),000 workers), and of these, 68 (67%) occurred in rkers employed in the crop production or support vities for crop production sectors, resulting in an averannual fatality rate of 0.39 deaths per 100,000 crop kers (Table). Analysis of fatality rates by 5-year periods gests an increase in rates over time; however, those rates e based on small numbers of deaths, and the increase r time was not statistically significant (Figure).

During 1992-2006, nearly all deceased crop workers re male,** and 78% were aged 20–54 years (Table). ring 1992-2006, the birth country was unknown for % of the decedents; however, during 2003–2006, roximately 20 (71%) of the 28 deceased crop workers

Data are not reported by sex because they do not meet BLS publication criteria.

were from Mexico or Central and South America. Nearly 60% of all heat-related deaths among crop workers occurred in July, and most deaths occurred in the afternoon. Although 21 states reported heat-related deaths among crop workers, California, Florida, and North Carolina accounted for 57% of all deaths, with North Carolina having the highest annualized rate.

Reported by: RC Luginbuhl, MS, North Carolina Dept of Labor. LL Jackson, PhD, DN Castillo, MPH, Div of Safety Research, National Institute for Occupational Safety and Health; KA Loringer, ND, EIS Officer, CDC.

Editorial Note: During 1992-2006, a total of 68 crop workers died from heat stroke, representing a rate nearly 20 times greater than for all U.S. civilian workers. The majority of these deaths were in adults aged 20–54 years, a population not typically considered to be at high risk for

heat illnesses (3). In addition, the majority of these deaths were among foreign-born workers.

Persons who work outside in hot and humid conditions are at risk for heatrelated mortality and morbidity. Heat-related illnesses range from minor heat cramps or rash to heat exhaustion, which is more serious and can lead to heat stroke, which can result in death if medical attention is not provided immediately. Heat stroke is characterized by a body temperature of >103°F (>39°C); red, hot, and dry skin (with no sweating); rapid, strong pulse; throbbing headache; dizziness; nausea; confusion; and unconsciousness. Crop workers might be at increased risk for heat stroke because they often wear extra clothing and personal protective equipment to protect against pesticide poisoning or green tobacco illness (transdermal nicotine poisoning). Employers and workers must be aware that heat-related illness, which can have symptoms similar to pesticide poisoning and green tobacco illness, requires immediate attention. The high proportion of heat-related deaths among foreign-born workers indicates that training and communications regarding the risk for heat-related illnesses should be provided in the workers' native language.

Guidance to help agricultural employers establish a heatillness prevention program is available from CDC and the U.S. Environmental Protection Agency (4,5). In addition, the Department of the Army and Air Force has published a technical bulletin that provides strategies for employers to control heat stress (6). Heat-related safety materials in English and Spanish are available from several other sources, including the California Division of Occupational Safety and Health and the North Carolina Department of Labor. California and Washington state have recently enacted regulations requiring that employers take action to prevent heat-related illnesses and deaths among their workers, including providing training to supervisors and workers and ensuring the availability of fluids (7,8). These regulations were prompted by deaths and illnesses in both states in recent years.

The findings in this report are subject to at least four limitations. First, certain fatality rates had to be calculated as average annualized rates for the entire 15-year study period because small numbers prevented publication according to BLS publishing criteria. This aggregation obscured variability between years. Second, CPS estimates likely underestimated the number of crop workers because of the seasonal nature of the work and because the CPS relies on stable residences for sequential interviews. An underestimate of the worker population would have resulted in an overestimation of the fatality rates. Third, heatrelated deaths were likely underreported because heat stroke

Available at http://www.dir.ca.gov/dosh/heatillnessinfo.html. $5 Available at http://www.nclabor.com/pubs.htm.

was not recognized at the time of death, was not indica as a contributing factor on the death certificate (3), or wa not recognized by the state agencies as meeting the cas definition for an injury-related death in CFOI. Finally, the fatality rates for 5-year periods were based on small nutbers with large confidence intervals, and the data do not allow an assessment of whether increased numbers over time might be a reflection of increased awareness and reporting

The illustrative case described in this report and another case previously reported by CDC (9) suggest that som: employers might not have heat stress management program in place. Agricultural employers should develop and implement heat stress management measures that include: training for field supervisors and employees to prevent, recognize, and treat heat illness, 2) implementing a hea acclimatization program, 3) encouraging proper hydration with proper amounts and types of fluids, 4) establishing work/rest schedules appropriate for the current heat ind ces, 5) ensuring access to shade or cooling areas, 6) montoring the environment and workers during hot conditions. and 7) providing prompt medical attention to workers who show signs of heat illness (5,6,10). Employers and workers should be vigilant for signs of heat illness, not only in themselves but in their coworkers, and be prepared to provide and seek medical assistance.

