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1.  Occupational Risk Factors for COPD Phenotypes in the Multi-Ethnic Study of Atherosclerosis (MESA) Lung Study 
COPD  2014;11(4):368-380.
The contribution of occupational exposure to the risk of chronic obstructive pulmonary disease COPD in population-based studies is of interest. We compared the performance of self-reported exposure to a newly developed JEM in exposure-response evaluation.
We used cross-sectional data from Multi-Ethnic Study of Atherosclerosis (MESA), a population-based sample of 45–84 year olds free of clinical cardiovascular disease at baseline. MESA ascertained the most recent job and employment, and the MESA Lung Study measured spirometry, and occupational exposures for 3686 participants. Associations between health outcomes (spirometry defined airflow limitation and Medical Research Council-defined chronic bronchitis) and occupational exposure [self-reported occupational exposure to vapor-gas, dust, or fumes (VGDF), severity of exposure, and a job-exposure matrix (JEM)-derived score] were evaluated using logistic regression models adjusted for non-occupational risk factors.
The prevalence of airflow limitation was associated with self-reported exposure to vapor-gas (OR 2.6, 95%CI 1.1–2.3), severity of VGDF exposure (P-trend<0.01), and JEM dust exposure (OR 2.4, 95%CI 1.1–5.0), and with organic dust exposure in females; these associations were generally of greater magnitude among never smokers. The prevalence of chronic bronchitis and wheeze was associated with exposure to VGDF. The association between airflow limitation and the combined effect of smoking and VGDF exposure showed an increasing trend. Self-reported vapor-gas, dust, fumes, years and severity of exposure were associated with increased prevalence of chronic bronchitis and wheeze (P<0.001).
Airflow limitation was associated with self-reported VGDF exposure, its severity, and JEM-ascertained dust exposure in smokers and never-smokers in this multiethnic study.
PMCID: PMC4096066  PMID: 24568208
Spirometry; airflow obstruction; job exposure matrix; gas; dust; fumes
2.  Associations of Work Hours with Carotid Intima Media Thickness and Ankle-Brachial Index: The Multi-Ethnic Study of Atherosclerosis (MESA) 
Long working hours may be associated with cardiovascular disease (CVD). The objective was to investigate cross-sectional associations of work hours with carotid intima media thickness (CIMT) and ankle brachial index (ABI).
Participants were 1,694 women and 1,868 men from the Multi-Ethnic Study of Atherosclerosis. CIMT and ABI were measured using standard protocols. Information on work hours was obtained from questionnaires. Mean values of CIMT and ABI were examined across five categories of hours worked per week (≤20, 21-39, 40, 41-50, >50) using ANOVA/ANCOVA. P-values for trend were obtained from linear regression models.
Mean age of participants was 56.9±8.4 years; 52.4% were men. Distinct patterns of association between work hours and the subclinical CVD biomarkers were found for women and men, although this heterogeneity by gender was not statistically significant. Among women only, work hours were positively associated with common (but not internal) CIMT (p=0.073) after full risk factor adjustment. Compared to women working 40 hours, those working >50 hours were more likely to have an ABI <1 (vs. 1-1.4) (OR=1.85, 95% CI=1.01-3.38). In men, work hours and ABI were inversely associated (p=0.046). There was some evidence that the association between work hours and ABI was modified by occupational category (interaction p=0.061). Among persons classified as Management/Professionals, longer work hours was associated with lower ABI (p=0.015). No significant associations were observed among other occupational groups.
Working longer hours may be associated with subclinical CVD. These associations should be investigated using longitudinal studies.
