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We aimed to describe coronavirus disease 2019 (COVID-19) deaths among first responders early in the COVID-19 pandemic. We used media reports to gather timely information about COVID-19–related deaths among first responders during March 30–April 30, 2020, and evaluated the sensitivity of media scanning compared with traditional surveillance. We abstracted information about demographic characteristics, occupation, underlying conditions, and exposure source. Twelve of 19 US public health jurisdictions with data on reported deaths provided verification, and 7 jurisdictions reported whether additional deaths had occurred; we calculated the sensitivity of media scanning among these 7 jurisdictions. We identified 97 COVID-19–related first-responder deaths during the study period through media and jurisdiction reports. Participating jurisdictions reported 5 deaths not reported by the media. Sixty-six decedents worked in law enforcement, and 31 decedents worked in fire/emergency medical services. Media reports rarely noted underlying conditions. The media scan sensitivity was 88% (95% CI, 73%-96%) in the subset of 7 jurisdictions. Media reports demonstrated high sensitivity in documenting COVID-19–related deaths among first responders; however, information on risk factors was scarce. Routine collection of data on industry and occupation could improve understanding of COVID-19 morbidity and mortality among all workers.

We characterized common exposures reported by a convenience sample of 202 US patients with coronavirus disease during January–April 2020 and identified factors associated with presumed household transmission. The most commonly reported settings of known exposure were households and healthcare facilities; among case-patients who had known contact with a confirmed case-patient compared with those who did not, healthcare occupations were more common. Among case-patients without known contact, use of public transportation was more common. Within the household, presumed transmission was highest from older (>65 years) index case-patients and from children to parents, independent of index case-patient age. These findings may inform guidance for limiting transmission and emphasize the value of testing to identify community-acquired infections.

ObjectivesTo use industry-specific denominators to more accurately examine trends in prevalence rates for occupational cases of elevated blood lead levels (eBLLs) in Pennsylvania.MethodsWe used adult (aged ≥16 years) blood lead level data from Pennsylvania (2007–2018) and industry-specific denominator data from the US Census Bureau’s County Business Patterns to calculate prevalence rates for eBLLs, defined as ≥25 µg/dL.ResultsOf the 19 904 cases with eBLLs, 92% were due to occupational lead exposure, with 83% from workers in the battery manufacturing industry. In 2018, the prevalence rate of eBLLs for battery manufacturing (8036.4 cases per 100 000 employed battery manufacturing workers) was 543 times the overall Pennsylvania prevalence rate. The prevalence rate for battery manufacturing steeply declined 71% from 2007 to 2018.ConclusionsThe battery manufacturing industry had the highest burden of occupational lead exposure in Pennsylvania, illustrating the importance of using industry-specific denominators to accurately identify sources of lead exposure. Although the prevalence rate of eBLLs declined over time, lead exposure remains a major concern among battery manufacturing workers.

On April 25, 2019, a farm tractor towing two 2-ton ammonia tanks on a county road in Lake County, Illinois, experienced a mechanical failure that resulted in the release of anhydrous ammonia, a colorless, pungent, irritating gas that can cause severe respiratory and ocular damage (1). Approximately 80% of anhydrous ammonia produced in the United States is used as a fertilizer in agriculture (1). Eighty-three persons, including first responders, motorists, and neighborhood residents, were evaluated at area hospitals because of exposure to the gas. Two weeks after the release, the Agency for Toxic Substances and Disease Registry (ATSDR) and CDC's National Center for Environmental Health (NCEH) collaborated with the Lake County Health Department and the Illinois Department of Public Health on an investigation using ATSDR's Assessment of Chemical Exposures program to describe the release, review the emergency response, and determine health effects associated with the exposure. First responders, community residents, and hospital personnel reported communication challenges related to the nature of the gas release and effective protective measures. Among the 83 persons evaluated at six area hospitals for effects of the chemical release, 14 (17%) were hospitalized, including eight (10%) who were admitted to the intensive care unit (ICU), seven (8%) of whom required endotracheal intubation and mechanical ventilation; no deaths occurred. In addition, ICU health care providers experienced symptoms of secondary exposure. The National Institute for Occupational Safety and Health's Emergency Responder Health Monitoring and Surveillance Program has specific recommendations and tools to protect responders during all phases of a response (2). Hospitals also need to review institutional policies and procedures for chemical mass casualty events, including decontamination (3). Prompt and correct identification of hazardous material (hazmat) events, and clear communication among responding entities, including on-scene and hospital responders, is important to ensure effective response after a chemical release.

