Biomonitoring of lead in blood of children living in a former mining area in Lower Saxony, Germany

Environmental exposure to lead substantially decreased over the past decades. However, soil of former mining areas still contains high lead levels. We therefore performed a biomonitoring study among children living in two former mining communities in Lower Saxony, Germany. In these communities, soil contains lead levels of 1000 to 30,000 mg/kg. Overall, 75 children (6-10 years of age) attending the two primary schools of the study area took part in the study. Parents completed a short questionnaire on sociodemographics, and children provided capillary whole blood samples. We analysed lead using inductively coupled plasma tandem mass spectrometer. We compared the results to current German (20 μg/l for boys, 15 μg/l for girls) and US (35 μg/l) reference values. Potential associations between questionnaire information and lead results were tested using lead as continuous outcome and using lead dichotomized at the reference values. Finally, we analysed spatial patterns of elevated biomonitoring results. Of all children, 48% exceeded the German reference values for lead (5% expected) and 8% the US reference value (2.5% expected). Children 6-8 years of age were more likely to exceed German reference values (63%) than 9-10 year old children were (32%; pFisher = 0.01). No other questionnaire information was statistically significantly associated with biomonitoring results. Additionally, we did not find any indication of spatial clustering. In conclusion, we observed elevated blood lead levels in primary school children living in a former mining area. In the next step, exposure pathways need to be identified to implement effective public health measures.

Cumulative occupational exposure to gases and fumes is associated with impairment in lung function and disease-related quality of life in a German COPD patient cohort

OBJECTIVES

The impact of occupational exposures on lung function impairments and quality of life (QoL) in patients with chronic obstructive pulmonary disease (COPD) was analysed and compared with that of smoking.

METHODS

Data from 1283 men and 759 women (Global Initiative for Chronic Obstructive Lung Disease (GOLD) grades 1-4 or former grade 0, without alpha-1-antitrypsin deficiency) of the COPD and Systemic Consequences Comorbidities Network cohort were analysed. Cumulative exposure to gases/fumes, biological dust, mineral dust or the combination vapours/gases/dusts/fumes was assessed using the ALOHA job exposure matrix. The effect of both occupational and smoking exposure on lung function and disease-specific QoL (St George's Respiratory Questionnaire) was analysed using linear regression analysis adjusting for age, body mass index, diabetes, hypertension and coronary artery disease, stratified by sex.

RESULTS

In men, exposure to gases/fumes showed the strongest effects among occupational exposures, being significantly associated with all lung function parameters and QoL; the effects were partially stronger than of smoking. Smoking had a larger effect than occupational exposure on lung diffusing capacity (transfer factor for carbon monoxide) but not on air trapping (residual volume/total lung capacity). In women, occupational exposures were not significantly associated with QoL or lung function, while the relationships between lung function parameters and smoking were comparable to men.

CONCLUSIONS

In patients with COPD, cumulative occupational exposure, particularly to gases/fumes, showed effects on airway obstruction, air trapping, gas uptake capacity and disease-related QoL, some of which were larger than those of smoking. These findings suggest that lung air trapping and QoL should be considered as outcomes of occupational exposure to gases and fumes in patients with COPD.

TRIAL REGISTRATION NUMBER

NCT01245933.

The Prospective COVID-19 Post-Immunization Serological Cohort in Munich (KoCo-Impf): Risk Factors and Determinants of Immune Response in Healthcare Workers

Antibody studies analyze immune responses to SARS-CoV-2 vaccination and infection, which is crucial for selecting vaccination strategies. In the KoCo-Impf study, conducted between 16 June and 16 December 2021, 6088 participants aged 18 and above from Munich were recruited to monitor antibodies, particularly in healthcare workers (HCWs) at higher risk of infection. Roche Elecsys^® Anti-SARS-CoV-2 assays on dried blood spots were used to detect prior infections (anti-Nucleocapsid antibodies) and to indicate combinations of vaccinations/infections (anti-Spike antibodies). The anti-Spike seroprevalence was 94.7%, whereas, for anti-Nucleocapsid, it was only 6.9%. HCW status and contact with SARS-CoV-2-positive individuals were identified as infection risk factors, while vaccination and current smoking were associated with reduced risk. Older age correlated with higher anti-Nucleocapsid antibody levels, while vaccination and current smoking decreased the response. Vaccination alone or combined with infection led to higher anti-Spike antibody levels. Increasing time since the second vaccination, advancing age, and current smoking reduced the anti-Spike response. The cumulative number of cases in Munich affected the anti-Spike response over time but had no impact on anti-Nucleocapsid antibody development/seropositivity. Due to the significantly higher infection risk faced by HCWs and the limited number of significant risk factors, it is suggested that all HCWs require protection regardless of individual traits.

The representative COVID-19 cohort Munich (KoCo19): from the beginning of the pandemic to the Delta virus variant

BACKGROUND

Population-based serological studies allow to estimate prevalence of SARS-CoV-2 infections despite a substantial number of mild or asymptomatic disease courses. This became even more relevant for decision making after vaccination started. The KoCo19 cohort tracks the pandemic progress in the Munich general population for over two years, setting it apart in Europe.

METHODS

Recruitment occurred during the initial pandemic wave, including 5313 participants above 13 years from private households in Munich. Four follow-ups were held at crucial times of the pandemic, with response rates of at least 70%. Participants filled questionnaires on socio-demographics and potential risk factors of infection. From Follow-up 2, information on SARS-CoV-2 vaccination was added. SARS-CoV-2 antibody status was measured using the Roche Elecsys® Anti-SARS-CoV-2 anti-N assay (indicating previous infection) and the Roche Elecsys® Anti-SARS-CoV-2 anti-S assay (indicating previous infection and/or vaccination). This allowed us to distinguish between sources of acquired antibodies.

