Factors linked to participant attrition in a longitudinal occupational health surveillance program.

BACKGROUND: For occupational medical screening programs focused on long-term health surveillance, participant attrition is a significant barrier to success. We investigate demographic, medical history, and clinical data from National Supplemental Screening Program (NSSP) examinees for association with likelihood of return for a second exam (rescreening). METHODS: A total of 15,733 individuals completed at least one NSSP exam before December 31, 2016; of those, 4832 also completed a second exam on or before December 31, 2019. Stepwise logistic regression models were used to identify variables associated with whether a participant was rescreened in the NSSP. RESULTS: Individuals were less likely to return for rescreening if they had a history of any cancer; cardiovascular problems; diabetes or kidney disease; or if they used insulin. Age at time of first exam and job site category significantly influenced likelihood of return. Workers categorized as "guests" were more likely to return. Participants were less likely to return if they had an abnormal urinalysis, abnormal pulmonary function, pneumoconiosis, aortic atherosclerosis, or hearing loss at their initial exam. Participants who received a chest X-ray at their initial screening were more likely to return. CONCLUSIONS: The presence of health problems is strongly linked to screening program attrition. Participants who are older at the time of their initial screening exam are less likely to return. The discovery of several strong demographic, medical, and job associations reveals the importance for medical screening programs to understand and address factors that influence participant retention and, consequently, the effectiveness of long-term health surveillance activities.

Cross-sectional study examining the accuracy of self-reported smoking status as compared to urinary cotinine levels among workers at risk for chronic kidney disease of unknown origin in Guatemala.

OBJECTIVES: There is a lack of information on cotinine levels in rural populations in low-income and middle-income countries like Guatemala. Therefore, there is a need to explore smoking status and biomarkers of tobacco use in epidemiological research in rural, low-income populations, in particular those at-risk for chronic kidney disease of unknown origin (CKDu). DESIGN: We evaluated self-reported smoking status against urinary cotinine levels, the gold standard biomarker of tobacco smoke exposure, among agricultural workers at four separate cross-sectional time points. SETTING: Guatemala. PARTICIPANTS: 283 sugarcane workers. PRIMARY OUTCOME MEASURES: Compared self-reported smoking status and urinary cotinine levels in two agricultural worker studies. RESULTS: Self-reported smoking prevalence was 12% among workers. According to cotinine levels (≥50 ng/mL), the smoking prevalence was 34%. Self-reported smoking status had 28% sensitivity and 96% specificity. Urinary cotinine levels show that smoking prevalence is underestimated in this worker population. CONCLUSIONS: According to our findings, smoking status should be objectively measured with biomarkers rather than self-reported in CKDu epidemiological research. Self-reported smoking status is likely an underestimate of the true smoking prevalence among agricultural workers. Research on the CKDu epidemic in Central America and other parts of the world might be underestimating tobacco exposure as a potential contributor to the development of CKDu.

Enfermedad renal crónica de causa desconocida: investigaciones en Guatemala y oportunidades para su prevención / Chronic kidney disease of unknown cause: investigations in Guatemala and opportunities for its prevention

El Centro para la Salud, el Trabajo y el Ambiente (CHWE por sus siglas en inglés) inició un proyecto de colaboración con Pantaleon, una empresa agrícola de caña de azúcar en Guatemala, para hacer frente a una epidemia de enfermedad renal crónica (ERC) de causa no tradicional (ERCnT) que afecta a las comunidades agrícolas en Centroamérica y otros lugares. Este artículo describe el conocimiento actual de la epidemia en Centroamérica, las manifestaciones clínicas, el tratamiento y el manejo; las hipótesis actuales de su etiología, la colaboración y el enfoque de CHWE-Pantaleon. Nuestro enfoque de Total Worker Health® (TWH) para abordar la salud renal en Guatemala incluye múltiples estudios de investigación con trabajadores de caña de azúcar, para evaluar la prevalencia, incidencia y factores de riesgo de la lesión renal aguda y la ERC; se incluye también el desarrollo e implementación de medidas de prevención mejoradas e intervenciones para proteger a los trabajadores abordando los factores de riesgo ya conocidos. Se examinan también las necesidades futuras de investigación y las implicaciones globales de la ERCnT, al igual que la producción de bienes y la economía, así como las recomendaciones actuales para las estrategias de prevención ocupacional y comunitaria.

