantly elevated standardized mortality ratios were observed for all causes (1.06, 95% confidence interval 1.01–1.11), ischemic heart disease (1.65, 1.35–1.99), and pneumoconiosis (11.01, 7.67–14.95) among workers exposed to respirable silica concentrations equal to or lower than 0.1 mg/m3. After adjustment for potential confounders, including smoking, silica dust exposure accounted for 15.2% of all deaths in this study. We estimated that 4.2% of deaths (231,104 cases) among Chinese workers were attributable to silica dust exposure. The limitations of this study included a lack of data on dietary patterns and leisure time physical activity, possible underestimation of silica dust exposure for individuals who worked at the mines/factories before 1950, and a small number of deaths (4.3%) where the cause of death was based on oral reports from relatives.
Conclusions
Long-term silica dust exposure was associated with substantially increased mortality among Chinese workers. The increased risk was observed not only for deaths due to respiratory diseases and lung cancer, but also for deaths due to cardiovascular disease.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Walk along most sandy beaches and you will be walking on millions of grains of crystalline silica, one of the commonest minerals on earth and a major ingredient in glass and in ceramic glazes. Silica is also used in the manufacture of building materials, in foundry castings, and for sandblasting, and respirable (breathable) crystalline silica particles are produced during quarrying and mining. Unfortunately, silica dust is not innocuous. Several serious diseases are associated with exposure to this dust, including silicosis (a chronic lung disease characterized by scarring and destruction of lung tissue), lung cancer, and pulmonary tuberculosis (a serious lung infection). Moreover, exposure to silica dust increases the risk of death (mortality). Worryingly, recent reports indicate that in the US and Europe, about 1.7 and 3.0 million people, respectively, are occupationally exposed to silica dust, figures that are dwarfed by the more than 23 million workers who are exposed in China. Occupational silica exposure, therefore, represents an important global public health concern.
Why Was This Study Done?
Although the lung-related adverse health effects of exposure to silica dust have been extensively studied, silica-related health effects may not be limited to these diseases. For example, could silica dust particles increase the risk of cardiovascular disease (diseases that affect the heart and circulation)? Other environmental particulates, such as the products of internal combustion engines, are associated with an increased risk of cardiovascular disease, but no one knows if the same is true for silica dust particles. Moreover, although it is clear that high levels of exposure to silica dust are dangerous, little is known about the adverse health effects of lower exposure levels. In this cohort study, the researchers examined the effect of long-term exposure to silica dust on the risk of all cause and cause-specific mortality in a large group (cohort) of Chinese workers.
What Did the Researchers Do and Find?
The researchers estimated the cumulative silica dust exposure for 74,040 workers at 29 metal mines and pottery factories from 1960 to 2003 from individual work histories and more than four million measurements of workplace dust concentrations, and collected health and mortality data for all the workers. Death from all causes was higher among workers exposed to silica dust than among non-exposed workers (993 versus 551 deaths per 100,000 person-years), and there was a positive exposure–response relationship between silica dust exposure and death from all causes, respiratory diseases, respiratory tuberculosis, and cardiovascular disease. For example, the hazard ratio for all cause death was 1.026 for every increase in cumulative silica dust exposure of 1 mg/m3-year; a hazard ratio is the incidence of an event in an exposed group divided by its incidence in an unexposed group. Notably, there was significantly increased mortality from all causes, ischemic heart disease, and silicosis among workers exposed to respirable silica concentrations at or below 0.1 mg/m3, the workplace exposure limit for silica dust set by the US Occupational Safety and Health Administration. For example, the standardized mortality ratio (SMR) for silicosis among people exposed to low levels of silica dust was 11.01; an SMR is the ratio of observed deaths in a cohort to expected deaths calculated from recorded deaths in the general population. Finally, the researchers used their data to estimate that, in 2008, 4.2% of deaths among industrial workers in China (231,104 deaths) were attributable to silica dust exposure.
What Do These Findings Mean?
