Indoor Air Quality Assessments in 10 Long-Term Care Facilities during the COVID-19 Pandemic, California, 2021-2023.

OBJECTIVES: This study aimed to assess indoor air quality (IAQ) in long-term care facilities (LTCFs) in California during the COVID-19 pandemic and evaluate their implementation of IAQ best practices described by public health authorities to control respiratory pathogen transmission via inhalation. DESIGN: This observational study conducted IAQ assessments in a convenience sample of LTCFs to gather qualitative data on the implementation of IAQ best practices. The design included 5 pilot visits to develop a standardized method of data collection and then systematic data collection at 10 facilities. SETTING AND PARTICIPANTS: The study focused on 10 LTCFs across California, chosen from facilities that responded to flyers advertising free IAQ assessments. Some of the facilities had previously experienced COVID-19 outbreaks affecting residents and staff. METHODS: State health department industrial hygienists performed site visits to collect data on each facility's heating, ventilation, and air-conditioning (HVAC) system operation, outdoor air introduction, recirculated air filtration, use of portable air cleaners, and directional airflow in isolation areas to evaluate implementation of IAQ best practices in each of these areas. Qualitative data were obtained through visual inspections and interviews with maintenance personnel. RESULTS: Findings indicated suboptimal implementation of IAQ best practices across the assessed facilities: no facility operated HVAC systems continuously, 40% had all outdoor air dampers open, 20% used MERV-13 or higher rated filters, 20% used portable air cleaners, and 20% performed directional airflow assessment and management for isolating COVID-19 cases. CONCLUSIONS AND IMPLICATIONS: Most LTCFs assessed were not adhering to IAQ best practices, highlighting a significant opportunity for improvement. IAQ best practices described in this study are achievable with existing systems and are critical for reducing virus transmission through the air in LTCFs. The findings underscore the need for more systematic assessments and improvements in IAQ within LTCFs to protect staff and residents.

Demographic changes in COVID-19 mortality during the pandemic: analysis of trends in disparities among workers using California's mortality surveillance system.

BACKGROUND: There is limited information on the extent and patterns of disparities in COVID-19 mortality throughout the pandemic. We aimed to examine trends in disparities by demographics over variants in the pre- and post-vaccine availability period among Californian workers using a social determinants of health lens. METHODS: Using death certificates, we identified all COVID-19 deaths that occurred between January 2020 and May 2022 among workers aged 18-64 years in California (CA). We derived estimates for at-risk worker populations using the Current Population Survey. The waves of COVID-19 mortality in the pre-vaccine availability period were March 2020-June 2020 (wave 1), and July 2020-November 2020 (wave 2), and in the post-vaccine availability period: December 2020-May 2021 (wave 3), June 2021-January 2022 (wave 4), and February 2022-May 2022 (wave 5). Poisson regression models with robust standard errors were used to determine wave-specific mortality rate ratios (MRRs). We examined the change in MRR across waves by including an interaction term between each demographic characteristic and wave period in different models. The role of potential misclassification of Race/ethnicity on death certificates was examined using probabilistic quantitative bias analysis as sensitivity analysis. RESULTS: Among the 24.1 million working age CA population included in the study, there were 26,068 COVID-19 deaths in the period between January 2020 and May 2022. Compared with their respective reference groups, workers who were 50-64 years old, male, Native Hawaiian, Latino, or African American, foreign-born; individuals who had lower education; and unmarried were disproportionately affected by COVID-19 mortality. While disparities by sex, race/ethnicity and foreign-born status narrowed in later waves (post-vaccine availability), disparities by age, education level and marital status did not change substantially across waves. CONCLUSION: Demographic disparities in COVID-19 mortality narrowed in the post-vaccine availability waves. However, the existence of disparities across all waves of the pandemic, even in an era of widespread vaccine coverage, could indicate remaining gaps in prevention and differential vulnerability. Addressing the underlying social, structural, and occupational factors that contribute to these disparities is critical for achieving health equity.

The Impact of Occupational Exposures on the Risk of Idiopathic Pulmonary Fibrosis: A Systematic Review and Meta-Analysis.