The Center for Health, Work and Environment (CHWE) began a collaborative project with Pantaleon, a Guatemalan sugarcane agribusiness, to address an epidemic of chronic kidney disease of unknown cause (CKDu) that affects agricultural communities in Central America and elsewhere. This paper describes the current knowledge of the epidemic in Central America including clinical manifestations, course, and management, current etiology hypotheses, and the CHWE-Pantaleon collaboration and approach. Our Total Worker Health® (TWH) approach to addressing kidney health in Guatemala has included multiple research studies with sugarcane workers to assess prevalence, incidence and risk factors for acute kidney injury and chronic kidney disease, as well as development and implementation of enhanced prevention measures and interventions to protect workers by addressing known risk factors. Future research needs and the global implications of CKDu including for economy and commodity production are discussed, as well as current recommendations for occupational and community prevention strategies.

Effect of an opioid management program for Colorado workers' compensation providers on adherence to treatment guidelines for chronic pain.

OBJECTIVE: The aim of this study was to examine adherence of state guidelines for Colorado workers' compensation physicians/providers treating individuals as injured workers with chronic pain after initiation of an opioid management program and provider incentives. METHODS: A retrospective cohort of chronic, non-cancer pain claims was constructed from the Colorado's workers' compensation database. Adherence to treatment guidelines and opioid prescribing practices were evaluated during implementation of a new billing code to incentivize adherence. RESULTS: Overall, less than 33% of claims showed evidence of opioid management. Comprehensive opioid management was observed in only 4.4% of claims. In 2010, after implementing the new billing code, the ratio of long acting opioids to short acting opioids decreased from 0.2 to 0.13; returning to 0.2 in one year. Similarly, morphine equivalent doses declined for a short period. CONCLUSIONS: Incentivizing physicians to adhere to chronic pain management guidelines only temporarily improves prescribing practices.

Relationships between home ventilation rates and respiratory health in the Colorado Home Energy Efficiency and Respiratory Health (CHEER) study.

BACKGROUND: As societies adopt green building practices to reduce energy expenditures and emissions that contribute to climate change, it is important to consider how such building design changes influence health. These practices typically focus on reducing air exchange rates between the building interior and the outdoor environment to minimize energy loss, the health effects of which are not well characterized. This study aims to evaluate the relationship between air exchange rates and respiratory health in a multi-ethnic population living in low-income, urban homes. METHODS: The Colorado Home Energy Efficiency and Respiratory Health (CHEER) study is a cross-sectional study that enrolled 302 people in 216 non-smoking, low-income single-family homes, duplexes and town-homes from Colorado's Northern Front Range. A blower door test was conducted and the annual average air exchange rate (AAER) was estimated for each home. Respiratory health was assessed using a structured questionnaire based on standard instruments. We estimated the association between AAER and respiratory symptoms, adjusting for relevant confounders. RESULTS: Air exchange rates in many homes were high compared to prior studies (median 0.54 air changes per hour, range 0.10, 2.17). Residents in homes with higher AAER were more likely to report chronic cough, asthma and asthma-like symptoms, including taking medication for wheeze, wheeze that limited activities and dry cough at night. Allergic symptoms were not associated with AAER in any models. The association between AAER and asthma-like symptoms was stronger for households located in areas with high potential exposure to traffic related pollutants, but this was not consistent across all health outcomes. CONCLUSIONS: While prior studies have highlighted the potential hazards of low ventilation rates in residences, this study suggests high ventilation rates in single-family homes, duplexes and town-homes in urban areas may also have negative impacts on respiratory health, possibly due to the infiltration of outdoor pollutants.

Cancer Survivorship and Employment: Intersection of Oral Agents, Changing Workforce Dynamics, and Employers' Perspectives.