OBJECTIVES To describe the demographics, clinical characteristics, and hospital course among persons METHODS We conducted a retrospective case series of suspected SARS-CoV-2-associated deaths in the United States in persons RESULTS We included 112 SARS-CoV-2-associated deaths from 25 participating jurisdictions. The median age was 17 years (IQR 8.5–19 years). Most decedents were male (71, 63%), 31 (28%) were Black (non-Hispanic) persons, and 52 (46%) were Hispanic persons. Ninety-six decedents (86%) had at least 1 underlying condition; obesity (42%), asthma (29%), and developmental disorders (22%) were most commonly documented. Among 69 hospitalized decedents, common complications included mechanical ventilation (75%) and acute respiratory failure (82%). The sixteen (14%) decedents who met multisystem inflammatory syndrome in children (MIS-C) criteria were similar in age, sex, and race and/or ethnicity to decedents without MIS-C; 11 of 16 (69%) had at least 1 underlying condition. CONCLUSIONS SARS-CoV-2-associated deaths among persons

BACKGROUND Use of worker's compensation (WC) as payer underestimates work-related (WR) injuries. We evaluated three methods to identify WR injuries: WC as payer, ICD-9-CM work-status codes E000.0/E000.1, and other ICD-9-CM external cause codes. METHODS We identified injury-related emergency department visits from North Carolina's syndromic surveillance system (2010-2013). Characteristics were compared by indicator. We manually reviewed 800 admission notes to confirm if the visit was WR or non-WR; WR keywords from the review were applied to all visits. RESULTS 133 156 injury-related visits (age, 16 years or older) were identified: WC = 69%, work-status codes = 18%, other ICD-9-CM codes = 13%. Among manually reviewed visits: few visits identified by WC (0.3%) or work-status codes (2%) were non-WR, while 12% of other ICD-9-CM code identified visits were non-WR; 53%, 46%, and 31% of visits identified by WC, work-status codes, and other ICD-9-CM codes were WR, respectively. CONCLUSIONS Findings support use of WC and work-status codes to capture WR injuries; other ICD-9-CM codes should be used with caution or in combination with other indicators.

The opioid epidemic affects multiple segments of the U.S. population (1). Occupational patterns might be critical to understanding the epidemic. Opioids are often prescribed for specific types of work-related injuries, which vary by occupation* (2). CDC used mortality data from the National Occupational Mortality Surveillance (NOMS) system to examine unintentional or undetermined drug overdose mortality within 26 occupation groups. This study included data from the 21 U.S. states participating in NOMS during 2007–2012.† Drug overdose mortality was compared with total mortality using proportional mortality ratios (PMRs) indirectly standardized for age, sex, race, year, and state. Mortality patterns specific to opioid-related overdose deaths were also assessed. Construction occupations had the highest PMRs for drug overdose deaths and for both heroin-related and prescription opioid–related overdose deaths. The occupation groups with the highest PMRs from methadone, natural and semisynthetic opioids, and synthetic opioids other than methadone were construction, extraction (e.g., mining, oil and gas extraction), and health care practitioners. The workplace is an integral part of life for the majority of the adult U.S. population; incorporating workplace research and interventions likely will benefit the opioid epidemic response.

