Vulnerable Workers and Communities at Environmental Risk and Updates in Occupational and Environmental Medicine

Division of Occupational and Environmental Medicine Department of Medicine University of California, San Francisco School of Medicine presents

March 13-16, 2019 San Francisco Marriott Fisherman’s Wharf San Francisco, CA

Course Chairs Paul D. Blanc, MD, MSPH Robert Kosnik, MD, DIH Samuel M. Goldman, MD, MPH University of California, San Francisco

University of California, San Francisco School of Medicine

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Table of Contents

Acknowledgements pg. 4

Overview pg. 6

General Information pg. 8

Federal and State Law Regarding Cultural Linguistics pg. 9

Faculty List pg. 11

Disclosures pg. 13

Program pg. 14

Vulnerable Workers and Communities at Environmental Risk

The Vulnerable Worker – Notes from the Field pg. 17

How Medical Humanities Can Inform Our Thinking about Vulnerable Populations pg. 45

Lung Disease, Miners and Mining Communities – a Global Population at Risk pg. 53

Vulnerable Workers in New York City – Workplace Hazards and Interacting Risk Factors pg. 89

Indigenous (Native) Latin American Immigrants: Among the Most Vulnerable Workers pg. 107

An Aging Population at Work and at Play – Vocations, Avocations, and Hobbies pg. 123

Military Service as a Vulnerable Occupation: Lung Disease as a Paradigm pg. 143

Pediatric and Environmentally Exposed: Doubly Vulnerable pg. 157

Updates in Occupational and Environmental Medicine Day 1

Sports Medicine: What An Occupational Medicine Practitioner Should Consider? pg. 169

Volcanology for the Health Care Provider: Hazards of Volcanic and Geothermal Areas pg. 199

Occupational Health in the Biotechnology Industry pg. 211

Dabs, Vapes and Third‐hand Smoke: An Update on Environmental Exposure to Tobacco and Marijuana pg. 219

Climate Change and Health in 2019 pg. 225

Hazardous Metals: Emerging and Long‐Standing Toxicants pg. 235

Key Publications in Occupational & Environmental Health: the Year in Review pg. 247

Updates in Occupational and Environmental Medicine Day 2

Occupational Dermatology in 2019 – More than Just Contact Dermatitis pg. 261

The Italian Mesothelioma Registry: Lessons Learned pg. 273

Innovation in Air Quality and Climate Change Mitigation Policies: The California Paradigm pg. 289

Acknowledgement of Commercial Support

This CME activity was supported in part by educational grants from the following:

Council for Education and Research on Toxics Glenn Law Firm Gordon Rees Hobson & Bradley McGuinn Hillsman & Palefsky Moss Bollinger, LLP Patton Law, P.C. SL Environmental Law Firm S. Reed Morgan, P.C.

4 Exhibitors

Medlock Consulting Dynavax

5 University of California, San Francisco School of Medicine Presents

Vulnerable Workers and Communities at Environmental Risk and Updates in Occupational and Environmental Medicine

Educational Objectives

Upon completion of this program, attendees will be able to:

 Evaluate the occupational and environmental risk to selected vulnerable work groups and communities;  Adopt new medical knowledge into preventive activities addressing emerging risk factors and new disease entities;  Evaluate scientific data in the field of occupational and environmental medicine;  Expand the differential diagnosis to incorporate a wider range of environmental and occupational factors in respiratory and other disease processes;  Diagnose and treat selected occupational and environmental conditions;  Improve management in terms of required regulatory management of specific work-related scenarios;  Inform the prioritization of clinical care, research, and public health policy with state of the art updates.

ACCREDITATION

The University of California, San Francisco School of Medicine (UCSF) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Physicians UCSF designates this live activity for a maximum of 17.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This CME activity meets the requirements under California Assembly Bill 1195, Continuing Education and Cultural and Linguistic Competency.

Pain Management and End-of-Life Care: The approved credits shown above include a maximum of 2.5 credits toward meeting the requirement under California Assembly Bill 487, Pain Management and End-of-Life Care.

Geriatric Medicine: The approved credits shown above include 2.5 credits toward meeting the requirement under California Assembly Bill 1820, Geriatric Medicine.

6 California Division of Workers Compensation- Medical Unit (QME Credit) This course has been reviewed and approved for 17.25 hours of credit. The course number is 1200.

American Board of Preventive Medicine The American Board of Preventive Medicine for Maintenance of Certification (MOC) has approved this course for a maximum of 17.25 MOC credits. The course ID for this module is 1047.

American Academy of Family Physicians This Live activity, Emerging and Re-Emerging Occupational and Environmental Exposure and Disease and Updates in Occupational and Environmental Medicine, with a beginning date of 03/08/2018, has been reviewed and is acceptable for up to 17.25 prescribed credit(s) by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

NURSES: For the purpose of recertification, the American Nurses Credentialing Center accepts AMA PRA Category 1 Credit™ issued by organizations accredited by the ACCME.

PHYSICIAN ASSISTANTS: AAPA accepts category 1 credit from AOACCME, Prescribed credit from AAFP, and AMA PRA Category 1 Credit™ from organizations accredited by the ACCME.

PHARMACY: The California Board of Pharmacy accepts as continuing professional education those courses that meet the standard of relevance to pharmacy practice and have been approved for AMA PRA Category 1 Credit™.

7 General Information

Attendance Verification/Sign-In Sheet / CME Certificates Please remember to sign-in on the sign-in sheet when you check in at the UCSF Registration Desk on your first day. You only need to sign-in once for the course, when you first check in.

After the meeting, you will receive an email from [email protected] with a link to complete your online Course Evaluation/ Electronic CME Certificate. Please make sure that you add this email to your safe senders list. The Qualtrics system will send you reminders to complete your CME Certificate Claiming until you complete it.

Upon completing the Electronic CME Certificate, your CME certificate will be automatically generated to print and/or email yourself a copy. For smartphone users, you may want to take a photo of your certificate as some settings prevent you from emailing the certificate.

The link will be available for 30 days after the last day of the course. However, after that date the link will expire and you will no longer be able to claim your credits online. You must then contact the Office of CME at [email protected] to receive your certificate and a $15 administrative fee may be applied.

Speaker Survey Your opinion is important to us – we do listen! The speaker survey is the bright yellow hand-out you received when you checked in. Please complete this during the meeting and turn it in to the registration staff at the end of the course.

Security We urge caution with regard to your personal belongings and syllabus books. We are unable to replace these in the event of loss. Please do not leave any personal belongings unattended in the meeting room during lunch or breaks or overnight.

Exhibits Industry exhibits will be available outside the ballroom during breakfasts and breaks, and lunches.

Final Presentations A link to PDF versions of the final presentations will be sent via e-mail approximately 3 – 4 weeks post course. Only presentations that have been authorized for inclusion by the presenter will be included

8 Federal and State Law Regarding Linguistic Access and Services for Limited English Proficient Persons

I. Purpose. This document is intended to satisfy the requirements set forth in California Business and Professions code 2190.1. California law requires physicians to obtain training in cultural and linguistic competency as part of their continuing medical education programs. This document and the attachments are intended to provide physicians with an overview of federal and state laws regarding linguistic access and services for limited English proficient (“LEP”) persons. Other federal and state laws not reviewed below also may govern the manner in which physicians and healthcare providers render services for disabled, hearing impaired or other protected categories

II. Federal Law – Federal Civil Rights Act of 1964, Executive Order 13166, August 11, 2000, and Department of Health and Human Services (“HHS”) Regulations and LEP Guidance. The Federal Civil Rights Act of 1964, as amended, and HHS regulations require recipients of federal financial assistance (“Recipients”) to take reasonable steps to ensure that LEP persons have meaningful access to federally funded programs and services. Failure to provide LEP individuals with access to federally funded programs and services may constitute national origin discrimination, which may be remedied by federal agency enforcement action. Recipients may include physicians, hospitals, universities and academic medical centers who receive grants, training, equipment, surplus property and other assistance from the federal government.

HHS recently issued revised guidance documents for Recipients to ensure that they understand their obligations to provide language assistance services to LEP persons. A copy of HHS’s summary document entitled “Guidance for Federal Financial Assistance Recipients Regarding Title VI and the Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons – Summary” is available at HHS’s website at: http://www.hhs.gov/ocr/lep/ .

As noted above, Recipients generally must provide meaningful access to their programs and services for LEP persons. The rule, however, is a flexible one and HHS recognizes that “reasonable steps” may differ depending on the Recipient’s size and scope of services. HHS advised that Recipients, in designing an LEP program, should conduct an individualized assessment balancing four factors, including: (i) the number or proportion of LEP persons eligible to be served or likely to be encountered by the Recipient; (ii) the frequency with which LEP individuals come into contact with the Recipient’s program; (iii) the nature and importance of the program, activity or service provided by the Recipient to its beneficiaries; and (iv) the resources available to the Recipient and the costs of interpreting and translation services.

Based on the Recipient’s analysis, the Recipient should then design an LEP plan based on five recommended steps, including: (i) identifying LEP individuals who may need assistance; (ii) identifying language assistance measures; (iii) training staff; (iv) providing notice to LEP persons; and (v) monitoring and updating the LEP plan.

A Recipient’s LEP plan likely will include translating vital documents and providing either on-site interpreters or telephone interpreter services, or using shared interpreting services with other Recipients. Recipients may take other reasonable steps depending on the emergent or non- emergent needs of the LEP individual, such as hiring bilingual staff who are competent in the skills required for medical translation, hiring staff interpreters, or contracting with outside public or private agencies that provide interpreter services. HHS’s guidance provides detailed

9 examples of the mix of services that a Recipient should consider and implement. HHS’s guidance also establishes a “safe harbor” that Recipients may elect to follow when determining whether vital documents must be translated into other languages. Compliance with the safe harbor will be strong evidence that the Recipient has satisfied its written translation obligations.

In addition to reviewing HHS guidance documents, Recipients may contact HHS’s Office for Civil Rights for technical assistance in establishing a reasonable LEP plan.

III. California Law – Dymally-Alatorre Bilingual Services Act. The California legislature enacted the California’s Dymally-Alatorre Bilingual Services Act (Govt. Code 7290 et seq.) in order to ensure that California residents would appropriately receive services from public agencies regardless of the person’s English language skills. California Government Code section 7291 recites this legislative intent as follows:

“The Legislature hereby finds and declares that the effective maintenance and development of a free and democratic society depends on the right and ability of its citizens and residents to communicate with their government and the right and ability of the government to communicate with them.

The Legislature further finds and declares that substantial numbers of persons who live, work and pay taxes in this state are unable, either because they do not speak or write English at all, or because their primary language is other than English, effectively to communicate with their government. The Legislature further finds and declares that state and local agency employees frequently are unable to communicate with persons requiring their services because of this language barrier. As a consequence, substantial numbers of persons presently are being denied rights and benefits to which they would otherwise be entitled.

It is the intention of the Legislature in enacting this chapter to provide for effective communication between all levels of government in this state and the people of this state who are precluded from utilizing public services because of language barriers.”

The Act generally requires state and local public agencies to provide interpreter and written document translation services in a manner that will ensure that LEP individuals have access to important government services. Agencies may employ bilingual staff, and translate documents into additional languages representing the clientele served by the agency. Public agencies also must conduct a needs assessment survey every two years documenting the items listed in Government Code section 7299.4, and develop an implementation plan every year that documents compliance with the Act. You may access a copy of this law at the following url: http://www.spb.ca.gov/bilingual/dymallyact.htm

10 Faculty List Course Chairs

Paul D. Blanc, MD, MSPH Professor of Medicine, Endowed Chair and Division Chief, Occupational and Environmental Medicine University of California, San Francisco

Robert Kosnik, MD, DIH Professor of Medicine, Medical Director, Occupational Health Services, Division of Occupational and Environmental Medicine, University of California, San Francisco

Samuel M. Goldman, MD, MPH Associate Professor of Medicine and of Neurology; Division of Occupational and Environmental Medicine, University of California, San Francisco

Course Faculty (University of California, San Francisco unless indicated) John Balmes, MD Professor of Medicine Division of Occupational and Environmental Medicine

Michael N. Bates, PhD Adjunct Professor of Epidemiology Division of Environmental Health Sciences School of Public Health University of California Berkeley

Robert A. Cohen, MD, FCCP Professor of Medicine Northwestern University Feinberg School of Medicine Chicago, IL

Brian Dolan, PhD Professor and Chair Department of Medical Anthropology, History, and Social Medicine

Paul English, PhD, MPH Senior Branch Science Advisor Environmental Health Investigations Branch CA Department of Public Health Richmond, CA

Mike Falvo, PhD Research Physiologist, VA NJ War Related Illness and Injury Study Center Assistant Professor Rutgers New Jersey Medical School

George Friedman-Jimenez, MD, DrPH Director, Bellevue / NYU Occupational & Environmental Medicine Clinic Assistant Professor of Population Health Medicine and Environmental Medicine Bellevue Hospital Center

Diana Gagliardi, MD Medical Researcher Head of Unit, Support to International Research Networks INAIL, Italian Workersâ€™ Compensation Authority Rome, Italy

11 Course Faculty (continued) (University of California, San Francisco unless indicated)

Robert Goodnough, MD Medical Toxicology Fellow University of California San Francisco and California Poison Control System San Francisco Division

Robert Harrison, MD, MPH Clinical Professor of Medicine Public Health Medical Officer California Department of Public Health

Stephanie Holm, MD, MPH Volunteer Clinical Professor, Division of Occupational Medicine Corresponding Medical Staff PhD Student in Epidemiology, UC Berkeley School of Public Health

Seth M. Holmes, MD, PhD Professor UC Berkeley School of Public Health

Ware Kuschner, MD Chief, Pulmonary Section, VA Palo Alto Health Care System Professor of Medicine Division of Pulmonary and Critical Care Medicine, Stanford University

Anthony Luke, MD, MPH Professor of Clinical Orthopedic Surgery

Howard Maibach, MD Professor of Dermatology

David Miedinger, MD, PhD Chief Occupational Health Officer F. Hoffmann-La Roche Ltd. Basel, Switzerland Acran

Salmen-Navarro, MD MSc Program Coordinator - Ergonomist Bellevue / NYU Occupational & Environmental Medicine Clinic Bellevue Hospital Center, NYU School of Medicine

Suzaynn Schick, PhD Associate Adjunct Professor, Division of Occupational and Environmental Medicine

Leoncio Vasquez Santos Director Center for Indigenous Oaxacan Development (Centro Binacional Para El Desarrollo) Indigena Oaxaqueno Fresno, CA

12 Disclosures

The following individuals have disclosed they have no financial interest/arrangement or affiliation with any commercial interests who provide products or services relating to their presentation(s) in this continuing medical education activity:

John R Balmes, MD Samuel M Goldman, MD, MPH Michael N Bates, PhD Robert Thomas Goodnough, MD Paul D. Blanc, MD MSPH Robert J Harrison Robert Andrew Cohen, MD Stephanie Holm, MD, MPH Brian Dolan, PhD Seth Holmes Paul English, PhD, MPH Robert Kosnik, MD DIH Michael J Falvo, PhD Ware Kuschner, MD George Friedman-Jimenez, MD, DrPH Howard I. Maibach, MD Diana Gagliardi Suzaynn F Schick, PhD

The following individuals have disclosed having a financial interest/arrangement or affiliation during the past twelve months with a commercial interest who provides products or services relating to their presentation(s) in this continuing medical education activity. All conflicts of interest have been resolved in accordance with the ACCME Standards for Commercial Support:

Stock Shareholder (excluding mutual funds) Anthony D Luke, MD, MPH Sportzpeak Inc Holder of Intellectual Property Rights

Employee David Miedinger, MD PhD F. Hoffmann‐La Roche Ltd Stock Shareholder (excluding mutual funds)

This UCSF CME educational activity was planned and developed to: uphold academic standards to ensure balance, independence, objectivity, and scientific rigor; adhere to requirements to protect health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA); and, include a mechanism to inform learners when unapproved or unlabeled uses of therapeutic products or agents are discussed or referenced.

This activity has been reviewed and approved by members of the UCSF CME Governing Board in accordance with UCSF CME accreditation policies. Office of CME staff, planners, reviewers, and all others in control of content have disclosed they have no relevant financial relationships.

13 Wednesday, March 13, 2019 6:30pm-8:30pm Evening Poster Session and Opening Reception (Napa Ballroom)

Thursday, March 14, 2019 7:00 am Registration (Golden Gate Foyer) and Continental Breakfast (St. Helena Room) Vulnerable Workers and Communities at Environmental Risk 7:45 Welcome & Overview (Golden Gate Ballroom) Course Leaders 8:00 The Vulnerable Worker: Notes from the Field Robert Harrison, MD, MPH 8:50 How Medical Humanities Can Inform Our Brian Dolan, PhD Thinking About Vulnerable Populations 9:40 Coffee Break (St. Helena Room) 10:10 Lung Disease, Miners and Mining Communities: Robert Cohen, MD a Global Population at Risk 11:00 G, P Vulnerable Workers in New York City – George Friedman-Jimenez, Workplace Hazards and Interacting Risk Factors MD, DrPH and Acran Salmen-Navarro, MD, MSc 11:50 Lunch on own 1:20 pm P Indigenous (Native) Latin American Immigrants: Seth M. Holmes, MD, PhD and Among the Most Vulnerable Workers Leoncio Vasquez Santos 2:10 G An Aging Population at Work and at Play – Ware Kuschner, MD Vocations, Avocations, and Hobbies 3:00 Coffee Break (St. Helena Room) 3:30 Military Service as a Vulnerable Occupation: Mike Falvo, PhD Lung Disease as a Paradigm 4:20 Pediatric and Environmentally Exposed: Doubly Stephanie Holm, MD, MPH Vulnerable 5:10 Closing Panel – What Experience May Teach Us Moderator: about Vulnerable Populations Robert Harrison, MD, MPH Panelists: Mike Falvo, PhD Stephanie Holm, MD, MPH Ware Kuschner, MD 6:30 pm Adjourn

Friday, March 15, 2019 7:15 am Continental Breakfast (St. Helena Room) 7:50 Welcome & Overview (Golden Gate Ballroom) Course Leaders 8:10 P Sports Medicine: What An Occupational Medicine Anthony Luke, MD, MPH Practitioner Should Consider? 9:00 Volcanology for the Health Care Provider Michael N. Bates, PhD 9:50 Coffee Break (St. Helena Room) 10:20 Occupational Health in the Biotechnology Industry David Miedinger, MD, PhD 11:30 Dabs, Vapes and Third-hand Smoke: An Update on Suzaynn Schick, PhD Environmental Exposure to Tobacco and Marijuana 12:20 pm Lunch on own 1:50 Climate Change and Health in 2019 Paul English, PhD, MPH 2:40 Hazardous Metals: Emerging and Long-Standing Robert Goodnough, MD Toxicants 3:20 Coffee Break (St. Helena Room) 3:50 OEM Published Research: The Year in Review Samuel Goldman, MD, MPH 4:45pm Adjourn 14 Saturday, March 15, 2019 7:45 am Continental Breakfast (St. Helena Room) 8:15 Welcome & Overview (Golden Gate Ballroom) Course Leaders 8:30 Occupational Dermatology in 2019 – More than Howard Maibach, MD Just Contact Dermatitis 9:30 G The Italian Mesothelioma Registry: Lessons Diana Gagliardi, MD Learned 10:20 Coffee Break (St. Helena Room) 10:40 Innovation in Air Quality and Climate Change John Balmes, MD Mitigation Policies: The California Paradigm 11:30 Closing Panel – What are the Persistent or Emerging Moderator: Problems in Occupational and Environmental Samuel Goldman, MD, Medicine? MPH Panelists: John Balmes, MD Diana Gagliardi, MD Howard Maibach, MD 12:10 Adjourn

P – Pain Credit G – Geriatric Credit

15 16 The Vulnerable Worker – Notes from the Field

Robert Harrison MD, MPH Public Health Medical Officer California Department of Public Health Clinical Professor of Medicine University of California, San Francisco

TEL: 415 885 7580 Email: [email protected]

Disclosure

I have nothing to disclose

Tony Mazzocchi 1926 - 2002

17 “Statistics are human beings with the tears wiped away”

Irving Selikoff, MD 1915-1992

Which of these most closely describes the “vulnerable (precarious” worker?” 1. Lack of access to medical treatment 2. Fear of reporting injury or illness 3. Language and/or cultural barriers 4. Contingent employment 5. Low wage 6. All of the above

3.1 million new residents in last 10 years 10 million immigrants By 2030, 1 in 5 residents will be age 65 or older

18 19 Inequality worsening

American Community Survey 2006-2010, American FactFinder. Accessed March 2014.

Wages of low-wage workers falling

“A Generation of Widening Inequality.” The California Budget Office. November 2011.

20 Historical trends in unionization and inequality

Eisenbrey, R and Gordon, C. “ As unions decline, inequality rises.” Economic Policy Institute. June 6, 2012

Union membership in last 20 years

Current Population Survey 1994-2010, Accessed March 2014.

Low-wage workforce in CA

• 89 occupations with hourly median wage less than $11.93 • Over 4 million workers • 28.4% of the CA employed workforce

21 Lowest paid occupations in CA, 2012

May 2012 State Occupational Employment and Wage Estimates California. Occupational Employment Statistics. Bureau of Labor Statistics. Accessed March 2014.

What does the future hold for CA?

There will be an estimated 929,000 new low-wage jobs by 2020.

Of the new jobs created by 2020, 36.2% of them will be low-wage.

Occupation Title % Occupation Title # New Growth Jobs by by 2020 2020 Home health aides 52.4% Personal care aides 138,200 Personal care aides 42.6% Retail salespersons 103,600 Bicycle repairers 35.7% Combined food preparation 73,400 and serving Pharmacy aides 32.1% Cashiers 64,600 Nonfarm animal caretakers 31.1% Waiters and waitresses 59,600

Projections of Employment by Industry and Occupation. State of California Employment Development Department. Accessed February 2014.

Asuncion Valdivia July 28, 2004 • 53 y.o. man with dizziness, nausea, confusion after picking grapes for 10 hours in >100o heat in Kern County • Paramedics initially called but did not arrive on scene • Brought to Kern County Medical Center by son, died on arrival with body temperature > 108o

22 “Meeting in the Sun” July 28, 2005

• July 13 - Salud Rodriguez dies in bell pepper field • July 14 - Ramon Hernandez dies in melon field • July 20 - Agustine Gudino dies in tomato field • July 31 - Constantino Cruz dies in tomato field

August 3, 2005

This is a tragedy…and we will do everything it takes to prevent this from happening again”

August 8, 2005 Emergency regulations for heat illness

Public health action

Effective July 27, 2006 Effective July 27, 2006

23 May 14, 2008

• Maria Isabel Vasquez, age 17, two months pregnant • Immigrant from Oaxaca • Pruning grapes, employed by labor contractor x 3 days • 95 degree heat in Atwater • Collapsed and taken by driver to clinic with core temp = 108o • Died 2 days later

"Maria's death should have been prevented, and all Californians must do everything in their power to ensure no other worker suffers the same fate." - Gov. Arnold Schwarzenegger, May 28, 2008

Other faces

Maria Isabel Jimenez Ramiro Rodriguez May 14, 2008 July 9, 2008 17 y.o. picking grapes 48 y.o. picking nectarines

Jose Hernandez Jorge Herrera June 20, 2008 July 31, 2008 64 y.o. picking squash 37 y.o. loading grapes

Abdon Garcia Maria Alvarez July 9, 2008 August 2, 2008 46 y.o. loading grapes 63 y.o. picking grapes

24 “Bob – the leaves are falling all over the sidewalk!”

25 “Here Bob, I got a flyer in the mail. Call this guy he says he can do it tomorrow. ”

117,000 looking for work each day

50/50 private households and construction contractors Moving and hauling, landscaping, painting, roofing, drywall

26 “You know Robin, I heard these guys may not be really trained all that well.”

“Okay fine Bob, but we really need those branches trimmed”

27 +

“I just called an arborist guy, he’s coming out here tomorrow to give us a bid”

Very awkward posture

Going solar! My roof in Noe Valley. Could he trip?

It’s a long way down

Will this hold if he falls?

28 Irma Ortiz

• 40 y.o. woman • Mixed dry powder with diacetyl x 5 years • Symptoms of shortness of breath and cough. Treated for asthma. • FEV1 = 0.55 L (18% predicted). HRCT with ground glass opacities.

California Department of Health Services http://www.dhs.ca.gov/ohb/flavorings.htm Baltimore Sun - April 23, 2006 Sacramento Bee - July 30, 2006

Bronchiolitis obliterans

• NIOSH study at “sentinel” microwave popcorn plant • 4 of 8 workers on lung transplant list • One recent death

29 Toxicology studies

Exposed • Multifocal necrotizing bronchitis in rats exposed to 285-371 ppm of diacetyl

Control

Hubbs et aL: Necrosis of nasal and airway epithelium in rats inhaling vapors of artificial butter flavoring. Tox Applied Pharm 185:128 (2002).

Epidemiology studies Abnormal Spirometry by Diacetyl Exposure

40 35 • Airways obstruction in 30 25 popcorn workers 20 15 related to cumulative 10 5 diacetyl exposure 0

% affected % Lowest Second Third Highest quartile quartile levels (dose-response relationship) Cumulative diacetyl exposure quartiles

Kreiss K et al. Clinical bronchiolitis obliterans in workers at a microwave popcorn plant. NEJM 347:330 (2002).

Public health action

• Risk notification of employers, HCPs • Study of CA companies with use of diacetyl • Proposed Cal/OSHA standard

30 April 27, 2007 MMWR Publication Materna B et al.

Industry-wide Medical Surveillance of Workers in California Flavor Manufacturing Companies: Cross-sectional Results

Kim TJ, Materna BL. Prudhomme JC, Fedan KB, Enright PL,Sahakian NM, Windham GC, Kriess K: Amer J Ind Med 53: 857-65, 2010.

Petition for emergency standard CalOSHA 2006 - 2010 • AFL/CIO petition 8/24/06 for emergency standard granted by Standards Board 1/18/07 - referred to advisory committee • Advisory meetings held 9/28/06, 2/13/07, 3/21/07, and 5/18/07 • Public hearing 11/19/09 • Final standard passed September 16, 2010

31 § 5197 Occupational Exposure to Food Flavorings Containing Diacetyl.

• Medical surveillance at least every 6 months if > 1% diacetyl is used, or case of fixed obstructive lung disease • “Knowledgeable” occupational or pulmonary medicine • Mandatory Flavor Worker Questionnaires • Spirometry by NIOSH-certified technician • Medical removal benefits

DCM fatalities in bathtub refinishers: US

• In early 2012, Michigan FACE, Fed/OSHA, and NIOSH collaborated on an MMWR article documenting a total of 13 fatalities among bathtub refinishers in US between 2000 and 2011. • All were linked to DCM inhalation.

32 33 .87 g/m3 ------ACGIH STEL

34 Baptist Church, Southern California (May 2010) • 24 year-old maintenance worker was assigned to strip the Baptismal Font of the church using DCM-containing stripper. • Worker applied ~ 1 gallon of “Klean-Strip Premium Sprayable Stripper” to floor.

35 June 23, 2017 - California

36 European Union banned sale to general public in 2009 “Paint strippers containing DCM are used by members of the general public at home to remove paints, varnishes and lacquers both indoors and outdoors. The safe use of DCM by them cannot be ensured by training or monitoring. Therefore, the only measure effective in eliminating the risks arising for the general public from paint strippers containing DCM is a ban, with respect to the general public, on the marketing, supply and use of such paint strippers.”

