Assessing the role of social determinants of health in health disparities: The need for data on work.

BACKGROUND: Work is a key social determinant of health. Without the collection of work-related information in public health data systems, the role of social determinants in creating and reinforcing health disparities cannot be fully assessed. METHODS: The Centers for Disease Control and Prevention (CDC) maintains or supports a number of public health surveillance and health monitoring systems, including surveys, case-based disease and exposure systems, vital status records, and administrative data systems. We evaluated a convenience sample of these systems for inclusion of information in three work-related domains: employment status, industry and occupation, and working conditions. RESULTS: While 12 of 39 data systems were identified as collecting work-related data, this information was often minimal (e.g., only employment status), restricted to a subset of respondents, or only gathered periodically. Information on working conditions was particularly sparse. CONCLUSION: Historically, the limited and inconsistent collection of work-related information in public health data systems has hindered understanding of the role work plays in health disparities. Current CDC data modernization efforts present opportunities to enhance the identification and mitigation of health disparities by prioritizing inclusion of an expanded set of work-related data elements.

Environmental exposures and pulmonary function among adult residents of rural Appalachian Kentucky.

BACKGROUND: Estimated residential exposures of adults to roadway density and several metrics of resource extraction, including coal mining and oil and gas drilling, were hypothesized to contribute to the prevalence of respiratory disease in rural Appalachia. OBJECTIVE: Determine how small-area geographic variation in residential environmental exposures impacts measures of pulmonary function among adults in a community-based study. METHODS: We examined associations between residential environmental respiratory exposures and pulmonary function among 827 adult participants of the "The Mountain Air Project", a community-based, cross-sectional study in Southeastern Kentucky during 2016-2018. Exposures characterized the density of roadways, oil/gas wells, or current/past surface and underground coal mining at the level of 14-digit hydrologic unit code (HUC), or valley "hollow" where participants resided. Each participant completed an in-person interview to obtain extensive background data on risk factors, health history, and occupational and environmental exposures, as well as a spirometry test administered by experienced study staff at their place of residence. Multivariable linear regression was used to model the adjusted association between each environmental exposure and percent predicted forced expiratory volume in one second (FEV1PP) and forced vital capacity (FVCPP). RESULTS: Adjusted regression models indicate persons living in HUCs with the highest level of roadway density experienced a reduction in both FEV1PP (-4.3: 95% CI: -7.44 -1.15;) and FVCPP (-3.8: 95% CI: -6.38, -1.21) versus persons in HUCs with the lowest roadway density. No associations were detected between the metrics associated with mining and oil and gas operations and individual pulmonary function. IMPACT STATEMENT: Our work demonstrates the potential adverse impact of roadway-related exposures on the respiratory health of rural Appalachia residents. We employed a novel method of small-area exposure classification based on the hydrologic unit code (HUC), representing potential exposure levels per hollow occurring  in proximity to the residence, and controlled for individual-level risk factors for reduced respiratory health. We highlight an overlooked yet ubiquitous source of residential exposure from motor vehicles that may contribute to the regionally high prevalence of respiratory disease in rural Appalachia.

Farmer Suicides Among States Reporting Violent Deaths, 2003 - 2017.

Research suggests that farmer suicide rates are at least two-fold higher than the general population. In estimating rates, prior research considered suicide events among farmers together with farmworkers, fishing, and forestry occupations and included non-farming populations in the defined at-risk populations (i.e., denominators). In this study, we sought to define and differentiate farmer suicide decedents from other agricultural occupations, estimate U.S. farmer suicide rates, and evaluate rate time trends. Farmer suicide decedents were ascertained from the 36 states in the National Violent Death Reporting System (NVDRS) from 2003-2017 using NVDRS occupation data. Farmers were defined as persons responsible for day-to-day farm decisions and operations. An expert panel was convened to classify farmer occupations. Rates were calculated using Census of Agriculture-identified farmers as the rate denominator, and time trends were evaluated using regression. Due to a low number of female decedents, female farmer suicide rates were not estimated. We identified1,575 male farmer suicide decedents and 77 female farmer decedents from the NVDRS during the study period. Aggregated age-specific male farmer suicide rates were highest among farmers ages 65 years and older (22.0/100,000). Estimated suicide rates for male farmers were highest during 2003 (31.8/100,000) and lowest during 2005 (19.2/100,000). Trend analysis revealed a statistically significant 2.4% annual percent change (APC) in rates over the 15-year study period. Suicide rates among male farmers showed evidence of an increase from 2003-2017. Farmer suicide rates parallel the rates of the U.S. population; thus, farmer suicide remains a public health concern.

