Opioid prescriptions among the World Trade Center Health Program population.

BACKGROUND: The World Trade Center Health Program (Program) provides limited health care to those directly affected by the 9/11 terrorist attacks. Because of physical/mental trauma arising from the 9/11 attacks, Program members might be at high risk of opioid use. To prevent prescription opioid overuse, in 2018 the Program implemented various measures to improve opioid prescribing and expand access to non-opioid pain management among Program members. However, the characteristics of opioid prescriptions dispensed among this population has never been described. METHODS: Administrative and claims data from 07/01/2011 to 09/30/2022 were used to describe opioid prescriptions dispensed during 2013-2021. RESULTS: From 2013-2021, 108,285 members were Program-enrolled for ≥ 10 months, 4,053 (3.7%) had 22,938 outpatient opioid prescriptions, of which, 62.1% were for cancer-related pain, 11.1% for hospice/end of life care, 4.8% for surgery pain, and 9.8% for acute/chronic pain. Among members with Program-paid diagnostic/treatment claims (n = 70,721), the proportion with opioid prescriptions for cancer/hospice/end of life care increased from 0.5% in 2013 to 1.6% in 2018 (p = 0.010), then decreased to 1.1% in 2021 (p = 0.070), and the proportion for non-cancer surgery/acute/chronic pain decreased from 0.6% in 2013 to 0.23% in 2021 (p = 0.0005). Among members prescribed opioids without cancer/hospice/sickle cell disease, the proportion who started with long-acting opioids or had opioid prescriptions from ≥ 4 prescribers were below 6.5% annually; the proportion receiving a high-dose (≥ 90 morphine milligram equivalents per day [MED]), or with concurrent opioids and benzodiazepines use, or who started opioids with MED ≥ 50 or with long duration (≥ 7 days' supply) were above 10% annually, but decreased since 2017. CONCLUSIONS: Prevalence of outpatient opioid prescriptions paid by the Program was very low and prescriptions were primarily dispensed for cancer/hospice/end of life care. Although Program efforts to improve opioid prescribing coincided with improvements in outcomes, ongoing surveillance is needed.

The World Trade Center Health Program: Cancer screening and cancer care best practices.

The events of September 11, 2001 (9/11) exposed nearly a half million persons to many carcinogenic chemicals and dusts, as well as psychological and physical stressors. Subsequent epidemiologic studies of 9/11-exposed persons have suggested elevated risks for some cancers, e.g., prostate cancer, thyroid cancer, and melanoma. To detect cancer at an early stage, the US Preventive Services Task Force recommends screening certain asymptomatic persons for lung, colorectal, cervical and breast cancer, but not for other cancers. High quality cancer diagnosis and treatment guidelines are available from the National Comprehensive Cancer Network and the National Cancer Institute. For enrolled members, the WTC Health Program provides coverage for cancer screening and diagnosis, and covers medically necessary treatment costs for all types of cancer, assuming 9/11-exposure and minimum latency requirements are met, and a Program-affiliated physician attests that 9/11 exposures were substantially likely to have been a significant factor in aggravating, contributing to, or causing the enrolled WTC member's cancer.

The World Trade Center Health Program: Smoking cessation.

Cigarette smoking can cause and/or worsen a variety of health conditions. The U.S. Preventive Services Task Force (USPSTF) recommends that smoking cessation services be offered to all adults who currently smoke, and governmental and non-governmental professional organizations support providing these interventions to patients who smoke. The World Trade Center (WTC) Health Program, a federal program that provides health monitoring and treatment to those directed exposed to the September 11, 2001 terrorist attacks, provides smoking cessation therapy for eligible members. This paper identifies treatment strategies for smoking cessation and references the treatment coverage policy in the WTC Health Program. In addition, this paper notes the higher smoking prevalence among those with mental health conditions such as posttraumatic stress disorder (PTSD), and the need for heightened cessation efforts given the lower quit success rates among such persons.

World Trade Center Health Program best practices for the diagnosis and treatment of gastroesophageal reflux disease.

