Increased Mortality Associated With Disability Among Workers' Compensation Claimants With Upper Extremity Neuropathy.

OBJECTIVE: The aim of the study was to evaluate and compare mortality after disabling and nondisabling occupational injuries. METHODS: Vital status was ascertained through 2020 for 2077 individuals with a workers' compensation claim for upper extremity neuropathy in West Virginia in 1998 or 1999. Standardized mortality ratios compared mortality to the West Virginia general population. Hazard ratios (HRs) obtained from Cox regression models compared mortality among those with and without lost work time or permanent disability. RESULTS: Overall, the standardized mortality ratio for accidental poisoning deaths was elevated (1.75, 95% confidence interval [CI]: 1.08-2.68). All-cause mortality HRs and cancer HRs were elevated for lost work time (HR = 1.09, 95% CI: 0.93-1.28; HR = 1.50, 95% CI: 1.09-2.08, respectively) and permanent disability (HR = 1.22, 95% CI: 1.04-1.44; HR = 1.78, 95% CI: 1.27-2.48, respectively). CONCLUSIONS: Work-related disability was associated with broad elevations in mortality.

End-stage renal disease incidence in a cohort of US firefighters from San Francisco, Chicago, and Philadelphia.

BACKGROUND: Firefighters perform strenuous work in hot environments, which may increase their risk of chronic kidney disease. The purpose of this study was to evaluate the risk of end-stage renal disease (ESRD) and types of ESRD among a cohort of US firefighters compared to the US general population, and to examine exposure-response relationships. METHODS: ESRD from 1977 through 2014 was identified through linkage with Medicare data. ESRD incidence in the cohort compared to the US population was evaluated using life table analyses. Associations of all ESRD, systemic ESRD, hypertensive ESRD, and diabetic ESRD with exposure surrogates (exposed days, fire runs, and fire hours) were examined in Cox proportional hazards models adjusted for attained age (the time scale), race, birth date, fire department, and employment duration. RESULTS: The incidence of all ESRD was less than expected (standardized incidence ratio (SIR) = 0.79; 95% confidence interval = 0.69-0.89, observed = 247). SIRs for ESRD types were not significantly increased. Positive associations of all ESRD, systemic ESRD, and hypertensive ESRD with exposed days were observed: however, 95% confidence intervals included one. CONCLUSIONS: We found little evidence of increased risk of ESRD among this cohort of firefighters. Limitations included the inability to evaluate exposure-response relationships for some ESRD types due to small observed numbers, the limitations of the surrogates of exposure, and the lack of information on more sensitive outcome measures for potential kidney effects.

The Wildland Firefighter Exposure and Health Effect (WFFEHE) Study: Rationale, Design, and Methods of a Repeated-Measures Study.

The wildland firefighter exposure and health effect (WFFEHE) study was a 2-year repeated-measures study to investigate occupational exposures and acute and subacute health effects among wildland firefighters. This manuscript describes the study rationale, design, methods, limitations, challenges, and lessons learned. The WFFEHE cohort included fire personnel ages 18-57 from six federal wildland firefighting crews in Colorado and Idaho during the 2018 and 2019 fire seasons. All wildland firefighters employed by the recruited crews were invited to participate in the study at preseason and postseason study intervals. In 2019, one of the crews also participated in a 3-day midseason study interval where workplace exposures and pre/postshift measurements were collected while at a wildland fire incident. Study components assessed cardiovascular health, pulmonary function and inflammation, kidney function, workplace exposures, and noise-induced hearing loss. Measurements included self-reported risk factors and symptoms collected through questionnaires; serum and urine biomarkers of exposure, effect, and inflammation; pulmonary function; platelet function and arterial stiffness; and audiometric testing. Throughout the study, 154 wildland firefighters participated in at least one study interval, while 144 participated in two or more study interval. This study was completed by the Centers for Disease Control and Prevention's National Institute for Occupational Safety and Health through a collaborative effort with the U.S. Department of Agriculture Forest Service, Department of the Interior National Park Service, and Skidmore College. Conducting research in the wildfire environment came with many challenges including collecting study data with study participants with changing work schedules and conducting study protocols safely and operating laboratory equipment in remote field locations. Forthcoming WFFEHE study results will contribute to the scientific evidence regarding occupational risk factors and exposures that can impact wildland firefighter health over a season and across two wildland fire seasons. This research is anticipated to lead to the development of preventive measures and policies aimed at reducing risk for wildland firefighters and aid in identifying future research needs for the wildland fire community.