Acknowledgments

The findings in this report are based, in part, on contributions by J Myers, MS, National Institute for Occupational Safety and Health CDC.

References

1. Bureau of Labor Statistics. Bureau of Labor Statistics handbook of methods. Washington, DC: US Department of Labor, Bureau o Labor Statistics; 2007. Available at http://www.bls.gov/opub/hom homch9_a1.htm.

2. Bureau of Labor Statistics. Current Population Survey, 1992-200 (microdata files) and labor force data from the Current Population Survey. In: BLS handbook of methods. Washington, DC: US Depar ment of Labor, Bureau of Labor Statistics; 2003. Available at http www.bls.gov/cps/home.htm.

3. CDC. Heat-related deaths-United States, 1999-2003. MMWE 2006;55:796-8.

4. CDC. Working in hot environments. Cincinnati, OH: US Depar ment of Health and Human Services, CDC, National Institute t Occupational Safety and Health; 1986. DHHS (NIOSH) publica tion 86-112. Available at http://www.cdc.gov/niosh/hotenvt.html 5. US Environmental Protection Agency. A guide to heat stress in ag culture. Washington, DC: US Environmental Protection Agency; 199 EPA-750-b-92-001. Available at http://www.epa.gov/oecaage

awor.html.

6. Department of the Army and Air Force. Heat stress control and hea casualty management. Washington, DC: Department of the Army an Air Force; 2003. Available at http://chppm-www.apgea.army.m documents/tbmeds/tbmed507.pdf.

California Division of Occupational Safety and Health. Heat-related illness prevention. Oakland, CA: California Division of Occupational Safety and Health; 2007. Available at http://www.dir.ca.gov/dosh/ heatillnessinfo.html.

Washington State Department of Labor and Industries. Outdoor heatrelated illness (heat stress). Olympia, WA: Washington State Department of Labor and Industries; 2008. Available at http://www.lni.wa.gov/ safety/topics/atoz/heatstress/default.asp.

CDC. Migrant farm worker dies from heat stroke while working on a tobacco farm-North Carolina. Morgantown, WV: US Department of Health and Human Services, CDC, National Institute for Occupational Safety and Health; 2007. FACE report 2006-04. Available at http://www.cdc.gov/niosh/face/in-house/full200604.html.

CDC. Criteria for a recommended standard: occupational exposure to hot environments (revised criteria 1986). Cincinnati, OH: US -- Department of Health and Human Services, CDC, National Institute for Occupational Safety and Health; 1986. DHHS (NIOSH) publication no. 86-113. Available at http://www.cdc.gov/niosh/86-113.html.

Influenza Vaccination Coverage
Among Persons with Asthma

United States, 2005-06
Influenza Season

During 2006, approximately 6.8 million (9.3%) U.S. ldren and 16.1 million (7.3%) U.S. adults were reported have asthma (1,2). Since 1964, the Advisory Commiton Immunization Practices (ACIP) has recommended luenza vaccination of all persons with asthma because of : higher risk for medical complications from influenza those persons (3,4). Influenza vaccination coverage of rsons with asthma varies by age group and remains ow Healthy People 2010 targets of 60% coverage of peris aged 18-64 years with high-risk conditions (14-29c) d 90% of all persons aged ≥65 years (14-29a) (5–7). luenza vaccination rates of children and older adults with hma have not been well studied. Using 2006 National alth Interview Survey (NHIS) data, this report provides e first examination of influenza vaccination rates and ated factors across a national sample of persons with hma aged ≥2 years. The results indicated that 36.2% ceived influenza vaccination during the 2005-06 influza season. Vaccination rates remained below target levels ong all subgroups examined, including those reporting greatest number of health-care visits in the past 12 ›nths. The results of this study indicate that influenza ccination coverage of all persons with asthma can be proved by increasing access to health care and using portunities for vaccination during health-care visits. NHIS is an ongoing, nationally representative, in-person usehold interview survey of the civilian, ninstitutionalized population of the United States.

