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5.0 per 100,000 Hispanic workers, compared with rates of 4.0 for all workers, 4.0 for non-Hispanic white workers, and 3.7 for non-Hispanic black workers. During 20032006, the work-related injury death rate for foreign-born Hispanic workers was 5.9, compared with a rate of 3.5 for U.S.-born Hispanic workers.

During 1992-1996, homicide was the most common fatal event among Hispanic workers (Figure 2). However, during 1997–2006, highway incidents were the most common fatal event, with the exception of 2000 and 2006 when falls to a lower level were most common. Workrelated homicides among Hispanics decreased 37% from 1992 to 2006, while the number of falls to a lower level increased approximately 370% during the same period.

During 2003–2006, 67% of Hispanic decedents were foreign born (Table), an increase from 52% in 1992 Approximately 70% of these decedents were born in Mexico. During 2003–2006, the most common industris employing Hispanics who died from work-related injure were construction (34%), administrative and waste services (11%), agriculture/forestry/fishing/hunting (10%), and transportation/warehousing (10%). Of those states with 30 or more work-related injury deaths among Hispania during 2003–2006, the highest numbers of fatalities were in California (773 deaths), Texas (687), and Florida (417) however, the highest fatality rates were in South Carolina (22.8 per 100,000 Hispanic workers), Oklahoma (10.3) Georgia (9.6), and Tennessee (8.9) (Table). Reported by: H Cierpich, L Styles, MPH, Public Health Institute Oakland; R Harrison, MD, Occupational Health Br, California Deport

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Editorial Note: Although work-related injury death rates declined generally and among Hispanics in the United States from 1992 to 2006, disparities between Hispanics and all workers persisted, with Hispanics consistently experiencing higher rates. In 2006, rates for Hispanics and all workers were above the Healthy People 2010 target for work-related injury deaths of 3.2 deaths per 100,000 workers (objective 20-1) (4). Foreign-born Hispanic workers were at especially high risk, and a large proportion of deaths occurred in the construction industry. Much of the increased risk for Hispanic workers likely can be attributed to holding high-risk jobs (5). However, an analysis of Hispanic work-related injury deaths in the construction industry found that Hispanic workers also had elevated rates when compared with non-Hispanic workers in the same occupations (e.g., laborers or roofers) (6).

In-depth investigations of approximately 200 deaths of Hispanic workers by CDC's National Institute for Occupational Safety and Health and state public health and labor agencies during 1992–2006 suggested characteristics that contributed to higher numbers of work-related injury deaths among Hispanic workers, including inadequate knowledge and control of recognized safety hazards and inadequate training and supervision of workers, often

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LE. Number, rate,* birth status, and most common fatal event and industry associated with Hispanic work-related injury deaths, w elected statesil - United States, 2003-2006

No.

Rate
Foreign-born %
Fatal event (%)

Industry (%)
114
3.9

62
Highway incident (20)

Construction (25) ornia 773 3.7 Fall to lower level (18)

Construction (27) che rado

87
5.4
Highway incident (29)

Construction (31) da 417 6.3

81
Highway incident (26)

Construction (34) Corgia

115
9.6

77
Fall to lower level (25)

Construction (56)
104
3.8

72
Fall to lower level (24)

Construction (28) land

58
6.8

91
Highway incident
(19)

Construction (59) igan

30
4.7

50
Highway incident (27)

Construction (27) Coonida

48
5.0

65
Fall to lower level (31)

Construction (46) Jersey 116 4.7

81
Fall to lower level (25)

Construction (29) Mexico

70
5.1

34
Highway incident (30)

Construction (30) York 172 3.4

73
Fall to lower level (25)

Construction (38) Carolina 97 7.8

75
Fall to lower level (18)

Construction (47)
33
5.5

61
Highway incident (21)

Construction (30)
32
10.3

44
Fall to lower level (19)

Construction (41)

Fire/explosion (19) sylvania

5.3

51
Homicide
(29)

Transportation/

warehousing (22) i Carolina

51
22.8

88
Fall to lower level (24)

Construction (63) essee

36
8.9

92
Fall to lower level (22)

Construction (44)
687
4.8

55
Highway incident (22)

Construction (37) via

63
6.5

87
Fall to lower level (33)

Construction (57)
33
4.0

70
Highway incident
(36)

Agriculture (39) 3,609

4.9

67
Highway incident (19)

Construction (34) 100,000 civilian workers aged >16 years. nt coded according to the Bureau of Labor Statistics Occupational Injury and Illness Classification System. stry coded according to the 2002 North American Industry Classification System. es reporting at least 30 work-related injury deaths of Hispanic workers during 2003–2006.