Rationale: Idiopathic pulmonary fibrosis (IPF) is a progressive fibrotic pulmonary disorder of unknown etiology that is characterized by a usual interstitial pneumonia pattern. Previous meta-analyses have reported associations between occupational exposures and IPF, but higher-quality studies have been published in recent years, doubling the number of studied patients. Objectives: To provide a contemporary and comprehensive assessment of the relationship between occupational exposures and IPF. Methods: We searched PubMed, Embase, and Web of Science through July 2023 to identify all publications on occupational exposure and IPF. We conducted a meta-analysis of the occupational burden, odds ratio (OR), and population attributable fraction (PAF) of exposures. Five exposure categories were analyzed: vapors, gas, dust, and fumes (VGDF); metal dust; wood dust; silica dust; and agricultural dust. A comprehensive bias assessment was performed. The study protocol was registered in the International Prospective Register of Systematic Reviews (identifier CRD42021267808). Results: Our search identified 23,942 publications. Sixteen publications contained relative risks needed to calculate pooled ORs and PAFs, and 12 additional publications reported an occupational burden within a case series. The proportion of cases with occupational exposures to VGDF was 44% (95% confidence interval [CI], 36-53%), with a range of 8-17% within more specific exposure categories. The pooled OR was increased for VGDF at 1.8 (95% CI, 1.3-2.4), with a pooled PAF of 21% (95% CI, 15-28%). ORs and PAFs, respectively, were found to be 1.6 and 7% for metal dust, 1.6 and 3% for wood dust, 1.8 and 14% for agricultural dust, and 1.8 and 4% for silica dust. The pooled ORs and PAFs within specific exposure categories ranged from 1.6 to 1.8 and from 4% to 14%, respectively. We identified some publication bias, but it was not sufficient to diminish the association between occupational exposures and IPF based on sensitivity analysis and bias assessment. Conclusions: Our findings indicate that 21% of IPF cases (or approximately one in five) could be prevented by removal of occupational exposure (alongside a pooled OR of 1.8). Additionally, 44% of patients with IPF report occupational exposure to VGDF. This meta-analysis suggests that a considerable number of cases of IPF are attributable to inhaled occupational exposures and warrant increased consideration in the clinical care of patients and future prevention efforts.

Temporal assessment of disparities in California COVID-19 mortality by industry: a population-based retrospective cohort study.

PURPOSE: To assess changes in the COVID-19 mortality rate and disparities over variants or waves by industry. METHODS: We identified COVID-19 deaths that occurred between January 2020 and May 2022 among California workers aged 18-64 years using death certificates, and estimated Californians at risk using the Current Population Survey. The waves in deaths were wave 1: March-June 2020, wave 2: July-November 2020, wave 3/Epsilon and Alpha variants: December 2020-May 2021, wave 4/Delta variant: June 2021-January 2022, and wave 5/Omicron variant: February-May 2022. We used Poisson regression to generate wave-specific mortality rate ratios (MRR) and included an interaction term between industry and wave in different models to assess significance of the change in MRR. RESULTS: In all waves of the pandemic, healthcare, other services, manufacturing, transportation, and retail trade industries had higher mortality rates than the professional, scientific, and technical industry. The healthcare industry had the highest relative rate earlier in the pandemic, while other services, utilities, and accommodation and food services industries had substantial increases in MRR in later waves. CONCLUSIONS: Industries that consistently had disproportionate COVID-19 mortality may have benefitted from protections that consider workers' increased exposure and vulnerability to severe outcomes.

Active Surveillance of Engineered Stone Workers Facilitates Early Identification of Silicosis: A Discussion of Surveillance of Occupational Lung Diseases.

Silicosis in workers exposed to respirable crystalline silica while fabricating engineered stone products is an emerging respiratory health issue. We describe silicosis in engineered stone workers in California and examine clinical features by the source of identification. Cases were identified passively using hospital-based patient discharge data or actively through outreach and medical testing following enforcement investigation. Outcomes were examined based on the source of case identification. We identified 18 cases diagnosed between 2006 and 2020. Cases identified passively compared to other identification methods were associated with lower percent predicted forced vital capacity (FVC) (P ≤ .01), forced expiratory volume in 1 s (FEV1) (P ≤ .01), and diffusing capacity of the lungs for carbon monoxide (DLCO) (P < .01) at the time of diagnosis and were more likely to be identified following death or lung transplant (P = .01). Our experience demonstrates delays in diagnosis and case identification when relying on passive surveillance methods. Enhanced public health surveillance systems can improve the early detection of occupational lung disease and inform future prevention policies.