Maternal occupational exposure to selected organic and chlorinated solvents and delivery of small-for-gestational age or preterm infants.

BACKGROUND: Potential reproductive effects of organic solvent exposure during pregnancy remain unclear. We investigated the association between maternal occupational exposure during pregnancy to six chlorinated solvents, three aromatic solvents, and Stoddard solvent, and delivery of preterm infants or those born small-for-gestational age (SGA). METHODS: In this case-control study of SGA and preterm birth (PTB) nested within the National Birth Defects Prevention Study (NBDPS) from 1997 to 2011, we analyzed data from 7504 singleton live births without major birth defects and their mothers. Self-reported information on jobs held in the periconceptional period was assessed for solvent exposure. Unconditional logistic regression was used to estimate the association between maternal occupational exposure (any, none) during early pregnancy to organic solvents and PTB and SGA. Linear regression was used to examine changes in mean birthweight potentially associated with maternal occupational solvent exposure. RESULTS: Maternal occupational exposure to any organic solvents overall was not associated with an increased odds of PTB (adjusted odds ratio [aOR] = 0.94; 95% confidence interval [CI] 0.67-1.33) or SGA (aOR = 0.93; 95% CI 0.65-1.34). Point estimates increased modestly for higher estimated exposure versus lower, but confidence intervals were wide and not statistically significant. Maternal exposure to solvents was not associated with a statistically significant change in term birthweight among infants. CONCLUSIONS: Occupational exposure to organic solvents at the frequency and intensity levels found in a population-based sample of pregnant workers was not associated with PTB or SGA; however, we cannot rule out any effects among pregnant workers with uncommonly high exposure to organic solvents.

Adult asthma associated with roadway density and housing in rural Appalachia: the Mountain Air Project (MAP).

BACKGROUND: Appalachian Kentucky is a rural area with a high prevalence of asthma among adults. The relative contribution of environmental exposures in the etiology of adult asthma in these populations has been understudied. OBJECTIVE: This manuscript describes the aims, study design, methods, and characteristics of participants for the Mountain Air Project (MAP), and focuses on associations between small area environmental exposures, including roadways and mining operations, and lifetime and current asthma in adults. METHODS: A cohort of residents, aged 21 and older, in two Kentucky counties, was enrolled in a community-based, cross-sectional study. Stratified cluster sampling was used to select small geographic areas denoted as 14-digit USGS hydrologic units (HUCs). Households were enumerated within selected HUCs. Community health workers collected in-person interviews. The proximity of nearby active and inactive coal mining operations, density of oil and gas operations, and density of roadways were characterized for all HUCs. Poisson regression analyses were used to estimate adjusted prevalence ratios. RESULTS: From 1,459 eligible households contacted, 1,190 individuals were recruited, and 972 persons completed the interviews. The prevalence of lifetime asthma was 22.8%; current asthma was 16.3%. Adjusting for covariates, roadway density was positively associated with current asthma in the second (aPR = 1.61; 95% CI 1.04-2.48) and third tertiles (aPR = 2.00; 95% CI 1.32-3.03). Increased risk of current asthma was associated with residence in public, multi-unit housing (aPR = 2.01; 95% CI 1.27-3.18) compared to a residence in a single-family home. There were no notable associations between proximity to coal mining and oil and gas operations and asthma prevalence. CONCLUSIONS: This study suggests that residents in rural areas with higher roadway density and those residing in public housing units may be at increased risk for current asthma after accounting for other known risk factors. Confirming the role of traffic-related particulates in producing high asthma risk among adults in this study contributes to the understanding of the multiple environmental exposures that influence respiratory health in the Appalachia region.

Perceptions of opioid and other illicit drug exposure reported among first responders in the southeast, 2017 to 2018.