RESULTS

The SARS-CoV-2 estimated cumulative sero-prevalence increased from 1.6% (1.1-2.1%) in May 2020 to 14.5% (12.7-16.2%) in November 2021. Underreporting with respect to official numbers fluctuated with testing policies and capacities, becoming a factor of more than two during the second half of 2021. Simultaneously, the vaccination campaign against the SARS-CoV-2 virus increased the percentage of the Munich population having antibodies, with 86.8% (85.5-87.9%) having developed anti-S and/or anti-N in November 2021. Incidence rates for infections after (BTI) and without previous vaccination (INS) differed (ratio INS/BTI of 2.1, 0.7-3.6). However, the prevalence of infections was higher in the non-vaccinated population than in the vaccinated one. Considering the whole follow-up time, being born outside Germany, working in a high-risk job and living area per inhabitant were identified as risk factors for infection, while other socio-demographic and health-related variables were not. Although we obtained significant within-household clustering of SARS-CoV-2 cases, no further geospatial clustering was found.

CONCLUSIONS

Vaccination increased the coverage of the Munich population presenting SARS-CoV-2 antibodies, but breakthrough infections contribute to community spread. As underreporting stays relevant over time, infections can go undetected, so non-pharmaceutical measures are crucial, particularly for highly contagious strains like Omicron.

Wastewater treatment plants, an "escape gate" for ESCAPE pathogens

Antibiotics are an essential tool of modern medicine, contributing to significantly decreasing mortality and morbidity rates from infectious diseases. However, persistent misuse of these drugs has accelerated the evolution of antibiotic resistance, negatively impacting clinical practice. The environment contributes to both the evolution and transmission of resistance. From all anthropically polluted aquatic environments, wastewater treatment plants (WWTPs) are probably the main reservoirs of resistant pathogens. They should be regarded as critical control points for preventing or reducing the release of antibiotics, antibiotic-resistant bacteria (ARB), and antibiotic-resistance genes (ARGs) into the natural environment. This review focuses on the fate of the pathogens Enterococcus faecium, Staphylococcus aureus, Clostridium difficile, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacteriaceae spp. (ESCAPE) in WWTPs. All ESCAPE pathogen species, including high-risk clones and resistance determinants to last-resort antibiotics such as carbapenems, colistin, and multi-drug resistance platforms, were detected in wastewater. The whole genome sequencing studies demonstrate the clonal relationships and dissemination of Gram-negative ESCAPE species into the wastewater via hospital effluents and the enrichment of virulence and resistance determinants of S. aureus and enterococci in WWTPs. Therefore, the efficiency of different wastewater treatment processes regarding the removal of clinically relevant ARB species and ARGs, as well as the influence of water quality factors on their performance, should be explored and monitored, along with the development of more effective treatments and appropriate indicators (ESCAPE bacteria and/or ARGs). This knowledge will allow the development of quality standards for point sources and effluents to consolidate the WWTP barrier role against the environmental and public health AR threats.

Socioeconomic and risk-related drivers of compliance with measures to prevent SARS-CoV-2 infection: evidence from the Munich-based KoCo19 study

OBJECTIVES

Although a growing share of the population in many countries has been vaccinated against the SARS-CoV-2 virus to different degrees, social distancing and hygienic non-pharmaceutical interventions still play a substantial role in containing the pandemic. The goal of this study was to investigate which factors are correlated with a higher compliance with these regulations in the context of a cohort study in the city of Munich, southern Germany, during the summer of 2020, i.e. after the first lockdown phase.

METHODS

Using self-reported compliance with six regulations and personal hygiene rules (washing hands, avoiding touching face, wearing a mask, keeping distance, avoiding social gatherings, avoiding public spaces) we extracted two compliance factor scores, namely compliance with personal hygiene measures and compliance with social distancing regulations. Using linear and logistic regressions, we estimated the correlation of several socio-demographic and risk perception variables with both compliance scores.

RESULTS

Risk aversion proved to be a consistent and significant driver of compliance across all compliance behaviors. Furthermore, being female, being retired and having a migration background were positively associated with compliance with personal hygiene regulations, whereas older age was related with a higher compliance with social distancing regulations. Generally, socioeconomic characteristics were not related with compliance, except for education, which was negatively related with compliance with personal hygiene measures.

CONCLUSIONS

Our results suggest that for a targeted approach to improve compliance with measures to prevent SARS-CoV-2 infection, special attention should be given to younger, male and risk-prone individuals.

Integrative modelling of reported case numbers and seroprevalence reveals time-dependent test efficiency and infectious contacts

Mathematical models have been widely used during the ongoing SARS-CoV-2 pandemic for data interpretation, forecasting, and policy making. However, most models are based on officially reported case numbers, which depend on test availability and test strategies. The time dependence of these factors renders interpretation difficult and might even result in estimation biases. Here, we present a computational modelling framework that allows for the integration of reported case numbers with seroprevalence estimates obtained from representative population cohorts. To account for the time dependence of infection and testing rates, we embed flexible splines in an epidemiological model. The parameters of these splines are estimated, along with the other parameters, from the available data using a Bayesian approach. The application of this approach to the official case numbers reported for Munich (Germany) and the seroprevalence reported by the prospective COVID-19 Cohort Munich (KoCo19) provides first estimates for the time dependence of the under-reporting factor. Furthermore, we estimate how the effectiveness of non-pharmaceutical interventions and of the testing strategy evolves over time. Overall, our results show that the integration of temporally highly resolved and representative data is beneficial for accurate epidemiological analyses.