Mortality in a cohort of US firefighters from San Francisco, Chicago and Philadelphia: an update.

OBJECTIVES: To update the mortality experience of a previously studied cohort of 29 992 US urban career firefighters compared with the US general population and examine exposure-response relationships within the cohort. METHODS: Vital status was updated through 2016 adding 7 years of follow-up. Cohort mortality compared with the US population was evaluated via life table analyses. Full risk-sets, matched on attained age, race, birthdate and fire department were created and analysed using the Cox proportional hazards regression to examine exposure-response associations between select mortality outcomes and exposure surrogates (exposed-days, fire-runs and fire-hours). Models were adjusted for a potential bias from healthy worker survivor effects by including a categorical variable for employment duration. RESULTS: Compared with the US population, mortality from all cancers, mesothelioma, non-Hodgkin's lymphoma (NHL) and cancers of the oesophagus, intestine, rectum, lung and kidney were modestly elevated. Positive exposure-response relationships were observed for deaths from lung cancer, leukaemia and chronic obstructive pulmonary disease (COPD). CONCLUSIONS: This update confirms previous findings of excess mortality from all cancers and several site-specific cancers as well as positive exposure-response relations for lung cancer and leukaemia. New findings include excess NHL mortality compared with the general population and a positive exposure-response relationship for COPD. However, there was no evidence of an association between any quantitative exposure measure and NHL.

Workers' compensation claims for traumatic brain injuries among private employers-Ohio, 2001-2011.

BACKGROUND: The purpose of this analysis was to identify and prioritize high-risk industry groups for traumatic brain injury (TBI) prevention efforts. METHODS: Workers with TBI from 2001 to 2011 were identified from the Ohio Bureau of Workers' Compensation data. To prioritize industry groups by claim type (lost-time (≥8 days away from work) and total claims) and injury event categories, we used a prevention index (PI) that averaged TBI counts and rate ranks (PI = (count rank + rate rank)/2). TBI rates per 10 000 estimated full-time equivalent (FTE = 2000 h/y) workers were calculated. RESULTS: From 2001 to 2011, 12 891 TBIs were identified among private employers, resulting in a rate of 5.1 TBIs per 10 000 FTEs. Of these, 40% (n = 5171) were lost-time TBIs, at a rate of 2.0 per 10 000 FTEs. Spectator Sports had the highest lost-time TBI rate (13.5 per 10 000 FTEs), whereas General Freight Trucking had the greatest number of lost-time TBIs (n = 293). Based on PIs, General Freight Trucking ranked first for lost-time TBIs for all injury events combined. Several industry groups within Construction, General and Specialized Freight Trucking, Services to Building and Dwellings, Employment Services, and Restaurants and Other Eating Places ranked high across multiple injury event categories for lost-time TBIs. CONCLUSIONS: The high-ranking industry groups identified from our study can be used to effectively direct occupational TBI prevention efforts.

Increased overall and cause-specific mortality associated with disability among workers' compensation claimants with low back injuries.

BACKGROUND: Mortality tends to be higher among people who do not work than among workers, but the impact of work-related disability on mortality has not been well studied. METHODS: The vital status through 2015 was ascertained for 14 219 workers with an accepted workers' compensation claim in West Virginia for a low back injury in 1998 or 1999. Mortality among the cohort compared with the West Virginia general population was assessed using standard life table techniques. Associations of mortality and disability-related factors within the cohort were evaluated using Cox proportional hazards regression. RESULTS: Compared to the general population, mortality from accidental poisoning was significantly elevated among the overall cohort and lost-time claimants. Most deaths from accidental poisoning in the cohort were due to drug overdoses involving opioids. Mortality from intentional self-harm was also significantly elevated among lost-time claimants. In internal analyses, overall mortality and mortality from cancer, heart disease, intentional self-harm, and drug overdoses involving opioids was significantly associated with lost time. Overall mortality and mortality from drug overdoses involving opioids were also significantly associated with amount of lost time, permanent partial disability, and percent permanent disability. Heart disease mortality was also significantly associated with the amount of lost time. CONCLUSIONS: The results suggest that disability itself may impact mortality risks. If confirmed, these results reinforce the importance of return to work and other efforts to reduce disability.