Gastroesophageal reflux disease (GERD) is one of the most common health conditions reported among persons exposed to the dust, debris and chemicals after the September 11, 2001 attacks in the United States. In the 9/11-exposed population, GERD is often found to be co-morbid with other conditions, such as asthma, post-traumatic stress disorder, and obesity. High-quality clinical practice guidelines for GERD are available from the American College of Gastroenterology. GERD diagnostic services and medically necessary treatment are covered by the WTC Health Program for persons who meet eligibility criteria.

Tracking diseases related to the terrorist attacks of September 11, 2001.

Accurate, timely, and complete disease reporting is essential to understanding the extent and long-term consequences of diseases related to the terrorist attacks of September 11, 2001 (9/11). Although there are no public health disease reporting requirements that specifically mention 9/11, other mechanisms exist to track 9/11-related illnesses. These include the availability of 9/11-exposed cohorts, some open to new member recruitment and others closed. Record linkages of 9/11 cohorts to various data registries (eg statewide cancer registries and the National Death Index) are periodically performed. This paper describes these 9/11 cohorts and the efforts to track their health experience.

The World Trade Center Health Program: an introduction to best practices.

More than 20 years have elapsed since the September 11, 2001 (9/11) terrorist attacks on the World Trade Center (WTC), Pentagon and at Shanksville, PA. Many persons continue to suffer a variety of physical and mental health conditions following their exposures to a mixture of incompletely characterized toxicants and psychological stressors at the terrorist attack sites. Primary care and specialized clinicians should ask patients who may have been present at any of the 9/11 sites about their 9/11 exposures, especially patients with cancer, respiratory symptoms, chronic rhinosinusitis, gastroesophageal reflux disease, psychiatric symptoms, and substance use disorders. Clinicians, especially those in the NY metropolitan area, should know how to evaluate, diagnose, and treat patients with conditions that could be associated with exposure to the 9/11 attacks and its aftermath. As such, this issue of Archives contains a series of updates to clinical best practices relevant to medical conditions whose treatment is covered by the WTC Health Program. This first paper in the 14-part series describes the purpose of this series, defines the WTC Health Program and its beneficiaries, and explains how relevant Clinical Practice Guidelines were identified. This paper also reminds readers that because physical and mental health conditions are often intertwined, a coordinated approach to care usually works best and referral to health centers affiliated with the WTC Health Program may be necessary, since all such Centers offer multidisciplinary care.

First Month of COVID-19 Vaccine Safety Monitoring - United States, December 14, 2020-January 13, 2021.

Two coronavirus disease 2019 (COVID-19) vaccines are currently authorized for use in the United States. The Food and Drug Administration (FDA) issued Emergency Use Authorization (EUA) for the Pfizer-BioNTech COVID-19 vaccine on December 11, 2020, and for the Moderna COVID-19 vaccine on December 18, 2020; each is administered as a 2-dose series. The Advisory Committee on Immunization Practices issued interim recommendations for Pfizer-BioNTech and Moderna COVID-19 vaccines on December 12, 2020 (1), and December 19, 2020 (2), respectively; initial doses were recommended for health care personnel and long-term care facility (LTCF) residents (3). Safety monitoring for these vaccines has been the most intense and comprehensive in U.S. history, using the Vaccine Adverse Event Reporting System (VAERS), a spontaneous reporting system, and v-safe,* an active surveillance system, during the initial implementation phases of the COVID-19 national vaccination program (4). CDC conducted descriptive analyses of safety data from the first month of vaccination (December 14, 2020-January 13, 2021). During this period, 13,794,904 vaccine doses were administered, and VAERS received and processed† 6,994 reports of adverse events after vaccination, including 6,354 (90.8%) that were classified as nonserious and 640 (9.2%) as serious.§ The symptoms most frequently reported to VAERS were headache (22.4%), fatigue (16.5%), and dizziness (16.5%). A total of 113 deaths were reported to VAERS, including 78 (65%) among LTCF residents; available information from death certificates, autopsy reports, medical records, and clinical descriptions from VAERS reports and health care providers did not suggest any causal relationship between COVID-19 vaccination and death. Rare cases of anaphylaxis after receipt of both vaccines were reported (4.5 reported cases per million doses administered). Among persons who received Pfizer-BioNTech vaccine, reactions reported to the v-safe system were more frequent after receipt of the second dose than after the first. The initial postauthorization safety profiles of the two COVID-19 vaccines in current use did not indicate evidence of unexpected serious adverse events. These data provide reassurance and helpful information regarding what health care providers and vaccine recipients might expect after vaccination.

