Polychlorinated biphenyls and incident coronary heart disease-related outcomes in Great Lakes fish consumers.

BACKGROUND: Exposure to polychlorinated biphenyls (PCBs) has been linked to risk factors for cardiovascular disease such as increased inflammation, accelerated atherosclerosis, diabetes, and sex hormone dysregulation. Furthermore, there is increasing evidence suggesting associations between internal dose of PCBs and cardiovascular outcomes. OBJECTIVES: The purpose of this study is to investigate longitudinal associations of PCBs with coronary heart disease (CHD)-related outcomes in a cohort of Great Lakes sport fish consumers. METHODS: The Great Lakes Sport Fish Consumer cohort was established in the early 1990's. Eight hundred nineteen participants were followed from 1993 to 2017. Serum PCBs were measured in 1994/1995 (baseline), in 2001, and in 2004, while health history questionnaires were administered in 1996, 2003, 2010, and 2017. Cox models were used to prospectively investigate associations of total PCBs and PCB groupings, based on aryl hydrocarbon receptor activity, with incident self-reported physician diagnosis of coronary heart disease (CHD), myocardial infarction (MI), and angina pectoris. RESULTS: A 2-fold increase in phenobarbital-type PCBs was associated with a 72% increase in likelihood of self-reported incident diagnosis of CHD (HR=1.72, 95% CI: 1.06-2.81; p=0.0294). Similar results were observed for total PCBs (HR=1.68, 95% CI: 1.05-2.69; p=0.0306) and mixed methacholine/phenobarbital type (mixed-type) PCBs (HR=1.60, 95% CI: 1.02-2.52; p=0.0427), but not methacholine-type PCBs. PCBs were not strongly associated with risk of MI or angina. CONCLUSIONS: This study presents evidence that exposure to PCBs increases the risk of developing coronary heart disease. Given the large number of risk factors and causal pathways for CHD, future research is required to better understand biological mechanisms of action for PCBs on CHD.

Association of methylmercury intake from seafood consumption and blood mercury level among the Asian and Non-Asian populations in the United States.

BACKGROUND: MeHg is a well-established neurotoxicant for fetal brain growth and development and has been shown to increase the risk of cardiovascular disease in aging populations. In the U.S., Asian populations are of particular concern because of their seafood consumption behaviors. OBJECTIVES: Our objective was to calculate the average daily MeHg intake (ADMI) from seafood and to assess the relationship between ADMI with blood methylmercury (BMeHg) concentrations, specifically among women of reproductive age (WORA) and adults ≥ 50 years of age. METHODS: We estimated ADMI from seafood using the 30-day fish consumption data from the NHANES 2011-2014 datasets. Using multivariable linear regression, we estimated the proportional change in mean BMeHg associated with a doubling of the ADMI. Further, correlations between ADMI and BMeHg were compared between Asians and other racial/ethnic groups. RESULTS: Our analysis found both Asian WORA and Asian adults age ≥ 50 years old had significantly higher BMeHg levels and ADMI than their Non-Asian counterparts. Correlations between ADMI from seafood and blood Hg levels were stronger among Asian WORA than among Non-Asian WORA. Key fish species that influenced the dietary MeHg intake for Asians were mackerel, tuna, and "other known/unknown fish species". CONCLUSION: We confirmed that Asian populations have higher MeHg intake than the Non-Asian population in the U.S. and seafood intake is a key predictor of blood Hg concentration, especially among Asian women of reproductive age. Future studies should incorporate information on other known and unknown fish species that are frequently consumed by Asian populations and different parts and fish organs eaten to better understand determinants of MeHg exposure.

Elevated Blood Lead Levels Associated with Retained Bullet Fragments - United States, 2003-2012.