Melanoma, thyroid cancer, and gynecologic cancers in a cohort of female flight attendants.

BACKGROUND: Flight attendants may have an increased risk of some cancers from occupational exposure to cosmic radiation and circadian disruption. METHODS: The incidence of thyroid, ovarian, and uterine cancer among ∼6000 female flight attendants compared to the US population was evaluated via life table analyses. Associations of these cancers, melanoma, and cervical cancer with cumulative cosmic radiation dose and metrics of circadian disruption were evaluated using Cox regression. RESULTS: Incidence of thyroid, ovarian, and uterine cancer was not elevated. No significant, positive exposure-response relations were observed. Weak, non-significant, positive relations were observed for thyroid cancer with cosmic radiation and time zones crossed and for melanoma with another metric of circadian disruption. CONCLUSIONS: We found little evidence of increased risk of these cancers from occupational cosmic radiation or circadian disruption in female flight attendants. Limitations include few observed cases of some cancers, limited data on risk factors, and misclassification of exposures.

Breast cancer incidence among female flight attendants: exposure-response analyses.

OBJECTIVE: The aim of this study was to examine the association of breast cancer incidence with cosmic radiation dose and circadian rhythm disruption in a cohort of 6093 US female flight attendants. METHODS: The association of breast cancer risk with cumulative cosmic radiation dose, time spent working during the standard sleep interval, and time zones crossed (all lagged by ten years), adjusted for non-occupational breast cancer risk factors, was evaluated using Cox regression. Individual exposure estimates were derived from work history data and domicile- and era-specific exposure estimates. Breast cancers were identified from telephone interviews and state cancer registries, and covariate data were obtained from telephone interviews. RESULTS: Breast cancer incidence in the overall cohort was not associated with exposure. Positive associations in breast cancer incidence were observed with all three exposures only among the 884 women with parity of ≥3. Adjusted excess relative risks for women with parity of ≥3 were 1.6 [95% confidence interval (95% CI) 0.14-6.6], 0.99 (95% CI -0.04-4.3), and 1.5 (95% CI 0.14-6.2) per 10 mGy, per 2000 hours spent working in the standard sleep interval, and per 4600 time zones crossed (the approximate means of the fourth exposure quintiles among breast cancer cases), respectively. CONCLUSIONS: Positive exposure-response relations, although observed only in a small subset of the cohort, were robust. Future studies of breast cancer incidence among other workers with circadian rhythm disruption should assess interaction with parity to see if our findings are confirmed.

Mortality among workers exposed to toluene diisocyanate in the US polyurethane foam industry: Update and exposure-response analyses.

BACKGROUND: Mortality among 4,545 toluene diisocyante (TDI)-exposed workers was updated through 2011. The primary outcome of interest was lung cancer. METHODS: Life table analyses, including internal analyses by exposure duration and cumulative TDI exposure, were conducted. RESULTS: Compared with the US population, all cause and all cancer mortality was increased. Lung cancer mortality was increased but was not associated with exposure duration or cumulative TDI exposure. In post hoc analyses, lung cancer mortality was associated with employment duration in finishing jobs, but not in finishing jobs involving cutting polyurethane foam. CONCLUSIONS: Dermal exposure, in contrast to inhalational exposure, to TDI is expected to be greater in finishing jobs and may play a role in the observed increase in lung cancer mortality. Limitations include the lack of smoking data, uncertainty in the exposure estimates, and exposure estimates that reflected inhalational exposure only. Am. J. Ind. Med. 59:630-643, 2016. Published 2016. This article is a U.S. Government work and is in the public domain in the USA.

Mortality from neurodegenerative diseases in a cohort of US flight attendants.