April 28, 2017 - Tennessee

37 Drew Wynne February 12, 1986 - October 14, 2017

Joshua Atkins November 9, 1986 – February 12, 2018

38 Artificial Stone Silicosis: Disease Resurgence Among Artificial Stone Workers

Kramer et al: Chest 2012

39 Outbreak of silicosis in Spanish quartz conglomerate workers

Perez-Alonso et al., Int J Occ Environ Health, 2014

MMWR Case Report February 13, 2015

40 41 Fatal silicosis in engineered stone fabrication worker – CA, 2019*

37 year old immigrant from El Salvador with 8 years exposure to silica dust (>20x PEL) while fabricating engineering stone. Biopsy + mixed dust pneumoconiosis 2013 (K. Jones), systemic sclerosis. Died from respiratory failure - September 2018. * Heinzerling, Flattery, Weinberg, Blanc, Balmes, Elicker, Potocko, Guiness, Harrison)

Bronchiolitis obliterans is best characterized by:

A. Reversible airways obstruction on PFTs

B. Mosaic attenuation and bronchial wall thickening on HRCT

C. Response to bronchodilators

D. Mononuclear cell infiltration and poorly formed granulomas on pathology

42 Silica dust exposure can cause all EXCEPT: A. Bilateral diffuse ground glass opacities

B. Increased risk of TB

C. Systemic sclerosis

D. Liver cancer

Acute methylene chloride fatalities may be due to: A. Carboxyhemoglobin formation

B. CNS depression

C. Cardiac sensitization

D. All of the above

43 44 How Medical Humanities Can Inform Our Thinking About Vulnerable Populations Brian Dolan, PhD Chair, Department of Anthropology, History & Social Medicine UCSF

I have nothing to disclose

What is / are the medical humanities? (a.k.a. health humanities)

Goes back 100 years referring to non‐science instruction for medical students in subjects such as history, accounting, foreign languages.

The rise of social sciences and literary studies in the 1960s onward now also groups in subjects such as bioethics, medical anthropology, sociology, and narrative medicine.

Broadly, anything that studies social relations of science, clinical practice, and patients.

45 What is a vulnerable population?

Vulnerable

Latin: vulnus (wound)

“capable of being attacked, harmed, or injured in some way.” ‐ R.E. Goodin, Protecting the Vulnerable (University of Chicago Press, 1985)

Universal Declaration of Human Rights

Adopted by United Nations General Assembly in 1948, the documents do not single out any particular group.

Considering the universal nature of human rights, does singling out a certain group defeat the purpose of seeing human rights (e.g., dignity and equality) as something for everyone?

Some philosophers suggest everyone has “embodied vulnerability” making vulnerability a universal, not a particular, trait.

Outline

History: The legislative evolution of the term “vulnerable population”

Bioethics: The rise of responsible conduct of research protocols

Global Health: The challenge of cross‐cultural research

Sociology: The irony of exclusion in clinical trials

Medical Anthropology: Refining the clinical encounter to detect structural vulnerabilities

Narrative Medicine: Giving voice to vulnerable populations

46 National Institutes of Health, WMA

1953: Clinical Research Center established Ethics board to review all proposed research at the hospital according to Nuremberg Code: informed consent, risk‐benefit analysis, patient’s right to withdraw participation

1964: NIH Director James Shannon established policy that all public research funded by NIH be reviewed by ethics board

1964: World Medical Association adopts Helsinki Declaration

47 Milestones in Ethical Codes

1947 Nuremberg Code 1949 World Medical Association International Code of Medical Ethics 1964 Helsinki Declaration 1966 U.S. Surgeon General policy statement

1974 National Research Act (Public Law 93‐348) * first federal law regulating human subject research

National Research Act (1974) Title I: Biomedical and Behavioral Research Training Title II: Protection of Human Subjects of Biomedical and Behavioral Research

Establishes National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research

Commission produces a number of recommendations to protect fetuses (1975), prisoners (1976), children (1977), mentally infirm (1978), IRBs (1978)

Culminates in “Belmont Report” (1979) that guides enforcement of federal regulations.

48 The challenges of global health interventions

2001: Office of Human Research Protection: “special classes of subjects”

* traumatized / comatose patients * elderly / aged patients * minorities * students * employees * normal volunteers

2002: WMA revised Helsinki Declaration: “economically and medically disadvantaged”

49 Six types of vulnerability 1. Cognitive 2. Juridic 3. Deferential 4. Medical 5. Allocational 6. Infrastructural

Academic Medicine 92:3 (2017)

Narrative Medicine and Voices of Vulnerability

50 Thank you

Quiz to follow

Q1: Which of the following represents the US Government’s FIRST federal law regulating biomedical research on human subjects?

A) The Nuremberg Code of 1947 B) The Helsinki Declaration of 1964 C) The National Research Act of 1974 D) The Belmont Report of 1979

Q2: “Infrastructural vulnerability,” referred to by Kenneth Kipnis when working for the National Bioethics Advisory Commission in 2001, does NOT refer to which the following:

A) The socio‐economic background of the research subject B) The availability of a skilled healthcare professional C) The existence of an Institutional Review Board (IRB) to check the study design D) A reliable supply of electricity when an investigation requires frozen biological agents

51 Q3: According to some philosophers, the Universal Declaration of Human Rights (UDHR) is at odds with the concept of identifying a specific vulnerable population because:

A) Modern medicine has elevated everyone above the threat of vulnerability B) The whole human rights system is founded on a concern for “embodied vulnerability” that affects everyone, universally C) Human rights apply only to citizens of Enlightened, democratic governments D) Vulnerability is a useless term that is impossible to define or measure

52 Lung Disease, Miners, and Mining Communities, a Global Population at Risk University of California, San Francisco – Division of OEM March 14, 2019

Robert Cohen, MD, FCCP Clinical Professor - EOHS, University of Illinois School of Public Health Chicago, Illinois

Professor of Medicine Northwestern University Feinberg School of Medicine

Aerial view of Brumadinho, Brazil 1/25/19

Disclosure of Financial Interest

 Funded by the Alpha Foundation for the Improvement of Mine Safety and Health  Funded by HHS/HRSA/ORHP/BLCP & BLCE  Employee of NIOSH/RHD  Funded by USDOL/OWCP & MSHA  Funded by Queensland Government, Australia  Provide IME’s for Occupational Lung Disease

Goals for Today’s Talk

 Discuss examples of mining related lung disease in global populations  Describe risks to communities from mining related activities  Surface Mining  Underground Mining  Mine Materials Processing  Give examples of mining related disasters that affect workers, their families, and their communities

53 Coal’s Deadly Dust – Frontline/PBS/NPR 1/22/19

Rapidly Progressive CWP by County

4.5 - 20.0%

22.2 - 40.0%

41.7 - 60%

61.5 - 80%

* Results from NIOSH Coal Workers’ Health Surveillance Program, 1996-2002 Not shown are counties with fewer than 5 miners evaluated

VA KY

54 Results

 Risk factors  Smaller mine > larger mine  Longer tenure in jobs at face  Younger > older  Implicating recent mining conditions  Other factors  Mining technique  Approaches to dust control  Enforcement of PEL

NIOSH CWHSP – Surveillance of Active Miners

. Participating medical facilities . NIOSH mobile outreach . Screening chest radiographs received in FY-2017  7423 radiographs received 3110 underground miners 2383 from surface miners 1930 from contractors  2812/7423 from mobile outreach unit . Screening lung function with spirometry currently being implemented as part of testing offered by CWHSP

Radiographic Findings of Pneumoconiosis in CWHSP Participants (5‐year moving average)

35 Mining Tenure 25+ 20-24 30 15-19 10-14 0-9 25

Prevalence (%) Prevalence 15

0 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 Year

55 Radiographic Findings of Pneumoconiosis in CWHSP Participants from KY, VA, and WV (5‐year moving average) 40

Mining Tenure 35 25+ 20-24 30 15-19 10-14 0-9 25

Prevalence (%) Prevalence 15

0 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 Year

Radiographic Findings of Pneumoconiosis in CWHSP Participants Other Than From KY, VA, WV (5‐year moving average) 40

35 Mining Tenure 25+ 20-24 30 15-19 10-14 0-9 25

Prevalence (%) Prevalence 15

0 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 Year

Blackley DJ, Halldin CN, Laney AS. Resurgence of a debilitating and entirely preventable respiratory disease among working coal miners. Am J Respir Crit Care Med. 2014;190(6):708-709. doi:10.1164/rccm.20 1407-1286LE.

Prevalence of progressive massive fibrosis (PMF) among working underground coal miners with at least 25 years of underground mining tenure in KY, VA, and WV

56  1/1/15–8/17/16, a total of 60 patients with PMF  49 had their radiograph taken during 2016.  High proportion of miners with very advanced disease:  52% category A  38% category B  10% category C  Surveillance data have indicated a resurgence of PMF in recent years, but the cases described in this report represent a large cluster not discovered through routine surveillance.

Chest radiograph image taken in 2016 of a 56-year-old male eastern Kentucky resident with 29 years of total mining tenure (including 11 years as a roof bolter). Category C PMF , Profusion q/q 3/2

57 416 Case of PMF from 3 Clinics in VA

Blackley et. al. JAMA 319:5 p. 500-501

 The prevalence of PMF among former miners is less well understood.  Data taken from the U.S. Department of Labor Office of Workers Compensation Administrative Data Set  Used DOL determination classification of PMF and total disability  This study is the first to report trends in the proportion of Black Lung claimants with PMF using data from the Federal Black Lung Program.  These data are independent of national surveillance data and help us further understand the burden of PMF among former U.S. coal miners.

58 Results

 Evaluated 341,176 claims between 1970–2016  PMF % of claims increased from 1970–2016  PMF % of claims accelerated since 1996.  2,474 cases of PMF identified from 1996–2016  This is more than 10 times the number identified CWHSP (n=225).  Increase in PMF occurred as workforce declined and claim rate remained stable.  PMF cases greatest from Kentucky, Virginia, and West Virginia.

450 250,000

400

200,000 350

300 150,000 250

200 100,000 150

Number of Claimants Claimants withPMF of Number 100 50,000

50 Employees Mine Coal of Number Average

0 0 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015

Year Figure 1. Number of miners with PMF compared to average annual coal mine employment, 1970– 2016. The number of claimants with PMF from 1970–1972 are combined due to small numbers. Office workers are included in employment totals from 1973–1977. Data sources: U.S. DOL, OWCP, DCMWC; U.S. DOL, MSHA; and the EIA.

Geographic Distribution of PMF Cases

59 PMF cases found in retired miners who never participated in NIOSH CWHSP.

 Why don’t miners participate?  Holes in the social safety net:  1985 – 2005, employment in the Appalachia coal mining industry declined by 56% due to  Cost of coal relative to oil and natural gas  Increased mechanization  Shift to contract labor  Fear of job loss  Fear of disease and associated disability  Mistrust of government

Reynolds L, Halldin CN, Laney AS, Blackley DJ. Coal miner participation in a job transfer program designed to prevent progression of pneumoconiosis, United States, 1986–2016. Arch Environ Occup Health. November 2017

Part 90 Option

Miner notified Miner can Miner of radiographic exercise Part 90 findings participates option through consistent with in CWHSP MSHA CWP

60 Part 90 Option Program Data

NIOSH MSHA CWHSP Miners who Eligible Part 90 exercised their Part option miners 90 option

Exercising the Part 90 Option

14% of eligible miners exercised their Part 90 right in the last 30 years Median days to exercise Part 90 option was 63 days (range 0 – 10831 days) Miners who exercised their option more quickly were older and had longer mining tenures

Exercising the Part 90 Option

Miners working in central Appalachia were less likely to exercise Part 90 compared to those in other states Miners from Virginia and Kentucky were least likely to exercise their option, at 8.9 % and 9.8% Miners from Utah and Colorado were most likely to exercise their option, at 32.8% and 30.2%

61 Mining Disasters

Mining Related Disasters

Explosions Inundations Roof Falls – Mine Collapse Fires

62 Inundations – Quecreek, Somerset, PA July 24-28, 2002

9 Miners trapped for 77 hours Rescue hole was drilled Capsule lowered and all were saved

SAGO MINE EXPLOSION

DRIFT JANUARY 2, 2006 OPENI NG INTERNATIONAL COAL GROUP SAGO MINE

MSHA I.D. No. 46-08791

Sago Mine Explosion and Fire

12 Miners died and one severely injured in the explosion occurred at approximately 6:26 AM on January 2, 2006.

63 5/22/2006 Darby Mine, Kentucky 5 Miners died in methane mine explosion

Aracoma Alma Mine # 1 Conveyer Belt Fire – 2 Deaths Logan County, WVA

Crandall Canyon Mine Utah

August 6, 2007 and August 16, 2007 Roof Fall During Retreat Mining 3 Rescuers died in subsequent bump event

64 Upper Big Branch Mine - April 5, 2010

Upper Big Branch, April 5, 2010

 Fire and Explosion Killed 29 Miners  Analysis of the pattern of injuries from the Upper Big Branch Disaster showed 10 deaths from CO  The remainder primarily due to blast and thermal injuries  A systematic pathologic review suggests a continuing high proportion had pneumoconiosis 86%  Settlement of law suit resulting from the disaster resulted in the formation of the Alpha Foundation which is funding part of our work

65 Copiapó mining accident – Chile 2010 33 Men trapped for 69 days – roof fall

The Case of the Cananea Copper Mine – Sonoro Mexico

66 Cananea Copper Mine

Mexico’s Largest Open Pit Mine Opened in 1899 Open pit mining techniques – drilling and blasting Ore greater than 0.34% copper is then ground to powder Agitated with water and reagents

Cananea Copper Mine

 Sent to flotation cells  Air pumped in causing it to froth and copper mineral floats  Copper then concentrates with average of 26.6% copper and sent to smelter for processing  Ore between 0.15% and 0.34% is sent to leaching facility where sulfuric acid is poured onto material in a leaching procedure solvent extraction with electrowinning

Cananea Copper Mine

Workers struck in 2007 over working conditions, health, and control of the union Site of 1906 Strike that fueled the Mexican revolution against then Presdient Porfirio Diaz. Mexican army took back the site in 2010.

67 68 69 70 71 72 73 74 75 76 77 Strike Support Rally

Mexican Miners Union National Forum Cananea Union Hall

February 2, 2008

Strike was crushed by Federal Government forces in 2010

78 79 Mining Related Environmental Disasters

Dam Failures Fresh Water Contamination with heavy metals, chemicals Air Pollution – dust, diesel exhaust particulate Subsidence

Cananea Copper Mine – Environmental Disaster – 8/6/14

Massive spill of copper sulfate 40,000 m3 leaked into tributary of Sonora river and San Pedro River

80 Cananea copper mine spill August 6, 2014

Polluted Arroyo Las Tinajas (17.6 km) Bacanuchi River (64 km) The main stream of the Sonora River (190 km) Affected seven municipalities inhabited by 20,048 people. The pollution led the government to close 322 wells, leaving local communities without water for domestic and farming uses.

Miners and farmers unite to protest Grupo Mexico’s Handling of Spill 3/27/15

81 Charleston West Virginia – Elk River

Kanawah River Contamination 1/9/2014

Storage Tanks of 4-methylcyclohexanemethanol (MCHM) – coal floculent ruptured and spilled into Kanawah River 7,500 gallons leaked Also contaminated with glycol ethers (PPH)

Kanawah River Contamination Charleston, WV

The chemical smelled like licorice in the parts per billion concentration so it was detected by the population. Seperates fossil fuel from dirt and rock Used in coal prep plants Affected 300,000 West Virginians Had been classified as non-hazardous chemical and therefore not regulated

82 Retention Dam Failures Brumadinho, Brazil 1/25/19

Brumadinho – Iron Ore Mine – Minas Gerais, Brazil

Killed 186 with 122 still missing Owned by BHP/Vale Mining Corporation Prior Dam Failure in 2015 Prosecutors removed top 3 executives March 3, 2019

83 Dam/incident Location Fatalities Details A tailings dam at copper mine near the city of Vratsa failed. A total 450,000 cu m of mud and water inundated Vratsa and Mina Plakalnitsa Vratsa, Retention Dam107 Failuresthe nearby village of Zgorigrad, which suffered widespread 5/1/1966 Bulgaria damage. The official death toll is 107, but the unofficial estimate is around 500 killed. Certej Mine, Certej dam failure 89 A tailings dam built too tall collapsed, flooding Certeju de 10/30/1971 Romania Sus with toxic tailings. Unstable loose constructed dam created by local coal Buffalo Creek Flood West Virginia, 125 mining company, collapsed in heavy rain. 1,121 injured, 507 2/26/1972 United States houses destroyed, over 4,000 left homeless.

Martin County coal slurry Failure of a coal slurry impoundment. The water supply for over Martin County, spill 27,000 residents was contaminated. One of the worst United States 0 10/11/2000 environmental disasters ever in the southeastern United States.

Failure of concrete impound wall on alumina plant tailings Ajka alumina plant Ajka, dam. One million cubic meters of red ;mud contaminated a accident 10 Hungary large area, within days the mud had reached the Danumbe 10/4/2010 river. Tailings dam collapsed. One village destroyed, 600 people Mariana dam disaster Mariana, 19 evacuated. 60 million cubic meters of iron waste slurry 11/5/2015 Minas Gerais, Brazil polluted Doce River, and the near the river's mouth. Brumadinho, Brumadinho dam disaster 142 Tailings dam suffered a catastrophic failure releasing 12 million 1/25/2019 Minas Gerais, Brazil cubic meters of tailings slurry. 248 people missing.

Tailings Dam Collapses

84 85 86 Risks associated with mining to workers and their communities include all of the following except:

A. Inundations/Dam Failure B. Infections such as HIV AIDS and Tuberculosis C. X-ray exposure D. Excess non-malignant respiratory disease E. Air and water pollution

All of the following mining related contaminants have been associated with lung cancer

A. Radon B. Silica C.Lead D.Diesel Exhaust

87 Rural communities have suffered major adverse health effects related to mining including all of the following except:

A.Subsidence B. Air pollution C.Water Pollution D.Retention Dam Failures E. Heavy metal toxicity

88 Vulnerable workers in NYC Workplace hazards and interacting risk factors

Presented at UCSF conference on Vulnerable workers and communities at environmental risk University of California, San Francisco March 14, 2019

George Friedman‐Jimenez, MD, DrPH, Director Acran Salmen‐Navarro, MD, MSc, Ergonomist and Program Coordinator

Bellevue/NYU Occupational Environmental Medicine Clinic NYU School of Medicine and Bellevue | NYC Health and Hospitals

Disclosure slide

Dr. Friedman‐Jimenez declares no conflicts of interest. Dr. Salmen‐Navarro declares no conflicts of interest.

Learning Objectives After this session, participants will be better able to: Describe important work‐related exposures and illnesses that may disproportionately impact vulnerable workers. Explain how non‐work‐related risk factors can increase vulnerability of workers to work‐related illness or injury. Use understanding of interacting work‐related and non‐work‐related risk factors to facilitate prevention of work‐related illnesses and injuries in vulnerable workers. 3

89 Definitions Vulnerable: Exposed to the possibility of being attacked or harmed (Oxford) Can include aspects of risk (probability), severity of potential harm, difficulty of avoiding harm Worker: A person who does a specified type of work or who works in a specified way, especially one who does manual or non‐executive work (Oxford) More inclusive than “employee”, can also include “independent contractors”, self‐employed Risk factor: A risk factor is any attribute, characteristic or exposure of an individual that increases the likelihood of developing a disease or injury. (WHO) This definition suggests causation but in common usage, some RFs have non‐causal explanations like chance or bias 4

Definition of Work‐Related

“You must consider an injury or illness to be work‐related if an event or exposure in the work environment either caused or contributed to the resulting condition or significantly aggravated a pre‐existing injury or illness.”

Source: US Federal OSHA 1904.5(a) determination of work‐relatedness

Demographics of working populations in NYC

In NYC (2016) population was 29% “Hispanic or Latino”, 32% “White”, 22% “Black or African American”, 13% “Asian”, 3% multiple races. Rates of low‐income and poverty among “Hispanic or Latino” and “Other race” are almost two times higher than those among “White”. More than one of third of the NYC population are foreign born and about half of them speak language other than English at home. Foreign‐born adults are less educated and less likely to have access to health care than US‐born adults.

90 NYC family income by race/ethnicity

Black / Hispanic Some Two or Race* White African Latino, Asian Other More American any race Race Races Total # of 812,449 473,282 519,327 235,169 275,434 38,228 family Total # of 3,535,281 2,007,826 2,279,348 1,020,507 1,186,755 212,724 people Income below 515,342 515,342 634,319 187,132 355,204 45,885 poverty Percent Income below 15% 22% 28% 18% 30% 22% poverty

NYC Family Income in The Past 12 Months (In 2011 Inflation-Adjusted Dollars) Source: U.S. Census Bureau, 2007-2011 American Community Survey 5-Year Estimates. * Except where noted, 'race' refers to people reporting only one race. ‘ Hispanic' refers to an ethnic category; Hispanics may be of any race. http://www.census.gov/easystats/ 7

Why do some people get a disease and others don’t?

Genetic factors Environmental factors including infections and socioeconomic factors Other (acquired) differences in susceptibility Aging “Chance”

Why do some people get a disease and others don’t?

If 80% of cases of a disease are believed to be caused by genetic factors, then all the other factors (environmental, socioeconomic, aging, etc) cause the other 20%, right?

91 Gene‐Environment Interaction Nearly all diseases result from a complex interaction between an individual’s genetic make‐up and the environmental agents that he or she is exposed to. (NIEHS website) When G‐E interaction, the “genetic” fraction and the “environmental” fraction typically add up to well over 100% Extreme example: Phenylketonuria Genetic fraction: close to 100% have phenylalanine hydroxylase (PAH) deficiency Environmental fraction: 100% have dietary phenylalanine exposure Sum near 200% because both genetic and environmental factors are needed to produce the disease in each individual G‐E interaction, "a different effect of an environmental exposure on disease risk in persons with different genotypes“ (Ottman, 1996) Environmental factors can interact with each other as well as with genetic factors

Some Occupations at High Risk for Work‐Related Illnesses (WRI) in NYC

Building maintenance and cleaning workers, residential, commercial Demolition / construction laborers Car wash workers Dry cleaning and laundry workers Food preparation, retail and delivery workers Musicians, other workers in entertainment venues with loud music Healthcare workers and health aides Mechanics, auto, public transport, aircraft Hairdressers, manicurists / pedicurists, and cosmetologists Sanitation and sewer workers Transportation workers: taxi, bus, subway Painters; furniture refinishers; Florists, landscapers, and groundskeepers; carpenters helpers & woodworkers; roofers; road repair & bridge workers; welders; animal handling workers; cashiers, convenience store and other retail workers; exterminators; artists and artisans; morticians and morgue workers; …

Common workplace exposures that can cause WRI

Cleaning and disinfection agents including chlorine bleach, quaternary ammonium compounds, detergent enzymes Poor ergonomic design of furniture, tools, machines, production processes Lead, mercury, arsenic, manganese, cadmium, other metals Asbestos, silica, coal, mixed mineral dusts Known and reasonably anticipated human carcinogens Methylene Chloride, trichloroethylene, perchloroethylene, methyl ethyl ketone, n‐hexane, other solvents Several hundred airborne high and low molecular weight sensitizing agents that can cause occupational asthma Even more airborne irritants that can aggravate asthma or other existing lung diseases

92 WRIs commonly seen in the BNOEMC

WR lung disorders: Asthma Upper airway irritation Other airway obstruction and COPD Pulmonary fibrosis HP/EAA Contact dermatitis, mostly irritant, sometimes allergic or unclear which Upper extremity WMSDs, other manual material handling injuries, CTS Lead, mercury toxicity and exposure Dietary/supplement elevations in arsenic, lead, mercury Sound induced hearing loss Fragrance‐related medically unexplained symptoms 13

Risk factors/causes for these WRI: RF is WR, Modifiable

Current toxicant, allergen, particulate, infectious exposures Poor ergonomics or physically unsafe conditions Low wages => long work hours, multiple jobs Workplace power relationships that discourage or block preventive interventions Workplace stress Unorganized workers may have more difficulty negotiating preventive workplace interventions Vocational training and ability to switch to job with less hazardous exposures Inadequate OSH training Workplace with racist, sexist, classist policies, prejudiced individual managers & coworkers Poor access to medical care, housing long distance from work 14

Risk factors/causes for these WRI: RF is WR, Not Modifiable Past WR exposures with potential long term effects: asbestos, ETS, Pb, other persistent toxicants, ergonomic risk factors Past allergen sensitization Relevant WR comorbid medical conditions

93 Risk factors/causes for these WRI: RF is Not WR, but is Modifiable

Language limitations Vocational training Match of educational/job skill limitations/aging and changing societal demand for job skills Current lifestyle: diet, exercise, tobacco, alcohol and other drugs Relevant non‐WR comorbid medical conditions

Risk factors/causes for these WRI: RF is Not WR, Not Modifiable Time (Age, Induction and latency period) Genetic constitution Past lifestyle exposures with potential long term effects: diet, exercise, tobacco and other drugs Race, ethnicity, immigrant status, religion Culturally/politically entrenched racism, sexism, classism Societal political forces discouraging unions, worker organizations, appropriate and effective regulatory legislation and enforcement Community and family poverty Sex, sexual orientation‐, gender identity‐related factors

Risk factors/causes for WRI

4 categories of WR/modifiability RF is probably Work‐Related and potentially modifiable RF is probably Work‐Related but difficult or impossible to modify RF is probably not Work‐Related but is potentially modifiable RF is probably neither Work‐Related nor modifiable While OH focuses on modifiable WR causes, non‐WR causes synergistic with WR causes may amplify the risk of the WR causes leading to disparities in risk of WRIs Subgroups with excess WRI risk due to synergisms with non‐WR causes may thus be particularly important targets for control of the modifiable WR causes

Irving Selikoff, “Go where the (occupational) dise1a8 se is.”

94 Medical conditions identified as most important in NYCH+H outpatients 10 most significant Community Health Needs as ranked by NYCH+H facilities 1) Hypertension 6) Substance use 2) Diabetes 7) Asthma 3) Obesity 8) Cancer 4) Heart disease 9) Smoking 5) Mental illness 10) Violence Some may be WR in some patients, some may interact with WR exposures to increase vulnerability to WRIs eConsult being developed to improve primary care providers’ access to specialist expertise, including OM

Multiple causes of a disease, illness or disability are the rule, not the exception

Different causes (WR or non‐WR) can be mutually exclusive Different causal pathways or “mechanisms” No interactions OR Different causes can contribute to the same causal pathway or “mechanism”

Note that “Mechanism” can be used in a general multilevel sense Genetic/epigenetic/molecular Cellular/organ Whole person Socioeconomic/political/societal

Understanding how multiple causes interact (or not) can help with preventive interventions as well as with Workers’ Compensation 20

Accurate judgment of work‐relatedness in individual patients is important Workers with actual WRI that are erroneously judged not WR or for whom WR causes are lightly dismissed or not even considered: May experience preventable worsening or progression of illnesses or disabilities due to ongoing WR exposures that should have been stopped Will not get Workers’ Compensation benefits to which they are entitled Workers with non‐WRI erroneously attributed to WR causes: May be fired, demoted, marginalized or otherwise harmed trying to get unneeded workplace interventions implemented These interventions are not needed and would not have been effective, since they did not cause, contribute to or aggravate the illness Workers’ Compensation for qualified WRIs can be critically important Enable access to medical care for the WRI Enable prevention of further exposure and progression of injury, disease or disability by avoiding forced re‐exposure to hazards Reduce the likelihood of poverty for the patient and his or her family, prevent need for public assistance, prevent homelessness. Make death benefits to family possible 21

95 Definition of Cause

“A cause of a disease occurrence is an event, condition or characteristic that preceded the disease onset and that, had the event, condition or characteristic been different in a specified way, the disease either would not have occurred or would have occurred at a later time.”