PMCID: PMC4084707  PMID: 22767870
Atherosclerosis; carotid artery stenosis; ankle-brachial index; work
3.  Factorial invariance, scale reliability, and construct validity of the job control and job demands scales for immigrant workers: The Multi-Ethnic Study of Atherosclerosis (MESA) 
Immigrants have a different social context from those who stay in their home country or those who were born to the country that immigrants now live. Cultural theory of risk perception suggests that social context influences one’s interpretation of questionnaire items. We examined psychometric properties of job control and job demand scales with US- and foreign-born workers who preferred English, Spanish, or Chinese (n=3114, mean age=58.1). Across all groups, the job control scale had acceptable Cronbach’s alpha (0.78–0.83) and equivalent factor loadings (ΔCFI<0.01). Immigrants had low alpha (0.42–0.65) for the job demands scale regardless of language, education, or age of migration. Two job-demand items had different factor loadings across groups. Among immigrants, both scales had inconsistent associations with perceived job stress and self-rated health. For a better understanding of immigrants’ job stress, the concept of job demands should be expanded and immigrants’ expectations for job control explored. (149/150 limit)
PMCID: PMC4068014  PMID: 20582720
job stress; factor analysis; internal consistency; acculturation; health disparities
4.  Promoting Integrated Approaches to Reducing Health Inequities among Low-Income Workers: Applying a Social Ecological Framework 
Nearly one of every three workers in the United States is low-income. Low-income populations have a lower life expectancy and greater rates of chronic diseases compared to those with higher incomes. Low- income workers face hazards in their workplaces as well as in their communities. Developing integrated public health programs that address these combined health hazards, especially the interaction of occupational and non-occupational risk factors, can promote greater health equity. We apply a social-ecological perspective in considering ways to improve the health of the low-income working population through integrated health protection and health promotion programs initiated in four different settings: the worksite, state and local health departments, community health centers, and community-based organizations. An example of successful approaches to developing integrated programs in each of these settings is described. Recommendations for improved research, training, and coordination among health departments, health practitioners, worksites and community organizations are proposed.
PMCID: PMC3843946  PMID: 23532780
Health inequities; Low-income workers; Total worker health; Disparities
5.  Neurodegenerative causes of death among retired National Football League players 
Neurology  2012;79(19):1970-1974.
To analyze neurodegenerative causes of death, specifically Alzheimer disease (AD), Parkinson disease, and amyotrophic lateral sclerosis (ALS), among a cohort of professional football players.
This was a cohort mortality study of 3,439 National Football League players with at least 5 pension-credited playing seasons from 1959 to 1988. Vital status was ascertained through 2007. For analysis purposes, players were placed into 2 strata based on characteristics of position played: nonspeed players (linemen) and speed players (all other positions except punter/kicker). External comparisons with the US population used standardized mortality ratios (SMRs); internal comparisons between speed and nonspeed player positions used standardized rate ratios (SRRs).
Overall player mortality compared with that of the US population was reduced (SMR 0.53, 95% confidence interval [CI] 0.48−0.59). Neurodegenerative mortality was increased using both underlying cause of death rate files (SMR 2.83, 95% CI 1.36−5.21) and multiple cause of death (MCOD) rate files (SMR 3.26, 95% CI 1.90−5.22). Of the neurodegenerative causes, results were elevated (using MCOD rates) for both ALS (SMR 4.31, 95% CI 1.73−8.87) and AD (SMR 3.86, 95% CI 1.55−7.95). In internal analysis (using MCOD rates), higher neurodegenerative mortality was observed among players in speed positions compared with players in nonspeed positions (SRR 3.29, 95% CI 0.92−11.7).
The neurodegenerative mortality of this cohort is 3 times higher than that of the general US population; that for 2 of the major neurodegenerative subcategories, AD and ALS, is 4 times higher. These results are consistent with recent studies that suggest an increased risk of neurodegenerative disease among football players.
PMCID: PMC4098841  PMID: 22955124
6.  Associations of occupation, job control and job demands with intima-media thickness: The Multi-Ethnic Study of Atherosclerosis (MESA) 
Occupation has been linked to cardiovascular disease (CVD) incidence and mortality, but few studies have investigated occupation in relation to early atherosclerotic disease. This study examined associations between various occupational characteristics and carotid artery intima-media thickness (IMT) in a multi-ethnic sample.
The Multi-Ethnic Study of Atherosclerosis (MESA) recruited 6814 adults aged 45e84 years and free of clinical CVD (response rate 60%, 51% female). Questionnaire data were used to determine occupational group (managerial/professional, sales/office, service, blue-collar), psychosocial job characteristics (ie, job demands, job control) and other sociodemographic information.