An estimated 115,000 firearm injuries occur annually in the United States, and approximately 70% are nonfatal (1). Retained bullet fragments (RBFs) are an infrequently reported, but important, cause of lead toxicity; symptoms are often nonspecific and can appear years after suffering a gunshot wound (2,3). Adult blood lead level (BLL) screening is most commonly indicated for monitoring of occupational lead exposure; routine testing of adults with RBFs is infrequent (3). States collaborate with CDC's National Institute for Occupational Safety and Health (NIOSH) to monitor elevated BLLs through the Adult Blood Lead Epidemiology and Surveillance (ABLES) program (4,5). To help assess the public health burden of RBFs, data for persons with BLLs ≥10 µg/dL reported to ABLES during 2003-2012 were analyzed. An RBF-associated case was defined as a BLL ≥10 µg/dL in a person with an RBF. A non-RBF-associated case was defined as a BLL ≥10 µg/dL without an RBF. During 2003-2012, a total of 145,811 persons aged ≥16 years with BLLs ≥10 µg/dL were reported to ABLES in 41 states. Among these, 457 RBF-associated cases were identified with a maximum RBF-associated BLL of 306 µg/dL. RBF-associated cases accounted for 0.3% of all BLLs ≥10 µg/dL and 4.9% of BLLs ≥80 µg/dL. Elevated BLLs associated with RBFs occurred primarily among young adult males in nonoccupational settings. Low levels of suspicion of lead toxicity from RBFs by medical providers might cause a delay in diagnosis (3). Health care providers should inquire about an RBF as the potential cause for lead toxicity in an adult with an elevated BLL whose lead exposure is undetermined.

Perfluoroalkyl substances and fish consumption.

BACKGROUND: Perfluoroalkyl substances (PFAS) are an emerging class of contaminants. Certain PFAS are regulated or voluntarily limited due to concern about environmental persistence and adverse health effects, including thyroid disease and dyslipidemia. The major source of PFAS exposure in the general population is thought to be consumption of seafood. OBJECTIVES: In this analysis we examine PFAS levels and their determinants, as well as associations between PFAS levels and self-reported fish and shellfish consumption, using a representative sample of the U.S. METHODS: Data on PFAS levels and self-reported fish consumption over the past 30 days were collected from the 2007-2008, 2009-2010, 2011-2012, and 2013-2014 cycles of the National Health and Nutrition Examination Survey. Twelve different PFAS were measured in serum samples from participants. Ordinary least squares regression models were used to identify factors (demographic characteristics and fish consumption habits) associated with serum PFAS concentrations. Additional models were further adjusted for other potential exposures including military service and consumption of ready-to-eat and fast foods. RESULTS: Seven PFAS were detected in at least 30% of participants and were examined in subsequent analyses (PFDA, PFOA, PFOS, PFHxS, MPAH, PFNA, PFUA). The PFAS with the highest concentrations were PFOS, followed by PFOA, PFHxS and PFNA (medians of 8.3, 2.7, 1.5 and 1.0ng/mL). Fish consumption was generally low, with a median of 1.2 fish meals and 0.14 shellfish meals, reported over the past 30 days. After adjusting for demographic characteristics, total fish consumption was associated with reduced MPAH, and with elevated PFDE, PFNA and PFuDA. Shellfish consumption was associated with elevations of all PFAS examined except MPAH. Certain specific fish and shellfish types were also associated with specific PFAS. Adjustment for additional exposure variables resulted in little to no change in effect estimates for seafood variables. CONCLUSIONS: PFAS are emerging contaminants with widespread exposure, persistence, and potential for adverse health effects. In the general population, fish and shellfish consumption are associated with PFAS levels, which may indicate an avenue for education and outreach.

Heat Vulnerability Index Mapping for Milwaukee and Wisconsin.

CONTEXT: Extreme heat waves elevate the population's risk for heat-related morbidity and mortality, specifically for vulnerable groups such as older adults and young children. In this context, we developed 2 Heat Vulnerability Indices (HVIs), one for the state of Wisconsin and one for the Milwaukee metropolitan area. OBJECTIVE: Through the creation of an HVI, state and local agencies will be able to use the indices as a planning tool for extreme heat events. DESIGN: Data used for the HVIs were grouped into 4 categories: (1) population density; (2) health factors; (3) demographic and socioeconomic factors; and (4) natural and built environment factors. These categories were mapped at the Census block group level. MAIN OUTCOME MEASURES: Unweighted z-score data were used to determine index scores, which were then mapped by quantiles ranging from "high" to "low" vulnerability. RESULTS: Statewide, Menominee County exhibited the highest vulnerability to extreme heat. Milwaukee HVI findings indicated high vulnerability in the city's inner core versus low vulnerability along the lakeshore. CONCLUSION: Visualization of vulnerability could help local public health agencies prepare for future extreme heat events.