Source: Rothman, Modern Epidemiology, 2008

Rothman (1976) “Pie Model” of Component and Sufficient Causes

SC1 SC2 SC3 SC4

Each exposure (Asbestos and/or Smoking) is a component cause (CC) in one or more Sufficient Causes (SC) Each U is a set of unmeasured CCs necessary to complete that particular SC mechanism, eg: Genetic factors eg, CYP1A1 and others for lung cancer Induction period for initiation, and latency period for development and clinical manifestation of the disease Comorbid conditions affecting disease risk 23

“Causal Pie Bingo” Source: Johnson & Howards ltr, Epidemiology 2013 The U and each observed exposure occur over time and can accumulate in each person. In a population, there is generally more than one SC for each outcome. Can think of each SC as a different complete mechanism for exposure‐disease causation. The outcome occurs as soon as the person has accumulated all the CCs for one SC mechanism. The first SC that is completed “wins”, ie is the only one that counts for attribution Which SC actually occurred often cannot be identified clinically or epidemiologically. 24

96 What is Interaction? RFs / causes can combine in additive, sub‐ additive or supra‐additive manner Additive causes often called no interaction Sub‐additive interactions called antagonism Supra‐additive interactions called synergism “Multiplicative” is a special case of supra‐ additive interaction

Asbestos, Asbestosis, Smoking, and Lung Cancer (Markowitz 2013)

Groups Exposures Age Adj RR All workers No ASB, No SMK 1 ASB, No SMK 5.2 No ASB, SMK 10.3 ASB, SMK 28.4

No Asbestosis No ASB, No SMK 1 ASB, No SMK 3.6 No ASB, SMK 10.3 ASB, SMK 14.4

Asbestosis No ASB, No SMK 1 ASB, No SMK 7.4 No ASB, SMK 10.3 ASB, SMK 36.8 27

97 Combined excess risk of LC from asbestos and smoking

Is there interaction between asbestos a and smoking s? In simplistic additive model (no interaction), sum of individualexcess RRs equal the joint excess RR (RRa‐1) + (RRs‐1) = joint excess RRas = RRas‐1

No asbestosis: Risks of LC due to asbestos and smoking are closeto additive, few cases due to joint a+s exposure (3.6‐1) + (10.3‐1) = 11.9 and joint excess RRas = 14.4‐1=13.4

Asbestosis: Risks of LC due to asbestos and smoking are supra‐ additive (interaction, synergism) (7.4‐1) + (10.3‐1) = 15.7 and joint excess RRas = 36.8‐1 = 35.8

More cases due to joint a+s exp than to either one alone Irving Selikoff, “Go where the disease is.” 28

56 year old woman food preparation worker with lateral epicondylitis

WR factors: shucked oysters 3‐4 hours a day, forceful supination R hand, high pace of work Non‐WR factors: accountant in Mexico, not used to manual labor, low English proficiency, could not find non‐manual job, workers not organized by union or worker center Diagnoses: Lateral epicondylitis, R; trigger finger, R middle Etiologies: Repetitive forceful R hand supination, poor tool design, forced fast pace of work, difficulty changing jobs, worker organization not available Medical tx: Rehab, PT, NSAIDS Workplace preventive treatment included: “Light duty” change in job tasks: her orthopaedist wrote letter that she should not lift more than 5 pounds, led to her being fired 3 months medical leave supported by Workers’ Comp New job in bakery with no repeated forceful supination of hand Potential role for Preventive Ergonomic interventions and Collaborative Community/University occupational health approach, collective bargaining for H&S improvements, however workplace was not organized

Ergonomic Oyster Shucking Knife A or B?

AB Why? 30

98 Community/university collaborative approaches

Sanctuary Service • New York City’s public policies, which is focused on a no discrimination policy regardless of income or immigration status • Safe Haven Hospital System

Clinic’s outreach program • Community Based Organizations (CBO) • Unions • Organized workers • Proactive employers

Community/university collaborative approaches

Community Organizations / Unions • Community Based worker centers are often ethnically focused • CBO worker centers and unions can synergistically enhance the effectiveness of one or the other to address workplace H&S issues of immigrant workers.

Proactive Employers • Case 1 ‐ ROC New York Project – Restaurant Workers • Case 2 ‐ Proactive improvement – Restaurant owner case • Case 3‐ Carwash encounter with Owner’s representative

Vulnerable Worker and Community

NYC working population disparities, cultural and social determinants

99 Vulnerable Worker and Community

Occupational health and Immigration • Over 3 million migrant workers in NYC • Over 300 thousand Undocumented workers in NYC • Voluntary / Forced Migration • Occupational downgrading and undervalued

Aging working population • Combined vulnerability • Shifting from physical to experience demand

Community / university industry‐specific ergonomic intervention

Restaurants • Chef / Sous chef • Cook • Pastries • Dishwasher • Waiter Office

• Office Ergonomics

Community / university industry‐specific ergonomic intervention

Carwash • Soaping • Vacuuming • Drying • Driving Hospitality • Housekeeping • Bell boys • Front desk • Hotel laundries • Kitchen Nail Salons • Steward • Manicure • Pedicure • Chemical exposure • UV Light

100 Community / university industry‐specific ergonomic intervention

Construction • Demolition • Carpenters • Cement • Bridge • Electricians • Plumbers

• Supermarkets Checkout cashiers • Shelving • Fruit / Vegetable • Meat / Fish / Poultry

Community / university industry‐specific ergonomic intervention

Laundries

• Bag sizes • Bag content • Sorting • Chemical usage

Community / university industry‐specific ergonomic intervention

Participatory Ergonomic intervention / Preventive Culture Training: Train‐the‐Trainer: Direct and Indirect Impact • Work Leaders • OSHA‐10 / 30 trainings • Daylabor (Paradas) trainings “Mujeres y hombres de la esquina” • Evidence based scientific program reviews • Community Awareness Clinic Referral: Case management / Safe return to work

101 42 year old man, car wash worker with foot infection WR factors Shoes frequently soaked all day with run‐off solution of cleaning chemicals including KOH solution used to clean wheels 12 hour workdays, 6 days per week, waterproof footwear not provided Non‐WR factors No medical insurance, poor access to medical care, poorly controlled DM Ecuadorian immigrant, difficulty finding other jobs Unable to take days off due to financial situation Diagnoses: Fungal infection of both feet, onychomycosis, cracked skin between toes, bacterial superinfection one foot Etiologies: direct effects and interaction between WR exposures, poorly controlled DM, inability to change jobs

42 year old man, car wash worker with foot infection Medical treatment: Antifungal, antibiotics, improved foot hygiene, treatment of DM Workplace preventive interventions: Waterproof footwear, change socks if wet, improve floor drainage Worker center collaborated with union to organize Latino workers Clinic provided IH and ergonomic recommendations for preventive interventions Current status: Union voted in, contract signed with H&S language, some H&S changes made but more negotiation will be needed to get employer to cooperate fully to implement H&S changes

Car wash worker in wet shoes

102 New programs at NYCH+H|Bellevue to improve OH of vulnerable workers

Telehealth and eConsult to improve referrals between occ med and primary care Identify, diagnose, preventively treat primary care patients with work‐related asthma Identify, diagnose, ergonomically evaluate and preventively treat primary care patients with work‐ related musculoskeletal disorders Facilitate filing of Workers’ Compensation for patients with WRIs seen in other Bellevue clinics OH needs assessment NYC Asian‐American workers

Collaborative approach to Occupational Health Unions Collective bargaining, negotiation of H&S language in contracts Facilitate access of clinic and industrial hygienist to the workplace H&S training and infrastructure Can facilitate medical care insurance. Community‐based worker organizations Facilitate access to and communication among workers, union, employer and clinic Help build trust among workers who otherwise may not feel comfortable with union or clinic Expertise in housing, immigration, cultural, other social issuesnot typically addressed by unions Occupational Medicine Clinic Medical care, clinical evaluations, identification of work related illnesses Facilitate safe return to work, protection of co‐workers Referrals to specialists and primary care Assistance obtaining Workers’ Compensation in appropriate c4a4ses.

Conclusions Find locally feasible ways to help vulnerable workers and address WR, non‐WR, and interacting causes of illness and injury Help keep people working by preventing disease, disability with emphasis on safe RTW, ie, avoid enabling premature RTW while sick or injured or before workplace hazards are adequately controlled Try to implement preventive interventions as much as possible When primary prevention fails, appropriate use of Workers’ Compensation to help support patients during medical leaves necessary for effective treatment and recovery Collaborative programs with unions and worker centers Participatory Preventive Intervention programs with workers, unions, worker centers and proactive employers to improve workplace H&S Collaborate with primary care, emergency and subspecialty clinicians to jointly care for their patients with WRIs Find ways to include occupational health studies in collaborative clinical and public health research projects 45

103 References

OSHA definition of work‐relatedness https://www.osha.gov/laws‐ regs/regulations/standardnumber/1904/1904.5 Ottman, R. Prev Med. 1996; Gene–Environment Interaction: Definitions and Study Designs 25(6): 764–770. Rothman K, Greenland S, Lash T. Modern Epidemiology (2008) Markowitz S, Levin S, et al. Am J Resp Crit Care Med 2013. Asbestos, asbestosis, smoking and lung cancer.

Q1 In addition to an Occupational Health Clinic / University, all of the following are generally part of an effective participatory workplace preventive intervention program except:

1) An employer 2) A Community Organization and / or Union 3) Federal or state OSHA 4) Individual workers

Q2 A 66 year old man is referred to you by a local pulmonologist who has diagnosed him with late stage metastatic lung cancer. He has a 35 PY cigarette smoking history and quit 10 years ago when he was diagnosed with pulmonary fibrosis with calcified pleural plaques. He has never been screened for lung cancer. He tells you he had worked from 1987 to 1996 for a small home improvement company that frequently did unlicensed weekend asbestos abatement jobs. He was provided with paper dust masks and gloves and there often was no ventilation system at the jobs. The company was fined several times and work stopped by OSHA for violating the asbestos standard. They finally went out of business in 1996 and he has worked loading trucks for a lumber distributor since then. Which is the best way to think about the probable (ie, “more probable than not”) cause(s) of his lung cancer? 1) Asbestos was the probable cause of his lung cancer. 2) Depending on doses, either smoking or asbestos exposure but not both could be the probable cause of his lung cancer. 3) Smoking and asbestos exposure could both simultaneously be probable causes of his lung cancer. 4) Failure to screen him with low dose CT was the probable cause of his lung cancer.

104 Q3 A woman food preparation worker developed nocturnal pain and paresthesias in her left index and middle fingers during the one year period after she began a new job requiring forceful repetitive grasp and wrist flexion of her left hand for several hours each day preparing food at work. She also complained of a great deal of psychological stress and gained 30 pounds during that period. Her BMI increased from 28.2 to 33.1 and electrodiagnostic testing confirmed carpal tunnel syndrome in her left hand but not her right hand. Assume that the multiple reviews of forceful repetitive wrist flexion and obesity in CTS can be interpreted as supporting a causal relationship between each of these two risk factors and CTS. Which intervention would be most likely to reduce the chances of the worker developing CTS during that year? 1) Modification of her work ergonomics to prevent forceful repetitive wrist flexion or avoidance of the 30 pound weight gain or both together but we do not know which in this particular patient. 2) Avoidance of the 30 pound weight gain but not modification of her work ergonomics. 3) Modification of her work ergonomics but not avoidance of the 30 pound weight gain. 4) Either intervention alone.

105 106 INDIGENOUS (NATIVE) LATIN AMERICAN IMMIGRANTS: among the most vulnerable workers

Leoncio Vasquez Santos Seth M. Holmes, PhD, MD

Faculty Disclosure

We have nothing to disclose

Indigenous Population in the Americas

Mexico 15.7 millions 15% Peru 13.8 millions 45% Bolivia 6.0 millions 55% Guatemala 5.8 millions 40% United States 5.2 millions 1.7% Ecuador 3.4 millions 25% Chile 1.9 millions 11% Canada 1.4 millions 4.3%

107 Indigenous Languages in Oaxaca Spanish Chontal Zapoteco Mazateco Mixteco Chinanteco Triqui Cuicateco Chatino Amusgos Serrano Huave Mixe Techuantepecano Netzichu Zoque

Indigenous History

• The 16 ethnic communities of Oaxaca are part of the Mesoamerican Pre- Hispanic Cultures. • Social & Political Organization:

o City States governed by royal lineages o Hierarchical social structure o Advance forms of art, literature, math, cosmology o Close relationship with nature o Practice of traditional medicine

• Indigenous People face stigma & discrimination even in Mexico.

108 Montealban

Indigenous Culture

• Written Language

o Mixtec Codex kept 1,000 years of history o Only nine Codex remained

• Oral tradition is predominant in the indigenous communities

Millenary Cultural Traditions • El Tequio • Offering ceremonies to the rain God to ask for good harvest. • Guelaguetza • Fiestas Patronales • Día de los Muertos • Traditional Medicine

109 Indigenous Medicine Common Beliefs and Practices ● Traditional Medicine Approaches: ● Herbolaria: Use of medicinal plants/herbs. ● Midwives: Treatment during pregnancy. ● Hueseros: Treatment for bone problems ● Sobadores: Treatment for muscle pain / sprains ● Spiritual Guides: Spiritual realm of supra-natural conditions

Migration to the U.S.

Mexican Migration Pattern

Mexico: (Always) • Veracruz • Distrito Federal • Sinaloa • Baja California Norte/Sur

United States: (’80s) • California • Washington State • Oregon • Florida • New York • North Carolina

110 Migration to U.S.

• 1960s & 1970s: First indigenous families arrived with the Bracero Program

• 1980s: Begins Massive Migration o Early ’80’s: Only Men o After IRCA (1986): Increased in the number of whole families • 1990: U.S. Census registers one Mixtec family

• 1991: The California Institute for Rural Studies conducted a research and found that 50,000 indigenous migrants worked in the fields of California.

• 2008-2009: The “Indigenous Farmworker Study” estimates that number of indigenous persons working in the agriculture sector in California is 120,000 and it reaches 165,000 when children are included. (Mines et al., 2010)

Estimate: 120,000 in CA Farmworker Families + 45,000 Children

Challenges Facing Indigenous Migrants

Racial Hierarchy • Racism & Prejudice (stereotypes) • “No seas indio!” Class Exploitation • Worse paid jobs for newcomers • “They like to work bent over.” Cultural and Language Barriers • Language not dialect • The glorious past vs. the harsh present • The politics of cultural difference

111 Conditions of Indigenous Migrants in the U.S.

• They perform the most physical demanded and less rewarded jobs (farm work and construction)

o They are exposed to pesticides, long working hours, no toilets with water to wash hands and drinking water. • They earn the minimum wage and too often below the minimum wage

• Zabin and others (1993) found that Mixtec workers were more likely to accept jobs paying less than the minimum wage and were more likely to be victims of non-payment and other law violations.

Living Conditions

• It is common to find two bedroom apartments with two or three families (15 people).

• Many live in caves, around the rivers, mountains and under the orchard trees.

112 Living Conditions

Living and Working Conditions

Immigration, Identity and Social Networks

• Informal Village Networks

• Formalization of Social Networks.

• Institutionalization of collective practices (political, social, economic and religious).

• Emergence of a subjective collective belief of membership and belonging.

113 Structural Competency

“A shift in medical education … toward attention to forces that influence health outcomes at levels above individual interactions.” –Metzl and Hansen 2014

The capacity for health professionals to recognize and respond to health and illness as the downstream effects of broad social, political, and economic structures.

Structural Competency

Develop trainees’ capacity in:

1. Recognizing the influences of structures on patient health 2. Recognizing the influences of structures on the clinical encounter 3. Responding to the influences of structures in the clinic 4. Responding to the influences of structures beyond the clinic 5. Structural humility

Social Structures

● The policies, economic systems, and other institutions (judicial system, schools, etc.) that have produced and maintain contemporary social inequities and health disparities, often along the lines of social categories such as race, class, gender, and sexuality.

114 Structural Violence

● “Structural violence is one way of describing social arrangements that put individuals and populations in harm’s way... The arrangements are structural because they are embedded in the political and economic organization of our social world; they are violent because they cause injury to people.”

– Farmer et al. 2006

Structural Vulnerability

● The risk that an individual experiences as a result of structural violence – including their location in multiple socioeconomic hierarchies. Structural vulnerability is not caused by, nor can it be repaired solely by, individual agency or behaviors.

115 Metzl and Roberts,

“We argue that, if stigmas are not primarily produced in individual encounters but are enacted there due to structural causes, it then follows that clinical training must shift its gaze from an exclusive focus on the individual encounter to include the organization of institutions and policies, as well as of neighborhoods and cities, if clinicians are to impact stigma-related health inequalities.”

116 Research shows:

• SC is effective in shifting student perceptions of disease etiology o Before SC Training: genetics, behavior, culture o Post-SC Training: poverty, racism, harmful policies, unequal resources • Trainees indicate increased empathy and solidarity with patients

Case One

“Mr. Martinez is a 28 year-old male found down and intoxicated, possible aspiration pneumonia. He's a frequent flyer with many similar presentations but no history of alcohol withdrawal seizures. Nothing to do. If he's agitated assess for withdrawal and start the withdrawal protocol.”

In Emergency Begins Drinking Department After Gets Assaulted More Heavily Found on the Street

Standard Medical History & Default Provider Interpretation Begins Working Injury, Can’t Pay Rent, as Day Laborer Can’t Work Moves to Street

Moves to San Influx of Cheap US 4th Generation Francisco Corn; Can’t Make Corn Farmer in a Living Oaxaca

117 In Emergency Begins Drinking Department After Gets Assaulted More Heavily Found on the Street City policies Punitive US immigration contributing to high Policy/Discrimination rents & displacement

Begins Working Injury, Can’t Pay Rent, Systematic as Day Laborer Can’t Work Moves to Street marginalization of and violence against indigenous North American Free communities in Racialized low-wage Trade Agreement S. Mexico labor markets No Health Insurance (NAFTA) (excluded from ACA) Moves to San Influx of Cheap US 4th Generation Francisco Corn; Can’t Make a Corn Farmer in Living Oaxaca

In Emergency Begins Drinking Department After Gets Assaulted More Heavily Found on the Street

Standard Medical History & Default Provider Interpretation Begins Working Injury, Can’t Pay Rent, as Day Laborer Can’t Work Moves to Street

Moves to San Influx of Cheap US 4th Generation Francisco Corn; Can’t Make a Corn Farmer in Living Oaxaca

Naturalizing Inequality

• The sometimes subtle, sometimes explicit, ways in which structural violence is erased and elided by claims of cultural difference, genetic variance, behavioral shortcomings, or racial categories. • “Noncompliant” “Lost to follow-up” “Frequent flyer” • The “Culture of Poverty” (usually poor communities of color) • “Risk factors” as decontextualized, objective, apolitical realities

118 In Emergency Begins Drinking Department After Gets Assaulted Found on the Street More Heavily City policies US immigration contributing to high Policy/Discrimination rents & displacement

Begins Working Injury, Can’t Pay Rent, as Day Laborer Can’t Work Moves to Street

North American Free Trade Agreement No Health Insurance (NAFTA)

Moves to San Influx of Cheap US 4th Generation Francisco Corn; Can’t Make Corn Farmer in a Living Oaxaca

Possibilities for Change

● How can we intervene on the structures affecting health and health care?

Levels of Intervention

1. Intrapersonal 2. Interpersonal 3. Clinic 4. Community 5. Research 6. Policy

119 Educate yourself and work against implicit and explicit racism and other Intrapersonal bias In Emergency Department After Found on Street Approach the patient without blame Interpersonal or judgment Begins Drinking More Heavily Use an interpreter Clinic Gets Assaulted

Can’t Pay Rent, Moves to Advocate for safe spaces for Community Street community members Injury, Can’t Work Research the structural forces that Begins Working as Day affect the lives and health of migrants Research Laborer who work as day laborers, including policy and racism in your research Moves to San Francisco questions and discussion Influx of Cheap U.S. Corn Advocate for more just housing Fourth Generation Corn policy Farmer in Oaxaca Policy Organize against trade agreements that contribute to the exploitation of foreign labor

Q1: Structural competency is defined as?

A. The capacity for health professionals to recognize and respond to health and illness as the downstream effects of broad social, political and economic structures B. The ability to interact effectively and respectfully with people of different cultures C. Coordinated care to individuals with multiple chronic health conditions, including mental health and substance use disorders D. The ability to navigate the institutions of health care effectively and efficiently

Q2: Compared to the general Latin American immigrant population, what are additional risk factors that indigenous Latin American Immigrants face?

A. Immigration status B. Racism C. Preferred language is assumed to be Spanish D. This is an understudied population

120 Q3: What can health professionals do to better serve indigenous Latin American immigrants?

A. Assume all Latin American immigrants the same and face the same experiences, thus being prepared to respond B. Research and seek to understand the unique circumstances that impact this population C. Interact with them the same way you would any other patient D. Learn Spanish

References

● Mines, R., Nichols, S., & Runsten, D. (2010). California’s Indigenous Farmworkers: Final Report of the Indigenous Farmworker Study (IFS) to the California Endowment. Retrieved at http://www.indigenousfarmworkers.org ● Metzl, J. M. (2010). The protest psychosis: How schizophrenia became a black disease. Beacon Press. ● Metzl, J. M., & Hansen, H. (2014). Structural competency: Theorizing a new medical engagement with stigma and inequality. Social Science & Medicine, 103, 126-133. ● Haldol advertisement. (1974). Archives of General Psychiatry. ● Farmer, P. E., Nizeye, B., Stulac, S., & Keshavjee, S. (2006). Structural violence and clinical medicine. PLoS medicine, 3(10), e449.

121 122 An Aging Population at Work and at Play Vocations, Avocations, and Hobbies

Ware Kuschner, M.D. VA Palo Alto Health Care System Division of Pulmonary and Critical Care Medicine Stanford University School of Medicine Palo Alto, California

Faculty disclosure

I have nothing to disclose.

An aging population at work and at play 1) The aging population

2) Normal aging

3) Abnormal (but not atypical) aging: common health conditions that afflict older adults

4) The aging workforce: challenges and opportunities

5) The older adult at play: staying healthy and having fun

123 WHO ‐ World report on ageing and health 2015 International Day of Older Persons ‐ ‐ October 1, 2015

• “ ...the number of people over the age of 60 is expected to double by 2050 and [this] will require radical societal change.”

• “Today, most people, even in the poorest countries, are living longer lives,”

Longer lives, but not necessarily healthier lives • “[There is] very little evidence that the added years of life are being experienced in better health than was the case for previous generations at the same age.”

• “Unfortunately, 70 does not yet appear to be the new 60. But it could be. And it should be”.

U.S. demographic shift

By 2030, all baby boomers will be older than age 65  1 in 5 residents will be retirement age

By 2035, older people will outnumber children: 78 million > 65 years old vs. 77 million < 18 years old

U.S. Census Bureau’s 2017 National Population Projections

U.S. Population: 1960 vs. 2060 United States Census Bureau National Population Projections, 2017 www.census.gov/programs‐ surveys/popproj.html

124 Percentage of U.S. Population in Selected Age Groups, 1960 to 2060

Population Reference Bureau analysis of data from the U.S. Census Bureau

Aging in the United States Positive Developments Education levels are increasing among people ages 65 and older • 1965: 5% had a bachelor’s degree or more 2015: 27%

Life expectancy has increased ‐ mostly due to the reduction in mortality at older ages • 1950: 68 years 2018: 79 years

Poverty rate dropped sharply for Americans ages 65 and older • 1966: 30% 2017: 9%

Aging in the United States Population Reference Bureau https://assets.prb.org/pdf16/aging‐us‐population‐bulletin.pdf and U.S. Census Bureau and Henry J. Kaiser Family Foundation

2017 Profile of older Americans

Challenges • Wide economic disparities across different population subgroups among adults ages 65 and older:  Living below the poverty line in 2016: 17% of Latinos and 19% of African Americans vs. 7% of non‐Hispanic whites • Increased numbers of Americans living with Alzheimer’s disease and other chronic diseases • Rising obesity (BMI > 30) rates among older adults:  40% of men and 43% of women who are 65‐to‐74‐year‐old 2017 Profile of Older Americans, The Administration for Community Living, U.S. Department of Health and Human Services

125 2017 Profile of older Americans

Challenges

• 35% of persons over age 65 report a disability • Increased demand for nursing home care and elder care • 22% of adults over age 85 require help with personal care • Increased Social Security and Medicare expenditures as percentage of GDP

Normal aging

Brain and cognitive function Processing speed – declines beginning in the 3rd decade  the speed with which cognitive activities are performed  the speed of motor responses

Attention ‐ ‐ the ability to concentrate and focus on specific stimuli declines with age Selective attention – ability to focus on specific information in the environment while ignoring irrelevant information; e.g. conversation while driving a car Divided attention – focus on multiple tasks simultaneously; talking to someone while typing

Normal aging

Memory ‐ stable with age • Recognition memory – able to retrieve information when given a cue; e.g., correctly giving details of a story when given yes/no questions

• Temporal order memory – recalling the sequence of past events; e.g. a week ago, had lunch then went to grocery store

• Procedural memory – e.g., how to ride a bike

126 Normal aging

Memory ‐ declines with age • Delayed free recall – retrieving information without a cue; e.g. recalling a grocery list

• Source memory – recalling the source of learned information; e.g., T.V. vs. newspaper vs. friend

• Prospective memory – remembering to perform actions in the future e.g., take medicine before going to bed

Normal aging

Executive Functioning ‐ defined • Ability to engage in independent, appropriate, purposive, and self‐serving behavior • Includes a wide range of cognitive abilities • Self monitor • Plan • Organize • Reason • Be mentally flexible • Solve problems

Normal aging

Executive function: dimensions that are stable throughout life • Ability to appreciate similarities

• Describe the meaning of proverbs

• Reason about familiar material

127 Normal aging

Executive function: dimensions that decline with aging • Concept formation, abstraction, and mental flexibility decline with age, especially after age 70

• Inductive reasoning as measured by verbal and mathematic reasoning tasks decline, beginning around age 45

Normal aging

Cardiovascular system • Preserved left ventricular ejection fraction

• Increased left ventricular wall thickness and stiffness  decreased relaxation of heart

• Blood vessels stiffen  afterload increases

• Decreased maximum predicted heart rate: 220 minus age in years

Normal aging

Lungs • Lung function begins to decline ~ age 25 • Alveolar ducts enlarge, ~ 1/3 of the surface area lost over the life span • Diffusion capacity decreases about 5% per decade • Worsened ventilation‐perfusion mismatching resulting in declining PaO2 with age

• Decreased FEV1 by 200 – 300 ml per decade with steeper declines in 7th and 8th decades

128 Normal aging

Exercise capacity • 3 to 6 percent decrease in peak aerobic capacity per decade in the 30s and • more than 20 percent decrease in peak aerobic capacity per decade in the 70s and beyond • Endurance training may mitigate the rate of decline before age 60

NIH National Institute on Aging Baltimore Longitudinal Study of Aging

Normal aging

Body composition and musculoskeletal changes • Decreased lean body mass

• Bone mineral loss

• Decreased joint elasticity

Normal aging

The 5 senses • Eyes: Presbyopia, diminished pupillary reflexes  glare, decreased acuity, loss of color perception, worsened night vision

• Ears: loss of high frequency hearing  diminished speech recognition

• Touch: diminished sensory perception to both touch and low frequency vibration, especially in the lower extremities

• Smell & Taste: diminished smell  diminished taste

129 Normal aging

Skin • Atrophy • Decreased elasticity • Dermis thins • Increase fragility to shear stress • Delayed wound healing

Diseases of aging (percentage of Americans over 65 yrs with selected conditions)

• Dementia (including Alzheimer’s disease – 11%) • Cardiovascular (37% of men; 26% of women) • Arthritis (50%) • Diabetes (25% ‐ diagnosed and undiagnosed) • Poor oral health (25% have no natural teeth) • Cataracts and age‐related macular degeneration • Parkinson’s disease

Source: CDC

Diseases and disorders of aging

• Cancer: lung, breast, colon, prostate, pancreatic, skin 413,885 deaths in 2014 among people over age 65 – 2nd leading cause • Chronic obstructive pulmonary disease (10% of men; 13% of women) • Falls  2.5 million people over 65 treated annually in the ED • Depression (15 ‐20% have experience depression) • Impaired immunity, shingles, pneumonia • Hearing loss • Urinary incontinence

130 Frailty

Frailty is . . . a syndrome of physiological decline in late life, characterized by marked vulnerability to adverse health outcomes. Frail older adults are less able to adapt to stressors such as acute illness or trauma than younger or non‐frail older adults. This increased vulnerability contributes to increased risk for multiple adverse outcomes, including procedural complications, falls, institutionalization, disability, and death. Increasingly, frailty in older patients is considered the hallmark geriatric syndrome and a forerunner to many other geriatric syndromes, including falls, fractures, delirium, and incontinence. UpToDate

Frailty screening tool

F R A I L F atigue ("Are you fatigued?") R esistance ("Can you climb one flight of stairs?") A mbulation ("Can you walk one block?") I llnesses (greater than five) L oss of weight (greater than 5 percent in last year)

Scale: 0 = robust, 1‐ 2 = pre‐frailty, > = frailty

Woo J. J Am Med Dir Assoc. 2015

The public health burden of frailty

• In a European study (the Survey of Health, Ageing, and Retirement in Europe [SHARE]) frailty prevalence ranged from 6 to 44 percent when applied to a database of individuals aged 50 to 104 years Theou O. J Am Geriatr Soc. 2013. • In the United States, frailty ranges from 4 to 16 percent in men and women aged 65 and older. Pre‐frailty has a prevalence ranging from 28 to 44 percent in several studies. Cawthon PM. J Am Geriatr Soc. 2007. Woods NF. J Am Geriatr Soc. 2005.

