Document gDBjYD4KKdBx6QOVEgOp7d6z3

EXHIBIT A p. 2 36qq TM rrv,, .., . ,. " . Morbidity and Mortality Weekly Repor t Weekly May 5, 2006 / Vol . 55 / No . 17 State Prevalence of Self-Reported Doctor-Diagnosed Arthritis and Arthritis-Attributable Activity Limitation - United States, 2003 Arthritis is costly ($86 billion annually), highly prevalen t (affecting 43 million U .S . adults), the leading cause of disability, and associated with substantial disparities in pain, activity limitations, and compromised quality of life (1-3) . State-based estimates of arthritis prevalence and impact help define the burden of arthritis and provide state arthritis programs with data for program planning. This report summarizes results from the 2003 Behavioral Risk Factor Surveillance System (BRFSS) survey on state-specific prevalence of self- reported doctor-diagnosed arthritis and arthritis-attributable activity limitation in 50 states, the District of Columbia (DC), and three territories . The findings indicated that the prevalence of adults with self-reported doctor-diagnosed arthritis ranged from 17 .9% to 37 .2% (state median: 27 .0%) and with arthritis-attributable activity limitation ranged from 6 .3% to 16.7% (state median: 9 .9%) ; the proportion ofadults with arthritis-attributable activity limitation among those with selfreported doctor-diagnosed arthritis ranged from 30 .1% to 49 .8% (state median: 37 .4%) . These high rates of arthritis prevalence and activity limitation are projected to increase with the aging of the population (4), requiring increased intervention measures to reduce this impact . INSIDE 481 Parental Report of Diagnosed Autism in Children Aged 4-17 Years - United States, 2003-2004 $ 486 Worker Illness Related to Ground Application of Pesticide Kern County, California, 2005 488 Respiratory Illness Associated with Boot Sealant Products Five States, 2005-2006 x {' 491 QuickStats . of.~et.: ,c. DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR DISEASE CONTROL AND PREVENTION p. 3 488 MMWR May 5, 2006 During 1998-2003 in California, 12% (297 of 2,470) of Brief Repotr occupational pesticide illness reports were attributed to pesticide drift (3) . Because weather patterns are unpredictable, Respiratory Illness Associated pesticide drift can occur even when applications are begun with Boot Sealant Products - during calm periods . In this incident, pesticide drifted onto Five States, 2005-2006 workers in a grape vineyard who had not been noti fi pesticide application in a neighboring citrus orch arded of a During February 2005-February 2006, six regional poi- equate communication between the applicator. sInaandd- s1o7n2 chounmtraolncaenntder1s9inanfiivmeasltates were consulted regarding (i .e ., pet cat or dog) exposures to farmworkers might have resulted in continued spraying de- shoe or boot leather protection or sealant products resulting spite the presence of workers in the grape vineyard . Employeerrss are required to give notification of cyfl respiratory illness . One product was associated with 1 2 6 s application conly t their employees - Neyietithlhee r th e uthr-incaofsheuman applica- illness and another product with seven cases- tor nor the oitrus grower own were required b raw co s qn ongoing investigation, begun in December 2005, is be- notification to the farmworkers, who worked for a differen t conducted by the poison centers . The majority of cases employer. occurred in Michigan, where poison control centers are col- workers in adjacent areas should he notified pesticide applications . Furthermore, pesticiadbeoauptpslcichaetdiounlesd l Health to further document exposures and adverse health should cease if workers are observed in neighboring areas . effects from the products . Results of the investigation of the Pyrethroid pesticides are in widespread use for both agri- 15 cases reported during 2005 underscore the continuing cultural and structural applications 0 need to assess the magnitude of the problem, evaluate th e be a safer alternative to many other p.eAstlitchidoeus,gphycroetnhsriodiedrPeCds-to toxic etiology of the products involved, and determine how ticides such as cyfluthrin can cause pesticide illness even at prtoodpurecvresnt further cases of illness resulting from use of the low doses. Evaluating physicians should be knowledgeable A case was . defined as a report co a poison control regarding the potential for occupational illness caused by pes- center of ticide exposure, signs and symptoms, and methods of treat- bootasfoterr sexhpooessure to an aerosol agent used for waterprooE ment. Nontoxic, sustainable methods of pest control should ing ; reports were made directly by persons be