Objectives: To improve heat-related illness surveillance, we evaluated and refined North Carolina’s heat syndrome case definition. Methods: We analyzed North Carolina emergency department (ED) visits during 2012-2014. We evaluated the current heat syndrome case definition (ie, keywords in chief complaint/triage notes or International Classification of Diseases, Ninth Revision, Clinical Modification [ ICD-9-CM] codes) and additional heat-related inclusion and exclusion keywords. We calculated the positive predictive value and sensitivity of keyword-identified ED visits and manually reviewed ED visits to identify true positives and false positives. Results: The current heat syndrome case definition identified 8928 ED visits; additional inclusion keywords identified another 598 ED visits. Of 4006 keyword-identified ED visits, 3216 (80.3%) were captured by 4 phrases: “heat ex” (n = 1674, 41.8%), “overheat” (n = 646, 16.1%), “too hot” (n = 594, 14.8%), and “heatstroke” (n = 302, 7.5%). Among the 267 ED visits identified by keyword only, a burn diagnosis or the following keywords resulted in a false-positive rate >95%: “burn,” “grease,” “liquid,” “oil,” “radiator,” “antifreeze,” “hot tub,” “hot spring,” and “sauna.” After applying the revised inclusion and exclusion criteria, we identified 9132 heat-related ED visits: 2157 by keyword only, 5493 by ICD-9-CM code only, and 1482 by both (sensitivity = 27.0%, positive predictive value = 40.7%). Cases identified by keywords were strongly correlated with cases identified by ICD-9-CM codes (rho = .94, P < .001). Conclusions: Revising the heat syndrome case definition through the use of additional inclusion and exclusion criteria substantially improved the accuracy of the surveillance system. Other jurisdictions may benefit from refining their heat syndrome case definition.

Objectives: The primary objective of this study was to identify patients with heat-related illness (HRI) using codes for heat-related injury diagnosis and external cause of injury in 3 administrative data sets: emergency department (ED) visit records, hospital discharge records, and death certificates. Methods: We obtained data on ED visits, hospitalizations, and deaths for Florida residents for May 1 through October 31, 2005-2012. To identify patients with HRI, we used codes from the International Classification of Diseases, Ninth Revision, Clinical Modification ( ICD-9-CM) to search data on ED visits and hospitalizations and codes from the International Classification of Diseases, Tenth Revision ( ICD-10) to search data on deaths. We stratified the results by data source and whether the HRI was work related. Results: We identified 23 981 ED visits, 4816 hospitalizations, and 140 deaths in patients with non–work-related HRI and 2979 ED visits, 415 hospitalizations, and 23 deaths in patients with work-related HRI. The most common diagnosis codes among patients were for severe HRI (heat exhaustion or heatstroke). The proportion of patients with a severe HRI diagnosis increased with data source severity. If ICD-9-CM code E900.1 and ICD-10 code W92 (excessive heat of man-made origin) were used as exclusion criteria for HRI, 5.0% of patients with non–work-related deaths, 3.0% of patients with work-related ED visits, and 1.7% of patients with work-related hospitalizations would have been removed. Conclusions: Using multiple data sources and all diagnosis fields may improve the sensitivity of HRI surveillance. Future studies should evaluate the impact of converting ICD-9-CM to ICD-10-CM codes on HRI surveillance of ED visits and hospitalizations.

Outdoor workers face elevated and prolonged heat exposures and have limited access to air-conditioned spaces. This study’s overarching research aim is to increase knowledge of municipal worker heat exposure and adaptation practices. The study’s sub-objectives are: (1) quantifying exposure misclassification from estimating personal heat exposure from the official weather station; (2) surveying worker’s knowledge and practices to adapt to extreme heat; and (3) relating heat exposure and adaptation practices to self-reported thermal comfort. Participants wore a personal heat exposure sensor over 7 days from June 1st to July 3rd, 2015 in Tallahassee, Florida US. Next, participants confirmed the days that they wore the sensor and reported their daily thermal comfort and heat adaptations. Finally, participants completed an extreme heat knowledge, attitudes, and practices survey. Some participants (37%) experienced hotter and more humid conditions (heat index > 2) than the weather station. The most common heat adaptations were staying hydrated (85%), wearing a hat (46%), and seeking shade (40%). During work hours, higher temperatures increased the odds (odds ratio: 1.21, 95% confidence interval: 1.03–1.41, p = 0.016) of a participant feeling too hot. Shifting work duty indoors made workers to feel more comfortable (odds ratio: 0.28, 95% confidence interval: 0.11–0.70, p = 0.005). In hot and humid climates, everyday, heat exposures continuously challenge the health of outdoor workers.

