The wildland firefighter exposure and health effect (WFFEHE) study: cohort characteristics and health behavior changes in context.

OBJECTIVES: Work is an under-recognized social determinant of health. There is limited research describing US wildland firefighter (WFF) workforce demographics or how to work associates with WFF health behaviors. In this study researchers characterized a WFF cohort and tested hypotheses that WFFs used tobacco, alcohol, and sugar-sweetened beverages (SSBs) differently over the course of the fire season and that different fire crews may exhibit different behavior patterns. METHODS: Researchers collected data in the field with 6 WFF crews during 2 consecutive fire seasons (2018 and 2019). WFF crews completed questionnaires before and after each season. WFFs with an initial preseason questionnaire and at least 1 follow-up questionnaire were included (n = 138). Descriptive statistics summarized WFFs' baseline demographic, employment, and health characteristics. Linear mixed models were used to test for changes in WFFs' substance use over time and assess crew-level differences. A meta-analysis of WFF longitudinal studies' population characteristics was attempted to contextualize baseline findings. RESULTS: WFFs were predominately male, less than 35 yr of age, non-Hispanic White, and had healthy weight. Smokeless tobacco use and binge drinking were prevalent in this cohort (52% and 78%, respectively, among respondents). Longitudinal analyses revealed that during the fire season WFFs' use of tobacco and SSBs increased and the number of days they consumed alcohol decreased. Crew-level associations varied by substance. The meta-analysis was not completed due to cross-study heterogeneity and inconsistent reporting. DISCUSSION: WFF agencies can promote evidence-based substance use prevention and management programs and modify working conditions that may influence WFF stress or substance use.

Suicide Rates by Industry and Occupation - National Vital Statistics System, United States, 2021.

The suicide rate among the U.S. working-age population has increased approximately 33% during the last 2 decades. To guide suicide prevention strategies, CDC analyzed suicide deaths by industry and occupation in 49 states, using data from the 2021 National Vital Statistics System. Industry (the business activity of a person's employer or, if self-employed, their own business) and occupation (a person's job or the type of work they do) are distinct ways to categorize employment. The overall suicide rates by sex in the civilian noninstitutionalized working population were 32.0 per 100,000 among males and 8.0 per 100,000 among females. Major industry groups with the highest suicide rates included Mining (males = 72.0); Construction (males = 56.0; females = 10.4); Other Services (e.g., automotive repair; males = 50.6; females = 10.4); Arts, Entertainment, and Recreation (males = 47.9; females = 15.0); and Agriculture, Forestry, Fishing, and Hunting (males = 47.9). Major occupation groups with the highest suicide rates included Construction and Extraction (males = 65.6; females = 25.3); Farming, Fishing, and Forestry (e.g., agricultural workers; males = 49.9); Personal Care and Service (males = 47.1; females = 15.9); Installation, Maintenance, and Repair (males = 46.0; females = 26.6); and Arts, Design, Entertainment, Sports, and Media (males = 44.5; females = 14.1). By integrating recommended programs, practices, and training into existing policies, workplaces can be important settings for suicide prevention. CDC provides evidence-based suicide prevention strategies in its Suicide Prevention Resource for Action and Critical Steps Your Workplace Can Take Today to Prevent Suicide, NIOSH Science Blog.

Fatalities Involving Substance Use Among US Oil and Gas Extraction Workers Identified Through an Industry Specific Surveillance System (2014-2019).

OBJECTIVE: Characteristics of oil and gas extraction (OGE) work, including long hours, shiftwork, fatigue, physically demanding work, and job insecurity are risk factors for substance use among workers. Limited information exists examining worker fatalities involving substance use among OGE workers. METHODS: The National Institute for Occupational Safety and Health's Fatalities in Oil and Gas Extraction database was screened for fatalities involving substance use from 2014 through 2019. RESULTS: Twenty-six worker deaths were identified as involving substance use. Methamphetamine or amphetamine was the most common substances (61.5%) identified. Other contributing factors were lack of seatbelt use (85.7%), working in high temperatures (19.2%), and workers' first day with the company (11.5%). CONCLUSIONS: Employer recommendations to mitigate substance use-related risks in OGE workers include training, medical screening, drug testing, and workplace supported recovery programs.