Common carotid artery (CCA)-IMT was greater for blue-collar jobs than for management/professional jobs (mean difference=0.012 mm, p=0.049) after adjustment for age, sex, race, place of birth (US or foreign born) and CVD risk factors. Compared to management/professional jobs, internal carotid artery (ICA)-IMT was greater for sales/office, service and blue-collar jobs (mean difference=0.071 mm, p<0.001; 0.057 mm, p=0.009; and 0.110 mm, p<0.001, respectively) after adjustment for age, sex, race and place of birth. The difference between blue-collar jobs and management/professional jobs remained significant after additional adjustment for CVD risk factors, income and education (mean difference=0.048 mm, p=0.045). Higher levels of control at work were associated with thinner CCA-IMT (mean difference=‒0.009 mm, p=0.016, adjusted for age, sex, race and place of birth) but not with ICA-IMT. Job demands had no significant association with IMT.
Blue-collar jobs and low levels of job control were associated with the development of subclinical atherosclerosis.
PMCID: PMC3073024  PMID: 20935285
7.  Formative Research in Occupational Health and Safety Intervention for Diverse, Underserved Worker Populations: A Homecare Worker Intervention Project 
Public Health Reports  2009;124(Suppl 1):84-89.
The increasing numbers of minority, low-income, and contingent workers in the U.S. labor force present new challenges to occupational safety and health interventions. Formative research can be used to help researchers better understand target populations and identify unanticipated barriers to safety changes. The National Institute for Occupational Safety and Health initiated an intervention project to improve health and safety among homecare workers in Alameda County, California. Investigators conducted systematic formative research to gather information to guide intervention development.
Various qualitative methods were used including 11 focus groups (conducted in English, Spanish, and Chinese) and 10 key informant interviews. This article focuses on two picture-based focus group activities that explored workers' views on their relationships with consumers and their perceived barriers to interventions.
Findings indicated cultural differences regarding workers' perceptions of their relationships with consumers. Chinese homecare workers mostly focused on respecting elders rather than initiating changes. Some English- and Spanish-speaking workers described efforts to negotiate with consumers. Results also identified workers' perceived barriers to interventions, such as consumers' resistance to changes and lack of resources. These findings played important roles in shaping the intervention materials. For example, given the lack of resources among consumers, the project tried to tap into community-level resources by collaborating with local stakeholders and developing community resource guides.
Formative research can be a valuable step to inform the development of occupational health and safety interventions for diverse, underserved worker populations.
PMCID: PMC2708659  PMID: 19618810
8.  Enduring Mental Health Morbidity and Social Function Impairment in World Trade Center Rescue, Recovery, and Cleanup Workers: The Psychological Dimension of an Environmental Health Disaster 
Environmental Health Perspectives  2008;116(9):1248-1253.
The World Trade Center (WTC) attacks exposed thousands of workers to hazardous environmental conditions and psychological trauma. In 2002, to assess the health of these workers, Congress directed the National Institute for Occupational Safety and Health to establish the WTC Medical Monitoring and Treatment Program. This program has established a large cohort of WTC rescue, recovery, and cleanup workers. We previously documented extensive pulmonary dysfunction in this cohort related to toxic environmental exposures.
Our objective in this study was to describe mental health outcomes, social function impairment, and psychiatric comorbidity in the WTC worker cohort, as well as perceived symptomatology in workers’ children.
Ten to 61 months after the WTC attack, 10,132 WTC workers completed a self-administered mental health questionnaire.
Of the workers who completd the questionnaire, 11.1% met criteria for probable post-traumatic stress disorder (PTSD), 8.8% met criteria for probable depression, 5.0% met criteria for probable panic disorder, and 62% met criteria for substantial stress reaction. PTSD prevalence was comparable to that seen in returning Afghanistan war veterans and was much higher than in the U.S. general population. Point prevalence declined from 13.5% to 9.7% over the 5 years of observation. Comorbidity was extensive and included extremely high risks for impairment of social function. PTSD was significantly associated with loss of family members and friends, disruption of family, work, and social life, and higher rates of behavioral symptoms in children of workers.
Working in 9/11 recovery operations is associated with chronic impairment of mental health and social functioning. Psychological distress and psychopathology in WTC workers greatly exceed population norms. Surveillance and treatment programs continue to be needed.