A Workshop on Cognitive Aging and Impairment in the 9/11-Exposed Population.

The terrorist attacks on 11 September 2001 potentially exposed more than 400,000 responders, workers, and residents to psychological and physical stressors, and numerous hazardous pollutants. In 2011, the World Trade Center Health Program (WTCHP) was mandated to monitor and treat persons with 9/11-related adverse health conditions and conduct research on physical and mental health conditions related to the attacks. Emerging evidence suggests that persons exposed to 9/11 may be at increased risk of developing mild cognitive impairment. To investigate further, the WTCHP convened a scientific workshop that examined the natural history of cognitive aging and impairment, biomarkers in the pathway of neurodegenerative diseases, the neuropathological changes associated with hazardous exposures, and the evidence of cognitive decline and impairment in the 9/11-exposed population. Invited participants included scientists actively involved in health-effects research of 9/11-exposed persons and other at-risk populations. Attendees shared relevant research results from their respective programs and discussed several options for enhancements to research and surveillance activities, including the development of a multi-institutional collaborative research network. The goal of this report is to outline the meeting's agenda and provide an overview of the presentation materials and group discussion.

Elevated blood lead levels in adults-Missouri, 2013.

BACKGROUND: Over 90% of adults with elevated blood lead levels (BLLs) in the United States are exposed occupationally. Missouri historically has been among the states with the highest prevalence rates of elevated BLLs. We characterized cases of elevated BLLs among Missouri adults to target preventive interventions. METHODS: We reviewed 2013 data on Missouri residents ≥16 years from the Missouri Adult Blood Lead Epidemiology and Surveillance system and analyzed characteristics of those with elevated BLLs. We used the contemporaneous CDC definition of elevated BLL as ≥10 µg/dL. RESULTS: Of the 15 123 residents with a BLL in 2013 (median: 1.5 µg/dL, range: 0-151 µg/dL), 3145 (21%) had BLLs ≥10 µg/dL. Occupational exposures accounted for the majority of residents (n = 3099, 98%) with elevated BLLs, mostly in battery manufacturing (n = 1373, 44%) and lead mining (n = 821, 26%) industries. CONCLUSIONS: Our findings highlight the need for focused interventions targeting battery manufacturing and lead mining, the high-risk industries, to further reduce overexposures to lead.

Phosphine Exposure Among Emergency Responders - Amarillo, Texas, January 2017.

Phosphine is a highly toxic gas that forms when aluminum phosphide, a restricted-use pesticide* typically used in agricultural settings, reacts with water. Acute exposure can lead to a wide range of respiratory, cardiovascular, and gastrointestinal symptoms, and can be fatal (1). On January 2, 2017, the Texas Department of State Health Services (DSHS) was notified by the Texas Panhandle Poison Center of an acute phosphine exposure incident in Amarillo, Texas. DSHS investigated potential occupational phosphine exposures among the 51 on-scene emergency responders; 40 (78.4%) did not use respiratory protection during response operations. Fifteen (37.5%) of these 40 responders received medical care for symptoms or as a precaution after the incident, and seven (17.5%) reported new or worsening symptoms consistent with phosphine exposure within 24 hours of the incident. Emergency response organizations should ensure that appropriate personal protective equipment (PPE) is used during all incidents when an unknown hazardous substance is suspected. Additional evaluation is needed to identify targeted interventions that increase emergency responder PPE use during this type of incident.

Codability of industry and occupation information from cancer registry records: Differences by patient demographics, casefinding source, payor, and cancer type.

INTRODUCTION: Industry and occupation (I&O) information collected by cancer registries is useful for assessing associations among jobs and malignancies. However, systematic differences in I&O availability can bias findings. METHODS: Codability by patient demographics, payor, identifying (casefinding) source, and cancer site was assessed using I&O text from first primaries diagnosed 2011-2012 and reported to California Cancer Registry. I&O were coded to a U.S. Census code or classified as blank/inadequate/unknown, retired, or not working for pay. RESULTS: Industry was codable for 37% of cases; 50% had "unknown" and 9% "retired" instead of usual industry. Cases initially reported by hospitals, covered by preferred providers, or with known occupational etiology had highest codable industry; cases from private pathology laboratories, with Medicaid, or diagnosed in outpatient settings had least. Occupation results were similar. CONCLUSIONS: Recording usual I&O for retirees and improving linkages for reporting entities without patient access would improve I&O codability and research validity.