Working Alone and/or in Remote Locations: Opportunities to Prevent the Risk of Fatality From Cardiovascular Events in Oil and Gas Extraction Workers.

OBJECTIVE: The aim of the study is to explore personal and work factors related to fatal cardiac events among oil and gas extraction (OGE) workers. METHODS: The National Institute for Occupational Safety and Health Fatalities in Oil and Gas Extraction database was reviewed to identify fatal cardiac events among OGE workers from 2014 through 2019. A case series design was used to review case files, provide descriptive statistics, and summarize the findings. RESULTS: There were 75 fatalities identified, including 55 (73%) with sufficient information for review. Of the 55 workers, 18 (33%) worked alone. Thirty-six fatal cardiac events (66%) were unwitnessed by a coworker. Toxicology findings suggested some possible exposures to hydrogen sulfide or hydrocarbon gases or vapors. Missing data were common. CONCLUSIONS: This study identified the need for cardiovascular disease prevention and treatment, emergency preparedness, lone worker programs, medical screening, and enhanced exposure control in the OGE industry.

Association of falls and fear of falling with objectively-measured driving habits among older drivers: LongROAD study.

OBJECTIVE: Falls in older adults are associated with increased motor vehicle crash risk, possibly mediated by driving behavior. We examined the relationship of falls and fear of falling (FOF) with subsequent objectively measured driving habits. METHODS: This multi-site, prospective cohort study enrolled 2990 active drivers aged 65-79 (53% female). At enrollment, we assessed falls in the past year and FOF (Short Falls Efficacy Scale-International). Driving outcomes included exposure, avoidance of difficult conditions, and unsafe driving during one-year follow-up, using in-vehicle Global Positioning System devices. RESULTS: Past-year falls were associated with more hard braking events (HBE). High FOF was associated with driving fewer days, miles, and trips, driving nearer home and more HBE. Differences were attenuated and not significant after accounting for health, function, medications and sociodemographics. DISCUSSION: Differences in objectively measured driving habits according to past-year fall history and FOF were largely accounted for by differences in health and medications. Rather than directly affecting driving, falls and FOF may serve as markers for crash risk and reduced community mobility due to age-related changes and poor health.

Self-reported exposure to hazards and mitigation strategies among oil and gas extraction workers in three U.S. states.

Numerous health and safety hazards exist at U.S. onshore oil and gas extraction worksites. Higher fatal injury rates have been reported among drilling and servicing companies, which are more likely to employ workers in construction and extraction occupations, compared to operators that employ more workers in management and office and administrative support roles. However, there is little information describing the extent to which workers encounter these hazards, are provided hazard mitigation strategies by their employers, or use personal protective equipment (PPE). A cross-sectional survey of 472 U.S. oil and gas extraction workers was conducted to identify and characterize factors related to on-the-job fatalities, injuries, and illnesses and determine workers' health and safety concerns. Workers were employed by servicing companies (271/472, 57.4%), drilling contractors (106/472, 22.5%), and operators (95/472, 20.1%). The likelihood of contact with hazardous substances varied by substance and company type. Drilling and servicing employees had significantly higher odds of self-reported contact with pipe dope (ORdrilling = 10.07, 95% CI: 1.74-63.64; ORservicing = 5.95, 95% CI: 2.18-18.34), diesel exhaust (ORdrilling = 2.28, 95% CI: 1.15-5.05; ORservicing = 4.93, 95% CI: 2.73-10.32), and drilling mud (ORdrilling = 24.36, 95% CI: 4.45-144.69; ORservicing = 3.48, 95% CI: 1.24-12.20), compared to operators. Safety policies, programs, and trainings were commonly reported by workers, although substance-specific training (e.g., respirable crystalline silica hazards) was less common. Differences in self-reported employer PPE requirements and worker use of PPE when needed or required for safety highlight a need for novel strategies to improve the use of PPE. Overall, this study highlights differences in work conditions by company type and uncovers gaps in employer administrative controls and PPE use.

