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The Morbidity and Mortality Weekly Report is prepared by the Centers for Disease Control, Atlanta, Georgia, and available on a paid subscription basis from the Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402, (202) 783-3238.

The data in this report are provisional, based on weekly reports to CDC by state health departments. The reporting week concludes at close of business on Friday; compiled data on a national basis are officially released to the public on the succeeding Friday. The editor welcomes accounts of interesting cases, outbreaks, environmental hazards, or other public health problems of current interest to health officials. Such reports and any other matters pertaining to editorial or other textual considerations should be addressed to: Editor, Morbidity and Mortality Weekly Report, Centers for Disease Control, Atlanta, Georgia 30333. Director, Centers for Disease Control

Editor James O. Mason, M.D., Dr.P.H.

Michael B. Gregg, M.D. Director, Epidemiology Program Office

Managing Editor Carl W. Tyler, Jr., M.D.

Gwendolyn A. Ingraham

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April 15, 1988 / Vol. 37 / No. 14



A 157 37 5 Apr.1988

213 Cluster of Suicides and Suicide

Attempts - New Jersey 217 Rabies Vaccine, Adsorbed: A New

Rabies Vaccine for Use in Humans 223 Quarterly Report to the Domestic

Policy Council on the Prevalence and
Rate of Spread of HIV and AIDS in the

United States
227 National Conference on Clustering of

Health Events



The University
MAY O 9 1988 of Michigan

Public Hol!!
Epidemiologic Notes and Reports


Cluster of Suicides and Suicide Attempts

New Jersey

On March 11, 1987, four teenagers from a suburban New Jersey community committed suicide by locking themselves inside a 13-car garage and sitting in a car with a running engine. Two of the young people were males aged 18 and 19, and two were females aged 16 and 17. The young women were sisters; the young men were not related. The two men died of a synergism of carbon monoxide poisoning, cocaine, and alcohol; the two young women, of a synergism of carbon monoxide and cocaine. The 19-year-old male had a history of alcohol abuse. Both males had evidence of recent, nonfatal cuts on their wrists. All four teenagers had had trouble in school: three had dropped out of high school, and one had recently been suspended. Both males had been friends of an 18-year-old youth who had died after falling from a cliff 6 months earlier (Table 1). One had witnessed this fall.

Within days after these suicides, the community responded with a number of efforts, coordinated mainly by the municipal government, to prevent other suicides. School officials identified students they thought might be at high risk, such as close friends of the victims or students with a history of suicide attempts, and provided counselors for these students and any others who wanted help. A local suicide hotline was started, and a walk-in center was opened and staffed 24 hours a day. Local police also assisted in locating anyone reported to have threatened suicide or who was thought to be at imminent risk of suicide. The garage where the suicides occurred was locked and put under periodic police surveillance.

Despite these measures, a 20-year-old female and a 17-year-old male attempted suicide together in the same garage by the same means 6 days after the simultaneous suicides. A policeman found them unconscious in a car after noticing that the lock on the garage had been broken. Both were successfully resuscitated. The garage door was removed.

During the following months, the municipal government developed a mental health emergency response plan in cooperation with school officials, clergy, and family guidance and mental health professionals. This plan called for creating a




Suicides Continued
community response team to coordinate the crisis response through four sectors of
the community: the municipal government, the school system, mental health agen-
cies, and the clergy. The plan was divided into precrisis planning, crisis operations,
and postcrisis programs. For each phase, specific protocols were developed to
address such issues as 1) the responsibilities of various community agencies during
a mental health crisis, 2) implementation of programs, 3) identification of persons at
high risk of suicide or otherwise in need of acute mental health services, and
4) provision of timely information to the public and the media.

An epidemiologic investigation of the suicides and suicide attempts was also carried out. Investigators assessed the comparative magnitude of background suicide mortality for the period 1980–1984* in the community by calculating 5-year suicide rates for residents of the community, the county in which the community lies, New Jersey, and the United States. Local health department and state medical examiner records for January 1, 1986, through March 11, 1987, were also reviewed for all deaths from nonnatural causes among residents of the community.

For this community, the 5-year crude suicide rate was 7.0/100,000 per year (Table 2). The county rate was 6.5 overall and 5.2 for persons 15–24 years of age. These community and county suicide rates are lower than those for both New Jersey and the United States as a whole.

From 1980 through 1986, one or two suicide deaths occurred annually among the residents of this community, for a total of 12 suicides over the 7-year period. Two of these 12 persons who committed suicide were between the ages of 15 and 24. For all of 1987, six persons committed suicide; five of these were between 15 and 24 years old. However, the number of suicides in 1987 would not have been unusually high had it not been for the cluster of four suicides on March 11.

* Population estimates for later years were not available.