Objectives This study aimed to evaluate the persistence of nasal carriage of Staphylococcus aureus, methicillin-resistant S. aureus and multidrug-resistant S. aureus over 14 days of follow-up among industrial hog operation workers in North Carolina. Methods Workers anticipating at least 24 h away from work were enrolled June–August 2012. Participants self-collected a nasal swab and completed a study journal on the evening of day 1, and each morning and evening on days 2–7 and 14 of the study. S. aureus isolated from nasal swabs were assessed for antibiotic susceptibility, spa type and absence of the scn gene. Livestock association was defined by absence of scn. Results Twenty-two workers provided 327 samples. S. aureus carriage end points did not change with time away from work (mean 49 h; range >0–96 h). Ten workers were persistent and six were intermittent carriers of livestock-associated S. aureus. Six workers were persistent and three intermittent carriers of livestock-associated multidrug-resistant S. aureus. One worker persistently carried livestock-associated methicillin-resistant S. aureus. Six workers were non-carriers of livestock-associated S. aureus. Eighty-two per cent of livestock-associated S. aureus demonstrated resistance to tetracycline. A majority of livestock-associated S. aureus isolates (n=169) were CC398 (68%) while 31% were CC9. No CC398 and one CC9 isolate was detected among scn-positive isolates. Conclusions Nasal carriage of livestock-associated S. aureus, multidrug-resistant S. aureus and methicillin-resistant S. aureus can persist among industrial hog operation workers over a 14-day period, which included up to 96 h away from work.

The failure of the human body to thermoregulate can lead to severe outcomes (e.g., death) and lasting physiological damage. However, heat-related illness (HRI) is highly preventable via individual- and community-level modification. A thorough understanding of the burden is necessary for effective intervention. This paper describes the burden of severe HRI morbidity and mortality among residents of a humid subtropical climate. Work-related and non-work-related HRI emergency department (ED) visits, hospitalizations, and deaths among Florida residents during May to October (2005–2012) were examined. Sub-groups susceptible to HRI were identified. The age-adjusted rates/100,000 person-years for non-work-related HRI were 33.1 ED visits, 5.9 hospitalizations, and 0.2 deaths, while for work-related HRI/100,000 worker-years there were 8.5 ED visits, 1.1 hospitalizations, and 0.1 deaths. The rates of HRI varied by county, data source, and work-related status, with the highest rates observed in the panhandle and south central Florida. The sub-groups with the highest relative rates regardless of data source or work-relatedness were males, minorities, and rural residents. Those aged 15–35 years had the highest ED visit rates, while for non-work-related hospitalizations and deaths the rates increased with age. The results of this study can be used for targeted interventions and evaluating changes in the HRI burden over time.