Work-related stress and atopic dermatitis: Results from the study on occupational allergy risks

Chronic stress at work is ubiquitous in modern societies. However, its influence on atopic dermatitis (AD) has hardly been investigated. This study aimed to elucidate the association between work-related stress and AD via a longitudinal study. The analysis comprised data from three phases (2002-2003, 2007-2009, 2017-2018) of the prospective Study on Occupational Allergy Risks (SOLAR), including 1,240 young adults aged 16 to 18 years at baseline (61% female) who were originally recruited for the International Study of Asthma and Allergies in Childhood Phase II in 1995-1996. AD was assessed at all three phases based on self-reports of a physician's diagnosis and symptoms. Work-related stress was measured at all three periods using the work discontent and work overload scales from the Trier Inventory for the Assessment of Chronic Stress with adaptions to school and university. Generalized estimating equations were used to analyze the association between stress and AD, treating work discontent and work overload first as continuous and then as categorical exposure variables. We observed 50 AD cases (4%) at SOLAR I, 48 (4%) at SOLAR II, and 42 (3%) at SOLAR III. A one-point increase in the work discontent score was associated with an odds ratio (OR) for AD of 1.05 (95% confidence interval [CI], 1.00-1.10). The respective increase in the work overload score led to an OR of 1.03 (95% CI, 0.99-1.06). In the categorical analysis, there was no clear indication of elevated odds of AD in the highest vs. lowest exposure group (4th vs. 1st quartile: OR, 1.53; 95% CI, 0.92-2.53 for work discontent; OR, 1.38, 95% CI, 0.83-2.27 for work overload). Altogether, we observed limited to no evidence for an association between work-related stress and AD. Our study's ability to detect stronger evidence may have been compromised by shortcomings such as nondifferential misclassification of the outcome or insufficient statistical precision due to small numbers of AD cases. Another explanation could be that AD predominantly becomes evident in childhood, not in adulthood.

Parental occupational exposures prior to conception and offspring wheeze and eczema during first year of life

PURPOSE

Parental exposures prior to conception might influence asthma and allergy risk in offspring. As occupational exposures are established risk factors for asthma and allergies, we investigated if parental occupational exposures prior to conception cause wheeze and eczema in offspring during the first year of life.

METHODS

We analysed data of 436 families from an offspring cohort based on a follow-up study of German participants of the International Study of Asthma and Allergies in Childhood (ISAAC). Offspring cohort data was collected between 2009 and 2019. Occupational exposures were based on participants' work histories and measured by a Job-Exposure-Matrix. We used Bayesian logistic regression models for analysis. Inference and confounder selection were based on directed acyclic graphs.

RESULTS

In mothers, for both allergic and irritative occupational exposures prior to conception suggestive effects on offspring eczema during the first year of life were found (allergens: odds ratio (OR) 1.22, 95% compatibility interval (CI) 0.92-1.57; irritants: OR 1.36, 95% CI 0.99-1.77), while no relation with wheeze was suggested.

CONCLUSIONS

Our results suggest that reduction of asthma-related occupational exposures might not only reduce the burden of disease for occupationally induced or aggravated asthma and allergies in employees but also in their children.

Residential proximity to oil and gas production sites and hematologic malignancies: A case-control study

BACKGROUND

We investigated the association between residential proximity to oil and gas production sites and hematologic malignancies, due to a cancer cluster in the German state of Lower Saxony.

METHODS

A registry-based case-control study was conducted including 3978 cases of hematologic malignancies diagnosed within 2013-2016 and 15,912 frequency-matched controls randomly drawn by population registries. Residential proximity to 5333 oil and gas production sites at the time of diagnosis was calculated. Unconditional logistic regression models were used to estimate the association between living within 1 km of any exposure site and developing a hematologic malignancy. Models were adjusted for matching variables sex, age group, district, and year of diagnosis as well as for proximity to main streets and to agricultural land.

RESULTS

We found no association between the development of hematologic malignancies and the proximity to all oil and gas production sites (odds ratio: 0.97; 95% confidence interval: 0.85, 1.11). Focusing on gas production sites increased the odds of developing hematologic cancer (odds ratio: 1.19; 95% confidence interval: 0.97, 1.45). In stratified analyses, associations were stronger in women and for acute myeloblastic leukemia. We also found an association in the district where the initial cluster occurred.

CONCLUSIONS

Our results suggest that residential proximity to oil and gas production is not a risk factor for all hematologic malignancies in general. Sporadic and past exposures are the most likely scenarios for mechanisms involving oil and gas production, leading to increased risk for certain subtypes of cancer in certain populations.

Farm living and allergic rhinitis from childhood to young adulthood - prospective results of the GABRIEL study

BACKGROUND

Growing up on a farm is associated with a reduced prevalence of respiratory allergies in childhood. It is unknown whether this protective effect remains into adulthood.

OBJECTIVES

We aimed to prospectively investigate the relationship between farm exposure and prevalence of allergic rhinitis and wheeze from childhood to early adulthood.

METHODS

Participants from phase 2 of the GABRIEL (Multidisciplinary Study to Identify the Genetic and Environmental Causes of Asthma in the European Community) study living in southern Germany (aged 6-11 years at baseline; 20-25 at follow-up) were invited to complete a questionnaire on sociodemographic data, farm contact, respiratory symptoms, and potential confounders. Odds ratios (OR) with 95% confidence intervals (95% CI) were modelled using generalized estimating equations (GEE).

RESULTS

Of the 2,276 phase 2 participants, 1,501 (66%) answered the follow-up questionnaire of which 1,333 could be included in the analyses. Living on a farm was associated with reduced prevalence of allergic rhinitis (persistent farm living OR 0.4; 95% CI 0.2-0.6; only baseline farm living 0.4; 0.2-0.8). The odds ratio for developing symptoms from baseline to follow-up was almost three (OR 2.7; 95% CI 2.1-3.3), irrespective of farm living. For symptoms of wheeze, no statistically significant association with farm living was observed.