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projects to develop culturally competent programs ir engage Hispanic workers in identifying and addressing 11 occupational health and safety concerns.

exacerbated by different languages and literacy levels of workers (CDC, unpublished data, 2008).” Preventing work-related injury deaths among Hispanics will require 1) employers to take additional responsibility for providing a safe work environment, 2) safety and health agencies to provide employers of Hispanic workers with safety information and ensure compliance with existing regulations, and 3) researchers and health communication professionals to develop additional materials that are culturally appropriate and effective for workers who speak different languages and have varying levels of literacy. In addition, labor unions, community groups, and workers themselves can contribute to research and prevention measures.

The findings in this report are subject to at least five limitations. First, the number of deaths of Hispanic workers might be undercounted in the CFOI database (6), resulting in an underestimate of the death rate among Hispanics. Second, Hispanic ethnicity might have been misclassified in CFOI, which relies on secondary data sources, and also in CPS, which uses a single reporter for all household members. Third, the number of Hispanic workers might be undercounted in the CPS, which relies on stable residences for sequential interviews and largely collects data via telephone. An undercount of the total population of Hispanic workers would result in overestimate of Hispanic work-related injury death rates (6). Fourth, Hispanic workers are a heterogeneous population, and analyses that aggregate deaths for all Hispanics might mask differences among subpopulations. Finally, the data do not address potential contributors to Hispanic worker risk associated with cultural and social norms or economic status. For example, Hispanic workers, especially those who are foreign born, might be more willing to perform tasks with higher risk and more hesitant to decline such tasks for fear of losing their jobs.

CDC, the Occupational Safety and Health Administration (OSHA), and other agencies have provided additional Spanish-language occupational health and safety materials and training opportunities for employers, supervisors, and workers (7,8). OSHA has worked with employers to publicize best practices for Hispanic worker education and training programs (8). In addition, federally supported research projects are exploring grassroots approaches to improving occupational health and safety among Hispanic and other immigrant workers. ** Others agencies can build upon these

Acknowledgments The findings in this report are based, in part, on contributions : B Materna, PhD, California Dept of Public Health;J Zhu, N Pavelcz AM Gibson, New York State Dept of Health; P Spielholz, PhD, W. ington State Dept of Labor and Industries; and S Pegula, MS. Bu Labor Statistics, US Dept of Labor. References 1. Franklin JC. Employment outlook: 2006-16: An overview of B?S=

jections to 2016. Monthly Labor Review, November 2007:3-12.40

able at http://www.bls.gov/opub/mlr/2007/11/artlfull.pdf 2. Bureau of Labor Statistics. Current Population Survey, 2006, and an

force, employment and unemployment from the Current Popu.. Survey. In: BLS handbook of methods. Washington, DC: L'S Dessa ment of Labor, Bureau of Labor Statistics; 2003. Available at her

www.bls.gov/cps/home.htm. 3. Loh K, Richardson S. Foreign-born workers: trends in fatal Occupido

tional injuries. Monthly Labor Review, June 2004:42–53. Ava'zbed:

http://www.bls.gov/opub/mlr/2004/06/art3full.pdf. 4. US Department of Health and Human Services. Healthy people 20.

(conference ed, in 2 vols). Washington, DC: US Department of Hezi" and Human Services; 2000. Available at http://www.healthypeople get

document/html/volume2/20occsh.htm. 5. Richardson S, Ruser J, Suarez P. Hispanic workers in the United Sre

An analysis of employment distributions, fatal occupational inisia and nonfatal occupational injuries. In: Safety is seguridad: a work.co summary. Washington, DC: The National Academies Press; 2003. Ava:

able at http://books.nap.edu/openbook.php?record_id=10641&page=1 6. Dong X, Platner J. Occupational fatalities of Hispanic construct

workers from 1992 to 2000. Am J Ind Med 2004;45:45–54. 7. National Institute for Occupational Safety and Health. NIOSH.

Español. Washington, DC: US Department of Health and Hurranxa vices, CDC, National Institute for Occupational Safety and Heart

2008. Available at http://www.cdc.gov/spanish/niosh. 8. Occupational Health and Safety Administration. OSHA compliant

assistance: Hispanic workers and employers. Available at hrs www.osha.gov/dcsp/compliance_assistance/index_hispanic.html

Hospital-Acquired Pertussis Among

Newborns Texas, 2004 On July 10, 2004, staff members at a children's hossz in Texas noted that six infants with pertussis diagnosed clinical symptoms and confirmed by polymerase chais reaction (PCR) testing had all been born during June 16 at the same area general hospital. The infants had sym toms consistent with pertussis, including cough, congesta cyanosis, emesis, or apnea. Infection-control personnel at the general hospital (general hospital A), children's hossa tal (children's hospital A), and the county health depet ment investigated and determined that an outbreak of pertussis among 11 newborns at general hospital A Fad

Individual case reports of Hispanic worker deaths are available at http:// www2a.cdc.gov/NIOSH-FACE/state.asp?Category=0009&Category2 = ALL&Submit=Submit. Additional information available at http://www.dph.sf.ca.us/phes/ work_unidos.htm.