Objective. Previous Florida evaluations of carbon monoxide (CO) poisoning have been disaster focused. The majority of prevention messages and risk-factor identification efforts have revolved around hurricane season (June-November). We evaluated the prevalence, risk factors, and causes of CO poisoning within Florida throughout the year to produce a more complete presentation of the burden of CO poisoning. Methods. We obtained data from death certificates, hospital discharge records, and emergency department records. We limited our analysis to unintentional poisonings, calculating rates for age, gender, race, and ethnicity, and reviewing poisoning chronology, location, and exposure situation. Results. From 1999 to 2007, 493 people were hospitalized, and 230 individuals died as a result of non-fire-related CO poisoning. From 2005 to 2007, 781 people visited emergency departments for non-fire-related CO poisoning. Rates of severe poisoning resulting in hospitalization or death were highest among the elderly (0.56 visits and 0.63 deaths per 100,000 Floridians). Acute poisoning rates were highest among people 25–34 years of age (2.48 visits per 100,000 Floridians). Poisonings were primarily due to motor vehicle exhaust (21%–69%) and generator exposure (12%–33%), and the majority (50%–70%) occurred within the home. A large number of poisonings (25%–29%) occurred during the winter months, outside of hurricane season. Conclusion. The findings of this study indicate a need for additional prevention strategies in conjunction with current activities to more effectively reduce the number of CO poisonings in Florida. Prevention activities should be conducted year-round, and additional strategies should include public awareness of the hazards of motor vehicle exhaust.

Purpose This study was conducted to determine whether or not contact with a WOC nurse improves quality of life for ostomy patients. Methodology Home health care agencies, hospitals, and a durable medical equipment company in northern Florida were contacted to participate in the study. The role of the participating facilities was to address the provided envelopes and mail the patient survey packet (introductory letter, Ostomy Quality of Life Questionnaire [OQLQ], and demographic survey) directly to the patient. Results The mean age or respondents was 62 years, and the mean time of living with an ostomy was 10 years. Ninety-six percent of the sample participants did not attend support groups, yet nearly 50% reported receiving education following discharge home. Analysis of OQLQ scores revealed statistically significant differences based on who the respondent lived with, the number of comorbidities, how the respondent received supplies, and the type of appliance worn. There was no significant difference between respondents who saw an ostomy nurse and those who did not among the various sections of the OQLQ, even though 83% indicated seeing an ostomy nurse. Body image was a concern to respondents. Conclusion The data demonstrated that most participants maintained satisfactory quality of life despite the presence of an ostomy. Individuals who were working part-time had a better health-related quality of life than those who worked full-time. More than 50% of our study sample participants reported satisfaction with the healthcare services they received, regardless of whether services were provided by a WOC or a nonspecialist nurse.

Background During August–September 2004, four major hurricanes hit Florida, resulting in widespread power outages affecting several million households. Carbon monoxide (CO) poisonings during this period were investigated to identify ways to prevent future poisoning. Methods Medical records from ten hospitals (two with hyperbaric oxygen chambers) were reviewed to identify individuals diagnosed with unintentional CO poisoning between August 13 and October 15, 2004. Multiple attempts were made to interview one person from each nonfatal incident. Medical examiner records and reports of investigations conducted by the U.S. Consumer Product Safety Commission of six fatal poisonings from five additional incidents were also reviewed. Results A total of 167 people treated for nonfatal CO poisoning were identified, representing 51 incidents. A portable, gasoline-powered generator was implicated in nearly all nonfatal incidents and in all fatal poisonings. Generators were most often located outdoors, followed by inside the garage, and inside the home. Telephone interviews with representatives of 35 (69%) incidents revealed that concerns about theft or exhaust most often influenced the choice of location. Twenty-six (74%) households did not own a generator before the hurricanes, and 86% did not have a CO detector at the time of the poisoning. Twenty-one (67%) households reported reading or hearing CO education messages before the incident. Conclusions Although exposure to public education messages may have encouraged more appropriate use of generators, a substantial number of people were poisoned even when the devices were operated outdoors. Additional educational efforts and engineering solutions that reduce CO emission from generators should be the focus of public health activities.

In 2008, the work-related injury fatality rate was 3.8 per 100,000 workers in the United States but was 5.2 per 100,000 workers for the southeast region. Work-related fatalities in the southeast were examined for the period 2008 to 2011. Median work-related injury fatality rates are reported for the southeast region, each of the 12 states, and the United States. The percentages of employees in high fatality industries and work-related fatalities by cause were calculated. Finally, the Occupational Safety and Health Administration’s database was searched for fatality reports. States with the highest rates (per 100,000 workers) included Arkansas (7.2), Louisiana (6.8), and West Virginia (6.6). Arkansas, Louisiana, Mississippi, and West Virginia each had more than 20% of their employees in high fatality industries. Forty percent of work-related injury fatalities were from transportation incidents in the southeast and the United States. Future analyses should include work-related injury fatality rates by industry and compare rates with other U.S. regions.