Occupational Contributions to Respiratory Health Disparities.

Occupation is an important contributor to disparities in respiratory disease, affecting financial status, health-care access, and exposure to hazardous substances. Although occupation and associated exposures are included in the socioecological models, work exposures remain persistently absent from research on health inequities and their contribution to health. This article focuses on the occupational contribution to disparities in asthma, chronic obstructive pulmonary disease, silicosis, coronavirus disease 2019, and lung cancer. Because occupational exposures are largely preventable through proper workplace controls, the recognition of occupational causes of disease can provide an opportunity for interventions to bring about health equity.

Silicosis Among Immigrant Engineered Stone (Quartz) Countertop Fabrication Workers in California.

Importance: Silicosis associated with inhalation of respirable crystalline silica among engineered stone countertop fabrication workers is an emerging health concern. Objective: To describe clinical, socioeconomic, and occupational characteristics of patients diagnosed with silicosis associated with engineered stone in California. Design, Setting, and Participants: This case series included reported cases of silicosis associated with fabrication of engineered stone countertops, as identified by statewide surveillance by the California Department of Public Health (2019-2022). Data analysis was performed from October 2022 to March 2023. Exposures: Patient interviews and medical record abstractions were used to assess occupational exposure to respirable crystalline silica, including duration of work tenure and preventive measures undertaken. Main Outcomes and Measures: Demographics, clinical characteristics, health care utilization, and clinical outcomes were obtained, including vital status, hypoxia, and lung transplant. Results: This case series identified 52 male patients meeting inclusion criteria; median (IQR) age was 45 (40-49) years, and 51 were Latino immigrants. Ten (19%) were uninsured, and 20 (39%) had restricted-scope Medi-Cal; 25 (48%) presented initially to an emergency department. A delay in diagnosis occurred in 30 (58%) patients, most commonly due to alternative initial diagnoses of bacterial pneumonia (9 [30%]) or tuberculosis (8 [27%]). At diagnosis, 20 (38%) patients had advanced disease (progressive massive fibrosis) with severely or very severely reduced forced expiratory volume in 1 second in 8 (18%) and 5 (11%), respectively. Of the cases, 10 (19%) were fatal; median (IQR) age at death was 46 (38-51) years, and 6 patients (12%) were alive with chronic resting hypoxia. Eleven were referred for lung transplant: 3 underwent transplant with 1 fatality; 7 were declined transplant, with 6 fatalities; and 1 died prior to listing. Median (IQR) work tenure was 15 (10-20) years; 23 (45%) reported use of water suppression for dust mitigation, and 25 (48%) continued to fabricate stone after being diagnosed with silicosis. Conclusions and Relevance: In this case series performed in California, silicosis associated with occupational exposure to dust from engineered stone primarily occurred among young Latino immigrant men. Many patients presented with severe disease, and some cases were fatal.

Evaluating the association between in-person work and the risk of SARS-CoV-2 infection through June 2021.