BACKGROUND: Opioid use has risen dramatically in recent years, and its illegal use puts first responders at risk when intervening in overdoses. Synthetic opioids, like fentanyl with a potency 50 to 100 times greater than morphine, pose a great risk and accidental exposure via ingestion, inhalation, mucosal, or percutaneous routes, can potentially lead to fatal outcomes. Anecdotal media accounts in early 2017 of accidental occupational opioid exposure among first responders generated a national concern. METHODS: To identify first responders' recollections, beliefs, and concerns about possible occupational exposure to opioids and other drugs, researchers in Kentucky, Virginia, Mississippi, and Georgia administered an emailed, anonymous convenience sample survey. RESULTS: A total of 5955 surveys were analyzed with 15% of respondents reporting they believed they had been exposed to opioids, and of those, less than 1% reported experiencing health effects from perceived exposure. Over half (51%) of respondents reported being "very or somewhat concerned" about developing health effects from exposure to opioids. Half of respondents reported being unaware of Centers for Disease Control and Prevention (CDC)/National Institutes for Occupational Safety and Health (NIOSH) guidelines for preventing occupational-related opioid exposures. CONCLUSIONS: Only a small fraction of first responders believed they had experienced symptoms related to opioid exposure in overdose response calls, but half were concerned about potential exposures and half were unaware of the educational guidance on prevention available. The high level of concern regarding potential exposure warrants the need for the development and or enhancement of targeted educational training interventions and further dissemination of pre-existing training interventions to ensure first responders have the knowledge and understanding of occupational opioid exposures and minimize stress associated with the potential rare exposures.

Evidence of nickel and other trace elements and their relationship to clinical findings in acute Mesoamerican Nephropathy: A case-control analysis.

BACKGROUND: Although there are several hypothesized etiologies of Mesoamerican Nephropathy (MeN), evidence has not yet pointed to the underlying cause. Exposure to various trace elements can cause the clinical features observed in MeN. METHODS AND FINDINGS: We measured 15 trace elements, including heavy metals, in renal case-patients (n = 18) and healthy controls (n = 36) in a MeN high-risk region of Nicaragua. Toenails clippings from study participants were analyzed using inductively coupled plasma mass spectrometry. A case-control analysis was performed, and concentrations were also analyzed over participant characteristics and clinical parameters. Nickel (Ni) concentrations were significantly higher in toenails from cases (1.554 mg/kg [0.176-42.647]) than controls (0.208 mg/kg [0.055-51.235]; p<0.001). Ni concentrations correlated positively with serum creatinine levels (p = 0.001) and negatively with eGFR (p = 0.001). Greater Ni exposure was also associated with higher leukocyte (p = 0.001) and neutrophil (p = 0.003) counts, fewer lymphocytes (p = 0.003), and lower hemoglobin (p = 0.004) and hematocrit (p = 0.011). CONCLUSIONS: Low-dose, chronic environmental exposure to Ni is a possible health risk in this setting. Ni intoxication and resulting systemic and renal effects could explain the clinical signs observed during early MeN. This study provides compelling evidence for a role of Ni in the acute renal impairment observed in this MeN high-risk population. Additional work to assess exposure levels in a larger and heterogeneous population, identify environmental sources of Ni and exposure pathways, and evaluate the link between Ni and MeN pathogenesis are urgently needed.

Development of Job Exposure Matrices to Estimate Occupational Exposure to Solar and Artificial Ultraviolet Radiation.

OBJECTIVES: Job exposure matrices (JEMs) are important tools for estimating occupational exposures in study populations where only information on industry and occupation (I&O) are available. JEMs The objective of this work was to create JEMs for solar and artificial ultraviolet radiation (UVR) using a US standardized coding scheme. METHODS: Using U.S. Census Bureau industry and occupation codes, separate lists of I&O pairs were developed for solar and artificial UVR by a panel of Certified Industrial Hygienists who assigned exposure ratings to I&O pairs with potential exposure. Parameters for exposure included prevalence (P) and frequency (F) for solar UVR and P, F, and intensity (I) for artificial UVR. Prevalence, or percent of all workers employed in an I&O pair who were exposed, was categorically rated: 0 to <1, 1 to <20; 20 to <80, and ≥80. Frequency of exposure, defined by the number of hours per week workers were exposed, was categorically rated: 0 to <5, 5 to <20, 20 to <35, and ≥35 h per week. For artificial UVR only, intensity of exposure was assigned three ratings: low, low with rare excursions, and >low under normal conditions. Discrepant ratings were resolved via consensus. RESULTS: After excluding I&O pairs assigned P and F ratings of 0 (solar UVR) and P, F, and I ratings of 0 (artificial UVR) from the JEM, 9206 I&O pairs were rated for solar UVR and 2010 I&O pairs for artificial UVR. For solar UVR, 723 (7.9% of all rated pairs) had ratings in the highest category for P and F; this group included 45 occupations in varied industries. Construction and extraction occupations represented most of the occupations (n = 20; 44%), followed by farming, fishing, and forestry occupations (n = 6; 13%). For artificial UVR, 87 I&O pairs (4.3% of all rated pairs) had maximum ratings for P, F, and I; these comprised a single occupation (welding, soldering, and brazing workers) in diverse industries. CONCLUSIONS: JEMs for solar and artificial UVR were developed for a broad range of I&O pairs in the US population and are available for use by researchers conducting occupational epidemiological studies.