Comprehension of Fish Consumption Guidelines Among Older Male Anglers in Wisconsin.

Although awareness of Wisconsin's fish consumption guidelines is high among older male anglers, little is known about comprehension of guideline content, and many anglers have levels of contaminants high enough to be associated with adverse health outcomes. The Environmental Protection Agency Great Lakes Restoration Initiative supported evaluation and revision of Wisconsin's fish consumption guideline program, using a web based survey of male Wisconsin anglers over the age of 50. A total of 3740 men completed the online survey; the median age of respondents was 62 years, and nearly all had lived and fished in Wisconsin for over 10 years. Comprehension of guideline content was relatively high, although two knowledge gaps were identified, one relating to mercury exposures and fish preparation, and the other to polychlorinated biphenyl content of certain fish species. The fishing regulations booklet distributed with annual fishing licenses and warning signs posted at fishing locations were commonly reported sources of guideline information in Wisconsin. Residents of coastal counties and consumers of Great Lakes fish were more likely to report guideline knowledge and behavior changes reflective of guideline knowledge, when compared to inland residents and those not consuming Great Lakes fish, respectively. In general, Wisconsin's consumption guidelines do not appear to discourage men from eating the fish they catch; rather, the most common behavioral changes included modifying the species eaten or the water body source of their meals. Continued efforts to educate anglers about the risks and benefits of fish consumption are needed.

Levels of nutrients in relation to fish consumption among older male anglers in Wisconsin.

Fish is an important source of nutrients including omega-3 fatty acids, which may reduce risk of adverse health outcomes such as cardiovascular disease; however, fish may also contain significant amounts of environmental pollutants. The Wisconsin Departments of Health Services and Natural Resources developed a survey instrument, along with a strategy to collect human biological samples to assess the risks and benefits associated with long-term fish consumption among older male anglers in Wisconsin. The target population was men aged 50 years and older, who fish Wisconsin waters and live in the state of Wisconsin. Participants provided blood and hair samples and completed a detailed (paper) questionnaire, which included questions on basic demographics, health status, location of catch and species of fish caught/eaten, consumption of locally caught and commercially purchased fish, and awareness and source of information for local and statewide consumption guidelines. Biological samples were used to assess levels of docosahexaenoic acid (DHA), docosapentaenoic acid (DPA), eicosapentaenoic acid (EPA); vitamin D; and selenium in blood. Quantile regression analysis was used to investigate the associations between biomarker levels and self-reported consumption of fish from the Great Lakes and other areas of concern, other locally caught fish, and commercially purchased fish (meals per year). Respondents were largely non-Hispanic white men in their 60's with at least some college education, and about half were retired. Fish consumption was high (median of 54.5 meals per year), with most fish meals coming from locally-caught fish. Multivariate regression models showed that the effect of supplement use was much greater than that of fish consumption, on nutrient levels, although consumption of fish from the Great Lakes and areas of concern was significantly associated with higher levels of vitamin D even after controlling for supplement usage.

Persistent organic pollutants and biomarkers of diabetes risk in a cohort of Great Lakes sport caught fish consumers.

BACKGROUND: Exposure to persistent organic pollutants (POPs) is associated with increased diabetes risk, although the mechanism of action is not well delineated. METHODS: We investigated established diabetes biomarkers that could implicate potential mechanistic pathways, including C-reactive protein (CRP), a marker of systemic inflammation; gamma glutamyl transferase (GGT), a liver enzyme associated with oxidative stress; and adiponectin, an adipokine modulating glucose regulation and fatty acid oxidation. These biomarkers as well as hemoglobin A1c (HA1c), and POPs [polychlorinated biphenyls (PCBs), p,p-dichlorodiphenyldichloroethylene (DDE) and polybrominated diphenyl ethers (PBDEs)] were measured in a cohort of Great Lakes sport caught fish (GLSCF) consumers. We examined associations of POPs and fish consumption with HA1c and incident diabetes, and evaluated mediation and moderation by the diabetes biomarkers. RESULTS: Odds of incident diabetes were elevated with exposure to DDE and PCBs. DDE and PCB 118 were positively, and fish meals were inversely, associated with HA1c. CRP was inversely associated with saltwater and total fish meals, particularly in persons with higher adiposity, but did not mediate the associations of fish meals with HA1c. There were few associations of POPs with adiponectin, CRP and GGT, with the exception of positive associations of PCB 118 with GGT, PBDEs with GGT in older persons, and PBDEs with adiponectin. Adiponectin, CRP and GGT did not mediate associations of DDE and PCBs with HA1c or incident diabetes. However, the association of DDE with HA1c was stronger in persons with higher CRP, GGT and BMI, and lower adiponectin, while the association of PCB 118 with HA1c was stronger in persons with higher GGT. CONCLUSIONS: These findings suggest that adiponectin, CRP and GGT did not mediate effects of POPs on diabetes or HA1c. However, POPs may have stronger effects on blood glucose in persons at higher risk for diabetes.