A process to deduplicate individuals for regional chronic disease prevalence estimates using a distributed data network of electronic health records.

Introduction: Learning health systems can help estimate chronic disease prevalence through distributed data networks (DDNs). Concerns remain about bias introduced to DDN prevalence estimates when individuals seeking care across systems are counted multiple times. This paper describes a process to deduplicate individuals for DDN prevalence estimates. Methods: We operationalized a two-step deduplication process, leveraging health information exchange (HIE)-assigned network identifiers, within the Colorado Health Observation Regional Data Service (CHORDS) DDN. We generated prevalence estimates for type 1 and type 2 diabetes among pediatric patients (0-17 years) with at least one 2017 encounter in one of two geographically-proximate DDN partners. We assessed the extent of cross-system duplication and its effect on prevalence estimates. Results: We identified 218 437 unique pediatric patients seen across systems during 2017, including 7628 (3.5%) seen in both. We found no measurable difference in prevalence after deduplication. The number of cases we identified differed slightly by data reconciliation strategy. Concordance of linked patients' demographic attributes varied by attribute. Conclusions: We implemented an HIE-dependent, extensible process that deduplicates individuals for less biased prevalence estimates in a DDN. Our null pilot findings have limited generalizability. Overlap was small and likely insufficient to influence prevalence estimates. Other factors, including the number and size of partners, the matching algorithm, and the electronic phenotype may influence the degree of deduplication bias. Additional use cases may help improve understanding of duplication bias and reveal other principles and insights. This study informed how DDNs could support learning health systems' response to public health challenges and improve regional health.

A Governance Framework to Integrate Longitudinal Clinical and Community Data in a Distributed Data Network: The Childhood Obesity Data Initiative.

CONTEXT: Integrating longitudinal data from community-based organizations (eg, physical activity programs) with electronic health record information can improve capacity for childhood obesity research. OBJECTIVE: A governance framework that protects individual privacy, accommodates organizational data stewardship requirements, and complies with laws and regulations was developed and implemented to support the harmonization of data from disparate clinical and community information systems. PARTICIPANTS AND SETTING: Through the Childhood Obesity Data Initiative (CODI), 5 Colorado-based organizations collaborated to expand an existing distributed health data network (DHDN) to include community-generated data and assemble longitudinal patient records for research. DESIGN: A governance work group expanded an existing DHDN governance infrastructure with CODI-specific data use and exchange policies and procedures that were codified in a governance plan and a delegated-authority, multiparty, reciprocal agreement. RESULTS: A CODI governance work group met from January 2019 to March 2020 to conceive an approach, develop documentation, and coordinate activities. Governance requirements were synthesized from the CODI use case, and a customized governance approach was constructed to address governance gaps in record linkage, a procedure to request data, and harmonizing community and clinical data. A Master Sharing and Use Agreement (MSUA) and Memorandum of Understanding were drafted and executed to support creation of linked longitudinal records of clinical- and community-derived childhood obesity data. Furthermore, a multiparty infrastructure protocol was approved by the local institutional review board (IRB) to expedite future CODI research by simplifying IRB research applications. CONCLUSION: CODI implemented a clinical-community governance strategy that built trust between organizations and allowed efficient data exchange within a DHDN. A thorough discovery process allowed CODI stakeholders to assess governance capacity and reveal regulatory and organizational obstacles so that the governance infrastructure could effectively leverage existing knowledge and address challenges. The MSUA and complementary governance documents can inform similar efforts.

The Childhood Obesity Data Initiative: A Case Study in Implementing Clinical-Community Infrastructure Enhancements to Support Health Services Research and Public Health.