The ability to continue employment during and following cancer diagnosis and treatment is critical to working-age cancer survivors. Prolonged survival combined with concerns of the financial burden associated with high-cost therapies makes the mitigation of work-related consequences all the more relevant, particularly in light of recent workforce trends and evolving employment dynamics. Research that integrates the needs of survivors, employers, and the workforce is required so that advancements are made to support employed cancer survivors. In this commentary, we present four priorities for research to advance what is known about the employment effects of cancer: 1) data needed to understand the impact of emerging treatments and their influence on employment and job performance; 2) cancer survivors in the changing work environment with respect to contractual arrangements and employment in small and medium-sized firms; 3) employers' perspectives and approaches to implementing workplace policies for cancer survivors; and 4) the development of feasible, scalable, and sustainable workplace interventions that can be implemented to address these issues. The confluence of these factors makes a strong argument for research to advance what is known and what can be done about the employment consequences of cancer.

The Impact of Worksite Wellness Programs by Size of Business: A 3-Year Longitudinal Study of Participation, Health Benefits, Absenteeism, and Presenteeism.

Objective: Worksite wellness programs (WWP) may positively impact employee health, medical expenditures, absenteeism, and presenteeism. However, there has been little research to assess the benefits of WWP in small businesses. The purpose of this study is to prospectively evaluate changes in health, absenteeism, and presenteeism for employees who participated in a WWP. Methods: We conducted an observational, 3-year cohort study of 5766 employees from 314 businesses of differing sizes. We followed two cohorts of employees, who completed at least two annual health risk assessments (HRA) between May 2010 and December 2014. Changes from baseline to the first and second follow-up periods were assessed for chronic and non-chronic health conditions, absenteeism, and presenteeism. Results: Small business employees were more likely to participate in the WWP than were employees from large businesses. Changes in chronic and non-chronic health conditions varied by size of business, with small business employees showing improvements in stress, overall health, depression, smoking status, vegetable and fruit consumption, and physical activity, and in their perceptions of job health culture. In contrast, large business employees experienced improvements in stress, vegetable consumption, and alcohol use. No changes in absenteeism or presenteeism were observed. Conclusions: Small businesses achieve higher employee participation rates and more health improvements when compared to employees from large employers. Findings suggest that small businesses may gain the most from a WWP.

Clinical and laboratory factors contributing to uninterpretable beryllium lymphocyte proliferation tests (BeLPT).

BACKGROUND: The beryllium lymphocyte proliferation test (BeLPT), has become the principal clinical test for detecting beryllium sensitization and chronic beryllium disease. Uninterpretable BeLPT results can occur in a small but significant proportion of tests from poor lymphocyte growth (PG) or over proliferation of lymphocytes (OP). The clinical and laboratory causes of uninterpretable results are not known. METHODS: BeLPT data from the US Department of Energy-supported Former Worker Screening Program were analyzed for a 10-year period. Drivers of uninterpretable BeLPTs were investigated using multivariable models and classification techniques. RESULTS: Three participant attributes were significantly associated with PG, while OP showed no significant associations. Serum lot for the lymphocyte growth medium accounted for 21% of the variation in PG and 16% in OP. CONCLUSION: Serum lots influence the likelihood of having uninterpretable BeLPT. To better understand uninterpretable results and possibly reduce their occurrence, additional laboratory-related factors should be addressed.

Reoccurring Injury, Chronic Health Conditions, and Behavioral Health: Gender Differences in the Causes of Workers' Compensation Claims.

OBJECTIVE: The aim of this study was o examine how work and nonwork health-related factors contribute to workers' compensation (WC) claims by gender. METHODS: Workers (N = 16,926) were enrolled in the Pinnacol Assurance Health Risk Management study, a multiyear, longitudinal research program assessing small and medium-sized enterprises in Colorado. Hypotheses were tested using gender-stratified logistic regression models. RESULTS: For both women and men, having incurred a prior WC claim increased the odds of a future claim. The combination of incurring a prior claim and having metabolic health conditions resulted in lower odds of a future claim. Behavioral health risk factors increased the odds of having a claim more so among women than among men. CONCLUSION: This study provides data to support multifactorial injury theories, and the need for injury prevention efforts that consider workplace conditions as well as worker health.

Risk Factors for Declines in Kidney Function in Sugarcane Workers in Guatemala.