encouraged for prima ry prevention of pesticide illness exposed, by family members or friends, or by health-care . facilities where persons sought treatment. Specific i ll ness symp- R 1 . CeDCfe. Crasee dneficniteiosn fotr oacum te psestiw cidce-terlateed inllnoesstanrd ienjq u ryucaisers ed to meet the case definition . reportable to the National Public Health Su rveillance System. Cincin- During 2005, the number of cases increased substantially nati . OH : US Department of Health and Human Services, CDC, with the onset of winter. One case was reported in Februa ry National Institute for Occupational Safety and Health; 2005 . Available and one in July; five were reported in August, four in Septem- at http ://wwwcdc .gov/niosh/topics/pesticides/pdfs/cucdef2003_rev APR2005.pdf. her, 11 (7%) in October, 36 (24%) in November, and 92 2. CDC. Severity index for use in statc-bascd surveillance of acute pesti- (61%) in December (Figure) . Eighty-four ( 5 6%) cases were cide-relaced illness and injury. Cincinnati, OH : US Department of reported in Michigan, 25 (17%) in Indiana, 19 (13%) in Health and Human Services, CDC, National Institute forOccupational Safe ty and Health; 2001 Available at http://wwwcdc.gov/niosh/topics/ wes tern Pennsylvania, 12 (8%) in central Ohio, and 10 (7%) pestiades/pdfs/pest-sevindexv6 .pdf in Kentueky. 3 . California Department of Pesticide Regulation . Pesticide use reporting. Ages of the 150 patients ranged from one to 70 years Sacramento, CA California Department of Pesticide Regulation . Available at http ://www.cdpr.ca .gov/does/pur/purmain.htm . 4 . Ecobichon DJ . Toxic effects of pesticides . In : Klaasscn CD, ed. Casarecc (median : 33 years) ; 33 (22%) were aged <18 years . Among the patients, 50% were the persons in their households who and Doull's toxicology: the basic science of poisons . 6th ed . New York, most used the product; however, persons who did not use the NY: McGraw-Hill Medical Publishing ; 2001 :784-5 . product also were affected . The product was sprayed indoors 5. Ray DE. Pyrcthroid insecticides. In : Krieger It, ed- Handbook of pesti- cide toxicology. Orlando . FL: Academic Press; 2001 : 1 289-- 1 303 . in 131 (87%) of 150 cases ; 19 (13%) of the patients were 6. Reigart JR. Roberts JR Rccognition and management of pesticide poi- exposed when the product was used outdoors . No evidence sonings . 5th ed. Washington, DC: US Environmental Protection Agency; was observed that substance abuse was related to the expo- 1999. Available at httpJ/www.epa.gov/pestiadcs/safery/healnccacc/handbook/handbook.htm . sures . Investigators determined that sprayed shoes and boots 7. Hardt J . Ange re r J. Biological monito ring of workers after the applica- brought into the home from garages or outdoors continued tion of insecticidal pyrethtoids . Int Arch Occup Environ Health to be a source of exposure to both humans and pets as the 2003 ;76 :492-8 . product evaporated . Five occupational exposures occurred, p. 4 Vol . 55/ No . 17 MMWR 489 FIGURE . Number' of exposures to boot sealant products one car met the case definition for chemical pneumoniris . reported to poison control centers, by month of exposu five states, 2005 -21106 re - Treatment included bronchodilators in one animal, corticos- teroids in one animal, diuretics with anti-inflammatory agent 100 in one animal, and no treatment other than oxygen and sup- W portive care in 12 (8%) animals . Two cats died from respira- tory failure. ~60 Two products were primarily associated with the 150 cases E of human illness, both manufactured by Assured Packaging Z40 (Mississauga, Ontario, Canada) and distributed by th e Manakey Group LLC (Grand Rapids, Michigan) . Use of 20 Jobsire Heavy Duty Bootmate was cited by patients in 126 0 (84%) cases_ Rocky Boot Weather and Stain Protector was Feb Jul Aug Sep Oct Nov Dec Jan Feb named in seven (5%) cases . The two Assured Packaging prod- 20L5 2oos ucts consist of 45% heptane, 200/6-30% petroleum distillates, Month and year 25%-30% isobutane propellant, 5Yo-10% propane propel- N=172. lant, 0 .33% fluoropolymer, and 0.33% silicone . Neither the product labels nor the material safety data sheets for the prod- ucts list fiuoropolymer or silicone. Previous outbreaks of acute four while spraying clothing items at work and one while dem- pulmonary illness associated with exposure to waterproofing onstrating a product to a customer. Preexisting respiratory risk agents have implicated Eiuoropolymer/hydrocarbon-based factors were identified in 40 (27%) of the 150 patients : asthma products (1-4)(13 [8%1) and smoking (27 [18%1) . The Consumer Product Safety Commission is evaluating A total of 144 patients were