CONTEXT: We describe a participatory framework that enhanced and implemented innovative changes to an existing distributed health data network (DHDN) infrastructure to support linkage across sectors and systems. Our processes and lessons learned provide a potential framework for other multidisciplinary infrastructure development projects that engage in a participatory decision-making process. PROGRAM: The Childhood Obesity Data Initiative (CODI) provides a potential framework for local and national stakeholders with public health, clinical, health services research, community intervention, and information technology expertise to collaboratively develop a DHDN infrastructure that enhances data capacity for patient-centered outcomes research and public health surveillance. CODI utilizes a participatory approach to guide decision making among clinical and community partners. IMPLEMENTATION: CODI's multidisciplinary group of public health and clinical scientists and information technology experts collectively defined key components of CODI's infrastructure and selected and enhanced existing tools and data models. We conducted a pilot implementation with 3 health care systems and 2 community partners in the greater Denver Metro Area during 2018-2020. EVALUATION: We developed an evaluation plan based primarily on the Good Evaluation Practice in Health Informatics guideline. An independent third party implemented the evaluation plan for the CODI development phase by conducting interviews to identify lessons learned from the participatory decision-making processes. DISCUSSION: We demonstrate the feasibility of rapid innovation based upon an iterative and collaborative process and existing infrastructure. Collaborative engagement of stakeholders early and iteratively was critical to ensure a common understanding of the research and project objectives, current state of technological capacity, intended use, and the desired future state of CODI architecture. Integration of community partners' data with clinical data may require the use of a trusted third party's infrastructure. Lessons learned from our process may help others develop or improve similar DHDNs.

Associations Between Socioeconomic Context and Congenital Heart Disease Related Outcomes in Adolescents and Adults.

Little is known about the relation between socioeconomic factors and health outcomes in adults and adolescents with congenital heart defects (CHD). Population-level data from the Colorado CHD surveillance system from 2011 to 2013 was used to examine the association between area deprivation and outcomes including hospitalizations, emergency department visits, cardiac procedures, all-cause and cardiac-related mortality, and major adverse cardiac events. Socioeconomic context was measured by the Area Deprivation Index at census tract level. Missing race/ethnicity was imputed using the Bayesian Improved Surname Geocoding algorithm. Generalized linear models were utilized to examine health disparities across deprivation quintiles after adjusting for insurance type, race/ethnicity, age, gender, urbanicity, and CHD severity in 5,748 patients. Cases residing in the most deprived quintile had 51% higher odds of inpatient admission, 74% higher odds of emergency department visit, 41% higher odds of cardiac surgeries, and 45% higher odds of major adverse cardiac events compared with cases in the least deprived quintile. Further, rates of hospitalizations, emergency department admissions, and cardiac surgeries were elevated in the most deprived compared with the least deprived quintile. Mortality was not significantly different across quintiles. In conclusion, findings suggest significant health equity issues for adolescent and adults with CHD based on area-based deprivation.

Evaluating Population Coverage in a Regional Distributed Data Network: Implications for Electronic Health Record-Based Public Health Surveillance.

OBJECTIVE: Electronic health records (EHRs) hold promise as a public health surveillance tool, but questions remain about how EHR patients compare with populations in health and demographic surveys. We compared population characteristics from a regional distributed data network (DDN), which securely and confidentially aggregates EHR data from multiple health care organizations in the same geographic region, with population characteristics from health and demographic surveys. METHODS: Ten health care organizations participating in a Colorado DDN contributed data for coverage estimation. We aggregated demographic and geographic data from 2017 for patients aged ≥18 residing in 7 counties. We used a cross-sectional design to compare DDN population size, by county, with the following survey-estimated populations: the county population, estimated by the American Community Survey (ACS); residents seeking any health care, estimated by the Colorado Health Access Survey; and residents seeking routine (eg, primary) health care, estimated by the Behavioral Risk Factor Surveillance System. We also compared data on the DDN and survey populations by sex, age group, race/ethnicity, and poverty level to assess surveillance system representativeness. RESULTS: The DDN population included 609 840 people in 7 counties, corresponding to 25% coverage of the general adult population. Population coverage ranged from 15% to 35% across counties. Demographic distributions generated by DDN and surveys were similar for many groups. Overall, the DDN and surveys assessing care-seeking populations had a higher proportion of women and older adults than the ACS population. The DDN included higher proportions of Hispanic people and people living in high-poverty neighborhoods compared with the surveys. CONCLUSION: The DDN population is not a random sample of the regional adult population; it is influenced by health care use patterns and organizations participating in the DDN. Strengths and limitations of DDNs complement those of survey-based approaches. The regional DDN is a promising public health surveillance tool.

