Using Medicaid Data to Improve Childhood Lead Poisoning Prevention Program Outcomes and Blood Lead Surveillance.

CONTEXT: Wisconsin-specific data revealed that not all Medicaid providers were testing children appropriately for blood lead levels and not all blood lead tests were reported to the Department of Health Services, Childhood Lead Poisoning Prevention Program. The Medicaid program requires blood lead screening for all Medicaid-enrolled children at specific ages. Wisconsin state law requires reporting of all blood lead test results. Projects were implemented to encourage appropriate testing for Medicaid-enrolled children and improve blood lead surveillance. METHODS: Medicaid billing data were linked to blood lead data to identify Medicaid-enrolled children who had not received the required tests. Medicaid provider report cards were distributed annually from 2006 to 2011 to inform providers of their compliance with federal testing requirements and of the names of children within their practice who had not been tested. Blood lead tests billed to Medicaid but not in the blood lead database were identified and billing providers were contacted to obtain the test report. RESULTS: The number of children tested increased from 81 834 children per year in 2006 to 106 003 children per year in 2010. Testing of Medicaid-enrolled children increased by 31% from 2006 to 2010. The percentage of Medicaid-enrolled children receiving an age-appropriate test increased from 46% in 2004 to a high of 55% in 2010. There were 9035 blood lead tests identified in the Medicaid billing data that had not been reported from 2007 to 2015. There were 468 billing providers who had unreported tests. All sites with unreported tests were contacted, 84% of test results were obtained, and 14% of test records could not be retrieved. Outpatient clinics accounted for the majority of all unreported tests (72%) and irretrievable test records (74%). DISCUSSION: Childhood lead poisoning prevention programs can effectively utilize Medicaid data to increase testing and improve blood lead surveillance. Primary health care providers should ensure that Medicaid-enrolled children in their care receive the age-appropriate tests. Many Wisconsin health care providers lack awareness of blood lead test reporting requirements. Outpatient clinics account for the largest proportion of unreported tests and highest priority should be given working with these sites to improve reporting practices.

An Occupational Legacy: Malignant Mesothelioma Incidence and Mortality in Wisconsin.

OBJECTIVES: The aim of the study was to describe mesothelioma occurrence in Wisconsin from 1997 to 2013 by usual industry and occupation (I&O), including occupations generally considered low risk. METHODS: Population-based rates and standardized incidence and mortality ratios were calculated. Two case-control analyses were designed to compare mesothelioma incidence and mortality in specific I&O groups with occurrence of (1) brain and central nervous system cancers and (2) other causes of death, using logistic regression. RESULTS: Mesothelioma incidence and mortality were elevated in Wisconsin (SIRadj = 1.20 [1.13 to 1.28]; SMRadj = 1.30 [1.22 to 1.38]). Certain industry (construction, manufacturing) and occupation (construction and extraction) groups were associated with increased odds of mesothelioma, with some evidence of increased risk among teachers. CONCLUSIONS: Forty years after the Occupational and Safety Health Act, mesothelioma incidence and mortality remain elevated in Wisconsin, with increased risk continuing for certain I&O groups.

Lead Exposure Among Workers at a Shipyard-Wisconsin, 2015 to 2016.

OBJECTIVE: In March 2016, the state health departments of Wisconsin and Minnesota learned of three shipyard workers with blood lead levels (BLLs) more than 40 µg/dL. An investigation was conducted to determine the extent of and risk factors for the exposure. METHODS: We defined a case as an elevated BLL more than or equal to 5 µg/dL in a shipyard worker. Workers were interviewed regarding their symptoms and personal protective equipment (PPE) use. RESULTS: Of 357 workers, 65.0% had received more than or equal to 1 BLL test. Among tested workers, 171 (73.7%) had BLLmax more than or equal to 5 µg/dL. Workers who received respirator training or fit testing had a median BLLmax of 18.0 µg/dL, similar to the median BLLmax of workers who did not receive such training (22.6 µg/dL, P = 0.20). CONCLUSIONS: Our findings emphasize the importance of adequate provision and use of PPE to prevent occupational lead exposure.

Changes in Hair Mercury Levels Among Women of Child-Bearing Age Following an Educational Intervention.

OBJECTIVE: Describe mercury exposures among women of childbearing age before and after an educational intervention. METHODS: Women age 18 to 45 were recruited to participate in an educational intervention concerning fish consumption. Fish consumption habits and total mercury concentration in hair were assessed pre- and post-intervention. Regression models examined associations between mercury, fish consumption, and demographics. RESULTS: Overall, 234 women completed the study. On average, mercury concentrations increased by 0.01 ppm (parts per million) following the intervention, despite declines in fish consumption; however, women in the 90th percentile for mercury at baseline decreased concentrations significantly while maintaining high rates of fish consumption. Mercury concentrations were positively correlated with fish consumption and certain demographic characteristics. CONCLUSIONS: The intervention reached individuals most at-risk. Healthcare providers should discuss fish consumption habits with women to encourage consumption of low-risk fish, and identify women needing education and counseling.

Perfluoroalkyl substances in older male anglers in Wisconsin.