Editorial: Response to "ROPS Are Not Homemade".

We are writing in response to the editorial "ROPS Are Not Homemade" by W. E. Field, R. Tormoehlen, S. Ehlers, C. Cheng, A. Talbert, G. Deboy, D. Haberlin, and C. V. Schwab, which was published in the July 2019 issue of the Journal of Agricultural Safety and Health (Field et al., 2019). The editorial warns secondary school teachers and FFA advisors about the potential liability of fabricating and installing low-cost rollover protective structures (ROPS) as service learning projects for agricultural education students. The apparent intent of the editorial is to discourage teachers and advisors from carrying out such projects. We wish to present arguments as to why these are actually highly beneficial projects to undertake, and perhaps one of our best hopes for significantly reducing the number of tractor overturn injuries and fatalities by directly involving our nation's youth.

The CHARGE study: an assessment of parental occupational exposures and autism spectrum disorder.

OBJECTIVES: The aim of this study is to determine if parental occupational exposure to 16 agents is associated with autism spectrum disorder (ASD). METHODS: Demographic, health and parental occupational data were collected as part of the CHildhood Autism Risks from Genetics and Environment study. The workplace exposure assessment was conducted by two experienced industrial hygienists for the parents of 537 children with ASD and 414 typically developing (TD) children. For each job, frequency and intensity of 16 agents were assessed and both binary and semi-quantitative cumulative exposure variables were derived. Logistic regression models were used to calculate adjusted odds ratios (OR) and 95% confidence intervals (CI) to assess associations between parental occupational exposures 3 months pre-pregnancy until birth. RESULTS: The OR of ASD in the children of mothers exposed to any solvents was 1.5 times higher than the mothers of TD children (95% CI=1.01-2.23). Cumulative exposure indicated that the OR associated with a moderate level of solvent exposure in mothers was 1.85 (95% CI=1.09, 3.15) for children with ASD compared with TD children. No other exposures were associated with ASD in mothers, fathers or the parents combined. CONCLUSION: Maternal occupational exposure to solvents may increase the risk for ASD. These results are consistent with a growing body of evidence indicating that environmental and occupational exposures may be associated with ASD. Future research should consider specific types of solvents, larger samples and/or different study designs to evaluate other exposures for potential associations with ASD.

Laboratory comparison of new high flow rate respirable size-selective sampler.

A newly developed high flow rate respirable size-selective cyclone sampler (GK4.162-also known as the Respirable Air Sampling Cyclone Aluminum Large (RASCAL)) was calibrated to determine its optimum operating flow rate. The Health and Safety Laboratory in the United Kingdom and two laboratories from the National Institute for Occupational Safety and Health in the United States conducted experiments using two different methods: (1) polydisperse aerosol and time-of-flight direct reading instrument (Aerodynamic Particle Sizer (APS)) and (2) monodisperse aerosol and APS. The measured performance data for the cyclone was assessed against the international respirable convention using the bias map approach. Although the GK4.162 cyclone was tested using different aerosols and detection methods, the results from the three laboratories were generally similar. The recommended flow rate based on the agreement of results from the laboratories was 9.0 L/min.

Organic solvent exposure and depressive symptoms among licensed pesticide applicators in the Agricultural Health Study.