131 The aging workforce

Americans are working longer Americans 65 yrs and older who worked:  2000: 12.5%  2017: 19%

U.S. Bureau of Labor Statistics

The aging workforce

The number of older workers is growing Projection in growth of labor force, annually, 2016 – 2016  Overall: 0.6%  65 – 74: 4.2%  75 and older: 6.7%

America’s Aging Workforce: Opportunities and Challenges Special Committee on Aging, United States Senate December 2017

Labor Force Participation Rate by Age Bureau of Labor Statistics

132 America’s Aging Workforce

Many older workers are struggling to prepare financially for retirement. Roughly one‐third of workers do not have access to a retirement plan at work, and many aging workers have not saved enough for retirement and may continue to work beyond when they intended to retire out of financial need.

Work is linked with improved health and well‐being. For many aging Americans, work provides a sense of purpose. Research consistently links work with improved physical, emotional, and cognitive health, financial stability and security, and quality of life.

America’s Aging Workforce: Opportunities and Challenges. A report of the Special Committee on Aging, United States Senate, Dec. 6, 2017

The aging workforce

Current challenges make it more difficult for older workers to thrive in the workplace • Age discrimination • Inadequate training opportunities • Working while managing health conditions and disabilities • Balancing caregiving responsibilities with work

Health of the aging American – self‐described

Health is fair or poor • 18 – 44 yrs: 6% • 55 – 64 yrs : 19% • 65 and older: 22% Two or more chronic health conditions • 18 – 44 yrs: 7% • 55 – 64 yrs: 40% • 65 and older: 62% U.S. Department of Health and Human Services, “Health, United States, 2016,” 2017, at https://www.cdc.gov/nchs/data/hus/hus16.pdf#045

133 Health of the aging American

Have a disability • 18 – 34 yrs: 6% • 35 to 64 yrs: 13% • 65 to 74 yrs: 25% • 75 and above: 50%

U.S. Census Bureau. “American Community Survey 2015” 2015, at https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_15_1YR_S1810 &prodType=table.

Health of the aging American

Among individuals ages 65 and above with disabilities • difficulty walking or climbing stairs – 67% • difficulties with hearing – 40% • cognition – 29 % • vision – 19%

Wan He and Luke Larsen, “Older Americans With a Disability: 2008‐2012,” National Institute on Aging and US Census Bureau, 2014, at https://www.census.gov/content/dam/Census/library/publications/2014/acs/acs‐ 29.pdf.

Income loss with a disability

Percentage of full‐time workers below the ages of 50 – 64 earning less than 200% of the federal poverty line ‐ With a disability: 17% Without a disability: 10%

Harriet Komisar, Donald Redfoot, and Carlos Figueiredo, “Disability and Employment,” AARP Public Policy Institute, 2014, at http://www.aarp.org/content/dam/aarp/ppi/2014‐10/disability‐and‐employment‐fact‐ sheet‐aarp.pdf.

134 Center for Strategic and International Studies Global Aging Initiative

How can aging societies maintain a decent standard of living for the old without imposing a crushing burden on the young? How will economic performance be affected as rates of savings and investment decline and workforces contract and gray? How will the changing structure of the family (which will often have more grandparents than grandchildren) affect the way we raise the young and care for the old? How will the rising average age of the population affect risk‐taking, entrepreneurship, and voter and leadership behavior? How is the differential impact of global aging, by country and by region, likely to transform the geopolitical landscape and the global balance of power?

Age discrimination / mandatory retirement

The Age Discrimination in Employment Act (ADEA) of 1967, outlawed forced retirement based on age . . . but . . . Congress has approved fixed retirement ages for some professions involved with public safety: • commercial airline pilot (65 years) • Federal Bureau of Investigation agent (57 years) • National Park Ranger (57 years) • air traffic controller (56 years) • lighthouse operator (55 years) but not for physicians. Mandatory retirement for surgeons does exist in some countries, such as Russia and China (in both countries, age 60 years for men and 55 years for women).

Assessing the performance of aging surgeons

In 2017, 44.1% of 103,032 active surgeons in the United States were 55 years or older. In a study of nearly 900,000 Medicare beneficiaries, patients who had operations performed by older surgeons (older than 50‐59 years and ≥60 years) had lower mortality than patients who had operations performed by younger surgeons. Another study examined the files of 461,000 Medicare patients . . . when compared with surgeons ages 41‐50 years, surgeons older than 60 years had higher operative mortality rates for pancreatectomy, coronary artery bypass grafting, and carotid endarterectomy. However, the difference in outcomes was small and limited to surgeons having low procedure volumes.

JAMA Viewpoint January 14, 2019 Assessing the performance of aging surgeons Katlic, MR. JAMA. 2019;321(5):449‐450

135 Assessing the performance of aging surgeons

American College of Surgeons recommends: • Voluntary physical examination, eye examination, and online screening tests of cognition for surgeons starting at age 65 – 70. • Regular interval reevaluation thereafter is prudent for those without identifiable issues on the index examination.

National Center for Productive Aging and Work

• Established at NIOSH in October, 2015 • Traditional occupational safety and health protection programs have primarily concentrated on ensuring that work is safe and that workers are protected from the harms that arise from work itself. • Total Worker Health (TWH) builds on this approach through the recognition that work is a social determinant of health; job‐related factors such as wages, hours of work, workload and stress levels, interactions with coworkers and supervisors, access to paid leave, and health‐promoting workplaces all can have an important impact on the well‐being of workers, their families, and their communities.

NIOSH – Productive aging and work

Safety and Health Outcomes Associated with Aging and Work • Workers who are older tend to experience fewer workplace injuries than their younger colleagues. • However, older workers often require more time to heal, underscoring the need for a well‐planned return to work program.

136 Morbidity and Mortality Weekly Report (MMWR) Nonfatal Occupational Injuries and Illnesses Among Older Workers ‐‐‐ United States, 2009 April 29, 2011 / 60(16);503‐508 Editorial Note Accommodating older workers positively impacts the entire workforce. For example, employer efforts to reduce fall risks for older workers, such as ensuring walkways are well‐lit, removing slipping and tripping hazards, and use of more slip‐resistant floors, will improve the safety of all workers.

Health Benefits Associated With Regular Physical Activity US Department of Health and Human Services. Physical Activity Guidelines for Americans, 2nd edition, US Department of Health and Human Services, Washington, DC 2018 https://health.gov/paguidelines/second‐edition/pdf/Physical_Activity_Guidelines_2nd_edition.pdf All adults ‐ ‐ and older adults • Lower risk of all‐cause mortality • Lower risk of cardiovascular disease mortality • Lower risk of cardiovascular morbiditiy (including heart disease and stroke) • Lower risk of hypertension • Lower risk of type 2 diabetes • Lower risk of adverse blood lipid profile • Lower risk of cancers of the bladder, breast, colon, endometrium, esophagus, kidney, lung, and stomach Note: The Advisory Committee rated the evidence of health benefits of physical activity as strong, moderate, limited, or grade not assignable. Only outcomes with strong or moderate evidence of effect are included in this list.

Health Benefits Associated With Regular Physical Activity

• Improved bone health • Improved physical function • Lower risk of falls (older adults) • Lower risk of fall‐related injuries (older adults) • Reduced anxiety • Reduced risk of depression • Improved sleep

137 Health Benefits Associated With Regular Physical Activity

• Slowed or reduced weight gain, prevention of weight gain following initial weight loss, +/‐ weight loss, • Improved cognition (executive function, attention, memory, processing speed) * • Reduced risk of dementia (including Alzheimer’s disease) * • Improved quality of life

* some literature suggests no benefit

Physical Activity Guidelines for Americans

Some physical activity is better than none. For substantial health benefits, adults should do at least: 2 hours and 30 minutes a week of moderate‐intensity, or 75 minutes vigorous intensity exercise per week

Adults should also do muscle‐strengthening activities of moderate or greater intensity and that involve all major muscle groups on 2 or more days a week

Physical Activity Guidelines for Americans

And for adults 65 yrs and older As part of their weekly physical activity, older adults should also do physical activity that includes balance training.

138 Recreational injuries among older Americans, 2001 Gerson LW. Injury Prevention 2004.

• In 2001, an estimated 62,164 persons ≥65 years old were treated in emergency departments for injuries sustained while participating in sport or recreational activities. • The overall injury rate was 177.3/100 000 population with higher rates for men (242.5/100 000) than for women (151.3/100 000). • “Exercising” caused 30% of injuries among women and bicycling caused 17% of injuries among men. • 27% of all treated injuries were fractures and women (34%) were more likely than men (21%) to suffer fractures.

Hobbies – and the respiratory system

• The home environment – where people spend as much as 50% of their life during their working life and likely much more during retirement – can affect the health and well being of the older adult • A diverse array of home‐based and leisure activities may generate hazardous respirable exposures. • Routine domestic activities such as cooking and cleaning, and a variety of hobbies have been associated with a spectrum of respiratory tract disorders, including acute irritation or lung injury, rhinitis, and asthma.

Respiratory Hobby Exposure Comments Health Effects

Sensitization – eye, skin, Wood dust Varies across species Wood working respiratory tract Metal fume fever, Welding Galvanized metal Metal work acute lung injury Ceramics Irritant gas exposure Irritation Kiln fumes Automotive spray Diisocyanates Bronchospasm Painting painting

Adapted from Ho. Clin Chest Med. 2012.

139 Don’t Ruin My Life — Aging and Driving in the 21st Century Aronson L. N Engl J Med. 2019

Approach to the Older Driver Key Facts • Driving is a sociomedical issue akin to sex and substance use. • Most older drivers are safe drivers, with few risky driving behaviors. • In accidents, older adults are at higher risk for injury and death. • Driving retirement will be necessary for most of us as we age. • As with younger drivers, some older drivers will be able to resume driving after treatment for relevant medical conditions.

Don’t Ruin My Life — Aging and Driving in the 21st Century Louise Aronson, M.D. February 21, 2019 N Engl J Med 2019; 380:705‐707 • History – ask about • Driving as part of routine health maintenance beginning at 60 yrof age • Driving specifics such as difficulty with turns, turn signals, parking, staying in lane, reversing, following traffic signs, maintaining usual speeds • Transportation and other mobility needs and alternatives • Neither self‐report nor report from family is always reliable

Q1. Normal aging is characterized by:

1) Stable temporal order memory 2) Stable visual acuity and stable hearing 3) A progressive decrease in left ventricular ejection fraction from >55% to 45% beginning at around age 65 and continuing until about age 85 4) A decline in inductive reasoning as measured by verbal and mathematic reasoning tasks beginning around age 70

140 Q2. Which of the following statements is true?

1) The Age Discrimination in Employment Act of 1967 has outlawed the forced retirement of workers based on age across all occupations in the United States without exception. 2) 60% of Americans over the age of 65 self characterize their health as either fair or poor. 3) Hearing loss is the most common self‐reported disability among Americans over the age of 65. 4) Nonfatal occupational injuries and illnesses are less common among older workers (age > 55) compared with younger workers.

Q3. Which statement is true?

• Adults with chronic conditions or disabilities, who are able, should aim to do 75 to 150 minutes a week of moderate‐intensity aerobic physical activity. • All of the key guidelines for “adults” regarding aerobic and muscle‐ strengthening activities apply to “older adults”; and older adults should also incorporate balance training into their training regimen. • Bicycling, golfing, and fishing account for just over half of all recreational injuries among men over the age of 65 • Asthma attributable to diisocyanates typically results form a one time high intensity unintended exposure after a mishap involving paint.

141 An Aging Population at Work and at Play – Vocations, Avocations, and Hobbies

Ware Kuschner, M.D.

Bibliography

Aronson L. Don't ruin my life - aging and driving in the 21st century. N Engl J Med 2019;380:705-707.

Bohle P. Time to call it quits? The safety and health of older workers. Int J Health Serv 2010;40:23-41.

Clegg A. Frailty in elderly people. Lancet 2013; 381:752-762.

Gerson LW. Recreational injuries among older Americans, 2001. Inj Prev 2004;10:134-8.

Harada CN. Normal cognitive aging. Clin Geriatr Med. 2013;29:737-752.

Ho LA. Kuschner WG. Respiratory health in home and leisure pursuits. Clin Chest Med 2012;33:715-29.

Katlic MR. Assessing the performance of aging surgeons. JAMA 2019;321:449-450.

Mather M. Aging in the United States. Population Reference Bureau December, 2015; Vol. 70, No. 2. Available at: https://assets.prb.org/pdf16/aging-us-population-bulletin.pdf Morbidity and Mortality Weekly Report (MMWR) Nonfatal occupational injuries and illnesses among older workers --- United States, 2009 April 29, 2011 / 60(16);503-508. NIOSH. Total Worker Health. Available at: https://www.cdc.gov/niosh/twh/totalhealth.html Sattelmair JR. Effects of physical activity on cardiovascular and noncardiovascular outcomes in older adults. Clin Geriatr Med 2009;25:677-702. Special Committee on Aging - United States Senate. America’s Aging Workforce: Opportunities and Challenges; December 2017. Available at: https://www.aging.senate.gov/imo/media/doc/Aging%20Workforce%20Report%20FINAL.pdf US Department of Health and Human Services. Physical Activity Guidelines for Americans, 2nd edition, US Department of Health and Human Services, Washington, DC 2018 https://health.gov/paguidelines/second- edition/pdf/Physical_Activity_Guidelines_2nd_edition.pdf Wan H. Older Americans with a disability: 2008-2012,” National Institute on Aging and US Census Bureau, 2014, available at: https://www.census.gov/content/dam/Census/library/publications/2014/acs/acs-29.pdf. White MS. The impact of an aging population in the workplace. Workplace Health Saf 2018;66:493-498.

142 Military Service is a Vulnerable Occupation: Lung Disease as a Paradigm

Michael J. Falvo, PhD Research Physiologist, VA War Related Illness & Injury Study Center – Airborne Hazards and Burn Pits Center of Excellence Assistant Professor, Rutgers New Jersey Medical School

Disclosure

• I have nothing to disclose

• Contents of this presentation do not represent the views of the U.S. Department of Veterans Affairs or the United States Government

Deployment‐Related Exposures

Agent Nerve Anti‐ Solvents Orange Agent Malarial

Dust & Fuels Pesticides Radiation Sand

Depleted Oil Well Vaccines Burn Pits Uranium Fires

143 Mean PM2.5 Concentration (06‐07) 15μg/m3 35μg/m3

Redrawn from: Engelbrecht et al. 2008

Non‐Inhalational Exposure

Figure from Cernak and Noble‐Haeusslein 2010, J Cereb Blood Flow Metab

144 Uniquely Vulnerable, Susceptible?

Falvo et al., 2015, Epidemiologic Rev

Epidemiologic Findings

• 15 epidemiologic studies (2005 – present) • Relationship to deployment? – Respiratory Symptoms: 9 studies, favorable – Asthma: 10 studies, mixed results – COPD: 7 studies, largely null – Other Outcomes: 6 studies, inconclusive • Limitations

↑ Chronic Lung Disease

3.50% 25000

3.00% 20000 2.50%

15000 2.00%

1.50% 10000 Prevalence (%) 1.00% No. of Veterans 5000 0.50%

0.00% 0 2003 2004 2005 2006 2007 2008 2009 2010 2011 Asthma COPD Redrawn from: Pugh et al. 2016 Mil Med ILD

145 Clinical Findings

• 18 clinical studies (2004 – present) – 4 Case reports/series – 5 Retrospective chart reviews – 2 Pre‐deployment evaluations – 6 Post‐deployment evaluations – 1 Pre‐ and post‐deployment evaluation • Main findings – Dyspnea….still complicated

% Preserved Spirometry 100% Morris et al. 95% (n=50), 84% Krefft et al. 90% (n=28), 82%

85% Falvo et al. (n=143), 75% 80%

75%

70%

65% Butzko et al. Holley et al. (n=178), 72% (n=267), 64% 60%

55%

50%

National VA Post‐Deployment Health Resource (Public Law 105‐368)

146 WRIISC  AHBPCE

• Increased reports of airborne hazards exposure 2007 and concerns (Helmer et al. 2007) • Working Group at National Jewish publishes 2010 recommendations (Rose et al. 2010)

• Full PFTs on all referrals 2011 • Expanded cardiopulmonary evaluations for 2013 Veterans with primary respiratory complaints • Airborne Hazards and Burn Pits Center of 2018 Excellence

NJ WRIISC Referral Cohort

110.00 Post‐9/11 100.00 Pre‐9/11

90.00

80.00 /FVC 1 70.00 FEV

60.00

50.00 n = 485 40.00

6.8 0.8

16.5 Normal Obstructed Restricted N = 485 Mixed

74.9

147 Preserved Spirometry

Age Sex 46.0 (37.0, 50.0) yrs 86.3% male

n = 364 Post‐Deploy Tobacco Pack Length Years 12.8 (7.3, 23.4) yrs 0.0 (0.0, 10.0)

Deployment‐Related Exposures 120

100

0 Burn Pits Air Pollution Sand/Dust Petrochem Blast Exposed Concerned

Lower Respiratory Symptoms (≥ 2d∙wk⁻¹)

Cough

Wheeze

Short of Breath

2+ Symp

0 102030405060

148 BD Reversibility

25.00

20.00

15.00

10.00 +12%

5.00

BD %change 0.00 1 ‐5.00 FEV ‐10.00

‐15.00 n = 357

Isolated ↓ DLCO 150

130

110

90 (%predicted)

CO 70 DL

50 n = 349 30 HgB corrected; Miller et al. 1983 predicted

• * N = 123 – Preserved spirometry – Current smokers excluded

• Low DLCO

– DLCO ≤ LLN – Miller ’83 – HgB corrected

Falvo et al. 2018 Clin Resp J

149 Forced Oscillation Technique (FOT)

20 Hz 5 Hz

Figure from: Brashier & Salvi 2015

Resistance (Rrs) Reactance (Xrs)

R5 R20

5 20 5 20 100 5 Figures from: Brashier & Salvi 2015

• 75% (93/124) demonstrate distal airway dysfunction Butzko et al. 2019 Respir Physiol Neurobiol

150 Butzko et al. 2019 Respir Physiol Neurobiol

BD Reversibility for R4 80.00

60.00

40.00

20.00

0.00

‐20.00 R4 Δ (% Change) ‐40.00

‐60.00

‐80.00

BD Reversibility for AX4

40.00

20.00

0.00

‐20.00

‐40.00 AX4 Δ (% Change) ‐60.00

‐80.00

‐100.00

151 MMRC Dyspnea

Severe

100 yards

15 min

When hurrying

Not troubled

0 1020304050

Borg Breathlessness at Peak

Maximal 1.00% 5.10% 8.10% Very Severe 13.10% 15.20% Severe 20.20% 27.30% Moderate 8.10% 2.00% Very Slight 0.00% 0.00% n = 99 Nothing at all 0.00%

CPET Patterns for Exertional Dyspnea

VE/VCO2 Slope Peak VO2 (%) etCO2 (mmHg) VE/MVV < 30 ≥ 100% Rest 36‐42 < 0.80 30.0 ‐ 35.9 75 ‐ 99% 3‐8 ↑ ex 36.0 ‐ 44.9 50 ‐ 75% Rest < 36 ≥ 0.80 ≥ 45.0 < 50% < 3 ↑ ex

Post‐Exercise Spirometry No Δ FEV1 or PEF post‐CPET ≥ 15% reduction in FEV1 or PEF post‐CPET

Hemodynamics ECG Pulse Oximetry ↑ SBP (10 mmHg/3.5 mL O2·kg·min No sustained arrhythmias, ectopic foci, and/or No Δ in SpO2 from VO2) ST segment changes during CPET or recovery baseline Altered rhythm, foci, and/or ST ‐ but did not ↔ or ↓ SBP during CPET, or lead to test termination excessive ↑ SBP (≥ 20 mmHg/3.5 >5% ↓in SpO2 from mL O2·kg·min VO2) Altered rhythm, foci, and/or ST ‐ led to test baseline termination

Adapted from: EACPR/AHA Statemen; Guazzi et al. 2012 Circ

152 CPET Pattern Results

VE/VCO2 Slope Peak VO2 (%) etCO2 (mmHg) VE/MVV < 30 50.5% ≥ 100% 18.2% Rest 36‐42 58.1% < 0.80 53.2% 30.0 ‐ 35.9 35.3% 75 ‐ 99% 50.5% 3‐8 ↑ ex 36.0 ‐ 44.9 12.1% 50 ‐ 75% 27.2% Rest < 36 41.9% ≥ 0.80 46.8% ≥ 45.0 2.0% < 50% 4.0% < 3 ↑ ex 29.7 (27.4, 32.8)83.8 (71.0, 95.5) 32.2 (30.2, 34.4) 0.77 (0.63, 0.96)

Post‐Exercise Spirometry No Δ FEV1, PEF post‐CPET (84.9%) ≥ 15% ↓ in FEV1, PEF post‐CPET (15.1%)

Hemodynamics ECG Pulse Oximetry ↑ SBP (10 mmHg/3.5 mL O2·kg·min No sustained arrhythmias, ectopic foci, and/or No Δ in SpO2 from VO2) ST segment changes during CPET or recovery baseline Altered rhythm, foci, and/or ST ‐ but did not ↔ or ↓ SBP during CPET, or lead to test termination >5% ↓in SpO2 from excessive ↑ SBP (≥ 20 mmHg/3.5 Altered rhythm, foci, and/or ST ‐ led to test mL O2·kg·min VO2) (1‐2%) baseline (9.1%) termination (1‐2%)

Conclusions

• Beyond spirometry • DLCO, FOT, CPET…

Acknowledgements

• Drew Helmer, MD • Anays Sotolongo, MD • WRIISC/AHBPCE Clinical, Research, Edu Teams • VA Post‐Deployment Health Service

• Funding – VA (1I01CX001329, 1I01CX001515) – DoD (W81XWH‐16‐1‐0663, W81XWH‐17‐1‐0575)

153 Questions

Q1. Which of the following deployment‐ related exposures are NOT relevant for the Veteran with dyspnea on exertion? a) Smoke from open burn pits b)Blast overpressure waves from IEDs c) Aircraft/military truck engine exhaust d)Multiple anthrax vaccinations

Q2. Which of the following conditions is NOT increasing in prevalence among post‐ 9/11 Veterans receiving care at VA Medical Centers? a) Constrictive bronchiolitis b)Asthma c) COPD d)Interstitial lung disease

154 Q3. Which pulmonary function assessment is most sensitive for assessing the small airways? a) Fractional exhaled nitric oxide b)Forced oscillation technique c) Diffusing capacity of the lung for carbon monoxide d)Exercise flow‐volume loop

155 156 Pediatric and Environmentally Stephanie Holm, MD MPH FAAP Staff Physician, Western States PEHSU Exposed: Doubly Volunteer Assistant Clinical Professor, UCSF PhD Student in Epidemiology, UC Berkeley Vulnerable

Disclosures: None

Painted by Berlinghiero 1230 CE

Madonna and Child

157 Children are NOT small adults!

HOWEVER

Children are human!

158 Why are Children More Vulnerable?

1. Behaviors and Preferences that Increase Exposure 2. Differences in Physiology that increase Dose 3. Unique Windows of Development

Behaviors and Preferences that Increase Exposure • Mouthing objects‐increased ingestion • Hands contacting the floor‐increased ingestion • Inability to assess risk • Often have higher exercise time relative to adults

PBDE Exposure

• Brominated Hydrocarbon flame retardants • Common in foam products until 2013 • Broken down foam settles in dust; high levels remain even in areas where it was phased out • Associated with neurobehavioral , liver and thyroid effects in animal studies • In children, associated with deficits in attention and executive functioning, possibly with leukemia

159 Behaviors and Preferences that Increase Exposure‐ Diet • Up to 4‐6 months of age‐ formula/breastmilk only • Mercury in breastmilk • Clean water for formula • Minimizing clear plastics • Small children often eat limited fruits and veggies • often ones with high pesticide exposures

Arsenic

• Rice cereal was often recommended as a first food historically • Apple products (apple sauce, apple juice also high in arsenic) • Also of particular concern for older children with restricted diets (such as gluten‐free)

Behaviors and Preferences that Increase Exposure‐Surroundings • More time at home • Airborne‐ radon, PM, second‐hand tobacco, aerosols from cleaning products • Dust‐ lead, PBDEs • Young children‐ care settings (either other homes or Early Care and Education settings) • VOCs in arts/craft supplies • Disinfectants • Older Children‐ School, activities • Teens‐ School, activities, workplaces, hobbies

160 Early Care and Education

• One of the few locations where disinfectant use is mandated with children present • Bleach and quaternary ammonia products are asthmagens

Differences in Physiology that Increase Dose • Rapid growth with higher metabolic rate • Eat more food • Drink more water • Breathe more air • Larger Body surface to mass ratio • Longer remaining life‐expectancy • Breathing zone closer to the floor • Some enzymes for processing/clearing toxicants are still developing

Air Pollutants

• Per kg of body weight, a one‐year old has a minute ventilation that is TWICE that of an adult. • Both short and long‐term ozone exposure is related to decrements in FEV1 in children, but less reliably in adults • More frequent respiratory infections (otitis, pneumonia, etc) • Risk in‐utero as well

161 https://envhealthcenters.usc.edu/infographics/infographic‐cleaner‐air‐healthier‐lungs

Windows of Susceptibility

• Small molecules and fat soluble molecules can cross the placenta • Because of rapid growth, many dividing cells • Lead exposure in infancy/toddlerhood particularly problematic • Adolescents have rapid gonadal development

Adverse Childhood Events (ACEs)

• Associated with a spectrum of health effects across the life course (including cancer, heart disease, diabetes, respiratory disease) • Children exposed to violence and air pollution are at increased risk of developing asthma • Early life stress thought to be able to reprogram the HPA axis • Some studies have found strongest effects for ACEs in early childhood

162 Taking a Pediatric Environmental Health History • Home • School • Workplace (teens) • Community • Tobacco • Water Source • Diet • Sun • Take‐Home Exposures

Pediatric Environmental Health Toolkit peht.ucsf.edu Optimized for Mobile!

For further education on environmental health through the lifecourse (with CME available!)

163 Western States PEHSU wspehsu.ucsf.edu

Don’t forget about the benefits of childhood!

164 When you grow up, people stop asking what your favorite dinosaur is.

It’s like they don’t even care.