Same-Day HIV Pre-Exposure Prophylaxis (PrEP) Initiation During Drop-in Sexually Transmitted Diseases Clinic Appointments Is a Highly Acceptable, Feasible, and Safe Model that Engages Individuals at Risk for HIV into PrEP Care.

OBJECTIVE: Strategies to increase pre-exposure prophylaxis (PrEP) uptake are needed. We hypothesized that same-day PrEP initiation in a sexually transmitted diseases (STD) clinic would be acceptable, feasible, and safe, and that individuals would engage in ongoing PrEP care. METHOD: Individuals aged ≥ 18 years were evaluated for PrEP. Exclusion criteria were HIV, history of renal dysfunction or chronic hepatitis B infection, pregnancy, indications for HIV post-exposure prophylaxis, or positive screen for acute HIV symptoms. One hundred individuals received a free 30-day PrEP starter pack and met with a patient navigator to establish ongoing care. Bivariate analysis and multivariable logistic regression were used to compare individuals who did and did not attend at least 1 PrEP follow-up appointment within 180 days of enrollment. Client satisfaction surveys were given 3 months after enrollment. RESULTS: The majority (78%) of participants completed at least 1 PrEP follow-up appointment, and 57% attended at least 2 follow-up appointments. After adjusting for race and ethnicity, age, health insurance status, and annual income, only income was associated with follow-up appointment attendance. Each additional $10,000 increase in income was associated with a 1.7-fold increase in the odds of attending a PrEP follow-up appointment (95% confidence interval, 1.07-2.66, P = .02). The majority (54%) of individuals completed the satisfaction survey and all respondents liked the option of same-day PrEP initiation. CONCLUSIONS: Our study suggests STD clinic-based, same-day PrEP initiation is acceptable, feasible, safe, and links a high proportion of individuals into ongoing PrEP care. Additional resources may be needed to support low-income individuals' retention in care.

The Associations Between Falls, Fall Injuries, and Labor Market Outcomes Among U.S. Workers 65 Years and Older.

OBJECTIVE: The aim of this study was to examine whether falls are associated with the subsequent ability to work among workers aged 65 years and older. METHODS: This longitudinal cohort study followed older workers enrolled in the Health and Retirement Study. Outcomes included time to health-related work limitation and to labor force exit. RESULTS: After adjustment, multiple falls with or without a medically treated injury were associated with time to limitation [hazard ratio (HR) = 1.77, 95% confidence interval (95% CI): 1.30 to 2.40; HR = 1.48, 95% CI: 1.26 to 1.73, respectively]. Adjustment mitigated a crude relationship between falls and time to exit. Significant interactions suggest that the relationship between falls and labor force exit depends on age, race, and job demands. CONCLUSION: Falls, both noninjurious and injurious, are associated with subsequent health-related work limitation among workers aged 65 years and older. Fall prevention activities would benefit workers who want or need to keep working past age 65.

Early labor force exit subsequent to permanently impairing occupational injury or illness among workers 50-64 years of age.

BACKGROUND: Severity of workplace injury tends to increase with age. Whether older workers who experience a workplace injury or illness exit the labor force sooner than comparable peers is not established. METHODS: A case-cohort study design and complementary log-log model were used to identify factors associated with average time to early substantial labor force exit among workers' compensation claimants 50-64 years of age with permanent impairment from an occupational injury or illness. Analysis was based on Ontario's workers' compensation claimant data from 1998 to 2006 linked with Canadian tax files. RESULTS: Workers with permanent impairment left the labor force earlier, on average, than peers without claims. Early retirement was associated with older age in the injury/illness year, greater impairment, lower pre-claim income, physically demanding jobs, and soft-tissue injuries. CONCLUSIONS: Policies aiming to extend older adults' working lives should account for the potentially disparate impacts on older workers of occupational injury and illness.