Quantile regression in environmental health: Early life lead exposure and end-of-grade exams.

Conditional means regression, including ordinary least squares (OLS), provides an incomplete picture of exposure-response relationships particularly if the primary interest resides in the tail ends of the distribution of the outcome. Quantile regression (QR) offers an alternative methodological approach in which the influence of independent covariates on the outcome can be specified at any location along the distribution of the outcome. We implemented QR to examine heterogeneity in the influence of early childhood lead exposure on reading and math standardized fourth grade tests. In children from two urban school districts (n=1,076), lead exposure was associated with an 18.00 point decrease (95% CI: -48.72, -3.32) at the 10th quantile of reading scores, and a 7.50 point decrease (95% CI: -15.58, 2.07) at the 90th quantile. Wald tests indicated significant heterogeneity of the coefficients across the distribution of quantiles. Math scores did not show heterogeneity of coefficients, but there was a significant difference in the lead effect at the 10th (ß=-17.00, 95% CI: -32.13, -3.27) versus 90th (ß=-4.50, 95% CI: -10.55, 4.50) quantiles. Our results indicate that lead exposure has a greater effect for children in the lower tail of exam scores, a result that is masked by conditional means approaches.

Drinking water systems, hydrology, and childhood gastrointestinal illness in Central and Northern Wisconsin.

OBJECTIVES: This study investigated if the type of drinking water source (treated municipal, untreated municipal, and private well water) modifies the effect of hydrology on childhood (aged < 5 years) gastrointestinal illness. METHODS: We conducted a time series study to assess the relationship between hydrologic and weather conditions with childhood gastrointestinal illness from 1991 to 2010. The Central and Northern Wisconsin study area includes households using all 3 types of drinking water systems. Separate time series models were created for each system and half-year period (winter/spring, summer/fall). RESULTS: More precipitation (summer/fall) systematically increased childhood gastrointestinal illness in municipalities accessing untreated water. The relative risk of contracting gastrointestinal illness was 1.4 in weeks with 3 centimeters of precipitation and 2.4 in very wet weeks with 12 centimeters of precipitation. By contrast, gastrointestinal illness in private well and treated municipal areas was not influenced by hydrologic conditions, although warmer winter temperatures slightly increased incidence. CONCLUSIONS: Our study suggests that improved drinking water protection, treatment, and delivery infrastructure may improve public health by specifically identifying municipal water systems lacking water treatment that may transmit waterborne disease.

The role of applied epidemiology methods in the disaster management cycle.

Disaster epidemiology (i.e., applied epidemiology in disaster settings) presents a source of reliable and actionable information for decision-makers and stakeholders in the disaster management cycle. However, epidemiological methods have yet to be routinely integrated into disaster response and fully communicated to response leaders. We present a framework consisting of rapid needs assessments, health surveillance, tracking and registries, and epidemiological investigations, including risk factor and health outcome studies and evaluation of interventions, which can be practiced throughout the cycle. Applying each method can result in actionable information for planners and decision-makers responsible for preparedness, response, and recovery. Disaster epidemiology, once integrated into the disaster management cycle, can provide the evidence base to inform and enhance response capability within the public health infrastructure.

Early lead exposure (<3 years old) prospectively predicts fourth grade school suspension in Milwaukee, Wisconsin (USA).