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 to dyslipidemia. The major source of PFAS exposure in the general population is seafood. OBJECTIVES: In this analysis we examine PFAS levels and their determinants, as well as associations between PFAS levels and self-reported health outcomes, in a group of older male anglers in Wisconsin with high fish consumption. METHODS: A biomonitoring study of male anglers aged 50 and older living in Wisconsin collected detailed information on fish consumption, demographics and self-reported health outcomes, along with hair and blood samples for biomarker analysis. Sixteen different PFAS were extracted from serum samples. Regression models were used to identify factors (demographic characteristics and fish consumption habits) associated with PFAS biomarker levels in blood, as well as associations between PFAS and self-reported health outcomes, adjusting for potential confounders. RESULTS: Seven PFAS were detected in at least 30% of participants and were used in subsequent analyses (PFDA, PFHpS, PFHxS, PFNA, PFOA, PFOS, PFuDA). The PFAS with the highest levels were PFOS, followed by PFOA, PFHxS and PFNA (medians of 19.0, 2.5, 1.8 and 1.4ng/mL). In general, increasing age was associated with higher PFAS levels, while increasing BMI were associated with lower PFAS levels. Greater alcohol consumption was associated with higher levels of PFHpS, PFHxS and PFOA. Associations with smoking and employment did not show a consistent pattern. Associations between fish consumption and PFAS were generally weak, with the exception of notably higher PFDA and PFHpS with both other locally-caught fish, and restaurant-purchased fish. Regarding associations with health outcomes, PFuDA, PFNA and PFDA were all associated with increased risk of pre-diabetes and/or diabetes. PFHpS was associated with a significantly increased risk of high cholesterol; PFDA and PFuDA also showed notable, though non-significant associations. All PFAS evaluated were associated with lower risk of hypertension although the only significant odds ratio was that for PFNA. There were no associations between any of the PFAS examined and either coronary heart disease, or the grouped outcome of any cardiovascular condition. CONCLUSIONS: PFAS are emerging contaminants with widespread exposure, persistence, and potential for adverse health effects. In this study population, demographic patterns may reflect differences in exposure sources, or possibly differences in adsorption and metabolism. PFAS were associated mainly with endocrine related outcomes, with a general trend towards increased risk of glucose intolerance and high cholesterol. Continued research on the risks and benefits of fish consumption is important due to potential exposure to PFAS and noted associations with highly prevalent adverse health outcomes.

Localized pleural thickening: smoking and exposure to Libby vermiculite.

There is limited research on the combined effects of smoking and asbestos exposure on risk of localized pleural thickening (LPT). This analysis uses data from the Marysville cohort of workers occupationally exposed to Libby amphibole asbestos (LAA). Workers were interviewed to obtain work and health history, including ever/never smoking and chest X-rays. Cumulative exposure estimates were developed on the basis of fiber measurements from the plant and work history. Benchmark concentration (BMC) methodology was used to evaluate the exposure-response relationship for exposure to LAA and a 10% increased risk of LPT, considering potential confounders and statistical model forms. There were 12 LPT cases among 118 workers in the selected study population. The mean exposure was 0.42 (SD=0.77) fibers/cc-year, and the prevalence of smoking history was 75.0% among cases and 51.9% among non-cases. When controlling for LAA exposure, smoking history was of borderline statistical significance (P-value=0.099), and its inclusion improved model fit, as measured by Akaike's Information Criterion. A comparison of BMC estimates was made to gauge the potential effect of smoking status. The BMC was 0.36 fibers/cc-year, overall. The BMC for non-smokers was approximately three times as high (1.02 fibers/cc-year) as that for the full cohort, whereas the BMC for smokers was about 1/2 that of the full cohort (0.17 fibers/cc-year).

Risk factors for lower respiratory tract infection death among infants in the United States, 1999-2004.

OBJECTIVE: To describe maternal and birth-related risk factors associated with lower respiratory tract infection (LRTI) deaths among infants. METHODS: Records for infants with LRTI as a cause of death were examined by using the linked birth/infant death database for 1999-2004. Singleton infants dying with LRTI and a random sample of surviving singleton infants were compared for selected characteristics. RESULTS: A total of 5420 LRTI-associated infant deaths were documented in the United States during 1999-2004, for an LRTI-associated infant mortality rate of 22.3 per 100,000 live births. Rates varied according to race; the rate for American Indian/Alaska Native (AI/AN) infants was highest (53.2), followed by black (44.1), white (18.7), and Asian/Pacific Islander infants (12.3). Singleton infants with low birth weight (<2500 g) were at increased risk of dying with LRTI after controlling for other characteristics, especially black infants. Both AI/AN and black infants born with a birth weight of > or =2500 g were more likely to have died with LRTI than other infants of the same birth weight. Other risk factors associated with LRTI infant death included male gender, the third or more live birth, an Apgar score of <8, unmarried mother, mother with <12 years of education, mother <25 years of age, and mother using tobacco during pregnancy. CONCLUSIONS: Low birth weight was associated with markedly increased risk for LRTI-associated death among all of the racial groups. Among infants with a birth weight of > or =2500 g, AI/AN and black infants were at higher risk of LRTI-associated death, even after controlling for maternal and birth-related factors. Additional studies and strategies should focus on the prevention of maternal and birth-related risk factors for postneonatal LRTI and on identifying additional risk factors that contribute to elevated mortality among AI/AN and black infants.