symptomatic, including 137 these exposures and boot sealant products . Local health de(95%) who reported symptoms of respiratory illness ; all were partmenrs and emergency departments were alerted to report encouraged to seek medical care . Among those who were symp- cases to their regional poison centers . The American Associa- tomatic, the most common symptoms were cough [(113 tion of Poison Control Centers has instituted 13 new product patients [789'0])] and dyspnea [(86 [60%])] . Eighty (56%) codes and three new generic codes for waterproofing agents were known to have been evaluated in hospitals or hospital to enable all poison centers to conduct surveillance on expoemergency departments, including 15 (10%) who were sures more readily. admitted and had hospital stays of up to 5 days . Pulse oxim- On January 3, 2006, at the request of the Michigan erry of patients evaluated in hospitals ranged from 61% to Department of Community Health, Manakey Group issued a 100% (median: 94 .9%) . Chest radiographs were positive for recall ofJobsite Heavy Duty Bootmate and Rocky Boot Weather infiltrates in 13 of 47 patients for whom this finding was and Stain Protector from store shelves, but not from consumrecorded_ Eight patients met the case definition for chemical ers' homes . During January-February 2006, 22 additional expncumonitis (i .e., bilateral infiltrates suggestive of chemical posures were reported to the six regional poison centers . Among pneumonitis and pulse oximetry<95% on room air) . One callers asked, all purchased the product before the recall date. person lost consciousness and was in respiratory distress, but No product defect has been identified . Consumers should be recovered ; no human patient died . encouraged to use all products for waterproofing shoes an d Among 134 persons whose treatment was known, treatment boors as directed, to apply them outdoors, and to [cave the consisted of bronchodilators alone in 28 (21%) patients, sprayed shoes and boots and any contaminated clothing out- bronchodilators plus corticosteroids in 13 (10%) patients, and doors until all fumes have dissipated . no intervention other than oxygen in 69 (51%) patients . The Reported by: S Smolinrke, PharmD, S White, MD. GP Daubert, duration of illness was determined on the basis of last follow- MD. Chifdrcni HorpitalofMichigan Regional Poison Control Center, up and ranged from 0 .25-360 hours (median: 17 .6 hours) in Detroir R Didrichmnr, B Euenga, MD, DrVor Childrnn'r Hospital 116 patients for whom duration could be evaluated . Regional Poison Center, GrandRapidr . Michigan,-JMomry, PharmD. Among the 19 pets with illness, four were evaluated by vet- Indiana Poison Center. Indianapolis; RMrvar, EKrcnzelok, PharmD, erinarians . Reported symptoms for the animals included dys- Pittsburgh Poison Center. Pennrylvania,M Caravant. MD . D Baktr, pnea (13 [68%]), cough (three), and vomiting (three) . Chest PharmD. Central Ohio Poison Center. Columbus; HA Spiller. MS radiographs were positive for infiltrates in one animal, and Kentucky Regional Poison Cenrer, Louisville . p. 5 ~ 490 MMWR May 5, 200 B . Acknowledgments Errata : Volume 54, No . 12 This report is based, in part, on technical assistance provided b y A Bronstein, MD, RD ocky Mountaine Poison n and Drug - Center, In the r~ort "Tobacco Use, Access, and Exposure toTobacoo in ver, Colorado; T Litovitz, MD, National Capital Poison Center, Media Among Middle and High School Students Washington DC; and M Lai, MD, American Association of Poison United States, 2004," an error was made in computing analytic Control Centers, Washington DC . Assistance with the invesriga- weights for data in the 2004 National Youth Tobacco Survey tion was provided by M Stanbury, Div of Environmental and (NYTS) ; consequently, both estimates and standard errors were Occupational Epidemiology, Michigan Dept ofCommuniryHealth, affected. The corrected report text and tables are available at Lansing, Michigan ; and G Liss, MD, Occupational Health and http :/lwwwcdc .gov/tobacco/nyts/correctionnotice .htm . Safety Branch, Ontario Ministry of Labour, Toronto, Canada . References 1 . CDC. Acute respiratory illness linked to use of aerosol leathcr condi- tioner-Oregon, December 1992. MMWR 1993 ;41 :965-7 . 2 . CDC. Severe acute respiratory illness linked to use of shoe sprays- Colorado, November 1993 . MMWR t993 ;42:885-7 . 3 . LalibertE M, Sanfacon G, Blais, R. Acute pulmonary toxicity linked to use of a leather protector. Ann ErnergMed 1995 ;25 :841-4 . 4. Burkhart KK. Bri tt A, Pettini G, O'Donnell S, Donovan JW. Pulmonary toxicity following exposure to an ac rosolized leather protector. J Toxicol Clin Toxicol 1996 ;34 :21-24 .