Cardiovascular conditions, hearing difficulty, and occupational noise exposure within US industries and occupations.

BACKGROUND: The purpose of this study was to estimate the prevalence of occupational noise exposure, hearing difficulty and cardiovascular conditions within US industries and occupations, and to examine any associations of these outcomes with occupational noise exposure. METHODS: National Health Interview Survey data from 2014 were examined. Weighted prevalence and adjusted prevalence ratios of self-reported hearing difficulty, hypertension, elevated cholesterol, and coronary heart disease or stroke were estimated by level of occupational noise exposure, industry, and occupation. RESULTS: Twenty-five percent of current workers had a history of occupational noise exposure (14% exposed in the last year), 12% had hearing difficulty, 24% had hypertension, 28% had elevated cholesterol; 58%, 14%, and 9% of these cases can be attributed to occupational noise exposure, respectively. CONCLUSIONS: Hypertension, elevated cholesterol, and hearing difficulty are more prevalent among noise-exposed workers. Reducing workplace noise levels is critical. Workplace-based health and wellness programs should also be considered.

Acute Illnesses and Injuries Related to Total Release Foggers - 10 States, 2007-2015.

Total release foggers (TRFs) (also known as "bug bombs") are pesticide products often used indoors to kill insects. After an earlier report found that TRFs pose a risk for acute illness (1), the Environmental Protection Agency required improved labels on TRFs manufactured after September 2012 (2). To examine the early impact of relabeling, the magnitude and characteristics of acute TRF-related illness were evaluated for the period 2007-2015. A total of 3,222 TRF-related illnesses were identified in 10 participating states, based on three data sources: Sentinel Event Notification System for Occupational Risk-Pesticides (SENSOR) programs, the California Department of Pesticide Regulation (CDPR) program, and poison control centers (PCCs) in Florida, Texas, and Washington. No statistically significant decline in the overall TRF-illness incidence rate was found. Failure to vacate treated premises during application was the most commonly reported cause of exposure. To reduce TRF-related illness, integrated pest management strategies (3) need to be adopted, as well as better communication about the hazards and proper uses of TRFs. Redesigning TRFs to prevent sudden, unexpected activation might also be useful.

Prevalence of Hearing Loss Among Noise-Exposed Workers Within the Health Care and Social Assistance Sector, 2003 to 2012.

OBJECTIVE: The purpose was to estimate the prevalence of hearing loss for noise-exposed U.S. workers within the Health Care and Social Assistance (HSA) sector. METHODS: Audiograms for 1.4 million workers (8702 within HSA) from 2003 to 2012 were examined. Prevalences and adjusted risks for hearing loss as compared with a reference industry were estimated for the HSA sector and all industries combined. RESULTS: While the overall HSA sector prevalence for hearing loss was 19%, the prevalences in the Medical Laboratories subsector and the Offices of All Other Miscellaneous Health Practitioners subsector were 31% and 24%, respectively. The Child Day Care Services subsector had a 52% higher risk than the reference industry. CONCLUSION: High-risk industries for hearing loss exist within the HSA sector. Further work is needed to identify the sources of noise exposure and protect worker hearing.

Prevalence of hearing loss among noise-exposed workers within the agriculture, forestry, fishing, and hunting sector, 2003-2012.

BACKGROUND: The purpose of this study was to estimate the prevalence of hearing loss among noise-exposed US workers within the Agriculture, Forestry, Fishing, and Hunting (AFFH) sector. METHODS: Audiograms for 1.4 million workers (17 299 within AFFH) from 2003 to 2012 were examined. Prevalence, and the adjusted risk for hearing loss as compared with the reference industry (Couriers and Messengers), were estimated. RESULTS: The overall AFFH sector prevalence was 15% compared to 19% for all industries combined, but many of the AFFH sub-sectors exceeded the overall prevalence. Forestry sub-sector prevalences were highest with Forest Nurseries and Gathering of Forest Products at 36% and Timber Tract Operations at 22%. The Aquaculture sub-sector had the highest adjusted risk of all AFFH sub-sectors (PR = 1.70; CI = 1.42-2.04). CONCLUSIONS: High risk industries within the AFFH sector need continued hearing conservation efforts. Barriers to hearing loss prevention and early detection of hearing loss need to be recognized and addressed.