CONCLUSIONS

The protective effect of farm living on allergic rhinitis persists from childhood to early adulthood. Continuing exposure over puberty does not add to the effect. This confirms that the window of opportunity for a protective effect might be found in childhood.

International Travel as a Risk Factor for Carriage of Extended-Spectrum β-Lactamase-Producing Escherichia coli in a Large Sample of European Individuals—The AWARE Study

Antibiotic resistance (AR) is currently a major threat to global health, calling for a One Health approach to be properly understood, monitored, tackled, and managed. Potential risk factors for AR are often studied in specific high-risk populations, but are still poorly understood in the general population. Our aim was to explore, describe, and characterize potential risk factors for carriage of Extended-Spectrum Beta-Lactamase-resistant Escherichia coli (ESBL-EC) in a large sample of European individuals aged between 16 and 67 years recruited from the general population in Southern Germany, the Netherlands, and Romania. Questionnaire and stool sample collection for this cross-sectional study took place from September 2018 to March 2020. Selected cultures of participants’ stool samples were analyzed for detection of ESBL-EC. A total of 1183 participants were included in the analyses: 333 from Germany, 689 from the Netherlands, and 161 from Romania. Travels to Northern Africa (adjusted Odds Ratio, aOR 4.03, 95% Confidence Interval, CI 1.67–9.68), Sub-Saharan Africa (aOR 4.60, 95% CI 1.60–13.26), and Asia (aOR 4.08, 95% CI 1.97–8.43) were identified as independent risk factors for carriage of ESBL-EC. Therefore, travel to these regions should continue to be routinely asked about by clinical practitioners as possible risk factors when considering antibiotic therapy.

Trajectories of asthma and allergy symptoms from childhood to adulthood

BACKGROUND

Phenotypes of asthma and allergic diseases are mainly studied separately for children and adults. To explore the role of adolescence and young adulthood, we investigated symptom trajectories at the transition from childhood into adulthood.

METHODS

Latent class analysis (LCA) was conducted in a population initially recruited for the German arm of Phase II of the International Study of Asthma and Allergies in Childhood and followed-up three times until their early 30s (N=2267). Indicators included in LCA were 12-month prevalences of symptoms of wheeze, rhinoconjunctivitis, and eczema. Latent classes were further characterised regarding important traits such as skin prick tests. Logistic regression models were used to investigate associations with environmental determinants such as smoking and occupational exposures.

RESULTS

Six latent classes were identified: an asymptomatic one as well as three with single and two with co-occurring symptoms. All trajectories essentially established between baseline assessment at around 10 years and the first follow-up at around 17 years. Probabilities for symptoms increased from childhood to adolescence, especially for wheeze-related latent classes, while they remained constant in adulthood. Wheeze-related latent classes were also positively associated with exposures during adolescence (e.g. active smoking).

CONCLUSION

Distinct trajectories of asthma and allergy symptoms establish from childhood through adolescence and stabilize during early adulthood. This pattern was most notable in wheeze-related latent classes which also showed the strongest positive associations with environmental exposures in adolescence/young adulthood. Therefore, not only childhood but also adolescence is relevant for disease development and offers considerable potential for prevention and health promotion.

The interplay of viral loads, clinical presentation, and serological responses in SARS-CoV-2 – Results from a prospective cohort of outpatient COVID-19 cases

Risk factors for disease progression and severity of SARS-CoV-2 infections require an understanding of acute and long-term virological and immunological dynamics. Fifty-one RT-PCR positive COVID-19 outpatients were recruited between May and December 2020 in Munich, Germany, and followed up at multiple defined timepoints for up to one year. RT-PCR and viral culture were performed and seroresponses measured. Participants were classified applying the WHO clinical progression scale. Short symptom to test time (median 5.0 days; p = 0.0016) and high viral loads (VL; median maximum VL: 3∙10⁸ copies/mL; p = 0.0015) were indicative for viral culture positivity. Participants with WHO grade 3 at baseline had significantly higher VLs compared to those with WHO 1 and 2 (p = 0.01). VLs dropped fast within 1 week of symptom onset. Maximum VLs were positively correlated with the magnitude of Ro-N-Ig seroresponse (p = 0.022). Our results describe the dynamics of VLs and antibodies to SARS-CoV-2 in mild to moderate cases that can support public health measures during the ongoing global pandemic.

Wireless phone use in childhood and adolescence and neuroepithelial brain tumours: Results from the international MOBI-Kids study

In recent decades, the possibility that use of mobile communicating devices, particularly wireless (mobile and cordless) phones, may increase brain tumour risk, has been a concern, particularly given the considerable increase in their use by young people. MOBI-Kids, a 14-country (Australia, Austria, Canada, France, Germany, Greece, India, Israel, Italy, Japan, Korea, the Netherlands, New Zealand, Spain) case-control study, was conducted to evaluate whether wireless phone use (and particularly resulting exposure to radiofrequency (RF) and extremely low frequency (ELF) electromagnetic fields (EMF)) increases risk of brain tumours in young people. Between 2010 and 2015, the study recruited 899 people with brain tumours aged 10 to 24 years old and 1,910 controls (operated for appendicitis) matched to the cases on date of diagnosis, study region and age. Participation rates were 72% for cases and 54% for controls. The mean ages of cases and controls were 16.5 and 16.6 years, respectively; 57% were males. The vast majority of study participants were wireless phones users, even in the youngest age group, and the study included substantial numbers of long-term (over 10 years) users: 22% overall, 51% in the 20-24-year-olds. Most tumours were of the neuroepithelial type (NBT; n = 671), mainly glioma. The odds ratios (OR) of NBT appeared to decrease with increasing time since start of use of wireless phones, cumulative number of calls and cumulative call time, particularly in the 15-19 years old age group. A decreasing trend in ORs was also observed with increasing estimated cumulative RF specific energy and ELF induced current density at the location of the tumour. Further analyses suggest that the large number of ORs below 1 in this study is unlikely to represent an unknown causal preventive effect of mobile phone exposure: they can be at least partially explained by differential recall by proxies and prodromal symptoms affecting phone use before diagnosis of the cases. We cannot rule out, however, residual confounding from sources we did not measure. Overall, our study provides no evidence of a causal association between wireless phone use and brain tumours in young people. However, the sources of bias summarised above prevent us from ruling out a small increased risk.