BACKGROUND: Concern exists about the potential chronic neurological effects among aircrew of exposure to chemical contaminants from engine oil in aircraft cabin air. We evaluated mortality from neurodegenerative diseases among 11,311 former US flight attendants. METHODS: Vital status was ascertained through 2007, and life table analyses were conducted to obtain standardized mortality ratios (SMRs). RESULTS: Amyotrophic lateral sclerosis (ALS) mortality was over twice as high in the cohort as in the US general population, based on nine observed ALS deaths. There was no clear pattern in risk when SMRs for ALS were stratified by exposure duration. Mortality from other neurodegenerative diseases was not elevated. CONCLUSIONS: Our findings are limited due to small numbers of observed deaths and reliance on mortality data, but suggest that flight attendants may have an increased risk of ALS. Additional research is needed. Am. J. Ind. Med. 59:532-537, 2016. Published 2016. This article is a U.S. Government work and is in the public domain in the USA.

Birth defects in infants born to employees of a microelectronics and business machine manufacturing facility.

BACKGROUND: Concerns about solvent releases from a microelectronics/business machine manufacturing facility in upstate New York led to interest in the health of former workers, including this investigation of birth defects in children of male and female employees. METHODS: Children born 1983 to 2001 to facility employees were enumerated and matched to New York State's Congenital Malformations Registry. Reported structural birth defects were compared with numbers expected from state rates (excluding New York City), generating standardized prevalence ratios (SPRs). Exposure assessors classified employees as ever/never potentially exposed at the facility to metals, chlorinated hydrocarbons, and other hydrocarbons during windows critical to organogenesis (female workers) or spermatogenesis (male workers). Among workers, adjusted prevalence ratios were generated to evaluate associations between potential exposures and specific birth defects. RESULTS: External comparisons for structural defects were at expectation for infants of male workers (SPR = 1.01; 95% confidence interval [CI], 0.77-1.29; n = 60) and lower for births to female workers (SPR = 0.84; 95% CI, 0.50-1.33; n = 18). Among full-term infants of male workers, ventricular septal defects (VSDs) were somewhat elevated compared with the general population (SPR = 1.58; 95% CI, 0.99-2.39; n = 22). Within the cohort, potential paternal metal exposure was associated with increased VSD risk (adjusted prevalence ratio = 2.70; 95% CI, = 1.09-6.67; n = 7). CONCLUSION: While overall SPRs were near expectation, paternal exposure to metals (primarily lead) appeared to be associated with increased VSD risk in infants. Take-home of occupational exposures, nonoccupational exposures, and chance could not be ruled out as causes. Case numbers for many defects were small, limiting assessment of the role of occupational exposures. Birth Defects Research (Part A) 106:696-707, 2016. © 2016 Wiley Periodicals, Inc.

Exposure-response relationships for select cancer and non-cancer health outcomes in a cohort of U.S. firefighters from San Francisco, Chicago and Philadelphia (1950-2009).

OBJECTIVES: To examine exposure-response relationships between surrogates of firefighting exposure and select outcomes among previously studied US career firefighters. METHODS: Eight cancer and four non-cancer outcomes were examined using conditional logistic regression. Incidence density sampling was used to match each case to 200 controls on attained age. Days accrued in firefighting assignments (exposed-days), run totals (fire-runs) and run times (fire-hours) were used as exposure surrogates. HRs comparing 75th and 25th centiles of lagged cumulative exposures were calculated using loglinear, linear, log-quadratic, power and restricted cubic spline general relative risk models. Piecewise constant models were used to examine risk differences by time since exposure, age at exposure and calendar period. RESULTS: Among 19,309 male firefighters eligible for the study, there were 1333 cancer deaths and 2609 cancer incidence cases. Significant positive associations between fire-hours and lung cancer mortality and incidence were evident. A similar relation between leukaemia mortality and fire-runs was also found. The lung cancer associations were nearly linear in cumulative exposure, while the association with leukaemia mortality was attenuated at higher exposure levels and greater for recent exposures. Significant negative associations were evident for the exposure surrogates and colorectal and prostate cancers, suggesting a healthy worker survivor effect possibly enhanced by medical screening. CONCLUSIONS: Lung cancer and leukaemia mortality risks were modestly increasing with firefighter exposures. These findings add to evidence of a causal association between firefighting and cancer. Nevertheless, small effects merit cautious interpretation. We plan to continue to follow the occurrence of disease and injury in this cohort.