PMCID: PMC2535630  PMID: 18795171
depression; disaster workers; functional impairment; occupational health; post-traumatic stress disorder; stress; World Trade Center
11.  The World Trade Center Disaster and the Health of Workers: Five-Year Assessment of a Unique Medical Screening Program 
Environmental Health Perspectives  2006;114(12):1853-1858.
Approximately 40,000 rescue and recovery workers were exposed to caustic dust and toxic pollutants following the 11 September 2001 attacks on the World Trade Center (WTC). These workers included traditional first responders, such as firefighters and police, and a diverse population of construction, utility, and public sector workers.
To characterize WTC-related health effects, the WTC Worker and Volunteer Medical Screening Program was established. This multicenter clinical program provides free standardized examinations to responders. Examinations include medical, mental health, and exposure assessment questionnaires; physical examinations; spirometry; and chest X rays.
Of 9,442 responders examined between July 2002 and April 2004, 69% reported new or worsened respiratory symptoms while performing WTC work. Symptoms persisted to the time of examination in 59% of these workers. Among those who had been asymptomatic before September 11, 61% developed respiratory symptoms while performing WTC work. Twenty-eight percent had abnormal spirometry; forced vital capacity (FVC) was low in 21%; and obstruction was present in 5%. Among nonsmokers, 27% had abnormal spirometry compared with 13% in the general U.S. population. Prevalence of low FVC among nonsmokers was 5-fold greater than in the U.S. population (20% vs. 4%). Respiratory symptoms and spirometry abnormalities were significantly associated with early arrival at the site.
WTC responders had exposure-related increases in respiratory symptoms and pulmonary function test abnormalities that persisted up to 2.5 years after the attacks. Long-term medical monitoring is required to track persistence of these abnormalities and identify late effects, including possible malignancies. Lessons learned should guide future responses to civil disasters.
PMCID: PMC1764159  PMID: 17185275
air pollution; disaster response; occupational lung disease; pulmonary function; September 11; spirometry; World Trade Center
12.  Biomonitoring of chemical exposure among New York City firefighters responding to the World Trade Center fire and collapse. 
Environmental Health Perspectives  2003;111(16):1906-1911.
The collapse of the World Trade Center (WTC) on 11 September 2001 exposed New York City firefighters to smoke and dust of unprecedented magnitude and duration. The chemicals and the concentrations produced from any fire are difficult to predict, but estimates of internal dose exposures can be assessed by the biological monitoring of blood and urine. We analyzed blood and urine specimens obtained from 321 firefighters responding to the WTC fires and collapse for 110 potentially fire-related chemicals. Controls consisted of 47 firefighters not present at the WTC. Sampling occurred 3 weeks after 11 September, while fires were still burning. When reference or background ranges were available, most chemical concentrations were found to be generally low and not outside these ranges. Compared with controls, the exposed firefighters showed significant differences in adjusted geometric means for six of the chemicals and significantly greater detection rates for an additional three. Arrival time was a significant predictor variable for four chemicals. Special Operations Command firefighters (n = 95), compared with other responding WTC firefighters (n = 226), had differences in concentrations or detection rate for 14 of the chemicals. Values for the Special Operations Command firefighters were also significantly different from the control group values for these same chemicals and for two additional chemicals. Generally, the chemical concentrations in the other firefighter group were not different from those of controls. Biomonitoring was used to characterize firefighter exposure at the WTC disaster. Although some of the chemicals analyzed showed statistically significant differences, these differences were generally small.
PMCID: PMC1241765  PMID: 14644665
13.  Research and dissemination needs for ergonomics in agriculture. 
Public Health Reports  2002;117(5):440-445.
In 1998, the National Institute for Occupational Safety and Health convened a conference of researchers interested in the ergonomics of agricultural workers. Participants included 20 representatives from universities, state governments, private agricultural and insurance companies, migrant worker organizations, agricultural industry organizations, and the Agricultural Extension Service. The attendees divided into three groups and brainstormed about research ideas and dissemination methods related to ergonomics for farm workers. The groups separately reported that interventions, cost-benefit analyses, and cultural belief systems were the main topics that needed to be researched to reduce physical risk factors for musculoskeletal disorders. The participants also presented ideas for disseminating information to farm owners and workers.
PMCID: PMC1497464  PMID: 12500960

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