Same-level fall injuries in US workplaces by age group, gender, and industry.

BACKGROUND: As the workforce ages, occupational injuries from falls on the same level will increase. Some industries may be more affected than others. METHODS: We conducted a cross-sectional study using data from the Bureau of Labor Statistics to estimate same-level fall injury incidence rates by age group, gender, and industry for four sectors: 1) healthcare and social assistance; 2) manufacturing; 3) retail; and 4) transportation and warehousing. We calculated rate ratios and rate differences by age group and gender. RESULTS: Same-level fall injury incidence rates increase with age in all four sectors. However, patterns of rate ratios and rate differences vary by age group, gender, and industry. Younger workers, men, and manufacturing workers generally have lower rates. CONCLUSIONS: Variation in incidence rates suggests there are unrealized opportunities to prevent same-level fall injuries. Interventions should be evaluated for their effectiveness at reducing injuries, avoiding gender- or age-discrimination and improving work ability.

Associations Between Falls and Driving Outcomes in Older Adults: Systematic Review and Meta-Analysis.

OBJECTIVES: To examine associations between falls and subsequent motor vehicle crashes (MVCs), crash-related injuries, driving performance, and driving behavior. DESIGN: Systematic review and metaanalysis. PARTICIPANTS: Observational studies including drivers aged 55 and older or with a mean age of 65 and older. MEASUREMENTS: Two authors independently extracted study and participant characteristics, exposures, and outcomes and assessed risk of bias. Pooled risk estimates for MVCs and MVC-related injuries were calculated using random-effects models. Other results were synthesized narratively. RESULTS: From 3,286 potentially eligible records, 15 studies (N = 27-17,349 subjects) met inclusion criteria. Risk of bias was low to moderate, except for cross-sectional studies (n = 3), which all had a high potential for bias. A fall history was associated with a significantly greater risk of subsequent MVC (summary risk estimate = 1.40, 95% confidence interval (CI) = 1.20-1.63; I2  = 28%, N = 5 studies). One study found a significantly greater risk of MVC-related hospitalizations and deaths after a fall (hazard ratio = 3.12, 95% CI = 1.71-5.69). Evidence was inconclusive regarding an association between falls and driving cessation and showed no association between falls and driving performance or behavior. CONCLUSION: Falls in older adults appear to be a risk marker for subsequent MVCs and MVC-related injury. Given the nature of the evidence, which is limited to observational studies, the identified associations may also result at least partly from confounding or bias. Further research is needed to clarify the mechanisms linking falls to crash risk and to develop effective interventions to ensure driving safety in older adults with a history of falls.

Occupational physical activity assessment for chronic disease prevention and management: A review of methods for both occupational health practitioners and researchers.

Occupational physical activity (OPA) is an occupational exposure that impacts worker health. OPA is amenable to measurement and modification through the hierarchy of controls. Occupational exposure scientists have roles in addressing inadequate physical activity, as well as excessive or harmful physical activity. Occupational health researchers can contribute to the development of novel OPA exposure assessment techniques and to epidemiologic studies examining the health impacts of physical activity at work. Occupational health practitioners stand to benefit from understanding the strengths and limitations of physical activity measurement approaches, such as accelerometers in smartphones, which are already ubiquitous in many workplaces and in some worksite health programs. This comprehensive review of the literature provides an overview of physical activity monitoring for occupational exposure scientists. This article summarizes data on the public health implications of physical activity at work, highlighting complex relationships with common chronic diseases. This article includes descriptions of several techniques that have been used to measure physical activity at work and elsewhere, focusing in detail on pedometers, accelerometers, and Global Positioning System technology. Additional subjective and objective measurement strategies are described as well.