The Indian River county health department, environmental health division (IRCHD EH) in Florida implemented the Protocol for Assessing Community Excellence in Environmental Health (PACE EH) in the low-income community of West Wabasso, Florida. Over two and a half years, IRCHD EH worked with the community and various governmental agencies to bring much-needed improvements to the area. At the end of the two and a half years, a survey was conducted to discover if the residents' quality of life had increased due to the community's improvements. The survey results yielded high satisfaction rates among residents. The general response was that their feelings of safety and overall well-being attributed to infrastructure improvements in their community had increased significantly. An unforeseen benefit realized by all parties involved was a renewed trust in government. The majority of surveyed residents (91%) felt that governmental agencies were better able to respond to their issues.

Background Previous population-based analyses of emergency department (ED) visits for anaphylaxis have been limited to small populations in limited geographic areas and focused on children or have included patients who had allergic conditions other than anaphylaxis. Objective We sought to describe the epidemiology and risk factors among patients with anaphylaxis presenting to Florida EDs. Methods Two thousand seven hundred fifty-one patients with anaphylaxis were identified for 2005-2006 within ED records by using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), and a validated ICD-9-CM–based algorithm. Age- and sex-specific rates were calculated. Regression analyses were used to determine relative risks for anaphylaxis caused by various triggers (food, venom, and medication) and risk factors (age, sex, race, and ethnicity). Results The highest observed rates were among the youngest male subjects (8.2/100,000 Floridians aged 0-4 years) and among adult female subjects (15-54 years) grouped in 10-year age categories (9.9-10.9/100,000 Floridians). Male and black subjects were 20% and 25%, respectively, more likely to have a food trigger than female and white subjects. White, male, and older subjects were more likely to have an anaphylaxis-related ED visit caused by insect stings. Venom-induced anaphylaxis was more likely in August through October. Children were less likely than those older than 70 years (referent) to have medication-induced anaphylaxis ( P Conclusion This is the only ED-based population study in a US lower-latitude state. The overall rate is considerably lower than other US ED-based population studies. The rates of anaphylaxis by age group differed by sex. Male and black subjects were more likely to have a food trigger.

Epidemiologic studies of anaphylaxis have been limited by significant underdiagnosis.The purpose of this study was to develop and validate a method for capturing previously unidentified anaphylaxis cases by using International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) based datasets.Florida emergency department data for the years 2005 and 2006 from the Florida Agency for Health Care Administration were used. Patients with anaphylaxis were identified by using ICD-9-CM codes specifically indicating anaphylaxis or an ICD-9-CM algorithm based on the definition of anaphylaxis proposed at the 2005 National Institute of Allergy and Infectious Disease and the Food Allergy and Anaphylaxis Network symposium. Cases ascertained with the algorithm were compared with the traditional case-ascertainment method. Comparisons included demographic and clinical risk factors, proportion of monthly visits, and age/sex-specific rates. Cases ascertained with anaphylaxis ICD-9-CM codes were excluded from those ascertained with the algorithm.One thousand one hundred forty-nine patients were identified by using anaphylaxis ICD-9-CM codes, and 1,602 patients were identified with the algorithm. The clinical risk factors and demographics of cases were consistent between the 2 methods. However, the algorithm was more likely to identify older subjects (P.0001), those with hypertension or heart disease (P.0001), and subjects with venom-induced anaphylaxis (P.0001).This study introduces and validates an ICD-9-CM-based diagnostic algorithm for the diagnosis of anaphylaxis to capture subjects missed by using the ICD-9-CM anaphylaxis codes. Fifty-eight percent of anaphylaxis cases would be missed without the use of the algorithm, including 88% of venom-induced cases.