OBJECTIVES: To characterize kidney function of sugarcane workers in Guatemala over the 6-month harvest and identify risk factors associated with changes in kidney function. METHODS: Demographic and biological data were collected for 330 sugarcane cutters at the beginning and end of the harvest. Multivariable regression analyses were used to assess factors related to kidney function. RESULTS: A decline in kidney function across the harvest was observed in 36% of the participants. Risk factors associated with this decline included working at a particular plantation mill, local area workers compared with highland workers, and current smokers. CONCLUSION: Results showed both occupational and behavioral factors play significant roles in declines in kidney function. These results underline the need for a comprehensive approach to the epidemic as well as further investigation of risk factors to guide research and interventions.

Health risk factors as predictors of workers' compensation claim occurrence and cost.

OBJECTIVE: The objective of this study was to examine the predictive relationships between employee health risk factors (HRFs) and workers' compensation (WC) claim occurrence and costs. METHODS: Logistic regression and generalised linear models were used to estimate the predictive association between HRFs and claim occurrence and cost among a cohort of 16 926 employees from 314 large, medium and small businesses across multiple industries. First, unadjusted (HRFs only) models were estimated, and second, adjusted (HRFs plus demographic and work organisation variables) were estimated. RESULTS: Unadjusted models demonstrated that several HRFs were predictive of WC claim occurrence and cost. After adjusting for demographic and work organisation differences between employees, many of the relationships previously established did not achieve statistical significance. Stress was the only HRF to display a consistent relationship with claim occurrence, though the type of stress mattered. Stress at work was marginally predictive of a higher odds of incurring a WC claim (p<0.10). Stress at home and stress over finances were predictive of higher and lower costs of claims, respectively (p<0.05). CONCLUSIONS: The unadjusted model results indicate that HRFs are predictive of future WC claims. However, the disparate findings between unadjusted and adjusted models indicate that future research is needed to examine the multilevel relationship between employee demographics, organisational factors, HRFs and WC claims.

Integrated approach to health screening of former department of energy workers detects both occupational and non-occupational illness.

BACKGROUND: The National Supplemental Screening Program (NSSP) uses a Total Worker Health(TM) approach to address U.S. Department of Energy (DOE) former worker health. This article provides the design of the integrated occupational health screening and promotion program. METHODS: The NSSP implemented a web-based relational health records system to process demographic, exposure, and clinical data. We present medical findings for 12,000 DOE former workers that completed an initial NSSP medical screening between October 1, 2005 and October 4, 2013. We discuss the DOE former worker participant population and the exposure-based and non-occupational medical screening tests used. RESULTS: The NSSP identified potential occupationally related health conditions in 40.5% of those screened. Notably, we identified 85.8% of participants with addressable non-occupational health conditions, many of which were previously undiagnosed. CONCLUSION: The NSSP demonstrates that the identification of potential occupational health issues in conjunction with addressable non-occupational health conditions provides former workers with information to more effectively manage health.

CpG promoter methylation status is not a prognostic indicator of gene expression in beryllium challenge.

Individuals exposed to beryllium (Be) may develop Be sensitization (BeS) and progress to chronic beryllium disease (CBD). Recent studies with other metal antigens suggest epigenetic mechanisms may be involved in inflammatory disease processes, including granulomatous lung disorders and that a number of metal cations alter gene methylation. The objective of this study was to determine if Be can exert an epigenetic effect on gene expression by altering methylation in the promoter region of specific genes known to be involved in Be antigen-mediated gene expression. To investigate this objective, three macrophage tumor mouse cell lines known to differentially produce tumor necrosis factor (TNF)-α, but not interferon (IFN)-γ, in response to Be antigen were cultured with Be or controls. Following challenges, ELISA were performed to quantify induced TNFα and IFNγ expression. Bisulfate-converted DNA was evaluated by pyrosequencing to quantify CpG methylation within the promoters of TNFα and IFNγ. Be-challenged H36.12J cells expressed higher levels of TNFα compared to either H36.12E cells or P388D.1 cells. However, there were no variations in TNFα promoter CpG methylation levels between cell lines at the six CpG sites tested. H36.12J cell TNFα expression was shown to be metal-specific by the induction of significantly more TNFα when exposed to Be than when exposed to aluminum sulfate, or nickel (II) chloride, but not when exposed to cobalt (II) chloride. However, H36.12J cell methylation levels at the six CpG sites examined in the TNFα promoter did not correlate with cytokine expression differences. Nonetheless, all three cell lines had significantly more promoter methylation at the six CpG sites investigated within the IFNγ promoter (a gene that is not expressed) when compared to the six CpG sites investigated in the TNFα promoter, regardless of treatment condition (p < 1.17 × 10(-9)). These findings suggest that, in this cell system, promoter hypo-methylation may be necessary to allow expression of metal-induced TNFα and that promoter hyper-methylation in the IFNγ promoter may interfere with expression. Also, at the dozen CpG sites investigated in the promoter regions of both genes, beryllium had no impact on promoter methylation status, despite its ability to induce pro-inflammatory cytokine expression.