PURPOSE: Although organic solvents are often used in agricultural operations, neurotoxic effects of solvent exposure have not been extensively studied among farmers. The current analysis examined associations between questionnaire-based metrics of organic solvent exposure and depressive symptoms among farmers. METHODS: Results from 692 male Agricultural Health Study participants were analyzed. Solvent type and exposure duration were assessed by questionnaire. An "ever-use" variable and years of use categories were constructed for exposure to gasoline, paint/lacquer thinner, petroleum distillates, and any solvent. Depressive symptoms were ascertained with the Center for Epidemiologic Studies Depression Scale (CES-D); scores were analyzed separately as continuous (0-60) and dichotomous (<16 versus ≥16) variables. Multivariate linear and logistic regression models were used to estimate crude and adjusted associations between measures of solvent exposure and CES-D score. RESULTS: Forty-one percent of the sample reported some solvent exposure. The mean CES-D score was 6.5 (SD 6.4; median 5; range 0-44); 92% of the sample had a score below 16. After adjusting for covariates, statistically significant associations were observed between ever-use of any solvent, long duration of any solvent exposure, ever-use of gasoline, ever-use of petroleum distillates, and short duration of petroleum distillate exposure and continuous CES-D score (p < 0.05). Although nearly all associations were positive, fewer statistically significant associations were observed between metrics of solvent exposure and the dichotomized CES-D variable. CONCLUSIONS: Solvent exposures were associated with depressive symptoms among farmers. Efforts to limit exposure to organic solvents may reduce the risk of depressive symptoms among farmers.

Different types of housing and respiratory health outcomes.

Evidence has shown that housing conditions may substantially influence the health of residents. Different types of housing have different structures and construction materials, which may affect indoor environment and housing conditions. This study aimed to investigate whether people living in different types of housing have different respiratory health outcomes. The data from the 1999-2006 National Health and Nutrition Examination Survey were used for the analyses. The types of housing included houses, townhouses, apartments, and mobile homes. Respiratory symptoms included wheezing, coughing, sputum, and dyspnea; respiratory diseases included asthma, chronic bronchitis, emphysema, and chronic obstructive pulmonary disease (COPD). Multiple logistic regression was used to calculate odds ratio (OR) and 95% confidence interval (CI) after adjustment for potential confounding factors. A total of 11,785 participants aged 40 years and older were included in the analyses. Compared with those living in single family houses, participants living in mobile homes were more likely to have respiratory conditions, the OR (95% CI) was 1.38 (1.13-1.69) for wheezing, and 1.49 (1.25-1.78) for dyspnea; whereas participants living in apartments were less likely to have respiratory conditions, the OR (95% CI) was 0.58 (0.36-0.91) for chronic bronchitis, and 0.69 (0.49-0.97) for COPD. Compared with living in single family houses, living in mobile home was associated with worse, whereas living in apartments was associated with better, respiratory health outcomes. Further research is needed to better understand the underlying mechanisms and prevent adverse respiratory effects associated with living in mobile homes.

Geographical Clusters and Predictors of Rabies in Three Southeastern States.

The rabies virus causes progressive encephalomyelitis that is fatal in nearly 100% of untreated cases. In the United States, wildlife act as the primary reservoir for rabies; prevention, surveillance, and control costs remain high. The purpose of this study is to understand the current distribution of wildlife rabies in three southeastern states, with particular focus on raccoons as the primary eastern reservoir, as well as identify demographic and geographic factors which may affect the risk of human exposure. This ecologic study obtained county-level rabies surveillance data from state health departments and the United States Department of Agriculture Wildlife services for North Carolina, Virginia, and West Virginia from 2010 to 2013. A spatial statistical analysis was performed to identify county clusters with high or low rates of raccoon rabies in the three states. Potential demographic and geographic factors associated with these varying rates of rabies were assessed using a multivariable negative binomial regression model. In North Carolina, raccoons constituted 50% of positive tests, in Virginia, 49%, and in West Virginia, 50%. Compared to persons residing in West Virginia counties, persons in North Carolina counties had 1.67 times the risk of exposure (p < 0.0001) to a rabid raccoon and those in Virginia counties had 1.82 times the risk of exposure (p < 0.0001) to a rabid raccoon. Compared to those counties where farmland makes up less than 17% of the total area, persons residing in counties with 17-28% farmland had a 32% increased risk of exposure to a rabid raccoon. In counties with 28-39% farmland, there was an 84% increased risk of exposure. State, rurality, and percent of area designated as farmland were the best predictors of risk of raccoon rabies exposure. Further research is needed to better understand the effect of the oral rabies vaccine program in controlling the risk of human exposure to raccoon rabies.