School suspensions are associated with negative student outcomes. Environmental lead exposure increases hyperactivity and sensory defensiveness, two traits likely to increase classroom misbehavior and subsequent discipline. Childhood Blood Lead Level (BLL) test results categorized urban fourth graders as exposed (2687; lifetime max BLL 10-20 µg/dL) or unexposed (1076; no lifetime BLL ≥5 µg/dL). Exposed children were over twice as likely as unexposed children to be suspended (OR=2.66, 95% CI=[2.12, 3.32]), controlling for covariates. African American children were more likely to be suspended than white children, but lead exposure explained 23% of the racial discipline gap. These results suggest that different rates of environmental lead exposure may contribute to the racial discipline gap.

Fish consumption and advisory awareness among older Wisconsin fishermen.

OBJECTIVES: The provision of fish consumption advice issued by the Wisconsin Department of Health Services (DHS) and Department of Natural Resources (DNR) has evolved over the past 40 years. In 2010, DHS received a US Environmental Protection Agency Great Lakes Restoration Initiative (GLRI) grant to evaluate existing advisory approaches, identify gaps, and adapt current communication approaches. METHODS: Previous research conducted by DHS found that older, male anglers eat more sport fish and have higher body burdens of persistent contaminants found in fish than other groups. As part of the GLRI, Wisconsin DHS and DNR aimed to engage this subpopulation and improve communication by using an Internet-based survey to collect information about fishing habits, consumption, and advisory awareness. At the end of the survey, participants were provided with answers to advisory questions and links to relevant online information. From fall 2011 through spring 2012, 827 men aged 50 and older completed this survey. RESULTS: Nearly all fishermen were aware of the existence of consumption advisories. Although awareness was high, penetration of traditional outreach materials was low with fewer than 35% having seen any of the pamphlets featured in the survey. Knowledge of the advisories was significantly higher among residents of counties along Lakes Michigan and Superior and among more frequent sport fish consumers. Men who were aware of these advisories were significantly more likely to have modified their consumption behavior. CONCLUSION: Wisconsin's experience suggests general awareness among older male anglers. Participation in the online survey and responses to sources of advisory information supports the need to expand the current outreach program to reach and inform the fish-consuming public.

Heat-related fatalities in Wisconsin during the summer of 2012.

BACKGROUND: The hottest year on record for the contiguous United States was 2012. July 2012 ranked as Wisconsin's fourth warmest July, which has profound implications for heat-related mortality. METHODS: We conducted a case series of 27 heat-related fatalities in Wisconsin during summer 2012. Data from death certificates supplemented by coroner reports were analyzed to characterize factors that increase vulnerability to heat-related fatality. RESULTS: The 2012 heat-related fatalities occurred in both urban and rural counties. All cases had 1 or more known risk factors: 100% lacked functioning residential air conditioning; 70% were over age 65; 75% had a cardiovascular disease; and 52% had a mental health condition. Of the 14 cases with a mental health condition, half were known to be taking psychotropic medication. None of the decedents had been in air conditioning immediately prior to death, and 8 (36%) had been using fans. CONCLUSIONS: Air conditioning is known to be a strong protective factor in preventing heat-related deaths whereas fans have not been shown to be significantly protective across all exposure situations. Prevention efforts should stress reducing social isolation by encouraging checks by friends, neighbors, or police. Prevention messages should also warn patients on psychotropic medications that the medication could increase their risk of heat-related illness or fatality.

Working for mom and dad: are teens more likely to get injured working in family-owned businesses?

Recent controversy regarding the issue of children working in family-owned businesses has come to the forefront, pitting safety and health versus parent's right to teach their children the family trade. While studies have characterized injury among working teens, no studies have assessed work and injury among teens employed in family-owned businesses. This study is the first to examine teenagers working in family-owned businesses and to compare the experiences of teens working in family-businesses to the experiences of other working teens. A questionnaire was distributed to 8,085 teens in high schools throughout the five public health regions of Wisconsin. A total of 6, 810 teens responded (84%). Overall 2,858 high school teens aged 14-17 reported working (42%); of which 963 (34%) worked in a family-business. Teens working in family-businesses were more likely to report that their injury was severe, affecting their activities for more than three days, compared with other working teens (33% vs. 21%, P = 0.05). The percentage of teens working in family-businesses that reported broken bones or crushed body parts was 17% compared to only 5% of other-working teens. Additionally, teens employed in family-businesses were more likely to file for workers' compensation (28% vs. 12%, P = 0.005). Teens working in family-owned businesses may be at a greater risk for more severe injury based on the jobs and tasks they are doing. Teens working in family-owned businesses were more likely to report engaging in dangerous tasks, including some that are illegal under the Hazardous Occupation Orders. More research is needed to assess the dynamics that exist for teens working in family-owned businesses.