OBJECTIVES: Recent studies have evaluated COVID-19 outbreaks and excess mortality by occupation sectors. Studies on SARS-CoV-2 infection across occupation and occupation-related factors remain lacking. In this study, we estimate the effect of in-person work on SARS-CoV-2 infection risk and describe SARS-CoV-2 seroprevalence among working adults. METHODS: We used Wave 1 data (May to June 2021) from CalScope, a population-based seroprevalence study in California. Occupation data were coded using the National Institute for Occupational Safety and Health Industry and Occupation Computerized Coding System. Dried blood spot specimens were tested for antibodies to establish evidence of prior infection. We estimated the causal effect of in-person work on SARS-CoV-2 infection risk using the g-formula and describe SARS-CoV-2 seroprevalence across occupation-related factors. RESULTS: Among 4335 working adults, 53% worked in person. In-person work was associated with increased risk of prior SARS-CoV-2 infection (risk difference: 0.03; [95% CI: 0.02-0.04]) compared with working remotely. Workers that reported job loss or who were without medical insurance had higher evidence of prior infection. Amongst in-person workers, evidence of prior infection was highest within farming, fishing, and forestry (55%; [95% CI: 26%-81%]); installation, maintenance, and repair (23%; [12%-39%]); building and grounds cleaning and maintenance (23%; [13%-36%]); food preparation and serving related (22% [13%-35%]); and healthcare support (22%; [13%-34%]) occupations. Workers who identified as Latino, reported a household income of <$25K, or who were without a bachelor's degree also had higher evidence of prior infection. CONCLUSIONS: SARS-CoV-2 infection risk varies by occupation. Future vaccination strategies may consider prioritizing in-person workers.

Risk factors for COVID-19 among Californians working outside the home, November 2020 - May 2021.

BACKGROUND: Higher incidences of COVID-19 mortality and outbreaks have been found in certain industries and occupations. Workplace factors, including working in close proximity to others and contact with the public can facilitate SARS-CoV-2 transmission, especially without appropriate protective measures. Limited information is available about workers at highest risk for SARS-CoV-2 infection. METHODS: A phone-based, nonprobability study was conducted between November 2020 and May 2021 among California workers who were tested for SARS-CoV-2. Participants were asked about demographics and workplace factors, including industry, occupation, and implementation of COVID-19 mitigation measures. Using the SARS-CoV-2 occupational exposure matrix, three exposure metrics and a combination index were used to categorize occupations. We assessed the association between workplace risks and SARS-CoV-2 test positivity using adjusted logistic regression. RESULTS: We enrolled 451 (13%) of 3475 potentially eligible workers in the study: 212 with positive and 239 with negative SARS-CoV-2 test results. Those working very close to others and with the highest combined exposure index had a positive association with SARS-CoV-2 positivity. Primarily indoor workers had a lower odds of test positivity compared to those with any outdoor work. There was no association between public-facing occupations and test positivity. Participants with employers who implemented mitigation measures in all three control categories-engineering, administrative, and personal protective equipment-had lower odds of test positivity than those with fewer mitigation measures. CONCLUSIONS: Worker groups with higher risk factors should be prioritized for outreach. Assessment of occupational risk factors collectively can provide insight to inform preventative actions for workers, employers, and public health entities.

Impact of Epidemic Intelligence Service Training in Occupational Respiratory Epidemiology.

The Centers for Disease Control and Prevention's Epidemic Intelligence Service (EIS) is a fellowship in applied epidemiology for physicians, veterinarians, nurses, scientists, and other health professionals. Each EIS fellow is assigned to a position at a federal, state, or local site for 2 years of on-the-job training in outbreak investigation, epidemiologic research, surveillance system evaluation, and scientific communication. Although the original focus of the program on the control of infectious diseases remains salient, positions are available for training in other areas of public health, including occupational respiratory disease. In this Perspective, we describe the EIS program, highlight three positions (one federal and two state-based) that provide training in occupational respiratory epidemiology, and summarize trainees' experiences in these positions over a 30-year period. For early-career health professionals interested in understanding and preventing occupational respiratory hazards and diseases, EIS offers a unique career development opportunity.

Rare case of occupational pulmonary hemorrhage in a firefighter.

Alveolar hemorrhage associated with physical exertion, known as exercise-induced pulmonary hemorrhage (EIPH), is a rare condition linked to strenuous exertion. This can be an unusual form of respiratory and occupational illness. We present the case of a healthy firefighter who developed fatal pulmonary hemorrhage after participating in a strenuous physical training exercise regimen. This case represents a severe presentation of EIPH, which results from the disruption of the pulmonary blood-gas barrier as a result of strenuous exertion. Clinicians caring for those in vocations and recreation involving extremely vigorous exercise should be aware that such activities can cause EIPH.

COVID-19 Outbreaks and Mortality Among Public Transportation Workers - California, January 2020-May 2022.