Implementation of a worksite wellness program targeting small businesses: the Pinnacol Assurance health risk management study.

OBJECTIVE: To assess small business adoption and need for a worksite wellness program in a longitudinal study of health risks, productivity, workers' compensation rates, and claims costs. METHODS: Health risk assessment data from 6507 employees in 260 companies were examined. Employer and employee data are reported as frequencies, with means and standard deviations reported when applicable. RESULTS: Of the 260 companies enrolled in the health risk management program, 71% continued more than 1 year, with 97% reporting that worker wellness improves worker safety. Of 6507 participating employees, 34.3% were overweight and 25.6% obese. Approximately one in five participants reported depression. Potentially modifiable conditions affecting 15% or more of enrollees include chronic fatigue, sleeping problems, headaches, arthritis, hypercholesterolemia, and hypertension. CONCLUSIONS: Small businesses are a suitable target for the introduction of health promotion programs.

Accelerator mass spectrometry detection of beryllium ions in the antigen processing and presentation pathway.

Exposure to small amounts of beryllium (Be) can result in beryllium sensitization and progression to Chronic Beryllium Disease (CBD). In CBD, beryllium is presented to Be-responsive T-cells by professional antigen-presenting cells (APC). This presentation drives T-cell proliferation and pro-inflammatory cytokine (IL-2, TNFα, and IFNγ) production and leads to granuloma formation. The mechanism by which beryllium enters an APC and is processed to become part of the beryllium antigen complex has not yet been elucidated. Developing techniques for beryllium detection with enough sensitivity has presented a barrier to further investigation. The objective of this study was to demonstrate that Accelerator Mass Spectrometry (AMS) is sensitive enough to quantify the amount of beryllium presented by APC to stimulate Be-responsive T-cells. To achieve this goal, APC - which may or may not stimulate Be-responsive T-cells - were cultured with Be-ferritin. Then, by utilizing AMS, the amount of beryllium processed for presentation was determined. Further, IFNγ intracellular cytokine assays were performed to demonstrate that Be-ferritin (at levels used in the experiments) could stimulate Be-responsive T-cells when presented by an APC of the correct HLA type (HLA-DP0201). The results indicated that Be-responsive T-cells expressed IFNγ only when APC with the correct HLA type were able to process Be for presentation. Utilizing AMS, it was determined that APC with HLA-DP0201 had membrane fractions containing 0.17-0.59 ng Be and APC with HLA-DP0401 had membrane fractions bearing 0.40-0.45 ng Be. However, HLA-DP0401 APC had 20-times more Be associated with the whole cells (57.68-61.12 ng) than HLA-DP0201 APC (0.90-3.49 ng). As these findings demonstrate, AMS detection of picogram levels of Be processed by APC is possible. Further, regardless of form, Be requires processing by APC to successfully stimulate Be-responsive T-cells to generate IFNγ.

The Protective Effect of Hispanic Ethnicity on Chronic Obstructive Pulmonary Disease Mortality is Mitigated by Smoking Behavior.