These findings indicate that long-term silica dust exposure is associated with substantially increased mortality among Chinese workers. They confirm that there is an exposure–response relationship between silica dust exposure and a heightened risk of death from respiratory diseases and lung cancer. That is, the risk of death from these diseases increases as exposure to silica dust increases. In addition, they show a significant relationship between silica dust exposure and death from cardiovascular diseases. Importantly, these findings suggest that even levels of silica dust that are considered safe increase the risk of death. The accuracy of these findings may be affected by the accuracy of the silica dust exposure estimates and/or by confounding (other factors shared by the people exposed to silica such as diet may have affected their risk of death). Nevertheless, these findings highlight the need to tighten regulations on workplace dust control in China and elsewhere.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001206.
The American Lung Association provides information on silicosis
The US Centers for Disease Control and Prevention provides information on silica in the workplace, including links to relevant US National Institute for Occupational Health and Safety publications, and information on silicosis and other pneumoconioses
The US Occupational Safety and Health Administration also has detailed information on occupational exposure to crystalline silica
What does silicosis mean to you is a video provided by the US Mine Safety and Health Administration that includes personal experiences of silicosis; Dont let silica dust you is a video produced by the Association of Occupational and Environmental Clinics that identifies ways to reduce silica dust exposure in the workplace
The MedlinePlus encyclopedia has a page on silicosis (in English and Spanish)
The International Labour Organization provides information on health surveillance for those exposed to respirable crystalline silica
The World Health Organization has published a report about the health effects of crystalline silica and quartz
doi:10.1371/journal.pmed.1001206
PMCID: PMC3328438  PMID: 22529751
23.  Epidemiology of Invasive Group A Streptococcal Disease in Alaska, 2001 to 2013 
Journal of Clinical Microbiology  2015;54(1):134-141.
The Arctic Investigations Program (AIP) began surveillance for invasive group A streptococcal (GAS) infections in Alaska in 2000 as part of the invasive bacterial diseases population-based laboratory surveillance program. Between 2001 and 2013, there were 516 cases of GAS infection reported, for an overall annual incidence of 5.8 cases per 100,000 persons with 56 deaths (case fatality rate, 10.7%). Of the 516 confirmed cases of invasive GAS infection, 422 (82%) had isolates available for laboratory analysis. All isolates were susceptible to penicillin, cefotaxime, and levofloxacin. Resistance to tetracycline, erythromycin, and clindamycin was seen in 11% (n = 8), 5.8% (n = 20), and 1.2% (n = 4) of the isolates, respectively. A total of 51 emm types were identified, of which emm1 (11.1%) was the most prevalent, followed by emm82 (8.8%), emm49 (7.8%), emm12 and emm3 (6.6% each), emm89 (6.2%), emm108 (5.5%), emm28 (4.7%), emm92 (4%), and emm41 (3.8%). The five most common emm types accounted for 41% of isolates. The emm types in the proposed 26-valent and 30-valent vaccines accounted for 56% and 78% of all cases, respectively. GAS remains an important cause of invasive bacterial disease in Alaska. Continued surveillance of GAS infections will help improve understanding of the epidemiology of invasive disease, with an impact on disease control, notification of outbreaks, and vaccine development.
doi:10.1128/JCM.02122-15
PMCID: PMC4702745  PMID: 26560536
24.  Fatal Occupational Injuries among Non-governmental Employees in Malaysia 
Background
In Malaysia, surveillance of fatal occupational injuries is fragmented. We therefore analyzed an alternative data source from Malaysia’s Social Security organization, the PERKESO.
Methods
We conducted a secondary data analysis of the PERKESO database comprised of 7 million employees from 2002 to 2006.
Results
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.
Conclusions
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.
doi:10.1002/ajim.22056
PMCID: PMC3505558  PMID: 22544443
occupational injuries; fatal; transportation; agriculture; Malaysia
25.  Hospitalised and Fatal Head Injuries in Viti Levu, Fiji: Findings from an Island-Wide Trauma Registry (TRIP 4) 
Neuroepidemiology  2012;38(3):179-185.
Background
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.
Methods
Using prospective data from the Fiji Injury Surveillance in Hospital system, the epidemiology of fatal and hospitalised head injuries was investigated (2004–2005).
Results
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.
Conclusion
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.
doi:10.1159/000337261
PMCID: PMC3375116  PMID: 22472517
Head injuries; Epidemiology; Traumatic brain injury; Surveillance; Fiji

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