Acute Pesticide-Related Illness Among Farmworkers: Barriers to Reporting to Public Health Authorities.

Farmworkers are at high risk of acute occupational pesticide-related illness (AOPI) and AOPI surveillance is vital to preventing these illnesses. Data on such illnesses are collected and analyzed to identify high-risk groups, high-risk pesticides, and root causes. Interventions to address these risks and root causes include farmworker outreach, education, and regulation. Unfortunately, it is well known that AOPI is underreported, meaning that the true burden of this condition remains unknown. This article reviews the barriers to reporting of farmworker AOPI to public health authorities and provides some practical solutions. Information is presented using the social-ecological model spheres of influence. Factors that contribute to farmworker AOPI underreporting include fear of job loss or deportation, limited English proficiency (LEP), limited access to health care, lack of clinician recognition of AOPI, farmworker ineligibility for workers' compensation (WC) benefits in many states, insufficient resources to conduct AOPI surveillance, and constraints in coordinating AOPI investigations across state agencies. Solutions to address these barriers include: emphasizing that employers encourage farmworkers to report safety concerns; raising farmworker awareness of federally qualified health centers (FQHCs) and increasing the availability of these clinics; improving environmental toxicology training to health-care students and professionals; encouraging government agencies to investigate pesticide complaints and provide easy-to-read reports of investigation findings; fostering public health reporting from electronic medical records, poison control centers (PCCs), and WC; expanding and strengthening AOPI state-based surveillance programs; and developing interagency agreements to outline the roles and responsibilities of each state agency involved with pesticide safety.

Summary of Notifiable Noninfectious Conditions and Disease Outbreaks: Surveillance Data Published Between April 1, 2016 and January 31, 2017 - United States.

The Summary of Notifiable Noninfectious Conditions and Disease Outbreaks: Surveillance Data Published Between April 1, 2016 and January 31, 2017 - United States, herein referred to as the Summary (Noninfectious), contains official statistics for nationally notifiable noninfectious conditions and disease outbreaks. This Summary (Noninfectious) is being published in the same volume of MMWR as the annual Summary of Notifiable Infectious Diseases and Conditions (1). Data on notifiable noninfectious conditions and disease outbreaks from prior years have been published previously (2,3).

Job Characteristics Associated With Self-Rated Fair or Poor Health Among U.S. Workers.

INTRODUCTION: Approximately 60% of the U.S. adult population is employed. Many aspects of a person's job may influence health, but it is unclear which job characteristics are most strongly associated with health at a population level. The purpose of this study was to identify important associations between job characteristics and workers' self-rated health in a nationally representative survey of U.S. workers. METHODS: Data from the 2010 National Health Interview Survey were used to calculate weighted prevalence rates for self-reported fair/poor health for five categories of job characteristics: occupation; pay/benefits (economic); work organization; chemical/environmental hazards; and psychosocial factors. Backward elimination methods were used to build a regression model for self-reported health with the significant job characteristics, adjusting for sociodemographic variables and health behaviors. Data were collected in 2010 and analyzed in 2012-2016. RESULTS: After adjusting for covariates, workers were more likely to have fair/poor health if they were employed in business operations occupations (e.g., buyers, human resources workers, event planners, marketing specialists; adjusted prevalence ratio [APR]=1.85, 95% CI=1.19, 2.88); had no paid sick leave (APR=1.35, 95% CI=1.11, 1.63); worried about becoming unemployed (APR=1.43, 95% CI=1.22, 1.69); had difficulty combining work and family (APR=1.23, 95% CI=1.01, 1.49); or had been bullied/threatened on the job (APR=1.82, 95% CI=1.44, 2.29). CONCLUSIONS: Occupation, lack of paid sick leave, and multiple psychosocial factors were associated with fair/poor health among U.S. workers at the population level in 2010. Public health professionals and employers should consider these factors when developing interventions to improve worker health.