The theory and application of UW ehealth-PHINEX, a clinical electronic health record-public health information exchange.

BACKGROUND: Electronic health records (EHRs) hold the promise of improving clinical quality and population health while reducing health care costs. However, it is not clear how these goals can be achieved in practice. METHODS: Clinician-led teams developed EHR data extracts to support chronic disease use cases. EHRs were linked with community-level data to describe disease prevalence and health care quality at the patient, health care system, and community risk factor levels. Software was developed and statistical modeling included multivariate, mixed-model, longitudinal, data mining, and geographic information system (GIS)/spatial regression approaches. RESULTS: A HIPAA-compliant limited data set was created on 192,201 patients seen in University of Wisconsin Family Medicine clinics throughout Wisconsin in 2007-2009. It was linked to a commercially available database of approximately 6000 variables describing community-level risk factors at the census block group. Areas of increased asthma and diabetes prevalence have been mapped, identified, and compared to economic hardship. CONCLUSIONS: A comprehensive framework has been developed for clinical-public health data exchange to develop new evidence and apply it to clinical practice and health policy. EHR data at the neighborhood level can be used for future population studies and may enhance understanding of community-level patterns of illness and care.

School-sponsored work programs: a first look at differences in work and injury outcomes of teens enrolled in school-to-work programs compared to other-working teens.

OBJECTIVES: To evaluate work experiences among teens enrolled in school-sponsored work (SSW) programs and compare the findings to other-working teens. This study, the first to assess work-related safety and health for teens in SSW programs, includes teens working one job and teens working multiple jobs. METHODS: A survey was conducted among 6810 teens in school districts in five public health regions in Wisconsin. Information on demographics, work characteristics, injury and school performance was collected. RESULTS: Of 3411 high school teens (14-18 years old) working during the school year, 461 were enrolled in SSW programs. SSW teens were more likely to hold multiple jobs, work over 40 h per week, and work 2 or more days per week before 8:00 h compared with other-working teens. SSW teens working only one job were no more likely to be injured than other-working teens. However, SSW teens working multiple jobs were significantly more likely to be severely injured compared to other-working teens (AOR 3.49; 95% CI 1.52 to 8.02). CONCLUSIONS: SSW programs were created to prepare youth for transition into the workforce after high school. This first study suggests that students in SSW programs working only one job are no more likely to be injured at work compared with other-working teens. However, being enrolled in SSW programs is not protective against work injury, which would have been expected based on the philosophy of these programs. Furthermore, when students work multiple jobs, those enrolled in SSW programs are more likely to be severely injured. Possible explanations are provided.

Students enrolled in school-sponsored work programs: the effect of multiple jobs on workplace safety and school-based behaviors.

BACKGROUND: Throughout the United States, over 70% of public schools with 12th grade offer school-sponsored work (SSW) programs for credit; 60% offer job-shadowing programs for students. Wisconsin offers a variety of work-based learning programs for students, including, but not limited to, job shadowing, internships, co-op education, and youth apprenticeship programs. No research has compared workplace injury and school-based behaviors in students enrolled in SSW programs who work only 1 job compared with those who work multiple jobs. METHODS: A total of 6810 students in the 5 public health regions in Wisconsin responded to an anonymous questionnaire that was administered in 2003. The questionnaire asked about employment, injury, characteristics of injury, and school-based behaviors and performance. RESULTS: A total of 3411 high school students aged 14 to 18 reported they were employed during the school year. Among the working students, 13.5% were enrolled in a SSW program. Of the SSW students, 44% worked multiple jobs. SSW students who worked multiple jobs were more likely to do hazardous job tasks, to work after 11 PM, to work over 40 hours per week, to have a near-miss incident, to have a coworker injured, and to be injured at work. CONCLUSIONS: SSW students who are working multiple jobs are violating labor laws that put their safety and their school performance at risk. The responsibilities of employers and schools have to be addressed to ensure that SSW students are abiding by labor laws when working multiple jobs.