Carriage of ESBL-producing Enterobacterales in wastewater treatment plant workers and surrounding residents - the AWARE Study

To investigate whether wastewater treatment plant (WWTP) workers and residents living in close proximity to a WWTP have elevated carriage rates of ESBL-producing Enterobacterales, as compared to the general population. From 2018 to 2020, we carried out a cross-sectional study in Germany, the Netherlands, and Romania among WWTP workers (N = 344), nearby residents (living ≤ 300 m away from WWTPs; N = 431) and distant residents (living ≥ 1000 m away = reference group; N = 1165). We collected information on potential confounders via questionnaire. Culture of participants' stool samples was performed with ChromID®-ESBL agar plates and species identification with MALDI-TOF-MS. We used logistic regression to estimate the odds ratio (OR) for carrying ESBL-producing E. coli (ESBL-EC). Sensitivity analyses included stratification by country and interaction models using country as secondary exposure. Prevalence of ESBL-EC was 11% (workers), 29% (nearby residents), and 7% (distant residents), and higher in Romania (28%) than in Germany (7%) and the Netherlands (6%). Models stratified by country showed that within the Romanian population, WWTP workers are about twice as likely (aOR = 2.34, 95% CI: 1.22-4.50) and nearby residents about three times as likely (aOR = 3.17, 95% CI: 1.80-5.59) to be ESBL-EC carriers, when compared with distant residents. In stratified analyses by country, we found an increased risk for carriage of ESBL-EC in Romanian workers and nearby residents. This effect was higher for nearby residents than for workers, which suggests that, for nearby residents, factors other than the local WWTP could contribute to the increased carriage.

Spatially resolved qualified sewage spot sampling to track SARS-CoV-2 dynamics in Munich - One year of experience

Wastewater-based epidemiology (WBE) is a tool now increasingly proposed to monitor the SARS-CoV-2 burden in populations without the need for individual mass testing. It is especially interesting in metropolitan areas where spread can be very fast, and proper sewage systems are available for sampling with short flow times and thus little decay of the virus. We started in March 2020 to set up a once-a-week qualified spot sampling protocol in six different locations in Munich carefully chosen to contain primarily wastewater of permanent residential areas, rather than industry or hospitals. We used RT-PCR and sequencing to track the spread of SARS-CoV-2 in the Munich population with temporo-spatial resolution. The study became fully operational in mid-April 2020 and has been tracking SARS-CoV-2 RNA load weekly for one year. Sequencing of the isolated viral RNA was performed to obtain information about the presence and abundance of variants of concern in the Munich area over time. We demonstrate that the evolution of SARS-CoV-2 RNA loads (between <7.5 and 3874/ml) in these different areas within Munich correlates well with official seven day incidence notification data (between 0.0 and 327 per 100,000) obtained from the authorities within the respective region. Wastewater viral loads predicted the dynamic of SARS-CoV-2 local incidence about 3 weeks in advance of data based on respiratory swab analyses. Aligning with multiple different point-mutations characteristic for certain variants of concern, we could demonstrate the gradual increase of variant of concern B.1.1.7 in the Munich population beginning in January 2021, weeks before it became apparent in sequencing results of swabs samples taken from patients living in Munich. Overall, the study highlights the potential of WBE to monitor the SARS-CoV-2 pandemic, including the introduction of variants of concern in a local population.

Head-to-head evaluation of seven different seroassays including direct viral neutralisation in a representative cohort for SARS-CoV-2

A number of seroassays are available for SARS-CoV-2 testing; yet, head-to-head evaluations of different testing principles are limited, especially using raw values rather than categorical data. In addition, identifying correlates of protection is of utmost importance, and comparisons of available testing systems with functional assays, such as direct viral neutralisation, are needed.We analysed 6658 samples consisting of true-positives (n=193), true-negatives (n=1091), and specimens of unknown status (n=5374). For primary testing, we used Euroimmun-Anti-SARS-CoV-2-ELISA-IgA/IgG and Roche-Elecsys-Anti-SARS-CoV-2. Subsequently virus-neutralisation, GeneScriptcPass, VIRAMED-SARS-CoV-2-ViraChip, and Mikrogen-recomLine-SARS-CoV-2-IgG were applied for confirmatory testing. Statistical modelling generated optimised assay cut-off thresholds. Sensitivity of Euroimmun-anti-S1-IgA was 64.8%, specificity 93.3% (manufacturer's cut-off); for Euroimmun-anti-S1-IgG, sensitivity was 77.2/79.8% (manufacturer's/optimised cut-offs), specificity 98.0/97.8%; Roche-anti-N sensitivity was 85.5/88.6%, specificity 99.8/99.7%. In true-positives, mean and median Euroimmun-anti-S1-IgA and -IgG titres decreased 30/90 days after RT-PCR-positivity, Roche-anti-N titres decreased significantly later. Virus-neutralisation was 80.6% sensitive, 100.0% specific (≥1:5 dilution). Neutralisation surrogate tests (GeneScriptcPass, Mikrogen-recomLine-RBD) were >94.9% sensitive and >98.1% specific. Optimised cut-offs improved test performances of several tests. Confirmatory testing with virus-neutralisation might be complemented with GeneScriptcPassTM or recomLine-RBD for certain applications. Head-to-head comparisons given here aim to contribute to the refinement of testing strategies for individual and public health use.