Work-related factors can contribute to risk for exposure to and infection with SARS-CoV-2, the virus that causes COVID-19, and subsequent COVID-19-attributable outcomes, including death. Comparing COVID-19 metrics across industries can help identify workers at highest risk. Elevated COVID-19 mortality rates have been reported among all transportation workers, as well as specifically in public transportation industries (1-3). The California Department of Public Health (CDPH) calculated public transportation industry-specific COVID-19 outbreak incidence during January 2020-May 2022 and analyzed all laboratory-confirmed COVID-19 deaths among working-age adults in California to calculate public transportation industry-specific mortality rates during the same period. Overall, 340 confirmed COVID-19 outbreaks, 5,641 outbreak-associated cases, and 537 COVID-19-associated deaths were identified among California public transportation industries. Outbreak incidence was 5.2 times as high (129.1 outbreaks per 1,000 establishments) in the bus and urban transit industry and 3.6 times as high in the air transportation industry (87.7) as in all California industries combined (24.7). Mortality rates were 2.1 times as high (237.4 deaths per 100,000 workers) in transportation support services and 1.8 times as high (211.5) in the bus and urban transit industry as in all industries combined (114.4). Workers in public transportation industries are at higher risk for COVID-19 workplace outbreaks and mortality than the general worker population in California and should be prioritized for COVID-19 prevention strategies, including vaccination and enhanced workplace protection measures.

Decrements in lung function and respiratory abnormalities associated with exposure to diacetyl and 2,3-pentanedione in coffee production workers.

Coffee production workers are exposed to complex mixtures of gases, dust, and vapors, including the known respiratory toxins, diacetyl, and 2,3-pentanedione, which occur naturally during coffee roasting and are also present in flavorings used to flavor coffee. This study evaluated the associations of these two α-diketones with lung function measures in coffee production workers. Workers completed questionnaires, and their lung function was assessed by spirometry and impulse oscillometry (IOS). Personal exposures to diacetyl, 2,3-pentanedione, and their sum (SumDA+PD) were assigned to participants, and metrics of the highest 95th percentile (P95), cumulative, and average exposure were calculated. Linear and logistic regression models for continuous and binary/polytomous outcomes, respectively, were used to explore exposure-response relationships adjusting for age, body mass index, tenure, height, sex, smoking status, race, or allergic status. Decrements in percent predicted forced expiratory volume in 1 second (ppFEV1) and forced vital capacity (ppFVC) were associated with the highest-P95 exposures to 2,3-pentanedione and SumDA+PD. Among flavoring workers, larger decrements in ppFEV1 and ppFVC were associated with highest-P95 exposures to diacetyl, 2,3-pentanedione, and SumDA+PD. Abnormal FEV1, FVC, and restrictive spirometric patterns were associated with the highest-P95, cumulative, and average exposures for all α-diketone metrics; some of these associations were also present among flavoring and non-flavoring workers. The combined category of small and peripheral airways plus small and large airways abnormalities on IOS had elevated odds for highest-P95 exposure to α-diketones. These results may be affected by the small sample size, few cases of abnormal spirometry, and the healthy worker effect. Associations between lung function abnormalities and exposure to α-diketones suggest it may be prudent to consider exposure controls in both flavoring and non-flavoring settings.

Elevated exposures to respirable crystalline silica among engineered stone fabrication workers in California, January 2019-February 2020.