RATIONALE: Studies in Hispanic/Latino populations have shown ethnicity to be either a predictive or protective factor for COPD mortality and it is unclear whether this disagreement is attributable to ethnic differences in smoking rates, smoking behavior or differences in genetic susceptibility. OBJECTIVES: This study will examine the role of smoking behavior as a means of explaining differences in risk for COPD mortality between Hispanics and non-Hispanic whites. METHODS: Participants were recruited into a cohort study from the San Luis Valley in Colorado beginning in the early 1980's and followed for mortality until 2012. COPD and cardiovascular disease are often comorbid conditions and account for the competing risk of CVD in the analysis of COPD mortality. Mortality searches were conducted regularly and all ICD codes were collected for mortality event. Primary and secondary causes of each event were assessed using appropriate codes. RESULTS: Hispanic current smokers did not differ from NHW current smokers in years smoked (p=0.6) but Hispanic former smokers accumulated more years smoked compared to NHW former smokers (22 vs. 20, p=0.047). Hispanic ethnicity was significantly protective for COPD mortality adjusting for age, gender, pre-existing emphysema, hypertension and smoking status and accounting for the effect of CVD mortality (RR=0.58, 95% C.I. 0.34-0.99, p=0.035). Further adjustment for smoking behavior mitigated this effect. CONCLUSIONS: The lower COPD mortality seen in Hispanic smokers may be due lower cumulative exposure to tobacco smoke. Thus, smoking behavior may play a key role in explaining differences in COPD mortality as they relate to Hispanic ethnicity.

Estimating the return on investment from a health risk management program offered to small Colorado-based employers.

OBJECTIVE: To determine whether changes in health risks for workers in small businesses can produce medical and productivity cost savings. METHODS: A 1-year pre- and posttest study tracked changes in 10 modifiable health risks for 2458 workers at 121 Colorado businesses that participated in a comprehensive worksite health promotion program. Risk reductions were entered into a return-on-investment (ROI) simulation model. RESULTS: Reductions were recorded in 10 risk factors examined, including obesity (-2.0%), poor eating habits (-5.8%), poor physical activity (-6.5%), tobacco use (-1.3%), high alcohol consumption (-1.7%), high stress (-3.5%), depression (-2.3%), high blood pressure (-0.3%), high total cholesterol (-0.9%), and high blood glucose (-0.2%). The ROI model estimated medical and productivity savings of $2.03 for every $1.00 invested. CONCLUSIONS: Pooled data suggest that small businesses can realize a positive ROI from effective risk reduction programs.

Occupational exposures in the oil and gas extraction industry: State of the science and research recommendations.

The oil and gas extraction industry is rapidly growing due to horizontal drilling and high volume hydraulic fracturing (HVHF). This growth has provided new jobs and economic stimulus. The industry occupational fatality rate is 2.5 times higher than the construction industry and 7 times higher than general industry; however injury rates are lower than the construction industry, suggesting injuries are not being reported. Some workers are exposed to crystalline silica at hazardous levels, above occupational health standards. Other hazards (particulate, benzene, noise, radiation) exist. In this article, we review occupational fatality and injury rate data; discuss research looking at root causes of fatal injuries and hazardous exposures; review interventions aimed at improving occupational health and safety; and discuss information gaps and areas of needed research. We also describe Wyoming efforts to improve occupational safety in this industry, as a case example.

Birth outcomes and maternal residential proximity to natural gas development in rural Colorado.

BACKGROUND: Birth defects are a leading cause of neonatal mortality. Natural gas development (NGD) emits several potential teratogens, and U.S. production of natural gas is expanding. OBJECTIVES: We examined associations between maternal residential proximity to NGD and birth outcomes in a retrospective cohort study of 124,842 births between 1996 and 2009 in rural Colorado. METHODS: We calculated inverse distance weighted natural gas well counts within a 10-mile radius of maternal residence to estimate maternal exposure to NGD. Logistic regression, adjusted for maternal and infant covariates, was used to estimate associations with exposure tertiles for congenital heart defects (CHDs), neural tube defects (NTDs), oral clefts, preterm birth, and term low birth weight. The association with term birth weight was investigated using multiple linear regression. RESULTS: Prevalence of CHDs increased with exposure tertile, with an odds ratio (OR) of 1.3 for the highest tertile (95% CI: 1.2, 1.5); NTD prevalence was associated with the highest tertile of exposure (OR = 2.0; 95% CI: 1.0, 3.9, based on 59 cases), compared with the absence of any gas wells within a 10-mile radius. Exposure was negatively associated with preterm birth and positively associated with fetal growth, although the magnitude of association was small. No association was found between exposure and oral clefts. CONCLUSIONS: In this large cohort, we observed an association between density and proximity of natural gas wells within a 10-mile radius of maternal residence and prevalence of CHDs and possibly NTDs. Greater specificity in exposure estimates is needed to further explore these associations.