References

• Agency for Toxic Substances and Disease Registry: Principles of Pediatric Environmental Health. What are Factors Affecting Children’s Susceptibility to Exposures? https://www.atsdr.cdc.gov/csem/csem.asp?csem=27&po=6 Atlanta, GA 2013 • Pediatric Environmental Health, 3rd Edition. Edited by Ruth A. Etzel and Sophie J. Balk. Itasca, IL, American Academy of Pediatrics, 2011 • Pediatric Environmental Health Specialty Units. https://www.pehsu.net/ Washington, DC 2019 • Western States Pediatric Environmental Health : Pediatric Environmental Health Toolkit. https://peht.ucsf.edu/index.php San Francisco, CA 2016 • American Association of Poison Control Centers. https://aapcc.org Alexandria, VA 2017 • Miller MD and Marty MA: Childhood ‐ A Time Period Uniquely Vulnerable to Environmental Exposures in The Praeger Handbook of Environmental Health, edited by Robert H. Friis, Santa Barbara, CA, ABC‐CLIO LLC, 2012, p 203

Children should be considered differently than adults because:

A. They have a higher metabolic rate B. They have a higher surface area to mass ratio C. They have particular windows of susceptibility D. All of the above

165 Adverse Childhood Experiences:

A. Do not affect adult health outcomes

B. Do not have interactive effects with environmental exposures

C. Are stressful or traumatic events occurring in childhood

Minute Ventilation by weight in a 1 year old is roughly __ times that in adults (Adults are roughly 0.1L/kg)

A. 0.5 B. 1 C. 2 D. 4

Diplodocus carnegii Statue in Pittsburgh, PA

Photograph by Wally Gobetz, used under CC license: https://creativecommons.org/licenses/by‐nc‐nd/2.0/

166 @dippy_the_dino: https://twitter.com/dippy_the_dino?lang=en

167 168 Sports Medicine:

What an Occupational Medicine Practitioner Should Consider?

Anthony Luke MD, MPH, CAQ (Sport Med) Benioff Distinguished Professor in Sports Medicine

12/15/2018

Disclosures

. Founder, RunSafe™ . Founder, SportZPeak Inc.

. Sanofi, Investigator initiated grant

Sports Is Hard Work

Can the athlete / worker return: . Safely? . Effectively? . Relatively painfree?

Avoid the secondary or CHRONIC injury

https://www.usatoday.com/story/sports/nba/playoffs/2015/05/26/stephen-curry-warriors-scary-injury-nba- playoffs/27946963/ Sports Is Hard Work

Practical Approaches for: 1. Rotator cuff 2. Meniscus 3. Femeroacetabular impingement 4. Tendinopathies

Shoulder Pain Differential Diagnosis

. Rotator cuff tendinopathy . Rotator cuff tears . SLAP Lesion . Calcific tendinopathy . “Frozen” shoulder (adhesive capsulitis) . Acromioclavicular joint problems . Scapular weakness . Cervical radiculopathy

Shoulder Impingement Syndrome

Mechanism . Impingement under acromion with flexion and internal rotation of the shoulder . Rotator cuff, subacromial bursa and biceps tendon Rotator Cuff Tears

Full Thickness Tear Partial Cuff Tear

Impingement

What is True About Rotator Cuff Tears?

1. An MRI is the best test to diagnose rotator cuff tears 2. The supraspinatus tendon is the most commonly torn 3. All patients with a rotator cuff tear are better off getting reconstruction vs non-op treatment 4. Patients can expect full recovery after rotator cuff repair

What is a rotator cuff tear?

Loss of attachment of the tendon to bone - Can be traumatic or without trauma Common condition over age of 60 - As high as 40% of patients over 60 will have a tear . Increasingly older population….who wants to stay active Usually (but not always) causes shoulder pain and weakness MOVE

Painful Arc 60 - 120° Flexion and External rotation

MOVE

External rotation Internal rotation

Rotator Cuff strength testing

Supraspinatus . Empty can . Thumbs down abducted to 30º . Horizontally adduct to 30º For tendonitis Sens = 77 % Spec = 38 % For tears, Sens = 19 % Spec = 100 % Naredo et al. Ann Rheum Dis, 2002; 61: 132‐136. Rotator Cuff strength testing

Infraspinatus/teres minor - External rotation . Keep elbows at 90º . Patte’s test at 90º shoulder abduction For tendonitis, Sens = 57 % Spec = 71 % For tears, Sens = 36 % Spec = 95 %

Naredo et al. Ann Rheum Dis, 2002; 61: 132-136.

Rotator Cuff strength testing Subscapularis – Internal rotation / Lift-off test

For lesions, Sens = 50 % Spec = 84 % For tears, Sens = 50 % Spec = 95 %

Naredo et al. Ann Rheum Dis, 2002; 61: 132-136.

Impingement Signs Neer . Passive full flexion . Positive is reproduction of shoulder pain Sens = 83 % Spec = 51 % PPV = 40 % NPV = 89 %

MacDonald et al. J Shoulder Elbow Surg, 2000; 9: 299-301. Impingement Signs

Hawkin’s test . Flex shoulder to 90º . Flex elbow to 90º . Internally rotate . Positive - reproduce shoulder pain Sens = 88 % Spec = 43 % PPV = 38 % NPV = 90 %

MacDonald et al. J Shoulder Elbow Surg, 2000; 9: 299-301.

Impingement Signs

. Spurling’s test for cervical radiculopathy

Sens = 64% Spec = 95% PPV = 58% NPV = 96%

X-ray AP Scapula

. Avulsion . Calcific tendinosis . Enthesopathy (traction spurs) . Alignment X-ray Lateral Scapula

Lateral AC joint Axillary

Ultrasound

. Dynamic test . Operator dependent . Areas of tendinosis hypoechoic . Tears

MRI - Rotator Cuff Tears

. Waldt et al. Radiology 2008 . 95% accurate at SS tears

Tear Rotator Cuff Treatment

Conservative Surgery . Education . If patient fails conservative treatment for . Modify Activities > 6-12 months . Alter Biomechanics / Decrease tendon load . If rotator cuff tear > 1 cm . Ice/NSAIDs (no evidence) . Rotator cuff repair . Eccentric exercise programs - +/- decompression/bursectomy . Steroid injection - slightly better than placebo

So who should have surgery?

Indications for surgery: Acute injuries Loss of function Smaller tears do better Better muscle quality (no atrophy, no fatty infiltration) Lower rate or rerupture Easier rehab Easier to repair

Randomized Trials Surgery vs. Conservative

. Degenerative Tears with 5 year f/u

- Surgery outcomes better 6.5 . Constant score, ASES, VAS pain and satisfaction - Clinical benefit debated (did not reach MCID) - 24% of PT group crossed over 9.0 - Nonop patients, 37% tear enlargement: assoc with inferior outcome

Moosmayer et al JBJS 2015 It’s all connected

Meniscus Tear

Mechanism Symptoms . Occurs after twisting . Catching injury or deep squat . Medial or lateral knee . Patient may not recall pain specific injury . Usually posterior aspects of joint line . Swelling

What is True About Meniscal Tears?

Fowler PJ, Lubliner JA. Arthroscopy 1989; 5(3): 184-186.

Test Sensitivity Specificity

Joint line tender 85.5% 29.4%

Hyperflexion 50% 68.2%

Extension block 84.7% 43.75%

McMurray Classic 28.75% 95.3% (Med Thud) McMurray Classic (Lat 50% 29% pain) Appley (Comp/Dist) 16% / 5%

Modified McMurray Testing

. Flex hip to 90 degrees . Flex knee . Internally or externally rotate lower leg with rotation of knee . Fully flex the knee with rotations

Courtesy of Keegan Duchicella MD

X-ray

. May show joint space narrowing and early osteoarthritis changes

. Rule out loose bodies MRI

. MRI for specific exam

. Look for fluid (linear bright signal on T2) into the meniscus

Arthroscopy Benefit?

. An RCT showed that physical therapy vs arthrosopic partial meniscectomy had similar outcomes at 6 months . 30% of the patients who were assigned to physical therapy alone, underwent surgery within 6 months.

- Katz JN et al. N Engl J Med. 2013 - Sihvonen R et al; N Engl J Med. 2013

Exercise as Good as Arthroscopy?

. RCT found that patients with degenerative meniscus tears but no signs of arthritis on imaging treated conservatively with supervised exercise therapy had similar outcomes to those treated with arthroscopy with 2 year follow up.

Kise NJ et al., BMJ, 2016 Meniscal Tear Treatment

Conservative Surgery . Often if degenerative . Operate if internal tear in older patient derangement . Similar treatment to symptoms mild knee osteoarthritis . Meniscal repair if possible . Analgesia . Physical therapy . General Leg Strengthening

What’s Hip?

ARS: 46 year old male plumber with overhead pain, difficulty lifting during work and pain sleeping on the shoulder. He had no injury. What is the likely DIAGNOSIS?

• Rotator cuff tendinitis • Shoulder bursitis • Rotator cuff tendinosis • Massive rotator cuff tear • Frozen shoulder Hip Pain can be Confusing Confounding Factors:

. 27‐90% of patients with groin pain have more than one coexisting injury

Morelli and Weaver, 2005

Femoral Acetabular Impingement (F.A.I.)

. Cam effect . Protrusion of femoral head neck – “bump” . Orientation of the acetabulum – acetabular version . Increased stress on labrum

Anatomy – Bony Examination Supine ‐ Hip

. Hip Internal and External ROM . Labral Impingement and Stress tests

Posterior Hip Pain

Piriformis syndrome 10% of population have sciatic nerve passing through the piriformis Beaton et al. Anat Rec, 70, 1937. Muscle strain vs sciatica

“FABER” Test

. For stressing anterior labrum . Positive in 15/17 . Also SI joint Does the Sacroiliac joint move ?

. Is a Diarthrodial Joint . Synovial fluid . Cartilage on both surfaces . A joint capsule . Ligamentous connections . Articular connections allowing movement

Examination Supine ‐ Hip

. Hip Internal and External ROM . Labral Impingement and Stress tests . Thomas test – for hip flexor tightness Posterior Hip Pain

Piriformis syndrome 10% of population have sciatic nerve passing through the piriformis Beaton et al. Anat Rec, 70, 1937. Muscle strain vs sciatica

MR Arthrogram

Enhanced sensitivity 90% Slightly higher false positive 20% Offers advantage of diagnostic injection of anaesthetic

Anterior Hip Pain Intra‐articular FAI

Cam procedure Labral repair or debridement Microfracture chondroplasty Osteoplasty

Complications: adhesions, fractures and AVN Anterior Hip Pain Intra‐articular FAI

Pincer procedure

Acetabular resection Labral reattachment

Terminology

. Tendinopathy – “tendon injury that originates from intrinsic and extrinsic etiological factors” . Usually not “tendinitis”

Tendon Load Mechanics . Usually tendons surrounding joints with high degree of motion . Usually tendons that cross two joints . Eccentric overload . Mechanical impingement

Where does the injury occur? Insertional . Occurs at insertions near the joint . Joint side Tears . At the musculo- tendinous junction . Areas of friction

Pathophysiology of Tears

. Microtears Spot Diagnosis?

. Macrotears

Miscellaneous . Instability / Subluxation . Calcific tendinosis . Enthesopathy . Contractures 38 year old female ran her first marathon. She finished but is limping one week after. She is happy to rest and do PT but is wondering how long will it take before she can be running painfree. She is TYPE A and you know you need to be conservative with her. She wants to plan her next marathon?

2 weeks 4 weeks 6 weeks 12 weeks 26 weeks Never

Basic Science – Tendon Healing

. Tendon healing creates more collagen fibrils and less mature cross-links with stress . Period of relative weakness before remodeling . Repetitive load can cause heat injury, hypoxia, free-radical injury, and enzyme damage . Degeneration becomes tendinosis

Tendon Healing . requires around 100 days to synthesize collagen Mild – 2 to 4 weeks Moderate – 4 to 6 weeks Severe – 6 to 12 weeks or longer Tendinosis

. Hyaline degeneration . Mucoid degeneration . Collagen Bundle disorganization . Increased ground substance . Increased tenocyte nuclei . Vascular infiltrations and small nerve ingrowth . Presence of non-acute inflammatory cells Abat et al. Journal of Experimental Orthopaedics, 2017

Guidelines for Fluoroquinolone Use in Athletes 1. Avoid the use of fluoroquinolones unless no alternative is available. 2. Oral or injectable corticosteroids should not be used concomitantly with fluoroquinolones. 3. Athletes, coaches, and training staff should understand the potential risk for developing this complication. 4. Close monitoring of the athlete should be undertaken for 1 month after fluoroquinolone use.

59 Presentation Title

Age affects Flexibility

Young patients . Average stiffness 242 +/- 28 N/mm and an ultimate load of 2160 +/- 157 N Older patients . Average stiffness 180 +/- 25 N/mm and an ultimate load of 658 +/- 129 N Woo , Lollis et al, Am J Sports Med, 1991. Hypermobility / Ehlers Danlos

Joint hypermobility syndrome/Ehlers-Danlos syndrome- hypermobility type had more MSK symptoms vs controls They reported: • Lower shoulder function (WOSI total: 49.9 versus 83.3; p < 0.001), • lower HRQol on SF-36 Physical Component Scale (PCS: 28.1 versus 49.9; p < 0.001) • higher pain intensity (NRS: 6.4 versus 2.7; p < 0.001) Neck and shoulder joints were rated as primary painful areas in both groups, with significantly higher frequency in JHS/EDS-HT (neck: 90% versus 27%; shoulder: 80% versus 37%). Johannessen et al. Disabil Rehabil, 2016

3/8/201961

Kinesiophobia

. Described in 1990 by Kori et al. . Kinesiophobia is described as irrational, weakening and devastating fear of movement and activity stemming from the belief of fragility and susceptibility to injury. . Symptoms occur when individual has to increase activity . Various defence mechanisms may appear, such as: repression (removing from consciousness), negation (there is no need for movement), simulation and projection (sports fan behaviour) or, most frequently used, rationalisation (e.g. lacking time). Knapik A, et al. J Hum Kinet. 2011.

Diagnosis History Early tendinopathy symptoms

. Usually a history of overuse or acute strain . Pain when using the affected muscle/tendon . May be present at the start of an activity then pain decreases after “warm-up” . Maybe painful for hours to days after activity . Improves after activity modification (i.e. Stopped running) . Usually does not radiate, but can in some cases (i.e. Shoulder, elbow) . Check for underlying spondyloarthropathy: Psoriasis, GI symptoms, STD

3 Basic P/E findings for tendinopathy

1. Tenderness on direct palpation 2. Reproduction of pain with resisted contraction (eccentric loading) 3. Reproduction of pain with passive stretch

Location

. Achilles Plantar Fasciitis

. Tender on insertion on medial tubercle of calcaneus

. Associated with age, obesity, pes planus and pes cavus

. More prolonged, more difficult to manage

Plantar Fasciitis

. Tender on insertion on medial tubercle of calcaneus

. Associated with age, obesity, pes planus and pes cavus

. More prolonged, more difficult to manage

Posterior tibialis tendinopathy

. >50 y.o. . F > M . Obese, pronation . Sudden collapse of the arch . Short AFO . Surgery Posterior tibialis tendinopathy

. >50 y.o. . F > M . Obese, pronation . Sudden collapse of the arch . Short AFO . Surgery

Patellar tendinosis “Jumper’s knee” . Pain over inferior pole of the patella in supine (less pain when knee flexed to 90°) . Pain with squat . U/S and MRI useful for confirming diagnosis

Patellar tendinosis “Jumper’s knee” . Pain over inferior pole of the patella in supine (less pain when knee flexed to 90°) . Pain with squat . U/S and MRI useful for confirming diagnosis Lateral epicondylitis

“Tennis Elbow” . Extensor carpi radialis brevis tendinosis . Tender lateral epicondyle . Resisted 3rd digit extension and wrist extension . Passive wrist flexion . Arm extended

. Check thumb abduction strength

Biceps Tendinitis

. Tender over the anterior shoulder . Can be very painful . Pain with reaching overhead and behind . Related to poor posture

Treatment Summary – Basic Strategy

Evaluation Treatment . Think tendinopathy: . Modify Activity Activity related, improves . Reduce Stress with rest . PHYSICAL THERAPY . Physical Exam: . Pain Management - #1 Tender on palpation, . Induce Healing – PRP ? - #2 Resisted eccentric contraction, - #3 Passive stretching

Evidence for Eccentric Exercise Wilson F et al. Br J Sports Med, 2018

Moderate level evidence Low level evidence . Eccentric exercise over . Eccentric exercise was not control for improving pain superior to stretching for and function in mid-portion pain or QoL. tendinopathy . Eccentric exercise over concentric exercise for reducing pain . No significant difference in pain or function between eccentric exercise and heavy slow resistance exercise

NSAIDs Evidence ?

. RCT Ibuprofen x 1 wk (600 mg tid) vs placebo, n=26 with chronic achilles tendinopathy, biopsy . PCR Expression of collagens and TGF-β isoforms showed relatively low variation and was unaffected by ibuprofen treatment. . No changes were seen in tendon thickness or VISA-A score Heinemeier et al. J Appl Physiol, 2017.

78 Steroid Injection Evidence ?

Extensor Carpi Radialis Brevis . At short-term follow-up, only local corticosteroid injection improved pain; however, it was associated with pain worse than placebo at long-term follow-up Lian J et al. Am J Sports Med, 2018 Plantar Fasciitis . Steroid injection may lead to lower heel pain (VAS) in the short-term (< 1 month) (MD -6.38, 95% CI -11.13 to -1.64; 5 studies; I² = 65%; low quality evidence). . Steroid injection made no difference to average heel pain in the medium-term (1 to 6 months follow-up) David JA et al. Cochrane Database Syst Rev 2017

Platelet Rich Plasma Injections

What is it?

. Concentrate the plasma by centrifugation . Blood must be drawn from a patient and the platelets are separated from other blood cells and concentration is increased

. CANNOT USE ANESTHETIC

https://orthoinfo.aaos.org

PRP Evidence ? - Inflammation

. PRP seems to control of the inflammatory process, involving in particular the hepatocyte growth factor (HGF) . PRP has been shown to activate Tumor Necrosis Factor TNF-alpha and NFkB pathways (pro-inflammatory) . Expression of genes related to cellular proliferation and tendon collagen remodeling seen after PRP

Hudgens et al. Am J Sports Medicine, 2016 PRP Evidence ?

Overall . Patellar and lateral elbow tendinopathy showed improvement from PRP treatment . Achilles tendon and rotator cuff do seem not to benefit from PRP application with either conservative treatment or surgery

. There is no consensus on efficacy . This is mainly due to the lack of standard PRP preparation procedures or methods of application Abat et al. Journal of Experimental Orthopaedics, 2018

What about a Needle Tenotomy ?

. Passing the needle through the area of tendon degeneration . Ultrasound-guided intratendinous PRP injection may lead to both clinical and MRI improvements in tendon pathology. Wesner et al. PLoS One 2016 Patellar tendon (Abat et al.

83 Presentation Title

Sports Is Hard Work

Think about Anatomy, Pathophysiology and Demand

Can the athlete / worker return: . Safely? . Effectively? . Relatively painfree?

Avoid the secondary or CHRONIC injury

https://www.usatoday.com/story/sports/nba/lakers/2018/12/26/lebron-james-injury-los-angeles- lakers/2413105002/ What is True About Rotator Cuff Tears?

What is True About Meniscal Tears?

1. An MRI is the best test to diagnose the Meniscus tear 2. The lateral meniscus is most commonly torn vs the medial meniscus 3. Patients with a symptomatic meniscus tear are better off getting arthroscopy vs non-op treatment 4. Patients can expect full recovery after meniscus surgery 38 year old female ran her first marathon. She finished but is limping one week after. She is happy to rest and do PT but is wondering how long will it take before she can be running painfree. She is TYPE A and you know you need to be conservative with her. She wants to plan her next marathon?

2 weeks 4 weeks 6 weeks 12 weeks 26 weeks Never Volcanology for the health care provider:

Hazards of volcanic and geothermal areas.

Michael N. Bates, Ph.D. School of Public Health University of California, Berkeley

Disclosures

I have no conflicts of interest to disclose.

Topics

 Basics of volcanoes and geothermal areas  Physical hazards  Chemical hazards  Supervolcanoes  California volcanoes  Basic precautions in the case of a volcanic eruption

171 Main Types of Volcano

 Stratovolcanoes (e.g., Mt. St. Helens, Mt. Pinatubo)  Formed at the intersection of tectonic plates  Magma is very viscous, retaining gases.  Often violent eruptions  Known also as ‘composite volcanoes’

 Shield Volcanoes (e.g., Hawaiian volcanoes, Galapagos Is.)  Form above “hotspots” in the Earth’s crust  Magma is more fluid, easily releasing gases.  Less violent eruptions; effusive lava flows and lava fountains

Photo of Stromboli by Steven W. Dengler

Stratovolcano formation in a subduction zone

By KDS4444 - Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=49035989

172 Geothermal areas

 Present in volcanically active areas that are currently quiescent.  Characterized by geysers, boiling mud and water pools, and degassing fumaroles.  Frequently used as a source of geothermal power.  Most well-known and visited sites of “geotourism” are Yellowstone Park, Geysir, Iceland, and Rotorua, New Zealand.  Hazards are mostly from thermal burns and exposure to toxic gases, particularly hydrogen sulfide.

Physical hazards of volcanoes

Pyroclastic flows Lahars Lava flows Tsunamis Tephra Earthquakes

173 Pyroclastic flows

 Fast moving (60->300mph) mixture of very hot gases, ash and rock streaming down the volcano. Mayon volcano, Philippines, 1984  Can travel tens of miles, incinerating everything in its path.

 Formed from the collapse of an eruption column.   Historically, the major cause of mortality from volcanic eruptions.

Lahars  Violent, very destructive mudflows down a volcano, usually in a river valley.  Large ones can travel up to 60 mph and for >100 miles.  Typically have consistency and viscosity of wet concrete.  Can occur as a result of:  Lava or a pyroclastic flow interacting with snow or a glacier  Collapse of a crater wall, even in the absence of an eruption  In 1985, Nevado del Ruiz eruption, a lahar killed 23,000 people in the city of Amero, Colombia.

Tsunamis (tidal waves)

 Major waves caused by the displacement of large volumes of water.  May be caused by undersea volcanic eruptions, earthquakes or landslides.  Travel through sea at very high speed.  Amplitude increases when the depth of water decreases.

174 Lava flows

 Mainly produced by shield volcanoes.

 Usually travel too slowly to kill many people.

 Most casualties from activities such as walking on a cooled and solidified lava crust.

 When molten lava reaches the sea it produces laze—a fog containing hydrochloric acid.

Tephra

 All the solid material ejected into the air from a volcano, including:  Ash—particles <2 mm diameter  Pumice  Blocks and lava bombs.

 Generally, the larger the fragments the closer they are deposited to the site of the eruption.

 Plumes may damage aircraft engines.

Volcanic ash

 Not really ‘ash’; actually finely pulverized particles of rock.

 Most concern about the inhalable fraction (<10 µm) and the respirable fraction (<2.5 µm).

 Silica content varies, but is often low and then poses only limited risk of silicosis.

 Major hazard is collapse of buildings from weight of ash on roofs.

 Chemicals (e.g., fluoride) adsorbed to the surface of ash particles may cause water pollution and livestock poisoning.

175 Fluoride poisoning

 Fluoride-containing volcanic ash deposited on pastures has been a major cause of livestock deaths in some areas, particularly Iceland.

 Most recently in 2010, during the eruption of Eyjafjallajökull.

Earthquakes

 Volcanic eruptions are often preceded or accompanied by swarms of earthquakes.

 They are caused by the magma breaking through rock barriers to reach the surface.

 Volcano earthquakes can also precipitate tsunamis and release of trapped gases and lava.

Volcanic and geothermal gases

 Carbon dioxide (CO2)

 Sulfur dioxide (SO2)

 Hydrogen sulfide (H2S)  Hydrogen fluoride (HF)  Hydrochloric acid (HCl)  Radon (Rn)

176 Carbon dioxide

 The major gas, apart from water vapor, emitted by volcanoes.

 CO2 is heavier than air and may cause asphyxiation if it collects in low lying areas.

 Large numbers of deaths have been caused by

releases of CO2 trapped under pressure at the bottom of volcanic lakes or calderas.  e.g., Lake Nyos, Cameroon, 1986: 1,700 deaths of people; >3,000 livestock deaths.

Lake Nyos disaster

Source: Oregon State University: Volcano World.

Sulphur dioxide

 A highly irritating and toxic gas released in large quantities by volcanoes.  In Hawai’i, a principal component of ‘vog’, mainly on the Kona side, from releases by the Kilauea volcano.  Can cause or exacerbate lung diseases, including asthma, and eye problems.  Sulphates may reach stratosphere and circle the globe—impacting climate, with crop failures and famine.  Dissolves in water to form sulfurous and sulfuric acids, which may result in acid rain.

177 Acid rain can:

 damage and kill vegetation,  corrode machinery and buildings,  cause skin burns to animals, and  contaminate water by corroding pipes, water tanks and roofs, releasing metals.

 For example, pH of rain affected by emissions from Masaya volcano, Nicaragua, was ~3--strongly acidic

Hydrogen sulfide

 Released by volcanoes, but more commonly in geothermal areas—responsible for the “rotten eggs” smell.

 Heavier than air and highly acutely toxic—resulting in many deaths in low-lying places where it collects.

 Can be detected by the human nose at very low concentrations (e.g., 5 ppb).

 Consequences of long-term, low-level exposure to

H2S are uncertain, but may be benign.

Supervolcanoes

 Volcanic eruptions with a magnitude of 8 on the Volcanic Explosivity Index—ejection of ≥1,000 km3 of material.

 Can cause major effects on a continental or global scale, including climate change and mass extinctions.

 The last VEI-8 eruption was 26,500 years ago, by New Zealand’s Taupo Volcano, now Lake Taupo (a caldera).

 The Yellowstone supervolcano last erupted 640,000 years ago.

178 The world’s supervolcanoes

How ash would be spread by a Yellowstone ‘supereruption’

USGS Assessment of California’s Volcanoes

Very-high threat: •Mount Shasta •Lassen Volcanic Center •Long Valley Volcanic Region

High threat: •Clear Lake Volcanic Field •Medicine Lake Volcano •Salton Buttes

Moderate threat: •Ubehebe Crater •Coso Volcanic Field

179 Cascade range eruptions in last 4000 years

Source: USGS

General civil defense precautions against imminent volcanic eruptions

 Continually monitor radio or TV broadcasts.

 Be prepared to evacuate at short notice.

 Maintain an emergency survival kit, including food, bottled water, dust masks, goggles, and flashlights.

 Remain calm!

Prevention of exposure to heavy ashfall

 Stay indoors as much as possible (pets too).

 Keep doors and windows closed and seal cracks with tapes or wet towels.

 When outside, wear ski goggle and dust mask, breathe through nose, and avoid physical exertion.

 Take off ash-covered clothing before entering a building.

180 Avoiding consumption of water contaminated by ashfall

 Fill up containers (including the bath) with water at an early stage.

 If a roof collection, disconnect the tank inlet pipe.

 Cover any open water supply tanks.

 Conserve water

Concluding points

 Volcanic events are very rare, but potentially catastrophic when they occur.

 There are a wide variety of physical and chemical hazards associated with volcanoes and geothermal areas. Each situation requires its own assessment of the likely hazards.

 Most events will require evacuation, but there are simple commonsense precautions that can also be taken.

Thank you!

181 Q.1: Which of the following is not a gas emitted by volcanoes or geothermal areas?

A) Nitrogen oxides (NOx)

B) Sulfur dioxide (SO2)

C) Carbon dioxide (CO2)

D) Radon (Rn)

E) Hydrogen sulfide (H2S)

Q.2: Which of the following has been the deadliest volcano‐related cause of death since 1900?