BACKGROUND: Workers fabricating engineered stone face high risk for exposure to respirable crystalline silica (RCS) and subsequent development of silicosis. In response, the California Division of Occupational Safety and Health (Cal/OSHA) performed targeted enforcement inspections at engineered stone fabrication worksites. We investigated RCS exposures and employer adherence to Cal/OSHA's RCS and respiratory protection standards from these inspections to assess ongoing risk to stone fabrication workers. METHODS: We extracted employee personal air sampling results from Cal/OSHA inspection files and calculated RCS exposures. Standards require that employers continue monitoring employee RCS exposures and perform medical surveillance when exposures are at or above the action level (AL; 25 µg/m3 ); exposures above the permissible exposure limit (PEL; 50 µg/m3 ) are prohibited. We obtained RCS and respiratory protection standard violation citations from a federal database. RESULTS: We analyzed RCS exposures for 152 employees at 47 workplaces. Thirty-eight (25%) employees had exposures above the PEL (median = 89.7 µg/m3 ; range = 50.7-670.7 µg/m3 ); 17 (11%) had exposures between the AL and PEL. Twenty-four (51%) workplaces had ≥1 exposure above the PEL; 7 (15%) had ≥1 exposure between the AL and PEL. Thirty-four (72%) workplaces were cited for ≥1 RCS standard violation. Twenty-seven (57%) workplaces were cited for ≥1 respiratory protection standard violation. CONCLUSIONS: Our investigation demonstrates widespread RCS overexposure among workers and numerous employer Cal/OSHA standard violation citations. More enforcement and educational efforts could improve employer compliance with Cal/OSHA standards and inform employers and employees of the risks for RCS exposure and strategies for reducing exposure.

Reported Exposures Among In-Person Workers With Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection in 6 States, September 2020-June 2021.

BACKGROUND: Surveillance systems lack detailed occupational exposure information from workers with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The National Institute for Occupational Safety and Health partnered with 6 states to collect information from adults diagnosed with SARS-CoV-2 infection who worked in person (outside the home) in non-healthcare settings during the 2 weeks prior to illness onset. METHODS: The survey captured demographic, medical, and occupational characteristics and work- and non-work-related risk factors for SARS-CoV-2 infection. Reported close contact with a person known or suspected to have SARS-CoV-2 infection was categorized by setting as exposure at work, exposure outside of work only, or no known exposure/did not know. Frequencies and percentages of exposure types are compared by respondent characteristics and risk factors. RESULTS: Of 1111 respondents, 19.4% reported exposure at work, 23.4% reported exposure outside of work only, and 57.2% reported no known exposure/did not know. Workers in protective service occupations (48.8%) and public administration industries (35.6%) reported exposure at work most often. More than one third (33.7%) of respondents who experienced close contact with ≥10 coworkers per day and 28.8% of respondents who experienced close contact with ≥10 customers/clients per day reported exposures at work. CONCLUSIONS: Exposure to occupational SARS-CoV-2 was common among respondents. Examining differences in exposures among different worker groups can help identify populations with the greatest need for prevention interventions. The benefits of recording employment characteristics as standard demographic information will remain relevant as new and reemerging public health issues occur.

Two-year follow-up of exposure, engineering controls, respiratory protection and respiratory health among workers at an indium-tin oxide (ITO) production and reclamation facility.

OBJECTIVES: To determine whether engineering controls and respiratory protection had measurable short-term impact on indium exposure and respiratory health among current indium-tin oxide production and reclamation facility workers. METHODS: We documented engineering controls implemented following our 2012 evaluation and recorded respirator use in 2012 and 2014. We measured respirable indium (Inresp) and plasma indium (InP) in 2012 and 2014, and calculated change in Inresp (∆Inresp) and InP (∆InP) by the 13 departments. We assessed symptoms, lung function, serum biomarkers of interstitial lung disease (Krebs von den Lungen (KL)-6 and surfactant protein (SP)-D) and chest high-resolution CT at both time points and evaluated workers who participated in both 2012 and 2014 for changes in health outcomes (new, worsened or improved). RESULTS: Engineering controls included installation of local exhaust ventilation in both grinding departments (Rotary and Planar) and isolation of the Reclaim department. Respiratory protection increased in most (77%) departments. ∆InP and ∆Inresp often changed in parallel by department. Among 62 workers participating in both 2012 and 2014, 18 (29%) had new or worsening chest symptoms and 2 (3%) had functional decline in lung function or radiographic progression, but average KL-6 and SP-D concentrations decreased, and no cases of clinical indium lung disease were recognised. CONCLUSIONS: Increased engineering controls and respiratory protection can lead to decreased Inresp, InP and biomarkers of interstitial lung disease among workers in 2 years. Ongoing medical monitoring of indium-exposed workers to confirm the longer-term effectiveness of preventive measures is warranted.