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urred after direct exposure to a health-care worker CW) with pertussis. This report describes the outbreak estigation and highlights the importance of following

ommendations to administer tetanus toxoid, reduced ens htheria toxoid, and acellular pertussis (Tdap) vaccine

HCWs to prevent transmission of pertussis to patients. mmediately after identification of the six infants with tussis at children's hospital A, hospital staff members ewed newborn nursery charts at general hospital A. One f member (HCW A) was identified as having directly ed for all six infants during their stay in the newborn sery. Review of work logs for all shifts identified four litional hospital workers who had been present while six infants were in the newborn nursery. rom early to mid-June until July 17, while working in

newborn nursery at general hospital A, HCW A had libited symptoms of pertussis, including cough, ttussive emesis, and dyspnea. Her spouse reportedly had ilar symptoms after he returned from a trip to Califor

2-3 weeks before HCW A began exhibiting her sympis. HCW A, aged 24 years, had been fully vaccinated pertussis during early childhood. HCW A and a nurscoworker with cough symptoms were tested for pertusby PCR; only HCW A tested positive. On July 17, HCW vas furloughed from general hospital A for 5 days and ted with erythromycin. Her husband also was prescribed thromycin. fter obtaining Institutional Review Board approval from institutions involved, staff members at children's hos1 A reviewed the charts and laboratory records of all ents aged <4 months who had received a diagnosis of tussis during June-August 2004. During that period, additional cases of pertussis were reported to the county Ith department from facilities other than children's pital A. A case of pertussis was defined in accordance a the Council of State and Territorial Epidemiologists ȘTE) case definition for pertussis, with one variation. · CSTE case definition for pertussis is a cough illness ing at least 2 weeks with one of the following sympis and no other apparent cause (as reported by a health fessional): paroxysms of coughing, inspiratory “whoop,” Dosttussive vomiting. Confirmatory criteria consist of er isolation of B. pertussis from a clinical specimen or tive PCR assay for B. pertussis. For this investigation,

definition was modified to include infants with cough ess of any duration so that the definition might cover s in newborns in the first 2 weeks of life. PCR amplifion and detection of a 114 nucleotide segment of the

B. pertussis IS481 sequence (1) was conducted using nucleic acid extracted from nasopharyngeal swabs.

The review of laboratory records and charts at children's hospital A revealed that 29 infants aged <4 months met the case definition for pertussis during June-August. Of these 29 infants, 11 (including the six previously known patients) had been born at general hospital A and directly exposed to HCW A in the newborn nursery. All 11 had been treated at children's hospital A with erythromycin and recovered; none developed hypertrophic pyloric stenosis, which has been reported as a complication of treatment of infants with erythromycin (2). Five of the infants required admission to the pediatric intensive care unit (PICU), and four were treated in the general pediatric medical unit; one infant was treated in the emergency department, and one was treated as an outpatient (Table). Median age of the 11 infants born at general hospital A was 31 days at the time of pertussis diagnosis, compared with a median age of 61 days for the other 18 infants with diagnosed pertussis, who were born at 12 other general hospitals during June-August.

On July 21, 2004, the county health department directed general hospital A to contact the families of all infants who had been in its newborn nursery during May 31-July 17 so that the infants could be screened for respiratory symptoms and administered antibiotics as needed. Families of 158 infants who had been in the newborn nursery during May 31-July 17 were contacted, and a total of 110 infants returned to general hospital A. Eighteen of the 110 had cough but were PCR negative; they received erythromycin prophylaxis. Two infants had cough and also were PCR positive; they were treated for pertussis, and one was admitted to children's hospital A. In addition, three family members reported cough or runny nose but were PCR negative; they were treated with erythromycin.

During the period that HCW A exhibited symptoms, she directly cared for 113 infants, 11 of whom subsequently had a diagnosis of pertussis, resulting in an attack rate of 9.7%. One other possible case was identified in a sibling aged 3 years. Interviews with families when they brought their infants back to general hospital A for screening, revealed no other exposures to pertussis. No secondary cases of pertussis among HCWs at either general hospital A or children's hospital A were discovered. After HCW A was furloughed and treated, no new cases of pertussis were identified during September October 2004 in infants born at general hospital A. Reported by: JL Hood, MPH, DK Murphey, MD, JJ Dunn, PhD, children's hospital A, Texas.