Effective dust control systems on concrete dowel drilling machinery.

Rotary-type percussion dowel drilling machines, which drill horizontal holes in concrete pavement, have been documented to produce respirable crystalline silica concentrations above recommended exposure criteria. This places operators at potential risk for developing health effects from exposure. United States manufacturers of these machines offer optional dust control systems. The effectiveness of the dust control systems to reduce respirable dust concentrations on two types of drilling machines was evaluated under controlled conditions with the machines operating inside large tent structures in an effort to eliminate secondary exposure sources not related to the dowel-drilling operation. Area air samples were collected at breathing zone height at three locations around each machine. Through equal numbers of sampling rounds with the control systems randomly selected to be on or off, the control systems were found to significantly reduce respirable dust concentrations from a geometric mean of 54 mg per cubic meter to 3.0 mg per cubic meter on one machine and 57 mg per cubic meter to 5.3 mg per cubic meter on the other machine. This research shows that the dust control systems can dramatically reduce respirable dust concentrations by over 90% under controlled conditions. However, these systems need to be evaluated under actual work conditions to determine their effectiveness in reducing worker exposures to crystalline silica below hazardous levels.

Predictors of intimate partner problem-related suicides among suicide decedents in Kentucky.

BACKGROUND: Suicide is the 10th leading cause of death in the United States. Furthermore, intimate partner problems are amid the top precipitating circumstances among suicide decedents. The aim of this study was to determine circumstantial associations of intimate partner problem-related suicides in suicide decedents in Kentucky. METHODS: All suicides that were reported to the Kentucky Violent Death Reporting System between 2005 and 2012 were eligible for this study. Multiple logistic regression was used to explore predictors (precipitating health-related problems, life stressors, and criminal/legal issues) of intimate partner problem-related suicides. RESULTS: Of the 4,754 suicides, included in this study, approximately 17% had intimate partner problems prior to suicide. In the adjusted analysis, mental health issues, alcohol problems, history of suicides attempts, suicides precipitated by another crime, and other legal problems increased the odds of having an intimate partner-related suicide. However, having physical health problems, prior to the suicide, decreased the odds of intimate partner-related suicide. CONCLUSIONS: These results provide insight for the development of suicide interventions for individuals with intimate partner problems by targeting risk factors that are prevalent among this population. Moreover, these results may help marriage/relationship and/or family/divorce court representatives identify individuals with intimate partner problems more at risk for suicide and alleviate the influence these suicide risk factors have on individuals experiencing Intimate partner problems.

Maternal occupational pesticide exposure and risk of congenital heart defects in the National Birth Defects Prevention Study.

BACKGROUND: Congenital heart defects (CHDs) are common birth defects, affecting approximately 1% of live births. Pesticide exposure has been suggested as an etiologic factor for CHDs, but previous results were inconsistent. METHODS: We examined maternal occupational exposure to fungicides, insecticides, and herbicides for 3328 infants with CHDs and 2988 unaffected control infants of employed mothers using data for 1997 through 2002 births from the National Birth Defects Prevention Study, a population-based multisite case-control study. Potential pesticide exposure from 1 month before conception through the first trimester of pregnancy was assigned by an expert-guided task-exposure matrix and job history details self-reported by mothers. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using multivariable logistic regression. RESULTS: Maternal occupational exposure to pesticides was not associated with CHDs overall. In examining specific CHD subtypes compared with controls, some novel associations were observed with higher estimated pesticide exposure: insecticides only and secundum atrial septal defect (OR = 1.8; 95% CI, 1.3-2.7, 40 exposed cases); both insecticides and herbicides and hypoplastic left heart syndrome (OR = 5.1; 95% CI, 1.7-15.3, 4 exposed cases), as well as pulmonary valve stenosis (OR = 3.6; 95% CI, 1.3-10.1, 5 exposed cases); and insecticides, herbicides, and fungicides and tetralogy of Fallot (TOF) (OR = 2.2; 95% CI, 1.2-4.0, 13 exposed cases). CONCLUSION: Broad pesticide exposure categories were not associated with CHDs overall, but examining specific CHD subtypes revealed some increased odds ratios. These results highlight the importance of examining specific CHDs separately. Because of multiple comparisons, additional work is needed to verify these associations.