From first to second wave: follow-up of the prospective COVID-19 cohort (KoCo19) in Munich (Germany)

BACKGROUND

In the 2nd year of the COVID-19 pandemic, knowledge about the dynamics of the infection in the general population is still limited. Such information is essential for health planners, as many of those infected show no or only mild symptoms and thus, escape the surveillance system. We therefore aimed to describe the course of the pandemic in the Munich general population living in private households from April 2020 to January 2021.

METHODS

The KoCo19 baseline study took place from April to June 2020 including 5313 participants (age 14 years and above). From November 2020 to January 2021, we could again measure SARS-CoV-2 antibody status in 4433 of the baseline participants (response 83%). Participants were offered a self-sampling kit to take a capillary blood sample (dry blood spot; DBS). Blood was analysed using the Elecsys® Anti-SARS-CoV-2 assay (Roche). Questionnaire information on socio-demographics and potential risk factors assessed at baseline was available for all participants. In addition, follow-up information on health-risk taking behaviour and number of personal contacts outside the household (N = 2768) as well as leisure time activities (N = 1263) were collected in summer 2020.

RESULTS

Weighted and adjusted (for specificity and sensitivity) SARS-CoV-2 sero-prevalence at follow-up was 3.6% (95% CI 2.9-4.3%) as compared to 1.8% (95% CI 1.3-3.4%) at baseline. 91% of those tested positive at baseline were also antibody-positive at follow-up. While sero-prevalence increased from early November 2020 to January 2021, no indication of geospatial clustering across the city of Munich was found, although cases clustered within households. Taking baseline result and time to follow-up into account, men and participants in the age group 20-34 years were at the highest risk of sero-positivity. In the sensitivity analyses, differences in health-risk taking behaviour, number of personal contacts and leisure time activities partly explained these differences.

CONCLUSION

The number of citizens in Munich with SARS-CoV-2 antibodies was still below 5% during the 2nd wave of the pandemic. Antibodies remained present in the majority of SARS-CoV-2 sero-positive baseline participants. Besides age and sex, potentially confounded by differences in behaviour, no major risk factors could be identified. Non-pharmaceutical public health measures are thus still important.

Executive Function among Chilean Shellfish Divers: A Cross-Sectional Study Considering Working and Health Conditions in Artisanal Fishing

Knowledge about professional diving-related risk factors for reduced executive function is limited. We therefore evaluated the association between decompression illness and executive functioning among artisanal divers in southern Chile. The cross-sectional study included 104 male divers and 58 male non-diving fishermen from two fishing communities. Divers self-reported frequency and severity of symptoms of decompression illness. Executive function was evaluated by perseverative responses and perseverative errors in the Wisconsin Card Sorting Test. Age, alcohol consumption, and symptoms of depression were a-priori defined as potential confounders and included in linear regression models. Comparing divers and non-divers, no differences in the executive function were found. Among divers, 75% reported a history of at least mild decompression sickness. Higher frequency and severity of symptoms of decompression illness were associated with reduced executive function. Therefore, intervention strategies for artisanal divers should focus on prevention of decompression illness.

Antibiotic Resistance in Wastewater Treatment Plants and Transmission Risks for Employees and Residents: The Concept of the AWARE Study

Antibiotic resistance has become a serious global health threat. Wastewater treatment plants may become unintentional collection points for bacteria resistant to antimicrobials. Little is known about the transmission of antibiotic resistance from wastewater treatment plants to humans, most importantly to wastewater treatment plant workers and residents living in the vicinity. We aim to deliver precise information about the methods used in the AWARE (Antibiotic Resistance in Wastewater: Transmission Risks for Employees and Residents around Wastewater Treatment Plants) study. Within the AWARE study, we gathered data on the prevalence of two antibiotic resistance phenotypes, ESBL-producing E. coli and carbapenemase-producing Enterobacteriaceae, as well as on their corresponding antibiotic resistance genes isolated from air, water, and sewage samples taken from inside and outside of different wastewater treatment plants in Germany, the Netherlands, and Romania. Additionally, we analysed stool samples of wastewater treatment plant workers, nearby residents, and members of a comparison group living ≥1000 m away from the closest WWTP. To our knowledge, this is the first study investigating the potential spread of ESBL-producing E. coli, carbapenemase-producing Enterobacteriaceae, and antibiotic resistance genes from WWTPs to workers, the environment, and nearby residents. Quantifying the contribution of different wastewater treatment processes to the removal efficiency of ESBL-producing E. coli, carbapenemase-producing Enterobacteriaceae, and antibiotic resistance genes will provide us with evidence-based support for possible mitigation strategies.

Occupational Safety and Health in a Community of Shellfish Divers: A Community-Based Participatory Approach

In artisanal fishing communities in Chile, the access to occupational safety and health (OSH) is limited by factors such as the informality of employment. Our objective was to analyze the working and health conditions of workers in a coastal town in Southern Chile, under a community-based participatory approach. We carried out two independent social dialogue workshops within the community. The first one (N of participants = 25) was aimed to identify the strengths, weaknesses and challenges for preventing decompression sickness among divers. The second workshop (N of participants = 10) was set to identify the work processes and to map the occupational risks during seafood harvesting and processing in the community. Community members' training for handling and preventing decompression sickness among divers, and the collaboration between a local health representative, stakeholders and authorities, were identified as contributing factors in reducing fatalities and sequels among divers in the past. Technology and safety on board the vessels, training of healthcare personnel in OSH, and access to health programs, were identified as remaining challenges. Through risk mapping, the participants identified the relationship between working and health conditions in the community, reinforcing the necessity of improving access to health and social security. The community participation in identifying and analyzing working and health conditions could be the first step for a strategy to address OSH through primary health care in rural communities. Community empowerment and involvement in action plans, training on basic OSH for health care workers, and public policies are required.