Beginning with the 2004-05 influenza season, influenza vaccination questions were included in the child questionnaire portion of the NHIS. Because of an influenza vaccine shortage during the 2004-05 season, 2005-06 was the first influenza season for which the NHIS was able to provide an estimate of influenza vaccination rates among children with asthma in a nonshortage season. This report examines NHIS data on influenza vaccination among all persons with asthma aged ≥2 years during the 2004-05 and 2005-06 influenza seasons and identifies characteristics associated with vaccination coverage. Age subgroups were chosen for convenient comparison with previously published Behavioral Risk Factor Surveillance System and NHIS results (5). Because diagnoses of asthma in children aged <2 years are considered unreliable, and to be consistent with other reports, the <2 years age group was excluded from this report (6).

To ensure that included respondents had equal opportunity for vaccination, only responses for persons who were within the stated age range for the entire influenza season (September 2005-February 2006) were included; furthermore, only responses from interviews that occurred following the influenza season (i.e., interviews conducted during March-August 2006) were included in the analysis to ensure that only vaccinations given for the 2005-06 season were counted. In addition, only persons who reported the month of their most recent vaccination to be in the period September 2005-February 2006 were considered vaccinated for the 2005-06 season. The same inclusion criteria were applied to 2004-05 influenza season data. For the 2004-05 and 2005-06 seasons, influenza vaccination status was stratified by characteristics reported to influence likelihood of vaccination, including age group, race/ethnicity, income, health insurance coverage, number of health-care visits, and possession of a usual place of health care (5,6). Differences in coverage were compared by chisquare test for within-year comparisons and z-test for comparisons in coverage across influenza seasons, with statistical significance defined as p<0.05.

Of the 15,295 survey participants aged ≥2 years for the entire 2005-06 influenza season, 1,277 (8.3%) reported current asthma, of whom 29 (2.2%) were excluded from further analysis because of incomplete answers regarding vaccination. Of the remaining 1,248 participants with asthma, 455 reported receiving influenza vaccinations, but 24 (5.3%) had received their vaccination before September 2005 or after February 2006 and were counted as unvaccinated for the 2005-06 season. Influenza vaccination coverage of persons aged ≥2 years with asthma in the 2005-06 influenza season was 36.2%, compared with

23.9% among those without current asthma (p<0.001) (Table 1). Both coverage rates represent significant increases from the 2004-05 season, in which respective rates were 31.5% (95% confidence interval [CI] = 28.9-34.3, p<0.05) and 16.7% (CI = 16.4–17.4, p<0.001). Among persons with asthma, those aged 50-64 years and ≥65 years had the highest influenza vaccination coverage in 200506 (48.6% and 75.7%, respectively). Among all age subgroups, persons with asthma were more likely to receive influenza vaccination than those without asthma (Table 1). Persons without a usual place for health care were more likely to remain unvaccinated during the 2005-06 season (89.6%, CI = 79.3-95.1) than those with at least one usual place for health care (61.3%, CI = 57.5–65.0; p<0.001); this difference persisted when limited to the insured (81.8%, CI = 58.6-93.5; and 59.2%, CI = 55.1-63.2, respectively; p<0.03). Influenza vaccination coverage was higher among participants with health insurance coverage (39.9%) than among the uninsured (14.5%, p<0.001) (Table 2). Vaccination coverage increased from 33.8% to

39.9% (p<0.02) among insured persons with asthma fre the vaccine shortage season of 2004-05 to the season regular supply in 2005-06, but coverage did not increst among those without insurance (13.5% to 14.5%, p=0.5 From the 2004-05 to the 2005-06 influenza seasons, vacination rates increased significantly only among perso in families earning annual incomes >4.5 times the fede poverty level (Table 2).

The likelihood of receiving an influenza vaccination increased with increasing numbers of health-care visit defined as a visit to a doctor's office, clinic, or other place .health care, but not counting hospitalizations, emergenc department visits, dental or home visits, or telephone cal (Table 3). Coverage ranged from 17.6% in persons with asthma reporting one visit or less to 50.8% in thos reporting 10 or more visits. Stratified by number of healthcare visits, influenza vaccination coverage was significant higher among persons with asthma than among those without for each stratum, except for the 6-9 health-care visits stratum. Stratified by available measures of asthma