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TABLE. Characteristics of 11 infants who received diagnoses of pertussis after being under the direct care of the same health-caz worker — Texas, 2004

Age at Infant Date of pertussis

Hospitalization status/
No. birth diagnosis

Symptoms
Length of hospitalization

Treatment
1
June 15 12 days Cough, apnea

PICU*/MEDT, 16 days

Ventilator, intravenous (IV) fluids,

erythromycin, tube feedings 2 June 15 16 days Cough, apnea, posttussive emesis PICU/MED, 12 days

Ventilator, IV fluids, erythromycin, tube

feedings 3 June 15

28 days
Cough, apnea, cyanosis

PICU/MED, 11 days

Oxygen, IV fluids, erythromycin 4 June 16 18 days Cough, cyanosis

PICU/MED, 13 days

Oxygen, IV fuilds, erythromycin, tube

feedings 5 June 14

21 days
Cough, apnea, cyanosis

MED, 14 days

Oxygen, erythromycin 6 June 4

32 days
Cough, apnea, cyanosis

MED, 12 days

Oxygen, erythromycin 7 June 14 31 days Cough, stridor, cyanosis

PICU/MED, 15 days

Ventilator, IV fluids, erythromycin, tube

feedings 8 June 8 44 days Cough, cyanosis

MED, 5 days

Oxygen, erythromycin
9
June 17
72 days
Cough, congestion

Emergency department only Erythromycin
June 3 123 days Cough, congestion

MED, 2 days

Oxygen, erythromycin, tube feedings 11 June 15 38 days Cough, congestion

Outpatient only

Erythromycin * Pediatric intensive-care unit. General pediatric medical unit.

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Editorial Note: Pertussis is a highly contagious, vaccinepreventable illness caused by Bordetella pertussis infection. Complications of pertussis (e.g., seizures, pneumonia, encephalopathy, and cardiovascular compromise) can occur, especially in infants aged <l year. Deaths from pertussis occur most frequently among infants; the case-fatality rate is 1.8% for newborns and infants aged <2 months (3). From 1980-1989 to 1990-1999, the number of infant deaths from pertussis increased from 61 (1.67 deaths per million) to 93 (2.40 deaths per million) (4). Newborns most commonly acquire pertussis from adults with undiagnosed disease (5). Reports on outbreaks of pertussis in health-care facilities and neonatal nurseries have been published previously (6,7).

In 2004, the reported incidence of pertussis in the United States nearly tripled compared with 2001, and the number of reported cases exceeded any year since 1959 (8). This increase might have resulted, in part, from increased use of more sensitive PCR testing (8). CDC recommendations call for culture confirmation of infection in one or more cases in an outbreak. However, in the outbreak described in this report, no culture confirmation was performed. The medical staff at children's hospital A requested PCR testing, as did the local health department. Current molecular detection methods for detection of B. pertussis have high sensitivity compared with culture, but occasionally can be prone to false positives, depending on the target sequences, interpretation of results, and subjects tested (9). In a recent report describing outbreaks of respiratory illness mistakenly attributed to pertussis, PCR was used inappropriately as a mass screening tool on a large number

of

persons who did not meet the CSTE case definition ico pertussis (9). For the infants described in this report, a high index of suspicion for pertussis was based on clinical syruptoms, and PCR testing was used to confirm diagnoses of pertussis. HCW A also met the CTSE case definition to pertussis.

In 2005, Tdap vaccine was licensed by the Food and Drug Administration for use in adolescents and adults. 1o December 2006, the Advisory Committee on Immunizetion Practices (ACIP) recommended use of Tdap vaccine for HCWs with direct patient contact and for adults wi have or might have close contact with infants aged <li months (3). This recommendation was based on the doo mented risk for transmission of pertussis in health-care facilities. Despite the costs involved for health-care facile

1 ties, one study suggests the return on investment from vai cinating HCWs with Tdap vaccine is twice the cost of the vaccine (10).

Widespread implementation of Tdap vaccination of adlescents and adults as recommended by ACIP can reduz the risk for pertussis in the community and the inciden: of pertussis transmission in health-care facilities. This out break also highlights the importance of rapid recognitica of pertussis transmission in health-care settings and raçu response from hospital and public health practitioners : identify the source and prevent more extensive spread of disease, particularly among vulnerable newborns and infants.

Acknowledgment The findings in this report are based, in part, on observations tist made by S Roderick.

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