A) Lahars

B) Volcanic gases

C) Pyroclastic flows

D) Famine

E) Tsunamis

Q.3: What is laze?

A) Low‐level haze associated with volcanic emissions.

B) Fumes resulting from the interaction of molten lava and seawater.

C) Particles in air formed by water and sulfur dioxide.

D) The (usually) fatal urge to linger at the crater rim of a volcano to observe its eruption in the early stages.

E) Mud and other debris that surges down a volcano’s slope when its crater wall collapses.

182 Occupational Health in the Biotechnology Industry David Miedinger MD PhD

Disclosure

• DM is a full-time employee at F. Hoffmann-La Roche Ltd and owns stocks and stock options of this organization

• DM is a former employee of Suva and has received research grants from this organization

• DM is a lecturer at the University of Basel

Definition

• Biotechnology according to Merriam-Webster: – the manipulation (as through genetic engineering) of living organisms or their components to produce useful usually commercial products (such as pest resistant crops, new bacterial strains, or novel pharmaceuticals)

183 Biotechnology research & development

• Integration of various disciplines – Molecular and cellular biology – Chemistry – Bio-chemistry – Genetics – Biochemical engineering – Process engineering – Computer science

• Hazards – Recombinant and nonrecombinant micororganisms – Active pharmaceutical ingredients (APIs) – Chemicals – Physical hazards Lee SB & Ryan LJ, Am Ind Hyg Ass J, 1996

Good Manufacturing Practice – GMP

• Regulations promulgated by the US FDA, EMA

• Require that manufacturers, processors, and packagers of drugs, medical devices, some food, and blood take proactive steps to ensure that their products are safe, pure, and effective

• Protects the consumer from purchasing a product which is not effective or even dangerous or eliminate instances of contamination, mixups, and errors

• Failure of firms to comply with GMP regulations can result in very serious consequences

www.ispe.org

Human factors and Ergonomics (I)

• Limited evidence that job rotation reduces the exposure of physical risk factors. Positive correlation between job rotation and higher job satisfaction. Worker training is a crucial component of a successful job rotation program

• Participatory ergonomics: Actively involving workers in developing and implementing workplace changes – Reduction of MSK injury risks, improved information flow, improved meningfulness of work, more rapid technological and organisational change, enhanced performance – Greater «ownership» by those affected leading to greater commitment to change – But: mixed nature of health effect evaluations, diversity of program designs, variety of organisational characteristics and contexts Simprini Paula R et al, Applied Ergonomics, 2017 Burgess-Limerick R, Applied Ergonomics, 2017

184 Occupational contact dermatitis (OCD) • Prevalence rates for OCD range from 19% to 50% depending on profession and source

• Workers in pharmaceutical manufacturing are in contact with reactive intermediates and drugs

• OCD to intermediates occurs almost exclusively in employees working in drug development and manufacturing plants By James Heilman, MD - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=94449 17 Winkler GC et al, Regul Toxicol Pharmacol, 2015 Antonov D et al; Bircher AJ; Diepgen, TL and Coenraads PJ all in Kanerva’s Occupational Dermatology, 2. Ed., 2012

Occupational dermatitis in the pharmaceutical industry

• Dermatology clinic in Ireland

• 73 patients seen in a 15 year period

• 2/3 contact dermatitis, 1/3 irritant contact dermatitis

• Primary site was the face in 66% of contact dermatitis patients

• Hand dermatitis more commonly due to irritants

• Causes for PPE associated allergies: – Thiurams (Latex gloves) – Tetramethylthiuram monosulfide (Rubber face mask) – Nickel (Metal clasp) – Uncertain (Nitrile gloves and boots)

Bennet MF et al, Br J Dermatol, 2016

Non-glove personal protective equipment- related occupational dermatoses

• EPIDERM (UK-wide surveillance sheme) 1993-2013

• 0.84% of all occupational skin disease

• at body sites less commonly associated with occupational skin disease

• 194 (9.2%) of PPE-related cases

• diagnosed as: allergic contact dermatitis (47%), irritant contact dermatitis (16%), friction (11%), occlusion (11%), unspecified dermatitis (9%), acne (3%), infections (2), and contact urticaria (1%)

• industries most associated: manufacturing (19%), public administration and defence (17%), health and social work (16%), and transport, storage, and communication (10%)

Bhoyrul B et al, Contact Dermatitis, 2018

185 Sharp Injury/Needlestick- What to do?

Biosafety Handling of instruments • All used instruments are potentially infectious  Everybody working with potentially infectious material must be vaccinated aginst hepatitis B  Correct use of PPE • Instruments must be prepared and labbeled for transport according to the regulations • Instruments and parts must be decontaminated before they are shipped Decontamination certificate must be attached

• Decontaminated instruments are still potentially infectious (only to a lesser degree) – must be disposed of in a safe way

Biosafety in Biotechnology Research Operations

• Laboratory-Acquired Infections (LAIs) seem to be rare

• US Report of Theft, Loss or Release of Select Agents and Toxins (TLR incident report) 2004-2010 – 11 LAIs associated with biological select agent and toxin (annual rate of 1,6 per 10’000 authorized workers) – All unrecognized and/or unreported exposures (aerosols?) – No fatalities and no secondary transmission to other humans

• But: – Lack of systematic reporting very likely (fear of reprisal or embarrassment) – Difficult to identify subclinical infections

– Atypical incubation periods and routes of infection Henkel RD et al., Applied Biosafety, 2012 Singh K, Clin Inf Dis, 2009

186 Advancement of Biotechnology

• First generation: Recombinant DNA technology – transfer of already existing genes from one cell to another

• Second generation: Synthetic Biology – Design, assembly, synthesis, or manufacture of new genomes, biological pathways, devices or organisms not found in nature – Re-designing of existing genes, cells or organisms for the purpose of gene therapy

Howard J et al., 2017 https://blogs.cdc.gov/niosh-science-blog/2017/01/24/synthetic-biology/

Risks of Lentivirus Vectors (LVVs) and Transgene Exposures

• LVVs can cause clonal expansion and may cause oncogenesis through insertional mutagenesis – SCID treated with retrovirus developed leukemia – X-linked chronic granulomatous disease treated with retrovirus developed myelodysplasia or acute myeloid leukemia – Beta-thalassemia treated with retrovirus developed nonmalignant clonal expansion of erythroblasts

• LVV-infected genes can become cancerous through activation of oncogenes or inactivation of tumor suppressor genes

• Recombination unintentionally reconstitutes a replication-competent and pathogenic virus There is a potential risk of accidental insertional mutagenesis for an Schlimgen R et al. JOEM 2016 Cavazzana-Calvo M et al, Science 2000 individual inadvertently exposed to LVV Hacein-Bey-Abina S et al, Science 2003 engineered for research purposes! Howe SJ et al J Clin Invest 2008 Stein S et al, Nat Med 2010 Cavazzana-Calvo M et al Nature 2010

Risk for transmission

• Clinically relevant exposures – Parenteral inoculation – Mucous membranes of the eyes, nose or mouth – Direct contact with nonintact skin

• Aerosol exposures through droplet transmission – Eg. Centrifuging or pipetting can generate droplets 5-10 µm diameter

• Replacement of HIV envelope with VSV-G – Entire mucosal membrane of tracheobronchial region can potentially be infected

• Authors recommend PEP after clinically relevant LVV exposure

Schlimgen R et al. JOEM 2016

187 Biosafety Levels: Risk Management Levels

• Company directive: Defines standards for the protection of employees, environment and general public from adverse effects due to exposure of biological material produced or handled in Roche facilities or under the responsibility of Roche • Risk calculation: Risk = Hazard x Exposure

difficult to Risk Group 1-4 measure – Exposure management defined by work practices and infrastructure

Risk and Biosafety Level 1-4 Risk Managment

– No measurements necessary – Biosafety rules and standards are well harmonized • Binding for all companies of the Roche Group

Primary and Secondary Prevention in the Biosafety Lab – Preplacement and Periodic Medical Evaluations • Primary prevention – Vaccination (HBV, …) – Review previous and ongoing medical problems (defective immune system skin disorders), medications (immunosuppressants) and allergies

• Secondary prevention – Health surveillance (limited value) • Small size of groups under study • Variability in individual exposures • Potentially long induction-latency period • Subclinical disease, uncertainty as to the adverse effect • Lack of sensitivity or specificity of screening tests • Uncertainty as to the connection between Biosafety in Microbiological and Biomedical Laboratories 5th Editio exposure and effect Goldman RH, Occupational Medicine, 1991

CME Question 1

• Which findings related to the workplace are most frequently encountered during medical health surveillance exams in the biotechnology industy?

a. Asbestos-related lung disease (eg. Asbestosis, pleural plaques, …) b. Repetitive stress related musculo-skeletal disorders (WRULD, RSI, …) c. Heat or cold burns related to extreme temperature during production processes d. PPE related contact dermatitis

188 CME Question 2

• Which statement regarding non-glove personal protective equipment related occupational dermatoses is incorrect

a. Are more frequently encountered than glove-related occupational dermatoses b. Thiurams, Tetramethylthiuram monosulfide and Nickel are possible allergens c. Often occur at body sites less commonly associated with occupational skin disease d. They may be a result of GMP requirements to produce medicines that are safe, pure, and effective

CME Question 3

• Which statement regarding Lentiviruses (LVVs) is false

a. LVVs can integrate a siginificant amount of viral cDNA into DNA of host cells and can even infect non-dividing cells b. LVVs with VSV-G envelope can potentially infect the mucosal membrane of the tracheobronchial region of the worker c. Aerosol exposures through droplet transmission is a rare but potential occupational exposure d. PEP for LVVs exposure is evidence based

189 190 Dabs, Vapes and Thirdhand Smoke: An Update on Environmental Exposure to Tobacco and Marijuana

Suzaynn F. Schick, PhD 3/5/2019

Conflicts and Acknowledgements

. No conflicts to disclose . Funding from the California Tobacco-Related Disease Research Program, grants 20PT-0184, 21ST-011, 24RT- 0039, 28IR-0049 and 28PT-0081

What is Thirdhand cigarette smoke? The 3 R’s

Chemicals in cigarette smoke that: . Remain on surfaces and in dust . Re-emit back into the gas phase . React with other chemicals in the environment to make new chemicals

| [footer text here] 191 What is smoke? • Gases • Particles and droplets of oils and waxes (Tar) • 10% of secondhand smoke is tar

Thirdhand Smoke starts with Tar

Remain

. Tar chemicals stick to surfaces before they can be removed by ventilation . Walls, carpet, dust, people… . Tar absorbs into porous materials . Tar contains nicotine and many toxins and carcinogens . Nitrosamines . Polycyclic aromatic hydrocarbons . Persistence increases exposure time

Re-Emit

. Combustion forces tar chemicals (normally solids or liquids) into the air . Tar cools, condenses and sticks to surfaces . Once on a surface, each chemical reaches equilibrium . Fraction in the air depends on the chemical

| [footer text here] 192 React

. Where there are chemicals, there are chemical reactions . Which reactions do we know about? - Nicotine + nitrous acid = NNK

. Carcinogen - Nicotine + ozone = formaldehyde

. Carcinogen - Tar + ozone = ultrafine particles

. Can cause heart and lung disease

PubMed citations in environmental smoke research

. “Tobacco smoke pollution” . “Marijuana smoke pollution” - 12,876 - 62 . “Secondhand tobacco smoke” . “Secondhand marijuana smoke” - 2135 - 23 . “Thirdhand tobacco” . “Thirdhand marijuana” - 77 - 2

Cannabis products

• Unfertilized female flowers (buds) • THC content = 10-30%; local dispensary average ≅ 20% • Concentrates • 40-98% THC • Physically separated trichomes (hash) • Hydrocarbon extracts (butane hash oil)

•CO2 extracts • Heat/pressure extracts • Cartridges and vape pens • Filled with concentrates • Edibles • Most use a cannabis-infused fat or oil with 5 - 10% THC • Tinctures • Most are oil-based, not alcohol • Topicals

| [footer text here] 193 Modes of use

. Combustion - Cigarettes - Pipes & water pipes - Blunts . Aerosolization - Vaporizing flowers - Vaporizing concentrates . Dabbing . Vape pens

Sources of Cannabis Emissions

Material Activity Temperature Mass per use Flowers, concentrates Smoking 400-900° C 0.2-2 g

Concentrates Dabbing 175-815° C 0.1-0.5 g Flowers, concentrates Vaporizing 150-220° C 0.1-2 g

Whole plant Indoor grow Ambient 0.5-200 kg Flowers, trim Extraction Varies with method 0.2-200 kg

Flowers, trim Decarboxylation, 115° C 0.02-20 kg cooking

Edible preparations Eating 37° C 0.1-2 g

Topical preparations Rubbing on skin 37° C 0.1-2 g

A Natural Experiment: 2 Dispensaries with different consumption policies

. Dispensary 1 - Vaporizing, dabbing and vaping - Only devices provided by dispensary are permitted - Estimated room area = 14,000 ft3 (400 m3) - Central HVAC w/ 2 vents + 4 window AC units . Dispensary 2 - Smoking, dabbing and vaping - Provides dab rigs, bongs and lighters, customer devices permitted - Estimated room area = 16,000 ft3 (450 m3) - One central HVAC vent (?), one small air circulating fan

| [footer text here] 194 Summary: Dispensary 1 vs Dispensary 2

• Dispensary 1 Particle concentration was 8 X less than Dispensary 2 • Particle concentration depends on:

Mass per source 1 Unknown 2

Number of sources 1 < 16-18 X 2

Air exchange rate 1 > 2

Particle deposition rate 1 Unknown 2

What would the air quality index be in these dispensaries?

• The US Air Quality Index (AQI) was designed for outdoor air • It integrates 6 pollutants into 1 value

•PM2.5 Nitrogen dioxide PM10 • Ozone Sulfur dioxide Lead • Carbon dioxide • AQI numbers do not equal pollutant concentrations • There is a different threshold scale for each pollutant

•PM2.5 AQI thresholds are for 24 hour averages

Health risks of PM2.5 exposure . Acute (minutes to days) - Increased risk of myocardial infarction - Exacerbation of respiratory disease (asthma and COPD) . Chronic (months and years) - Atherosclerosis - Myocardial infarction and stroke - Chronic obstructive pulmonary disorder (emphysema) - Asthma - Cancer - …

| [footer text here] 195 Question 1: The California Medicinal and Adult Use Cannabis Regulation and Safety Act allows consumption of cannabis in all the following places, except:

a) In licensed retail stores and microbusinesses, with on site consumption permits b) At special events at county fairgrounds and agricultural associations c) Outdoors, in public places d) In private residences, with the owner’s permission

Question 2: Please select the cannabis consumption methods that can increase airborne particle concentrations:

a) Smoking b) Vaporizing and Vaping c) Dabbing d) All of the above

Question 3:

Acute exposure to PM2.5, at any concentration, is associated with?

a) Endothelial dysfunction, increased risk of myocardial infarction

b) Decreased FEV1, increased risk of bronchitis c) Fever d) Increased risk of lung cancer

| [footer text here] 196 Climate and Health in 2019

Paul English, PhD MPH

Tracking California Public Health Institute

2019 Photos credit: Jon Tyson; Adrien Taylor on Unsplash

Disclaimer

I have nothing to disclose

OUTLINE

‐ Immediate and Medium‐Term Threats

‐ Case studies: Transportation and Industrial Agriculture

‐ Moving Forward: Positive and Negative Social Pressures

197 Continuing Climate‐Related Health Threats

• Wildfires/Air Quality • Heat Waves • Heat‐Related Neuropathy • Increased probability of rare catastrophic weather events • Population Displacement • Infectious Disease Spread

Medium‐Term Health Threats

• Limits of Human Tolerance to Heat • Food supply • Mental Health

Air Quality from Woolsey/Camp Fires CA November 2018

11/9/18 Location Air Quality Index San Francisco 177 Fremont 179 Beijing 34 Source: NASA Nov 14 2 PM image Hong Kong 63 New Delhi 237 Ukiah 336

Ongoing Issues on Wildfire Smoke Exposures

‐ Childhood exposures ‐ Acute smoke exposures ‐ Long term consequences on lung function?

‐ Exposure to 24 hr avg PM2.5 during 2008 CA wildfires related to asthma ER and hosp (Reid, et al 2016)

‐ Wildfires could double the number of premature deaths from fine PM by 2100 (Ford et al 2018)

‐ Rescue meds to reduce airway inflammation among asthmatics during wildfire events

‐ Use of masks during wildfire events

‐ Prenatal exposures (UC Davis work)

‐ Firefighter exposures (biomonitoring)

198 Solution

Source: Atlantic Magazine

Heat Stress Neuropathy

• Up to 20,000 deaths among sugarcane workers in El Salvador and Costa Rica

• Moyce et al 2016 (UC Davis): 12% of approx. 300 workers had acute kidney disease after a summer work shift (heat stress and dehydration) • Not associated with traditional risk factors (diabetes, hypertension, etc.)

• “one of the first epidemics due to global warming?”

What is the limit of human survivability for heat?

“Human exposure to approx 35°C (95°F) wet bulb temperature for even a few hours will result in death even for the fittest of humans under shaded, well‐ventilated conditions” (Im, et al 2017)

(ambient air wet bulb temperature (combined measure of temp and humidity)

Threshold likely to be reached in South Asia by end of this century (Im, et al 2017)

199 Fig. 1 Spatial distribution of highest daily maximum wet-bulb temperature, TWmax (°C), in modern record (1979–2015).

Eun-Soon Im et al. Sci Adv 2017;3:e1603322

Published by AAAS

Fig. 3 Vulnerability due to population density, poverty, and outdoor working conditions.

Eun-Soon Im et al. Sci Adv 2017;3:e1603322

Published by AAAS

Solution

Dubai Mall of the World

“The world’s first temperature‐controlled city”

Dubai summer average high around 106 °F and overnight lows around 88 °F

Totally enclosed 13 million square feet 250‐room inn, 22 movie theatres, 120 restaurants, 14,000 parking spaces Street car system To be built using state of the art green technology?

200 Ongoing extreme events

2017:

Houston Flooding CA: 5 of its 20 worst wildfires ever India: Epic monsoon flooding

Insurance payout that year: $135 b Uninsured losses: $195 b (Source: The Economist 2.23.19)

Photo credits: CDC

Increased probability of rare catastrophic weather events

e.g. Hurricane Harvey August 2017 Source: ‐ 1 year of rain in 1 week (Third “500 year” CDC flood in less than 40 years) ‐ Massive evacuations, massive damage ‐ Largest flood event in Houston history

Atmospheric river rare mega storm in CA scenario

• Could last for weeks and cause more than 1.5 million people to evacuate • Floodwaters would inundate cities and form lakes in the Central Valley and Mojave Desert • Damage estimated at more than $725 billion statewide. Source: US Army Corps Engineers and USGS.

Whittier Narrows Dam Source: Army Corp Engineers

Post‐storm infectious disease spread

Mosquito‐borne: Dengue Chikungunya Malaria Zika West Nile

• Migration of vectors due to changes in precipitation, humidity, temperature Source: Dominican Republic after Tropical Storm Isaac, 2012, CDC • Rise in drug and pesticide resistance

201 Climate Change Migration

(photo courtesy of CDC)

• Role of climate change (drought, flooding, extreme weather) in causing famine, conflict, and population displacement/migration ‐ Occurring in poorest areas with high vulnerability/few resources

• “Climate Gentrification” (residents moving to areas without climate change hazards resulting in higher property values) • Example: Phoenix to Flagstaff

• Mobility responses should be related to rate of onset of climate hazard (UNEP)

Climate Change Migration

Public Health Capacity to Address Climate‐Related Health Threats

• Lack of capacity at national, state and local levels: 75% of local health dept respondents reported that their agencies “lacked the expertise to assess the potential impacts” of climate change (NACCHO 2008; 2012 and Roser‐Renouf, et al 2016)

• Over 19% of total state and local health dept workforce were lost from 2008 to 2014 (51,000 jobs). (ASTHO)

• Only 14 percent of the workforce has formal training in public health, despite a 300 percent increase in public health graduates since 1992. (ASTHO: PH WINS study 2017)

202 The Web of Climate‐Related Impacts on Human Health, Transportation Example

Drought Transportation Human Wildfires (Anthropogenic Limit on climate forcing ) Heat Air Respiratory Tolerance pollution and other Non‐ disease Loss of active outcomes Public Public Transport Health Health Action Capacity Lack of Diabetes Trust in /Obesity Science

Adaptation and other Increase in preventative Vaccine activities Preventable Illness

Industrial Agriculture, Ecological Impacts, and Climate Change

‐ Livestock (confined agricultural feeding) and Rice cultivation: Methane emissions

‐ Fossil Fuel use/fertilizers/pesticides

‐ Deforestation/Land Use

‐ Monoculture practice leading to loss of biodiversity/pesticide resistance: potential threats to food supply

Nearly half of all insect species are In rapid decline

Causes: deforestation Pollution Pesticides Climate change

Source: International Union for the Conservation of Nature and Sanchez‐Bayo and Wyckhuys, 2019

203 The Web of Climate‐Related Impacts on Human Health, Industrial Agriculture Example

Industrial Ag/CAFO Meat (Anthropogenic Catastrophic Consumption Climate Forcing) Insect Collapse

Methane Increased Food Antibiotic Cancer Availability Resistance Risk / Quality

Ocean warming CO2 /Acidification Deforestation

Social Trends: PROS

73% of respondents think global warming is happening, which is a 10% increase from 2015. 62% think climate change is mostly caused by Humans (source: Leiserowitz et al 2018.)

Nearly half of Americans support a carbon tax. That share is higher when told that the tax would go toward environmental restoration or renewable energy R&D. (Source: Univ Chicago and AP, 2018)

Green New Deal: focus on public spending on green energy

Social Trends: CONS Rise of Scientific Populism

“America was founded on liberty and independence, and not on government coercion, domination, and control. We are born free, and we will stay free.” ‐ 45th President of the United States

“Global warming is not about science, but about politics ‐‐ that is, about expanding the power of elites using the coercive instruments of government to control the lives of people everywhere. ” Charles Kadlec, “The Goal Is Power: The Global Warming Conspiracy,” Forbes Magazine, 7/25/11

“Why, then, are we allowing an elite aristocracy of doctors and professors to bully people who disagree with them about laws that disempower parents and place an unequal vaccine risk burden on vulnerable children in the name of the public health?” (“Zero Tolerance Vaccine Laws in America: Will You Defend Vaccine Freedom?, National Vaccine Information Center, 2.19.19)

Riots in France

204 Conclusions

• Climate‐related health threats continue to multiply; with wildfires, air quality, and heat‐related issues continued top threats nationally and globally

• If warming continues unabated, threshold of human heat tolerance will be reached (e.g. south Asia), with large implications for health, worker productivity, and society

• Global inequities in resources and vulnerability status allows one to predict where greatest health burden of climate change is occurring/will occur

• Climate change not only directly affects human health, but also affects health indirectly via ecosystem impacts

• Winner of struggle between populism and mainstream science will have impacts on ability to address climate change threats.

REFERENCES

Sánchez‐Bayo, Francisco, and Kris AG Wyckhuys. "Worldwide decline of the entomofauna: A review of its drivers." Biological Conservation 232 (2019): 8‐27.

Reid, C. E., Jerrett, M., Tager, I. B., Petersen, M. L., Mann, J. K., & Balmes, J. R. (2016). Differential respiratory health effects from the 2008 northern California wildfires: A spatiotemporal approach. Environmental research, 150, 227‐235.

Ford, B., et al. "Future fire impacts on smoke concentrations, visibility, and health in the contiguous United States." GeoHealth 2.8 (2018): 229‐247.

Moyce, S., Joseph, J., Tancredi, D., Mitchell, D., & Schenker, M. (2016). Cumulative incidence of acute kidney injury in California's agricultural workers. Journal of occupational and environmental medicine, 58(4), 391‐397.

Im, E. S., Pal, J. S., & Eltahir, E. A. (2017). Deadly heat waves projected in the densely populated agricultural regions of South Asia. Science advances, 3(8), e1603322.

Roser‐Renouf, C., Maibach, E.W. and Li, J., 2016. Adapting to the changing climate: an assessment of local health department preparations for climate change‐related health threats, 2008‐2012. PloS one, 11(3), p.e0151558.

ASTHO and de Beumont Foundation. 2017 Public Health Workforce Interests and Needs Survey (PH WINS) https://www.debeaumont.org/phwins/ accessed 2.28.19

Warren, R., et al. "The projected effect on insects, vertebrates, and plants of limiting global warming to 1.5 C rather than 2 C." Science 360.6390 (2018): 791‐795.

Leiserowitz, A., Maibach, E., Rosenthal, S., Kotcher, J., Ballew, M., Goldberg, M., & Gustafson, A. (2018). Climate change in the American mind: December 2018. Yale University and George Mason University. New Haven, CT: Yale Program on Climate Change Communication.

Energy Policy Institute at the University of Chicago (EPIC) and The Associated Press‐NORC Center for Public Affairs Research, Nov 2018 Poll https://epic.uchicago.edu/news‐events/news/ new‐poll‐nearly‐half‐americans‐are‐more‐convinced‐they‐were‐five‐years‐ago‐climate accessed 2.28.19

Thank You Paul English [email protected]

205 1. How is the anti‐vaccination movement related to difficulties in communicating the health harms of climate change?