Breast cancer incidence in a cohort of U.S. flight attendants.

BACKGROUND: Flight attendants may have elevated breast cancer incidence (BCI). We evaluated BCI's association with cosmic radiation dose and circadian rhythm disruption among 6,093 female former U.S. flight attendants. METHODS: We collected questionnaire data on BCI and risk factors for breast cancer from 2002-2005. We conducted analyses to evaluate (i) BCI in the cohort compared to the U.S. population; and (ii) exposure-response relations. We applied an indirect adjustment to estimate whether parity and age at first birth (AFB) differences between the cohort and U.S. population could explain BCI that differed from expectation. RESULTS: BCI was elevated but may be explained by lower parity and older AFB in the cohort than among U.S. women. BCI was not associated with exposure metrics in the cohort overall. Significant positive associations with both were observed only among women with parity of three or more. CONCLUSIONS: Future cohort analyses may be informative on the role of these occupational exposures and non-occupational risk factors.

Mortality among a cohort of U.S. commercial airline cockpit crew.

BACKGROUND: We evaluated mortality among 5,964 former U.S. commercial cockpit crew (pilots and flight engineers). The outcomes of a priori interest were non-chronic lymphocytic leukemia, central nervous system (CNS) cancer (including brain), and malignant melanoma. METHODS: Vital status was ascertained through 2008. Life table and Cox regression analyses were conducted. Cumulative exposure to cosmic radiation was estimated from work history data. RESULTS: Compared to the U.S. general population, mortality from all causes, all cancer, and cardiovascular diseases was decreased, but mortality from aircraft accidents was highly elevated. Mortality was elevated for malignant melanoma but not for non-chronic lymphocytic leukemia. CNS cancer mortality increased with an increase in cumulative radiation dose. CONCLUSIONS: Cockpit crew had a low all-cause, all-cancer, and cardiovascular disease mortality but elevated aircraft accident mortality. Further studies are needed to clarify the risk of CNS and other radiation-associated cancers in relation to cosmic radiation and other workplace exposures.

Mortality from cancer and other causes in commercial airline crews: a joint analysis of cohorts from 10 countries.

BACKGROUND: Commercial airline crew is one of the occupational groups with the highest exposures to ionising radiation. Crew members are also exposed to other physical risk factors and subject to potential disruption of circadian rhythms. METHODS: This study analyses mortality in a pooled cohort of 93 771 crew members from 10 countries. The cohort was followed for a mean of 21.7 years (2.0 million person-years), during which 5508 deaths occurred. RESULTS: The overall mortality was strongly reduced in male cockpit (SMR 0.56) and female cabin crews (SMR 0.73). The mortality from radiation-related cancers was also reduced in male cockpit crew (SMR 0.73), but not in female or male cabin crews (SMR 1.01 and 1.00, respectively). The mortality from female breast cancer (SMR 1.06), leukaemia and brain cancer was similar to that of the general population. The mortality from malignant melanoma was elevated, and significantly so in male cockpit crew (SMR 1.57). The mortality from cardiovascular diseases was strongly reduced (SMR 0.46). On the other hand, the mortality from aircraft accidents was exceedingly high (SMR 33.9), as was that from AIDS in male cabin crew (SMR 14.0). CONCLUSIONS: This large study with highly complete follow-up shows a reduced overall mortality in male cockpit and female cabin crews, an increased mortality of aircraft accidents and an increased mortality in malignant skin melanoma in cockpit crew. Further analysis after longer follow-up is recommended.

Retrospective cohort study of a microelectronics and business machine facility.

OBJECTIVES: We examined health outcomes among 34,494 workers employed at a microelectronics and business machine facility 1969-2001. METHODS: Standardized mortality ratio (SMR) and standardized incidence ratios were used to evaluate health outcomes in the cohort and Cox regression modeling to evaluate relations between scores for occupational exposures and outcomes of a priori interest. RESULTS: Just over 17% of the cohort (5,966 people) had died through 2009. All cause, all cancer, and many cause-specific SMRs showed statistically significant deficits. In hourly males, SMRs were significantly elevated for non-Hodgkin's lymphoma and rectal cancer. Salaried males had excess testicular cancer incidence. Pleural cancer and mesothelioma excesses were observed in workers hired before 1969, but no available records substantiate use of asbestos in manufacturing processes. A positive, statistically significant relation was observed between exposure scores for tetrachloroethylene and nervous system diseases. CONCLUSIONS: Few significant exposure-outcome relations were observed, but risks from occupational exposures cannot be ruled out due to data limitations and the relative youth of the cohort.