Prevalence and Risk Factors of Infection in the Representative COVID-19 Cohort Munich

Given the large number of mild or asymptomatic SARS-CoV-2 cases, only population-based studies can provide reliable estimates of the magnitude of the pandemic. We therefore aimed to assess the sero-prevalence of SARS-CoV-2 in the Munich general population after the first wave of the pandemic. For this purpose, we drew a representative sample of 2994 private households and invited household members 14 years and older to complete questionnaires and to provide blood samples. SARS-CoV-2 seropositivity was defined as Roche N pan-Ig ≥ 0.4218. We adjusted the prevalence for the sampling design, sensitivity, and specificity. We investigated risk factors for SARS-CoV-2 seropositivity and geospatial transmission patterns by generalized linear mixed models and permutation tests. Seropositivity for SARS-CoV-2-specific antibodies was 1.82% (95% confidence interval (CI) 1.28-2.37%) as compared to 0.46% PCR-positive cases officially registered in Munich. Loss of the sense of smell or taste was associated with seropositivity (odds ratio (OR) 47.4; 95% CI 7.2-307.0) and infections clustered within households. By this first population-based study on SARS-CoV-2 prevalence in a large German municipality not affected by a superspreading event, we could show that at least one in four cases in private households was reported and known to the health authorities. These results will help authorities to estimate the true burden of disease in the population and to take evidence-based decisions on public health measures.

Third Follow-Up of the Study on Occupational Allergy Risks (SOLAR III) in Germany: Design, Methods, and Initial Data Analysis

Introduction: Asthma and allergies are complex diseases affected by genetic and environmental factors, such as occupational and psychosocial factors, as well as interactions between them. Although childhood is a critical phase in the development of asthma and allergies, few cohort studies on occupational outcomes followed up participants from childhood onwards. We present design, methods, and initial data analysis for the third follow-up of SOLAR (Study on Occupational Allergy Risks), a prospective and population-based German asthma and allergy cohort. Methods: The SOLAR cohort was initially recruited in 1995-1996 for Phase II of the German branch of the International Study of Asthma and Allergies in Childhood (ISAAC II) and followed up three times since, in 2002-2003, 2007-2009, and 2017-2018. During the third follow-up (SOLAR III), participants were between 29 and 34 years old. Since SOLAR focuses on occupational exposures, follow-ups were conducted at important points in time of the development of participants' career. To evaluate the potential of selection bias, responders and non-responders were compared based on variables from earlier study phases. In responders, frequency and pattern of missing values were examined and compared within the subsets of paper and online versions of the used questionnaires. Results: In total, 1,359 participants completed the questionnaire of the third follow-up (47.3% of eligible participants). Initially, the cohort started with 6,399 participants from the ISAAC II questionnaire study. A selection process led to a study population that is more female, higher educated, smokes less and has a higher proportion of certain asthma and allergy symptoms (also in their parents) than the initial cohort. Pattern and frequency of missing values were different for paper and online questionnaires. Discussion: The third follow-up of the SOLAR cohort offers the opportunity to analyze the course of asthma and allergies and their associations to environmental, occupational and psychosocial risk factors over more than 20 years from childhood to adulthood. Selection processes within the cohort might lead to bias that needs to be considered in future analyses.

Long-term effects of asthma medication on asthma symptoms: an application of the targeted maximum likelihood estimation

Background

Long-term effectiveness of asthma control medication has been shown in clinical trials but results from observational studies with children and adolescents are lacking. Marginal structural models estimated using targeted maximum likelihood methods are a novel statistiscal approach for such studies as it allows to account for time-varying confounders and time-varying treatment. Therefore, we aimed to calculate the long-term risk of reporting asthma symptoms in relation to control medication use in a real-life setting from childhood to adulthood applying targeted maximum likelihood estimation.

Methods

In the prospective cohort study SOLAR (Study on Occupational Allergy Risks) we followed a German subsample of 121 asthmatic children (9–11 years old) of the ISAAC II cohort (International Study of Asthma and Allergies in Childhood) until the age of 19 to 24. We obtained self-reported questionnaire data on asthma control medication use at baseline (1995–1996) and first follow-up (2002–2003) as well as self-reported asthma symptoms at baseline, first and second follow-up (2007–2009). Three hypothetical treatment scenarios were defined: early sustained intervention, early unsustained intervention and no treatment at all. We performed longitudinal targeted maximum likelihood estimation combined with Super Learner algorithm to estimate the relative risk (RR) to report asthma symptoms at SOLAR I and SOLAR II in relation to the different hypothetical scenarios.

Results

A hypothetical intervention of early sustained treatment was associated with a statistically significant risk increment of asthma symptoms at second follow-up when compared to no treatment at all (RR: 1.51, 95% CI: 1.19–1.83) or early unsustained intervention (RR:1.38, 95% CI: 1.11–1.65).

Conclusions

While we could confirm the tagerted maximum likelihood estimation to be a usable and robust statistical tool, we did not observe a beneficial effect of asthma control medication on asthma symptoms. Because of potential due to the small sample size, lack of data on disease severity and reverse causation our results should, however, be interpreted with caution.

Adaptation of an international virtual patient collection to the COVID-19 pandemic

The COVID-19 pandemic posed new global challenges for teaching. We met these challenges as an international collaboration by adapting a collection of virtual patients for clinical reasoning training to this novel context.