A. Vaccines contain global warming gases B. Because communities with an increasing lack of trust in science will likely greet climate change warnings with skepticism C. Children who are not vaccinated are likely to become climate change skeptics D. Anti‐vaxxers are more likely to be worried about climate change than the average citizen

2. What percentage of Americans think global warming is now occurring, according to a recent survey?

A. 10%

B. 46%

C. 0.01%

D. 73%

3. How much are the majority of Americans willing to spend each month to fight climate change?

A. $1

B. $50

C. $10

D. $100

206 Partner Logo

Hazardous Metals Emerging and Long-standing Toxicants

Robert Goodnough, MD Medical Toxicology Fellow UCSF Department of Emergency Medicine Zuckerberg San Francisco General Hospital California Poison Control System – San Francisco Division

3/6/2019

Financial Disclosures

. None

2 Hazardous Metal 3/6/2019

Case Introduction

Presentation: . A 40 year old man is referred to occupational health clinic. . 2-3 months of progressive dyspnea on exertion . Normal CBC, chemistry panel. . Social History: negative . Medical History: none . Occupational History: grinding Indium Tin Oxide plates for the last 9 years

3 Hazardous Metals 3/6/2019

207 Objectives

What we’ll cover: . Historic • Vanadium • Germanium . Emerging • Tellurium • Rare Earth Elements • Indium Trioxide . NOT covering: • Cobalt, Arsenic, Lead, Mercury

4 Hazardous Metals 3/6/2019

Historical Hazards . Vanadium

. Uses: • Minor ‒ Pesticides ‒Dyes ‒ paints • Major ‒ Alloying hard steel • Nonessential element

https://commons.wikimedia.org/wiki/Vanadium#/media/File:Brookite-Quartz-221044.jpg

5 Hazardous Metals 3/6/2019

Historical Hazards . Vanadium

. Absorption: • Mainly Pulmonary • GI (2%) • Cutaneous (minor)

. Detection (normal) • Serum: 0.12 ug/L

6 Hazardous Metals 3/6/2019

208 Vanadium . Adverse Health Effects in Workers

. Pulmonary • ILDH 70mg/m3 • Cough, respiratory distress • Lacrimation/rhinorrhea . GI . Nervous System • Headache, tremor . Mucosa • Green discoloration*

7 Hazardous Metals 3/6/2019

Vanadium pentoxide V205

. IARC classification • 2B “possible carcinogen • Animal inhalation data and lung cancer • Cannot be extrapolated to all vanadium compounds

• Unclear/Possible mechanism ‒ Generation of inflammation ‒ Generation of reactive oxygen species ‒ By acting as phosphate analogues

Assen 2009

8 Hazardous Metals 3/6/2019

Historic Hazards . Germanium

. Non-essential Trace Element . Occupational use • Fiberoptics • Semiconductor manufacture • Germanium tetrahydride . Alternative use • Dietary “supplement”

https://commons.wikimedia.org/wiki/Germanium#/media/File:Diode_germaniu m_OA85.JPG

9 Hazardous Metals 3/6/2019

209 Germanium . Occupational Exposure

. Absorption: • Pulmonary: rapid • Gastrointestinal: rapid . Preference for Kidney and liver . Urinary excretion . Accumulation in Bone

https://commons.wikimedia.org/wiki/Germanium#/media/File:Polycrystalline-germanium.jpg

10 Hazardous Metals 3/6/2019

Germanium . Occupational Toxicity

. Irritant: • Lungs • Skin • Mucosa . Kidney: • Evidence for proteinuria • Glomerular toxin

https://commons.wikimedia.org/wiki/Germanium#/media/File:Polycrystalline-germanium.jpg

11 Hazardous Metals 3/6/2019

Dietary Supplementation . Antitumor and anti-inflammatory

• Organic . Inorganic

. Animal studies with some . Well described nephrotoxicity effect . Reports since 1980s • Antitumor • Organic compounds . Dosing: 16-320g . No supporting human trials . Time period: 4-36 months . No clear nephrotoxicity

Schauss 1991

12 Hazardous Metals 3/6/2019

210 Emerging Hazards . Tellurium

. Historical Uses • Syphilis • leprosy . Current Uses • Vulcanization • Alloys* • Oxidation (Jewelry) • Semiconductors • catalytic

https://commons.wikimedia.org/w/index.php?search=vulcanized+rubber&title=Special%3ASearch&go=Go#/media/File:In _Touch_by_Joseph_Fahys_%26_co.png

13 Hazardous Metals 3/6/2019

Tellurium dioxide . ingestion

. Acute Toxicity • CNS Depression • Mucosal injury (solvent) • GI effects • Garlic Odor: • Decreased sweat • Black Discoloration ‒ Mucosa ‒ skin

https://commons.wikimedia.org/wiki/Category:Tellurium_dioxide#/media/File:TeO2.jpg

14 Hazardous Metals 3/6/2019

Workplace . Tellurium

. OSHA . Exposure: • PEL: 0.1mg/m3 per 8 hrs • Copper refining . NIOSH • vulcanization • REL: 0.1 mg/m3 per 10 hrs . Absorption: • Mainly pulmonary Normal: • Moderate GI Whole Blood: 0.15-0.3 ug/L • Less cutaneous Urine: 0.1-10 ug/L

15 Hazardous Metals 3/6/2019

211 Tellurium . Workplace

. Case Series • 3 lab workers with “classic” symptoms • Tellurium fumes • Symptomatic • Urine levels: 8-16 ug/L

• 98 iron foundry workers • Urine detectable tellurium

https://upload.wikimedia.org/wikipedia/commons/5/54/Hydrogen_telluride.svg

16 Fumigants, Herbicides, and Insecticides 3/6/2019

https://commons.wikimedia.org/w/index.php?search=smart+phone&title=Special%3ASearch&go=Go#/media/File:Traditional_cell_phone_vs_Smart_phone.jpg

17 Hazardous Metals 3/6/2019

https://commons.wikimedia.org/w/index.php?search=hybrid&title=Special%3ASearch&go=Go#/media/File:Harrier_hybrid_frontface.jpg

18 Hazardous Metals 3/6/2019

212 What are Rare Earths Elements . Sources and Uses

. Not necessarily rare • Minable deposits . Value of Import to US $160 million (2018) . Mineral sources (US) • Bastnaesite • Monazite . 17 elements . ”Critical Mineral”

https://commons.wikimedia.org/w/index.php?search=rare+earth&title=Special%3ASearch&go=Go#/media/File:RareEarthO (USGS 2018) reUSGOV.jpg

19 Hazardous Metals 3/6/2019

Rare Earths . Sources and Uses

. Sources of US import • Mainly China (80%) • Present also: ‒ Estonia (6%) ‒ France (3%) ‒ Japan (3%) ‒ Other (8%)

https://commons.wikimedia.org/w/index.php?search=rare+earth&title=Special%3ASearch&go=Go#/media/File:RareEarthO reUSGOV.jpg

20 Hazardous Metals 3/6/2019

Rare Earths . Sources and Uses

. Uses • Screens: TVs, Smart Phones • Hybrid Vehicles, wind turbines (magnets) • Catalysts (diesel, oil refining) . Breakdown • Catalysts (60%) • Glass/Ceramics (15%) • Alloys/Polishing (10%, each)

https://commons.wikimedia.org/wiki/Cerium#/media/File:Cerium.jpg

21 Hazardous Metals 3/6/2019

213 Rare Earths . General Hazards and Population based effects

. Potential Hazards • Radioactive Contamination • Hypertension* • Pneumoconiosis • iatrogenic

. Contamination • Airborne • Food https://commons.wikimedia.org/w/index.php?search=radioactive&title=Special%3ASearch&go=Go#/media/File:Radioactive_symbol.png

22 Hazardous Metals Rim 2013 3/6/2019

Pneumoconiosis

. Case Descriptions Exposure to carbon arc lamps photoengravers movie projectionists

. Interstitial Lung disease . BAL fluid • Presence of Rare Earth Elements • Retention of Rare Earth Elements (potential bio-persistence)

Rim 2013

23 Hazardous Metals 3/6/2019

Iatrogenic Harm . Lanthanum

. Lanthanum Carbonate • Phosphate binder . Case Reports • 75F on HD ‒ Encephalopathy ‒ 2.13 ug/L on presentation • 70M: ischemic colitis •3rd case: hepatitis

https://commons.wikimedia.org/w/index.php?search=dialysis&title=Special%3ASearch&profile=advanced&fullt ext=1&advancedSearch- Muller 2009 current=%7B%22namespaces%22%3A%5B6%2C12%2C14%2C100%2C106%2C0%5D%7D&ns6=1&ns12=1& ns14=1&ns100=1&ns106=1&ns0=1#/media/File:Dialysis_-_arm_-_01.jpg

24 Hazardous Metals 3/6/2019

214 Rare Earths . Monitoring

. Scalp Hair Analysis . OEM limits: • Yttrium • TWA: 1mg/m2 • IDLH: 500mg/m3

. General Paucity of data

https://commons.wikimedia.org/wiki/Category:Monitoring#/media/File:Acceleromyograp hy_monitoring_with_preload_hand_adapter.jpg . Future work/research required

25 Hazardous Metals 3/6/2019

Indium Trioxide . Emerging Hazards

. Rising importance: • Plasma screens • Flat panel displays • Touch panel displays

• Poor Enteral Absorption • Increasing Pulmonary Toxicity

https://commons.wikimedia.org/w/index.php?search=touch+screen&title=Special%3ASearch&go=Go#/media/File:Touch_screen.jpg

26 Hazardous Metals 3/6/2019

Indium Trioxide . Emerging Hazards

. “Indium Lung” . Production of ITO •Start ‒ Pulmonary alveolar proteinosis • Progression: ‒ Emphysema and Fibrosis

https://commons.wikimedia.org/w/index.php?search=touch+screen&title=Special%3ASearch&go=Go#/media/File:Touch_screen.jpg

27 Hazardous Metals 3/6/2019

215 Summary Slides . Some Takeaways and Future Directions

. Rare Earths: . Vanadium: • Potentially growing US • Generally Pulmonary industry Toxicity • Pneumoconiosis • Green Discoloration of mucosa • radiation hazard • Further Research Needed Regarding Carcinogenicity

28 Hazardous Metals 3/6/2019

Summary Slides . Some Takeaways and Future Directions

. Indium: . Tellurium: • Semiconductor • CNS depression • Pulmonary • Weakness Fibrosis/Emphysema • GI symptoms • Blue-Black discoloration . Germanium: • Garlic Odor • Industry: ‒ Pulmonary irritant ‒ Possible nephrotoxin • Home/Alternative Med: ‒ nephrotoxin

29 Hazardous Metals 3/6/2019

30 Fumigants, Herbicides, and Insecticides 3/6/2019

216 CME Questions Robert Goodnough Metals: Past and Emerging

The primary organ (s) of toxicity of Vanadium are:

. A) Skin/Epithelium

. B) Pulmonary

. C) Tongue

. D) Nail Bed

Clinical Features of Tellurium Toxicity are likely to include

. A) Microcytic Anemia and wrist drop

. B) Respiratory Symptoms, garlic odor and blue-black discoloration of skin and mucosa

. C) Nail bed alteration and ”Rain Drop on a dusty road” rash

. D) Pill rolling tremor, shuffling gait, and masked facies

217 Occupational Exposure To Lanthanum likely places a worker at risk for the following:

. A) No Documented Toxicity

. B) Epithelial Malignancy

. C) Cataract formation

. D) Respiratory Symptoms/Pneumoconiosis

218 Key Publications in Occupational & Environmental Health: the Year in Review

Samuel M. Goldman, MD, MPH Associate Clinical Professor UCSF Division of Occupational & Environmental Medicine

Disclosures: None

Key Publications in OEM

. From late 2016 through August 2017, US government personnel serving on diplomatic assignment in Havana, Cuba, reported neurological symptoms associated with exposure to auditory and sensory phenomena

Key Publications in OEM

219 Background

. Reports of variable auditory & sensory phenomena in embassy, homes, hotel rooms since 2016 . Perceived directional emanation . 80 diplomatic staff referred by embassy medical unit to U. Miami . 24 with similar “exposure” history and constellation of neurological features c/w mild-TBI . Referred to U. Penn by State Dept Medical Services expert panel

Key Publications in OEM

Methods

. Retrospective Case Series of 21 US personnel in Havana . Multidisciplinary team: PM&R, OEM, Neurology, Neuroradiology, Neurosurgery - Each specialist independently obtained clinical histories and conducted comprehensive assessments - Additional referrals: vestibular PT, neuro- optometry, neuropsych, OT, ENT, audiology

Key Publications in OEM

Results Population Men (n=10) Women (n=11) Total (n=21) Age, mean (SD) 39 (7) 47 (8) 43 (8) Mean days (SD) from exposure to eval 229 (98) 180 (85) 203 (93)

. “Exposure” - 18/21 reported hearing localized sound at onset of symptoms in their homes/hotels - Directional, intensely loud, pure tonality . High pitched in 16, also buzzing, grinding, piercing squeals . 12 noted vibratory or sensory stimuli (“air baffling”) . Sensation emanated from a direction, modified by changing location . Unchanged by covering head - Some reported 10-second pulses, others >30 min, woke from sleep

Key Publications in OEM

220 Domain Acute n (%)

Symptoms: Acute Combined 16 (76) Desire to change location 10 (48) Confusion/Disorientation 8 (38) Agitation/Irritability 6 (29) Desire to cover head/ears 5 (24) . Fatigue 3 (14) Immediate onset in 20/21 Feeling of paralysis 3 (14) . ”good day-bad day” pattern Cognitive / Behavioral Combined 10 (48) Nausea 7 (33) common Dizziness 5 (24) Balance / Vestibular

. Cognitive & physical Combined 2 (10)

Visual changes 1 (5) symptoms often worse Eye pain 1 (5) after exercise Visual Combined 10 (48)

Ear pain 7 (33) Tinnitus 6 (29)

Auditory Hearing change 1 (5)

Sleep problem 4 (19) Sleep

Combined 11 (50) Headache 8 (38) Head Pressure 5 (24)

Headache Unilateral jaw pain 1 (5)

Key Publications in OEM Overall Combined acute 21 (100)

Persistent Symptoms (>3 months) & Signs

• 6 of 6 with neuropsych tests had “significant areas of cognitive weakness and/or impairment”

Key Publications in OEM

221 Course

. MRI imaging normal in 21/21

. Rehabilitation - Neuro-optometric rehabilitation: “manipulation of disparity vergence and accommodative amplitude and latency” - Vestibular PT: “focused on oculomotor function with the body in motion” - Cognitive rehabilitation “with OT, speech therapy or both”

. Early RTW exacerbated symptoms in 1/3 . ”Individualized return to work plans were designed to reintegrate individuals using a stepwise process”

Key Publications in OEM

Conclusions

. “Clinical manifestations may represent a novel clinical entity” with “widespread brain network dysfunction” . “Neurological exam & cognitive screens did not reveal evidence of malingering” . Oculomotor & vestibular findings could not be manipulated . Mass psychogenic illness usually transient, benign

. Critique (4 letters to editor!): . Functional neurological diagnosis (not malingering!) not excluded . Mass psychogenic illnesses often chronic and debilitating . Claims that objective manifestations can’t be “consciously or unconsciously manipulated” are misleading. High rates of vestibular abnormalities in patients with anxiety disorders . Social network analysis should be done: many subjects had extensive communication prior to evaluations

Key Publications in OEM

September 1, 2018

Key Publications in OEM

222 Potential Causes?

. Sound frequency waves NOT known to cause neurological damage

. Microwaves? . US, Soviet, Chinese research into weaponizing the Frey Effect . Microwave-induced auditory perceptions through temporal lobe stimulation . “Mind Control” through auditory hallucinations

Microwave Weapons

Key Publications in OEM

. Suicide rate among US working age population increased 34% from 2000-2016, from 12.9/100,000 to 17.3/100,000

. This report examines occupation-specific suicide rates in 2012 & 2015 for persons aged 16-64 using data from the National Violent Death Reporting System (NVDRS)

Key Publications in OEM

Methods

. NVDRS: “Death from intentional use of physical force or power, against oneself, another person, or a group or community” - Death certificates, coroner reports, law enforcement reports - 17 states participated in 2012 & 2015: Alaska, Colorado, Georgia, Kentucky, Maryland, Massachusetts, New Jersey, New Mexico, North Carolina, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, Utah, Virginia, and Wisconsin

. Occupational coding - 2010 US Census codes converted to Standard Occupational Classification (SOC) major groups

. Total n = 22,053

Key Publications in OEM

223 Methods

. Suicide rates calculated using annual civilian noninstitutionalized working population counts by occupational group from the US Census Current Population Survey Annual Social and Economic Supplement as denominators

. Exclusions: - unemployed at time of suicide (10%) - incarcerated, homemaker, student, military, unpaid, or unclassifiable occupations (23%)

. Total numerator in analyses for 2012 + 2015 = 14,728

Key Publications in OEM

Male Suicide Rates by Occupation 2012 2015 Rate change Occupation Rate Rank Rate Rank % Rank Construction & Extraction 43.6 1 53.2 1 22% 5 Arts, Design, Sports, Media 26.9 7 39.7 2 47% 1 Installation, Repair 31.6 2 39.1 3 24% 3 Transportation 28.4 4 30.9 4 9% 8 Production 28.4 3 30.5 5 7% 10 Protective Services 27.1 6 28.2 6 4% 11 Bldg cleaning, maintenance 27.3 5 26.8 7 -2% 14 Health care practitioners 20.8 14 25.6 8 23% 4

Key Publications in OEM

Female Suicide Rates by Occupation 2012 2015 Rate change Occupation Rate Rank Rate Rank % Rank Arts, Design, Sports, Media 11.7 1 15.6 1 34% 2 Protective Services 11.6 2 12.2 2 5% 9 Health care support 8.4 5 11.0 3 31% 3 Food Preparation & Serving 6.1 11 9.4 4 54% 1 Legal 11.1 3 9.2 5 -17% 15 Health care practitioners 10.3 4 9.0 6 -13% 13 Production 7.6 7 9.0 7 18% 6 Personal care services 6.8 9 7.7 8 14% 7

Key Publications in OEM

224 Summary

. Largest proportion of suicides in both 2012 & 2015 - Men: Construction & Extraction = 20% - Women: Unpaid occupations = 29%

. Highest rates of suicides in both 2012 & 2015 - Men: Construction & Extraction (43.6, 53.2) - Women: Arts, Design, Entertainment, Sports, Media (11.7, 15.6)

. Fastest increase from 2012 to 2015 - Men: Arts, Design, Entertainment, Sports, Media; 47% - Women: Food preparation & Serving; 54%

Key Publications in OEM

Conclusions . Suicide rates vary widely across occupations . Rates in men 3x women, but gap narrowing . Both work (low job control, job insecurity) & nonwork (e.g., relationship conflict) factors associated with psychological distress and suicide . Other factors - Access to lethal means (e.g., protective services, health care practitioners) - Socioeconomic (lower income, low education) . Limitations: - SOC groups contain broad range of education/income - Single “usual” job captured . Authors suggest opportunities for workplace suicide prevention programs

Key Publications in OEM

. Entomofauna: the insects of an environment or region . Systematic review of 73 long-term studies around the world

Key Publications in OEM

225 Background

. Insects comprise 2/3 of all terrestrial species on Earth

. Germany: 27-year study found 76% decline in flying insect biomass (2.8%/year) in protected areas (Hallmann et al, 2017) . Puerto Rico rainforest: 78-98% decline in ground-foraging and canopy- dwelling arthropods over 36 years (2.2-2.7%/year) (Lister & Garcia, 2018)

. Previous reviews are partial in scope, restricted to individual groups of insects (e.g. butterflies, carabids) in specific regions . No study has put together a comprehensive review of all insect taxa nor compared local findings among different parts of the world

Key Publications in OEM

Methods

. Compiled all long-term insect surveys from the past 40 years

. Searched Web of Science database using keywords [insect*] AND [declin*] AND [survey]: resulted in a total of 653 publications . Excluded reports that focused on individual species, pest outbreaks or invasive species . Required periods longer than 10 years . Additional papers obtained from the literature references

Key Publications in OEM

Geographic location of the 73 reports Columns represent relative proportion of taxa studied

Key Publications in OEM

226 Insect Orders

. Lepidoptera: butterflies & moths . Hymenoptera: bees, wasps, ants . Diptera: flies . Coleoptera: beetles (the largest Order) . Hemiptera: cicadas, aphids, “bugs” . Orthoptera: grasshoppers, crickets . Odonata: dragonflies . Plecoptera: stoneflies . Ephemeroptera: mayflies

Key Publications in OEM

Annual Rates of Decline of 3 Major Taxa

Key Publications in OEM

Proportions of Terrestrial Species In Decline

Key Publications in OEM

227 Proportion of Declining Species by Region

Key Publications in OEM

Main Factors Associated with Insect Declines

Key Publications in OEM

Summary

. 41% of insect species are in decline, twice the rate of vertebrates

. 33% of insect species threatened with extinction, increasing 1% annually

. 2.5% annual insect biomass decline

. Declines similar in tropical & temperate regions

. Habitat change is biggest driver: urbanization, agriculture, industrialization

. Pollution next biggest driver: pesticides > fertilizers >> urban/industrial pollutants

Key Publications in OEM

228 What now?

. Change ways of food production - Abolish use of synthetic pesticides: integrated pest management - Drastically reduce use of agro-fertilizers . Habitat restoration - Agricultural “redesign” . Flower & grassland strips around fields . Increased crop rotations . Engineering controls to reduce runoff - Marshland rehabilitation

Key Publications in OEM

Lancet Public Health, 3(4), 2018

. Lead exposure is a risk factor for cardiovascular disease . Population risk poorly understood . Quantifies association of lead and all-cause mortality, cardiovascular mortality, ischemic heart disease mortality

Key Publications in OEM

Methods

. Third National Health and Nutrition Exam (NHANES-III) - Nationally representative sample aged > 20 - Baseline exams in 1988 . Medical exam & home interviews: demographics, numerous covariates . Blood: lead (graphite furnace atomic absorption spectrophotometry), HbA1c . Urine: cadmium, creatinine . Serum: cholesterol, cotinine . Cause death by linkage to National Death Index - Followed through 2011 (n=14,289) - All cause mortality (n=4422) - Underlying cause: CVD (n=1801), IHD (n=988)

Key Publications in OEM

229 Analyses

. Cox proportional hazards models adjusted for: - age, sex, income, ethnicity, BMI, smoking (never, current, former), serum cotinine, EtOH, physical activity, urine cadmium, hypertension, Healthy Eating Index, and HbA1c

. Explored effect modification by: BP, DM, sex, age, urban residence, ethnicity, secular trends

. Pb modeled as: continuous, tertiles, 5-knot restricted cubic splines

Key Publications in OEM

230 Attributable deaths due to th th Risk for increase from 10 to 90 %ile modifiable risk factors (1.0-6.7 ug/dL)

HR Attributable Avoidable fraction deaths All cause 1.37 18% 412k CVD 1.70 28.7% 256k IHD 2.08 37.4% 185k

Key Publications in OEM

Summary

. Of 2.3 million annual deaths, 400,000 attributable to lead, 250,000 of which are due to cardiovascular disease

. 10-fold higher than prior estimates that assumed no risk < 5ug/dL

. Proposed mechanism: endothelial inflammation & oxidative damage promoting atherosclerosis

. Despite striking reductions in blood lead over the past 50 years, levels are still 10-100x higher than pre-industrial era

. Limitations: single blood lead measurement 1988; residual confounding

Key Publications in OEM

231 Question 1: Among men, what occupational group has the highest rate of suicide?

a) Health care practitioners b) Construction & extraction c) Food preparation d) Architecture & engineering

Key Publications in OEM

Question 2: Which of the following is NOT a proposed cause of the cluster of neurological illnesses seen in US diplomatic personnel in Cuba?

a) Sound waves b) Microwave radiation c) Mass psychogenic illness d) Frey effect

Key Publications in OEM

Question 3: Which factor is thought to be most responsible for insect declines? a) Climate change b) Invasive species c) Intensive agriculture d) Air pollution

Key Publications in OEM

232 DISCLOSURE

I HAVE NOTHING TO DISCLOSE.

HOWARD MAIBACH, MD

THE KNOWLEDGE “KANERVA” OCCUPATIONAL DERMATOLOGY 3RD EDITION SPRINGER VERLAG (METEOR®)

HARD COPY & ONLINE

90+ % – THE EVIDENCE

233 REGULATORY CHANGE ! EUROPEAN PARLIAMENT 7TH AMENDMENT

NO ANIMAL TESTING: COSMETIC INGREDIENTS

IMPACT ON OCCUPATIONAL MEDICINE !!!

REGULATION

SKIN CANCER | PRE CANCER GERMANY

3RD MOST COMMON OCCUPATIONAL DISEASE INSURANCE COVERAGE NOW COMPENSATED

(DIEPGEN)

SOLAR UV RADIATION

WORK & LEISURE

• DOSIMETRY (RELIABLE & EXPENSIVE) • WORK EXPOSURE SIGNIFICANT

(PHOTOCHEMISTRY PHOTOBIOL, 94:807)

234 PATCH TESTING UNINTENDED CONSEQUENCES TRUE TEST®: LIMITATIONS

INADEQUATE FOR MANY INDUSTRIES OCCUPATIONS

(ROYALTIES TO SWEDISH COLLEAGUE)

REGULATION AND UNINTENDED CONSEQUENCES !

• FORMALDEHYDE – CARCINOGEN • METHYLCHLOROISOTHIAZOLONE (MI)– POTENT ACD DISAPPEARING FROM MSDS | PRODUCT LABELS NOW OCCULT EXPOSURE (UBIQUITOUS)

(PAUL SIEGEL: CUT OCUL TOX, 2018)

OFFICE SPOT TESTS POST PATCH TESTING

•FORMALIN •M I •COBALT •Ni

(U C S F)

235 VERIFICATION | VALIDATION

L S | MASS SPEC

(NIOSH)

NO REGULATION • GLOVES – ADDITIVES (MBT, THIURAMS) • SOLUTION –PATCH TEST ACTUAL WORK SITE GLOVES BEFORE WORK RETURN

MUCH MISLABELING !

( U C S F)

REGULATION: IRRITANT DERMATITIS

WATER EXPOSURE: < 4 HOURS

GERMANY

( DIEPGEN)

236 PROLONGED OCCLUSIVE GLOVE WEARING

NOT OVERT SKIN DAMAGING BUT TEMPORARY NAIL DAMAGE

[ J TOX ENV HEALTH (A), 2017]

PREVENTION ?

IRRITANT DERMATITIS MORE FREQUENT THAN A C D MAINSTAYS ‐GLOVES ‐ (BARRIERS) ‐MOISTURIZERS ‐EDUCATION PAPADATOS: “NO EVIDENCE”

( JBI DATABASE SYSTEMATIC REV, 16:1398, 2018)

SEVERE HAND ECZEMA FAILURES RESCUE !!

• 6 WEEK AMBULATORY HOSPITALIZATION

• 80% + SUCCESS

( SWEN JOHN, OSNABRUCK, GERMANY)

237 WORK SITE REGULATIONS – INCONSISTENT ______DECREASING CHEMICAL EXPOSURE AT HOMES

• SHOWERING • FRESH CLOTHING

[ STATE & EMPLOYER VARIABILITY]

SKIN CHEMICAL DECONTAMINATION

• ACUTE vs. CHRONIC EXPOSURE • OFTEN > LIFE TIME DRUG EXPOSURE • 30 MINUTE RULE (ROUGIER) • WATER WASHING EFFECT (ACUTE)

(U C S F LABS)

DECONTAMINATION HUMAN STRATUM CORNEUM

• BRICK (PROTEIN) & MORTAR (LIPID) (ALAN MICHAELS) • WATER COMPARTMENT (~ 20%) • HAIR FOLLICLES

238 DERMATOTOXICOLOGY PREDICTION ALLERGIC CONTACT DERMATITIS • LOCAL LYMPH NODE ASSAY (L L N A) (BANNED – COSMETIC INGREDIENTS) • GUINEA PIG ASSAYS (SAME BAN – COSMETIC INGREDIENTS) • REPEAT INSULT PATCH TEST (EUROPEAN ETHICS)

REPLACEMENT ?

IN VITRO ASSAYS • IRRITATION – CORROSION – PHOTOIRRITATION •A C D

(ESKES, 2017)

BUT – NOT !

•ORGAN TOXICITY •REPRODUCTION • CARCINOGENICITY

239 PESTICIDE

ACUTE POISONING – SKIN EXPOSURE

(HONG KONG J EMER MED)

PERCUTANEOUS PENETRATION

BLADDER CANCER – METAL WORKING FLUID

– ORTHO TOLUIDINE

– FIREFIGHTERS

REFERENCES

J OCCUP HEALTH (BLADDER O‐TOLUIDINE) 80:307 OCCUP ENVIR MED 75:328 “ “ “ 75:389 “ “ “ 75:543 “ “ “ 75:604 ENV SCI TECH 52:8330 (POLYCYCLIC AROMATIC HYDROCARBONS)– BARBECUE FUMES SCI REPORTS (FIREFIGHTERS) 8:2476

240 OTHER ORGANS

CHRONIC SOLVENT ENCEPHALOPATHY

(INT ARCH OCC ENV HEALTH, 91:843)

SKIN CHEMICAL EXPOSURE MONITORING

• SKIN – TAPE STRIPPING –DIRECTINSTRUMENTS

• BLOOD | URINE

241 CME QUESTIONS

OCCUPATIONAL DERMATOLOGY

Howard I. Maibach, M.D.

So called routine diagnostic patch testing can address which of the following in occupational dermatitis?

A. Contact urticaria B. Irritant dermatitis C. Delayed hypersensitivity dermatitis D. Multiple chemical sensitivity

Occupational allergic contact dermatitis is routinely identified by so called routine diagnostic patch testing:

A. Always B. Never C. Contraindicated D. Possibly half the time

242 Current USA product content labeling and MSDS has recently identified the following significant occupationally related allergens‐ as not be identified:

A. Parabens B. Lanolin C. Formalin D. Isothiazolones

243 244 The Italian Mesothelioma Registry: lessons learned

San Francisco, 16 March 2019 Diana Gagliardi, MD

[email protected]

Vulenrable workers and Communities at Environmental Risk And Updates in Occupational and Environmental Medicine

FACULTY DISCLOSURE

«I have nothing to disclose»

06/03/2019 2

Key points

 The Italian experiences of epidemiological surveillance of mesothelioma incidence;

 Epidemiological findings by occupational cancer surveillance systems as a tool for prevention policies and insurance system effectiveness;

 Epidemiology and burden of asbestos-related cancers;

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245 Can epidemiological surveillance be a tool for etiologic research and risk prevention?