Mortality and cancer incidence in a pooled cohort of US firefighters from San Francisco, Chicago and Philadelphia (1950-2009).

OBJECTIVES: To examine mortality patterns and cancer incidence in a pooled cohort of 29 993 US career firefighters employed since 1950 and followed through 2009. METHODS: Mortality and cancer incidence were evaluated by life table methods with the US population referent. Standardised mortality (SMR) and incidence (SIR) ratios were determined for 92 causes of death and 41 cancer incidence groupings. Analyses focused on 15 outcomes of a priori interest. Sensitivity analyses were conducted to examine the potential for significant bias. RESULTS: Person-years at risk totalled 858 938 and 403 152 for mortality and incidence analyses, respectively. All-cause mortality was at expectation (SMR=0.99, 95% CI 0.97 to 1.01, n=12 028). There was excess cancer mortality (SMR=1.14, 95% CI 1.10 to 1.18, n=3285) and incidence (SIR=1.09, 95% CI 1.06 to 1.12, n=4461) comprised mainly of digestive (SMR=1.26, 95% CI 1.18 to 1.34, n=928; SIR=1.17, 95% CI 1.10 to 1.25, n=930) and respiratory (SMR=1.10, 95% CI 1.04 to 1.17, n=1096; SIR=1.16, 95% CI 1.08 to 1.24, n=813) cancers. Consistent with previous reports, modest elevations were observed in several solid cancers; however, evidence of excess lymphatic or haematopoietic cancers was lacking. This study is the first to report excess malignant mesothelioma (SMR=2.00, 95% CI 1.03 to 3.49, n=12; SIR=2.29, 95% CI 1.60 to 3.19, n=35) among US firefighters. Results appeared robust under differing assumptions and analytic techniques. CONCLUSIONS: Our results provide evidence of a relation between firefighting and cancer. The new finding of excess malignant mesothelioma is noteworthy, given that asbestos exposure is a known hazard of firefighting.

Exposure assessment at 30 000 feet: challenges and future directions.

Few studies of cancer mortality and incidence among flight crew have included a detailed assessment of both occupational exposures and lifestyle factors that may influence the risk of cancer. In this issue, Kojo et al. (Risk factors for skin cancer among Finnish airline cabin crew. Ann Occup. Hyg 2013; 57: 695-704) evaluated the relative contributions of ultraviolet and cosmic radiation to the incidence of skin cancer in Finnish flight attendants. This is a useful contribution, yet the reason flight crew members have an increased risk of skin cancer compared with the general population remains unclear. Good policy decisions for flight crew will depend on continued and emerging effective collaborations to increase study power and improve exposure assessment in future flight crew health studies. Improving the assessment of occupational exposures and non-occupational factors will cost additional time and effort, which are well spent if the role of exposures can be clarified in larger studies.

Cohort mortality study of garment industry workers exposed to formaldehyde: update and internal comparisons.

BACKGROUND: To further evaluate the association between formaldehyde and leukemia, we extended follow-up through 2008 for a cohort mortality study of 11,043 US formaldehyde-exposed garment workers. METHODS: We computed standardized mortality ratios and standardized rate ratios stratified by year of first exposure, exposure duration, and time since first exposure. Associations between exposure duration and rates of leukemia and myeloid leukemia were further examined using Poisson regression models. RESULTS: Compared to the US population, myeloid leukemia mortality was elevated but overall leukemia mortality was not. In internal analyses, overall leukemia mortality increased with increasing exposure duration and this trend was statistically significant. CONCLUSIONS: We continue to see limited evidence of an association between formaldehyde and leukemia. However, the extended follow-up did not strengthen previously observed associations. In addition to continued epidemiologic research, we recommend further research to evaluate the biological plausibility of a causal relation between formaldehyde and leukemia.