TABLE 1. Nonnatural deaths in a suburban community - New Jersey, January 1, 1986–March 11, 1987

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Number Date Age


Manner of Death* 1

28-Apr-86 62 male Suicide (asphyxia, plastic bag)

14-Jun-86 21 male Pending (hit by train) 3 13-Aug-86 21 male Suicide (drowning) 4

11-Sep-86 18 male Accident (fell off cliff) 5

28-Sep-86 22 male Accident (hit by train)
04-Oct-86 24 male Undetermined (synergism: chlordiazepoxide,

demoxepam, and secobarbital) 7

24-Oct-86 59 female Suicide (gunshot wound to the head) 8

27-Oct-86 27 female Accident (motor vehicle crash) 9

27-Jan-87 50 male Suicide (hanging) 10

11-Mar-87 16 female Suicide (synergism: cocaine and carbon monoxide) 11

11-Mar-87 17 female Suicide (synergism: cocaine and carbon monoxide) 12 11-Mar-87 18

male Suicide (synergism: cocaine, alcohol, and carbon monoxide) 13 11-Mar-87 19 male Suicide (synergism: cocaine, alcohol, and carbon monoxide) "Manner of death" is a medicolegal term referring to the circumstances under which a death occurs, while "cause of death” refers to the injury or illness responsible for the death. When a death occurs under accidental circumstances, the preferred term within the public health community for the cause of death is "unintentional injury."


Suicides Continued

In the 9 months preceding the multiple-suicide incident of March 11, 1987, nine community residents died of nonnatural causes; five were 15–24 years of age (Table 1). One of these five decedents committed suicide, and two died from unintentional injuries. Both of these latter deaths were rumored to have been suicides, but in neither case was the evidence sufficient to justify such a determination. The manner of death was undetermined in one case and is pending in another. Reported by: JW Farrell, MSW, ME Petrone, MD, WE Parkin, DVM, State Epidemiologist, New Jersey Dept of Health. Intentional Injuries Section, Epidemiology Br, Div of Injury Epidemiology and Control, Center for Environmental Health and Injury Control, CDC. Editorial Note: This cluster of suicides in New Jersey is the first investigated by CDC in which all of the decedents committed suicide together in an apparent "suicide pact." Nevertheless, there are more similarities than differences between this cluster in New Jersey and others: 1) as in most other reported suicide clusters ( 1 ), the New Jersey decedents were all teenagers or young adults; 2) the imitative suicide attempts on March 17 suggest that suicide may have a "contagious" (2, effect; 3) other young people had died from nonnatural causes before the identified cluster, and these deaths may have influenced the young people involved in the cluster of suicides; 4) the suicide cluster caused anger, confusion, and fear in the community as well as an urgent sense that something needed to be done to prevent other suicides; 5) community leaders felt that the intense demands of the media for information disrupted efforts to address the crisis; and 6) although some opportunities for prevention may have been missed initially, a coordinated community response was developed

Reports of suicides committed simultaneously by two or more individuals apparent suicide pact (multiple simultaneous suicides) are relatively rare. Suicide clusters in general – whether multiple simultaneous suicides or a series of suicides occurring close together in time and space - may account for no more than 1%-5% of all youth suicides (4). Nevertheless, when a suicide cluster does occur, an extraordinary amount of community effort and resources is temporarily devoted to suicide prevention. This is true even when, as in the New Jersey community, background mortality rates do not suggest that the community has any ongoing problem with suicide.

Such a response by a community faced with a suicide cluster is appropriate. Anecdotal evidence suggests that suicides early in a cluster may influence the


*The earlier deaths were from suicide and unintentional injuries.

TABLE 2. Numbers and rates of suicide among residents of a New Jersey community,
the county, New Jersey, and the United States, 1980-1984

New Jersey

United States
All Ages 15-24* All Ages

15-24* All Ages

All Ages

15-24* Year No. Rate No. Rate No. Rate No. Rate


Rate No. Rate No. Rate No. Rate 1980 2 7.8 0

62 7.3 12 8.6 576 7.8 131 10.2. 26,869 11.9 5,239 12.3 1981 2 7.7

56 6.6 7 5.0 552 7.4 92 7.3 27,596 12.0 5,161 12.3 1982 2 7.8

43 5.1 5 3.5 605 8.1 111 8.9 28,242 12.2. 5,025 12.1 1983 2 7.8 1

47 5.6 5 3.5 572 7.7 97 7.9 28,295 12.1 4,845 11.9 1984 1 3.9 0

66 7.8 8 5.6 650 8.6 115 9.5 29,286 12.4 5,026 12.5 Total 9 7.0 1

274 6.5 37 5.2 2,955 7.9 546 8.8 140,288 12.1 25,296 12.2 *Years of age.

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