Epidemiology of occupational cancers extent. Global burden of diseases 2016 Global all age attributable deaths and DALYs, both genders combined (2016).

Occupational carcinogens.

Attributable deaths : 746,540

DALYs: 20,682,730 years

Change in number of DALYs 2006-2016: Men +18.7% Women +17.7%

Source: GDB 2016 Risk Factors Collaborators. Lancet 2017;390:1345-422 INAIL, DIPARTIMENTO MEDICINA, EPIDEMIOLOGIA, IGIENE DEL LAVORO DEL IGIENE EPIDEMIOLOGIA, MEDICINA, DIPARTIMENTO INAIL, Epidemiology of occupational cancers extent. Analytical epidemiological studies

 Driscoll T et al. The global burden of disease due to occupational carcinogens. Am J Ind Med 2005;48(6):419-31 Attempts to estimate  Straif K. 2008. The burden of occupational cancer. Occup Environ Med the extent of 65(12):787-8. occupational cancers  Nurminen M, Karjalainen A. Epidemiologic estimate of the proportion of have been performed fatalities related to occupational factors in Finland. Scand J Work Environ in many countries. Health 2001;27(3):161-213  Steenland K et al. Dying for work: The magnitude of US mortality from All these exercises are selected causes of death associated with occupation. Am J Ind Med based on attributable 2003;43:461–82 fraction obtained from  Boffetta P et al. An estimate of cancers attributable to occupational analytical studies or exposures in France. J Occup Environ Med 2010;52(4):399-406

meta‐analyses.  Rushton L al. Occupation and cancer in Britain. Br J Cancer ED AMBIENTALE (DiMEILA) 2010;102(9):1428-37  Järvholm B et al. Mortality attributable to occupational exposure in Sweden. Scand J Work Environ Health 2013;39(1):106-1

246 Epidemiology of occupational cancers extent. Occupational cancers burden in Great Britain Estimated attributable fraction (%) by anatomical site.

Men Women

Bladder 7.1 1.9 Breast 4.6 Lung 21.1 5.3 Mesothelioma 97.0 82.5 Nasopharynx 10.8 2.4 Sinonasal 43.3 19.8 …

«Overall, 8,010 (5.3%) total cancer deaths in Britain Total and 13,598 (4.0%) cancer registration Based on deaths 8.2 2.3 were attributable to occupation». Based on incidence 5.7 2.1

Source: Rushton L et al. Occupational cancer burden in Great Britain. Br J Cancer 2012;107:S3‐S7

Cumulative asbestos consumption and Italian context

[Iceland, Norway ban; 1983] Between 1955 and 1965, R Doll and IJ Selikoff demonstrated the association between asbestos exposure and mesothelioma (and lung cancer) risk. [Doll R; 1954 Selikoff IJ; 1965]

[Italy ban; 1992]

Asbestos production time trend (at aggregate world level) is increasing until ’90.

Source: Virta R. United States Geological survey, different years

Cumulative asbestos consumption and Italian context

In Italy, the largest asbestos cave of western Europe (Balangero, TO) has been active until 1990.

Casale Monferrato asbestos cement Imported plant was active until 1986.

Produced Between 1945 and 1992 (year of the ban) 3,748,550 tons of raw asbestos have been produced and additional 1,900,885 tons were imported

Source: INAIL, ReNaM national reports, different years

247 Cumulative asbestos consumption and Italian context

Linear correlation between asbestos consumption and MM mortality (i), the role of surveillance systems (ii) and the specific Italian context (iii).

ITALY

In Italy the reduction of asbestos consumption begun about ten years later than many other industrialized countries.

Source: Park EK, et al. EHP, 2011;119(4):514‐8. Marinaccio A, et al. IJC, 2012;130(9):2146‐54

Cumulative asbestos consumption and Italian context

The correlation between asbestos consumption and the incidence of MM (even after a long latency) is so significant that the two dimensions are defined by two translated curves with the same shape

Source: Health and Safety Executive (HSE). Mesothelioma mortality in Great Britain: estimating the future burden. Available at: www.hse.gov.uk/statistics/causdis/proj6801.pdf

How to tackle asbestos-related cancers?

1. develop, implement and apply primary prevention measures to limit or avoid future exposures to occupational carcinogens ASBESTOS

2. combine primary prevention measures with appropriate and effective secondary prevention strategies for monitoring subjects exposed (or Asbestos has been banned previously exposed) to occupational carcinogens in 55 countries

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248 Italian national mesothelioma registry (ReNaM). Structure, aims, procedures.

• D. Lgs 277/91, art. 36. Registry of asbestos-related cancer • D. Lgs 626/94, art. 71. Registry of occupational cancer • DPCM 308/2002. ReNaM implementation procedures • D. Lgs 81/2008, art. 244. Confirmation and development of the epidemiological surveillance system for occupational cancer

 Estimate the incidence of MMs in Italy  Collect information on previous exposure to asbestos  Contribute to evaluate the effects of asbestos use and to identify sources of exposure  Promote research projects

Italian national mesothelioma registry (ReNaM). Structure, aims, procedures.

ReNaM keywords  National network with regional structure;  Active search of MM incident cases (all anatomical sites);  Specific coding system of diagnosis;  Individual anamnestic analysis on the basis of structured questionnaire;  Environmental, familial and leisure activities anamnesis included.

Regional operative centers (COR) in each Italian regions:  Actively searching MM cases;  Verifying and coding diagnosis;  Interviewing affected people (or care givers);  Defining asbestos exposure.

ReNaM:  National data analyses;  Research projects;  Supporting COR and contributing to uniform procedures (Guide Lines).

Italian national mesothelioma registry (ReNaM). Structure, aims, procedures.

ReNaM has defined a specific coding system to define the level of certainty of diagnosis:

Definite MM (histological confirmation)

Probable MM (cytological diagnosis)

Possible MM (only radiological or clinical evidences)

249 Italian national mesothelioma registry (ReNaM). Structure, aims, procedures.

ReNaM has defined a specific system of coding the modalities of asbestos exposures.

 Occupational (definite, probable, possible)

 Familial  Environmental  Leisure related

 Unlike  Unknown

Italian national mesothelioma registry (ReNaM). Structure, aims, procedures.

ReNaM territorial development has gradually increased.

As of today, a Regional Operative Center (COR) has been established in all twenty Italian regions

Unfortunately, in three regions registration activities are still incomplete.

Italian national mesothelioma registry (ReNaM). Structure, aims, procedures.

Methods of Methods of Type of detecting detecting Country Coverage detection occupational environmental exposure exposure

Individual Individual Italy Incident cases National questionnaire questionnaire Individual Individual Australia Incident cases National questionnaire questionnaire Individual Individual South Korea Incident cases National questionnaire questionnaire Individual Individual France Incident cases Partial (30%) questionnaire questionnaire Reporting No exposure Germany OD reports National MM incidence national documents evaluation Occupation + No exposure Uk Deaths National surveillance systems with death certificate evaluation individual exposure assessment, The Reporting No exposure OD reports National including environmental Netherlands documents evaluation Scandinavian census data No exposure exposure, are on going in Incident cases National countries documentation evaluation France, South Korea and No exposure No exposure USA Incident cases Partial (28%) Australia evaluation evaluation

Source: Ferrante P, et al. EP, 2016;40:215-23 [in Italian]

250 Italian national mesothelioma registry (ReNaM). Periodic reports.

I Report, published 2001, data until 1996 II Report, published 2006, data until 2001 III Report, published 2010, data until 2004 IV Report, published 2012, data until 2008 V Report, published 2015, data until 2012 VI Report published 2018, data until 2015

Italian national mesothelioma registry (ReNaM). Research papers. Survival [Eur J Cancer; 2003] [Int J Cancer; 2009a, 2009b]

Incidence and asbestos exposure [Am J Ind Med; 2003] [Int J Cancer; 2012]

Forecast scenario [Int J Cancer; 2005]

Latency [Eur J Cancer; 2007]

Environmental exposure, gender differences [Occ Env Med; 2010; 2015; 2018]

Extrapleural mesothelioma [Occ Env Med; 2010]

Epidemiology and insurance system [BMC Public Health; 2012]

Territorial clustering, contaminated sites [BMC Cancer; 2015] [SJWEH, 2017]

Italian national mesothelioma registry (ReNaM). Forecast scenario.

On the basis of an age-period- cohort model and including asbestos consumption trend in the past (as explicative variable), ReNaM has predicted a peak in MM epidemic curve in Italy between 2015 and 2020.

Recent mortality and incidence data confirm these scenarios.

Source: Marinaccio A, et al. IJC, 2005;115(1):142-7

251 Italian national mesothelioma registry (ReNaM). Gender differences and MM incidence in women.

Non occupational exposure (environmental and familial)

Occupational exposure (textile sector)

Source: Marinaccio A, et al. OEM, 2018;75(4):254-62

Italian national mesothelioma registry (ReNaM). Territorial clustering analyses.

In Italy some areas (Casale Monferrato, Broni, Monfalcone, …) present incidence rates 30 times higher than mean national level. The territorial map of MM cases is a sort of map of industrial use of asbestos in the past.

Source: Corfiati M, et al. BMC Cancer, 2015;15:286

Italian national mesothelioma registry (ReNaM). Changing in exposure patterns.

Third wave ? Asbestos in place Remediation or maintenance of ACM

Second wave Persons who used asbestos products

First wave Mining and manufacture of Vol. 132; 1965 asbestos products

(1) (2) (3)

Source: Landrigan PJ. The third wave of asbestos disease: exposure to asbestos in place. Ann NY Acc Sciences. 1991;643:xv-xvi

252 Italian national mesothelioma registry (ReNaM). Changing in exposure patterns. N=937 N=2,276 N=3,836 N=4,556 N=4,499 N=3,250 18 Asbestos‐cement plants Railways carriage maintenance Shipbuilding and repair Construction 16 14 Ratio between economic 12 sector of exposure and MM 10 cases by period of diagnosis. 8 Selected sectors 6 4 2

1993‐96 97‐2000 2001‐04 2005‐08 2009‐12 2013‐15 Increasing weight (%) in Asbestos‐ construction sector cement plants 7.9 4.7 3.3 2.3 2.4 2.3 Railways maintenance 4.6 3.5 3.3 2.7 3.4 2.9 Shipbuilding Decreasing weight (%) in and repair 14.0 11.6 8.2 7.4 5.5 5.0 «traditional» sectors Construction 11.0 13.9 15.7 15.1 16.4 17.1 Source: INAIL, ReNaM national reports, different years

Italian national mesothelioma registry (ReNaM). Non-traditional sectors of exposure. Public health and insurance effectiveness

ReNaM analyses demonstrated that odds of claims for compensation are tightly related with the modalities of exposure to asbestos.

Less claims are observed when the economic sector is not «traditionally» involved in asbestos exposure.

RR of not claiming for compensation (for MM cases with occupational origin detected by Italian national mesothelioma register):

RR = 1 Direct use of asbestos … RR = 1.71 Atypical exposure RR = 1.86 Construction

Source: Marinaccio A, et al. BMC Public Health, 2012;12:314

Italian national mesothelioma registry (ReNaM). Non-traditional sectors of exposure. Public health and insurance effectiveness

Findings of epidemiological surveillance can improve the effectiveness of public health and welfare systems, spreading knowledge and raising awareness on different modalities of asbestos exposure.

… Particularly if these modalities are unexpected and unusual …

 Recycling of jute bags  Textile (non asbestos)  Agriculture  Car mechanics  School teachers  Jewellers  …

Source: Binazzi A, et al. Epidemiol Prev. 2013 Jan‐Feb;37(1):35‐42

253 Italian national mesothelioma registry (ReNaM). Environmental exposure to asbestos

According to ReNaM, the extent of non-occupational exposure to asbestos

accounts for around 10% of detected Milano Casale Monferrato Monfalcone 170 85 cases. Trieste 17 Familial exposure Environmental exposure Venezia Leisure-related exposure Padova

Stradella Broni

Parma

Reggio nell'Emilia Familial exposure 4.4% Collegno Genova Ravenna La Spezia Environmental exposure 4.3% Torino Bologna

Leisure related exposure 1.6% Livorno Bari

Roma

Recently, a special fund for MM patients Taranto (or their survivors) has been implemented, only for cases without Biancavilla occupational exposure evidences.

Source: Marinaccio A, et al. OEM. 2015; 72(9):648-55

Epidemiological surveillance, public health and risk prevention. Biancavilla Etnea.

Epidemiological surveillance of asbestos related diseases mortality and incidence in Biancavilla Etnea, leaded by Istituto Superiore di Sanità, dott. Pietro Comba, has put in light the role of fluoro‐edenite in MM onset

As a consequence of these evidences, IARC classified fluoro‐ edenite as carcinogens agent (group 1) and remediation and public health measures have been

Source: Ann Ist Super Sanità . 2014;50(2):1-139

Italian national mesothelioma registry (ReNaM). International cooperation

The epidemiological surveillance of MM incidence, by the means of a national registry, could represent a reference for the countries where the use of asbestos is still allowed or the management of the ban is still on-going.

Utility tools:  Registry structure and network  Diagnostic certainty level coding system  Exposure classification and coding system  Anamnestic questionnaire

In this framework, international cooperation experiences have been developed or are on going with many countries: Ecuador, Australia, Brazil, France, Japan, Georgia.

254 GLOBAL BURDEN OF ASBESTOS

125 million people exposed to asbestos

107.000 people die from asbestos-related disease each year: 59,000 mesothelioma - 41,000 lung cancer - 7,000 asbestosis

Over 1,500,000 lost years of life (DALYs)

US$ 54 billion spent In 2008 the direct economic cost of asbestos- on asbestos litigation related cancer was estimated at US$ 2.4 billion

The cost of eliminating the results of the usage of asbestos in Western Europe and USA is approximately 280 billion dollars.

Source: WHO 2006, 2011

06/03/2019 31

Epidemiology of occupational cancers extent. Occupational cancers burden in Italy

“Around 8,000-8,500 deaths/year from occupational cancer are estimated to occur in Italy, leading to around 360M euros in indirect economic costs.”

Mesothelioma and sinonasal cancer epidemiology (high occupational AF and low population incidence) suggests developing surveillance systems, based on individual registration.

Source: Binazzi A et al. The burden of mortality and costs in productivity loss from occupational cancer in Italy. Am J Ind Med 2013;56:1272‐9

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255 Estimates of mesothelioma costs Based on French figures

Further to pleural mesothelioma,

154 375 000 asbestos can also cause other forms of cancer in different sites

 Pericardium  Peritoneum  Tunica vaginalis testis

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COSTS CLASSIFICATION Cost group Type of cost

Outpatient 1. Medical care cost Inpatient

Direct Annuity

Public 2. Insurance cost Annuity to Surviving costs Family Members

Income tax

3. Fiscal Cost Consumption tax

Retirement expenditure (-)

Social 4. Productivity loss Costs Human Capital Costs

06/03/2019 35

1. MEDICAL CARE COSTS

 Lack of a standard therapy  Scant literature regarding assessment of the medical costs of the disease

Analyzed the case relating to damage caused by asbestos exposure in an Italian shipbuilding company (Fincantieri Navali Italiani s.p.a.)

SOURCES METHODOLOGY RESULTS

DRG • Identified all hospitalizations related to (Diagnosis-related groups) previous disease Sentence no. 1196/08 of the Ordinary Court of classify all the patients discharged from a Venice for compensation to the Veneto Region hospital ward or day hospital in homogeneous • Each case associated with the duration for the medical costs of treatment of workers groups as regards the resources employed, of the disease, hospital treatment and affected by mesothelioma on the basis of the information in the hospital patient’s age discharge form (HDF)

06/03/2019 36

256 2. INSURANCE COSTS

Annuity to Direct Annuity surviving relatives

 main economic benefit provided by  Economic benefit distributed to surviving family Inail when, due to an injury work or members (if annuity-holder die of causes an occupational disease, remains an connected to the occupational accident) absolute or a partial psycho-physical damage.  The annuity is divided in proportion to the degree of kindship

VARIABLES VARIABLES

• N. direct annuity in force at 31 December 2011 •Share of indemnity for biological damage (annual earnings • N. annuity to surviving relatives in force at 31 by degree of disability) December 2011 •Worker’s average annual earnings (level of disability) • Worker’s average annual earnings • Probability of survival • Probability of not dying or re-marring in 2012

INAIL METHOD

06/03/2019 37

3. FISCAL COSTS

Impact of interrupted labour activity on public budget:

 Loss of tax revenue due to the labour interruption  Saving of present and future flow of retirement expenditure

VARIABLES SOURCES METHODOLOGY

ReNaM Mesothelioma cases registered by economic sector, age, • Income tax gender and year of incidence (OLS) Ordinary Least Squares • Consumption tax Regression model • Retirement expenditure (-) ECHP - European Community Household Panel - EUROSTAT • Old-age benefits EU-SILC – Statistics on Income and Living Conditions ISTAT

06/03/2019 38

4. SOCIAL COSTS

All losses borne by a country due to:

Reduction of production capacity of the workforce Reallocation of resources that could have been used in other fields Premature deaths related to mesothelioma reduce the “human capital”

VARIABLES SOURCES METHODOLOGY

 Earnings (t) ReNaM Human capital method  Discount rate Mesothelioma cases registered by economic (OLS)  Average probability of being alive at sector, age, sex and year Ordinary Least Squares time (t) of incidence Regression model  Average probability of being employed at time (t) ECHP EU-SILC

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257 RESULTS SUMMARY OF ESTIMATED COSTS PER PATIENT (2013)

Group of Costs Type of cost Euros

Outpatient 5,533 Medical care cost Inpatient 28,122

Direct Annuity 14,000 Costs updated to 2013 to ensure homogeneous Public costs Insurance cost Annuity to Surviving 11,000 results. Relatives Updating was Tax Revenue Loss 68,288 based on the Fiscal cost inflation rates Retirement Expenditure (-) - 68,155 during the period covered by the Human Capital analysis Social costs Productivity loss 192,284 Opportunity Costs

Total € 251,072

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Additional intangible costs

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ECONOMIC BURDEN OF MESOTHELIOMA IN ITALY (1993-2008)

Italian National Mesothelioma Registry (ReNaM)

The Fourth Report analyzed 15,845 cases recorded 1993-2008

15,845 X 251,072 = EUR 3.97 billion (1993-2008)

UNDERESTIMATED

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258 06/03/2019 43

1. How many countries have a total asbestos ban in place?

A. There is global coverage with asbestos ban

B. 135

C. 55

D. 32

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2. In addition to pleural localization, what other forms of MM can we list?

A. Pericardial

B. All of them

C. Peritoneal

D. Tunica vaginalis testis

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259 3. What are the estimated costs per patient of a MM case (including medical care, fiscal costs, compensation and litigation)?

A. € 251,072

B. € 103,751

C. € 1,360,853

D. € 25,830

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“When it comes to knowing the burden of asbestos-related diseases, we have only been able to scratch the surface of the problem.” Ken Takahashi, 2014

Ancient Roman artefact, I-III sec. B.C. Vatican Museum

260 Innovation in Air Quality and Climate Change Mitigation Policies: The California Paradigm

John R. Balmes, MD University of California, San Francisco and Berkeley

Outline

• California Air Resources Board • Problems with implementation of the Clean Air Act • Integration of air quality and climate change policies • Mandate to achieve environmental justice

Disclosure

• I am the Physician Member of the California Air Resources Board

261 My Role in Air Quality and Climate Change Policy

• Appointed the Physician Member of the California Air Resources Board by Gov. Schwarzenegger in 2008

Air Quality Regulation in the U.S.

• California Air Resources Board (1967) • Clean Air Act and U.S. EPA (1970) • National Ambient Air Quality Standards for criteria pollutants

California Air Resources Board 6

262 Los Angeles 50 Years Ago

• Unhealthy levels of lead, NO2, SO2, CO, ozone, particulate matter (PM), and air toxics • In Los Angeles: • Over 100 air pollution alerts annually • Over 200 days with unhealthy air annually • 49 1‐hour ozone peaks, up to 5X the allowable level

Los Angeles Today

• NO2, SO2, and CO: Attained National Standards • Ozone: • Los Angeles peak cut over 60% • Hours of exposure reduced 90% • PM: Annual levels cut in half • Toxics: Nearly 50% risk reduction

Vehicle Rules Cut Ozone‐Forming Emissions

Positive crankcase ventilation 90% reduction in 20 years 14 Exhaust standards 12 Oxidation catalyst Exhaust gas 10 recirculation 3‐way catalyst, on‐board computer 8 Advanced computer 6 fuel injection, oxygen sensor g/mile HC + NOx 4

California Air Resources Board 9

263 Clean Air Act

• Challenges • The air quality standard setting process is siloed by criteria pollutant • Increasing scientific evidence is pushing the safety envelope • For example, ozone effects have been documented near the background level • The reliance on scientific evidence for revising NAAQS allows doubt to be sown through portraying the epidemiological evidence as “uncertain”

Multi‐Pollutant Exposures

• Real‐life ambient exposures are not to single criteria pollutants • How to monitor and regulate exposures to multiple pollutants has proved technically difficult

Traffic‐Related Air Pollution • Exposures to traffic emissions have been increasingly associated with adverse health effects • It has not been possible to parse out a specific pollutant responsible for the observed traffic effects • How to best monitor and regulate traffic emissions is challenging

264 Ultrafine Particles • Ultrafine particles (PM<0.1μm) are generated both as primary emissions from combustion and friction processes and as secondary products of atmospheric chemistry • Toxicological studies suggest UFP are a potentially high‐risk hazard for adverse effects, but epidemiological data are sparse, in part because there is no monitoring network

Air Pollution Exposure Inequality

• People of color and low SES have • Greater exposures to outdoor air pollution • Disproportionate proximity to polluting land uses and toxic emissions

Inequality Curve

Environ Sci Technol 2009;43:7626–34.

265 Environ Sci Technol 2009;43:7626–34.

• People of color

266 Ozone Increases with Higher Temperatures

Capitman and Tyner, 2011

267 Climate Change Delays Clean Air Progress

Climate change could overwhelm existing ozone emission reduction efforts. • CARB and UC researchers estimate up to 30 more days of unhealthy ozone annually by 2050 (especially in Los Angeles and the San Joaquin Valley) • CARB estimates $8 billion additional annual cost of ozone controls in 2050

• Steiner et al., “Influence of future climate and emissions on regional air quality in California”, JGR 2006; and • Millstein D.E. and R. A. Harley. “Impact of Climate Change on Photochemical Air Pollution in Southern California”, JGR 2009.

AB 32 – Global Warming Solutions Act 2006

• Mandates regulatory and market mechanisms to reduce emissions of greenhouse gases (GHG) • Establishes GHG cap for 2020 based on 1990 levels • Means a roughly 25% reduction from business as usual • Required a “scoping plan” to achieve 2020 targets • 2020 compliance expected • SB 32 passed in 2016 mandates even more ambitious reductions – a 40% reduction from 1990 levels by 2030

The Major Sources of Greenhouse Gases and Aerosols also Contribute to Smog and Soot

268 AB32 Has Led to a Paradigm Shift

• All regulations now are evaluated re: both climate change mitigation and health co‐benefits from improved air quality • Focus now on emission reduction rather than ambient air quality • i.e., regulate sources rather than at the regional air quality level

AB32 Has Led to a Paradigm Shift

• CARB knows the sources of CO2 emissions and actually spent a year developing a quantitative inventory

• CARB mandates reductions in CO2 emissions that provide public health co‐benefits through simultaneous reduction of hazardous pollutants • Without needing to rely on “sound science” to determine levels that are harmful

269 AB32 Has Led to a Paradigm Shift

• The focus on emissions reduction drives technology and innovation that provides economic stimulus (i.e., jobs) to counter the anti‐ regulatory (i.e., “job killer”) rhetoric

AB32 Has Led to a Paradigm Shift • The typical 2‐way battle between industry and environmental health advocacy groups at the federal level now occurs less often in CA • The focus on emission reductions has empowered clean technology companies to support many climate change mitigation policies • For example, automobile manufacturers have invested billions in fuel cell vehicles and are pushing the oil companies to invest in hydrogen fueling infrastructure

AB32 Has Led to a Paradigm Shift

• Enforcement is also easier to implement when reduction of emissions is the focus rather than ambient level of a criteria pollutant

• California levels of PM2.5 have been dramatically reduced as a result of CARB regulations mandating reduction of diesel emissions from heavy‐duty trucks and buses, off‐road construction equipment, and port‐related activities

270 Benefits of Diesel Engine Standards

AB 32 Emission Reduction Strategies

Market Mechanism to Reduce Carbon Emissions • Cap‐and‐Trade • Caps carbon emissions • Price of carbon fluctuates • Complicated to administer • Carbon Tax • Variable carbon emission reductions • Fixed price of carbon • Simpler to administer • Politically difficult

271 What is Cap-and-Trade?

• The “cap” limits total GHG emissions from all regulated sources • The “cap” declines over time -- reduces emissions • State issues GHG emissions allowances per capped facility based on emissions inventory • Participants are allowed to “trade” allowances -- creates flexibility, reduces costs of compliance

California Air Resources Board 34

How Cap‐and‐Trade Works

Environmental Justice concerns for people living adjacent to high GHG emitting facilities

Assembly Bill 1550

• Requires that 35% of cap‐and‐trade revenue • is spent on projects that benefit disadvantaged communities • at least 25% is spent on projects located in disadvantaged communities • Cal Enviroscreen identifies disadvantaged communities

272 273 AB 398

• Extend’s CARB’s authority to implement the cap‐and‐trade program through 2030 • To achieve 2/3 majority for passing AB 398, support need from legislators with concerns about environmental justice issues related to cap‐and‐trade • AB 617 was a companion bill written to address EJ concerns

AB 617 • Mandates CARB to develop guidelines for community air quality monitoring • Requires local air districts to work with communities identified by CARB as having high cumulative exposure burden • To develop plans for community air quality monitoring to determine local “hot spots” • To review the results from such monitoring to develop community emission reductions programs • CARB must review the community emission reduction programs and provide grants to community‐based organizations to assist their participation in the programs • Best available retrofit control technology must be used if the district is in non‐attainment for one or more pollutants • Requires stationary sources to report their annual emissions of criteria air pollutants and toxic air contaminants to CARB for public dissemination

274 43

David Bates, MD, PhD from “Air Pollution and Global Warming: the Seamless Web,” Health & Clean Air Newsletter, 2005

• “Reducing emissions of air pollutants will slow global warming, and minimizing releases of greenhouse gases will save lives that would otherwise be lost to pollution. • A well inclined government genuinely committed to ‘sound’ science, would recognize this and assemble a package of policy measures designed to save our lives and our future. • Some governments are at least attempting to do this. Most are not.”

Policy Needs • The sources of air pollutants that harm health are the same as those that emit greenhouse gases and aerosols • To improve air quality and mitigate climate change, we need strong policies to move our economy away from reliance on fossil fuels

275 Question 1

Which of the following is NOT mandated by the U.S. Clean Air Act A) Develop ambient air quality standards for pollutants that harm public health B) Provide a margin of safety to protect the most vulnerable subgroups in the population C) Address health disparities due to local hot spots D) Address air quality problems using the best available technology

Question 2

Why has the California Air Resources Board been recently focusing on emissions reduction vs. regional air quality? A) The auto industry has complained that regional air quality targets are too hard to meet B) Air quality monitors for U.S. EPA compliance are sited near point sources C) Emissions reduction is cheaper than improving regional air quality D) Climate change mitigation policies can produce health co‐benefits

Question 3

Assembly Bill 617 mandates which of the following: A) Community air monitoring B) Community emission reduction plans C) Use of the best available retrofit control technology D) Public reporting of community emissions data E) All of the above

276 Thank you!

277