Protocol of a population-based prospective COVID-19 cohort study Munich, Germany (KoCo19)

BACKGROUND

Due to the SARS-CoV-2 pandemic, public health interventions have been introduced globally in order to prevent the spread of the virus and avoid the overload of health care systems, especially for the most severely affected patients. Scientific studies to date have focused primarily on describing the clinical course of patients, identifying treatment options and developing vaccines. In Germany, as in many other regions, current tests for SARS-CoV2 are not conducted on a representative basis and in a longitudinal design. Furthermore, knowledge about the immune status of the population is lacking. Nonetheless, these data are needed to understand the dynamics of the pandemic and hence to appropriately design and evaluate interventions. For this purpose, we recently started a prospective population-based cohort in Munich, Germany, with the aim to develop a better understanding of the state and dynamics of the pandemic.

METHODS

In 100 out of 755 randomly selected constituencies, 3000 Munich households are identified via random route and offered enrollment into the study. All household members are asked to complete a baseline questionnaire and subjects ≥14 years of age are asked to provide a venous blood sample of ≤3 ml for the determination of SARS-CoV-2 IgG/IgA status. The residual plasma and the blood pellet are preserved for later genetic and molecular biological investigations. For twelve months, each household member is asked to keep a diary of daily symptoms, whereabouts and contacts via WebApp. If symptoms suggestive for COVID-19 are reported, family members, including children < 14 years, are offered a pharyngeal swab taken at the Division of Infectious Diseases and Tropical Medicine, LMU University Hospital Munich, for molecular testing for SARS-CoV-2. In case of severe symptoms, participants will be transferred to a Munich hospital. For one year, the study teams re-visits the households for blood sampling every six weeks.

DISCUSSION

With the planned study we will establish a reliable epidemiological tool to improve the understanding of the spread of SARS-CoV-2 and to better assess the effectiveness of public health measures as well as their socio-economic effects. This will support policy makers in managing the epidemic based on scientific evidence.

Exposure to Medical Radiation during Fetal Life, Childhood and Adolescence and Risk of Brain Tumor in Young Age: Results from The MOBI-Kids Case-Control Study

BACKGROUND

We explored the association between ionizing radiation (IR) from pre-natal and post-natal radio-diagnostic procedures and brain cancer risk within the MOBI-kids study.

METHODS

MOBI-kids is an international (Australia, Austria, Canada, France, Germany, Greece, India, Israel, Italy, Japan, Korea, New Zealand, Spain, The Netherlands) case-control study including 899 brain tumor (645 neuroepithelial) cases aged 10-24 years and 1,910 sex-, age-, country-matched controls. Medical radiological history was collected through personal interview. We estimated brain IR dose for each procedure, building a look-up table by age and time period. Lifetime cumulative doses were calculated using 2 and 5 years lags from the diagnostic date. Risk was estimated using conditional logistic regression. Neurological, psychological and genetic conditions were evaluated as potential confounders. The main analyses focused on neuroepithelial tumors.

RESULTS

Overall, doses were very low, with a skewed distribution (median 0.02 mGy, maximum 217 mGy). ORs for post-natal exposure were generally below 1. ORs were increased in the highest dose categories both for post and pre-natal exposures: 1.63 (95% CI 0.44-6.00) and 1.55 (0.57-4.23), respectively, based on very small numbers of cases. The change in risk estimates after adjustment for medical conditions was modest.

CONCLUSIONS

There was little evidence for an association between IR from radio-diagnostic procedures and brain tumor risk in children and adolescents. Though doses were very low, our results suggest a higher risk for pre-natal and early life exposure, in line with current evidence.

Precarious employment and migrant workers' mental health: a protocol for a systematic review of observational studies

BACKGROUND

Precarious employment has become an urgent public health issue at a global scale with potential consequences for quality of life and health of employees, especially in vulnerable groups such as migrants. The primary aim of this systematic review is thus to analyze and summarize existing research on the association between precarious employment and migrant workers' mental health.

METHODS

We will search PubMed/MEDLINE, PsycINFO, Web of Science (from January 1970 onwards) for original articles on observational studies (e.g., cohort, case-control and cross-sectional, and qualitative) published in English, German, Turkish, and Spanish. The primary outcome will be depression and anxiety disorders. Secondary outcomes will be burnout, sleeping problems, and occupational stress. Two reviewers will independently screen all citations, full-text articles, and abstract data. Potential conflicts will be resolved through discussion. The methodological quality (or risk of bias) of individual studies will be appraised using an appropriate tool. A narrative synthesis will summarize and explain the characteristics and findings of the studies. If feasible, we will conduct random effects meta-analyses where appropriate.

DISCUSSION

This systematic review will analyze the ways in which precarious employment affects migrant workers' mental health and the process that underlies this relationship. The results from the systematic review outlined in this protocol will be of interest to labor and health professionals, policy makers, labor unions, and non-governmental organizations. Our findings may encourage and impel related policy makers to establish human-focused, safe and healthy work environments, and workplace conditions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42019132560.

Working Below Skill Level as Risk Factor for Distress Among Latin American Migrants Living in Germany: A Cross-Sectional Study

About 84,710 Latin American migrants currently live in Germany. Knowledge about their work situation in relation to their skill level and its association with mental health is limited. Therefore, the aims of this study were to assess the prevalence of working below skill level and its association with the prevalence of distress in Latin Americans living in Germany. This cross-sectional study included a convenience sample of 282 Latin American migrants living in Germany. Participants were recruited by a short online (Facebook, personal contacts) or interview-based questionnaire from November 2015 to April 2016. Questions included skill level, job category (categorized by ISCO 2008 code), socio-demographics, violence at the workplace and distress. The latter was assessed by Goldberg's General Health Questionnaire using a cut-off of 4/5. Descriptive statistics were followed by logistic regression analyses adjusting for potential confounders. About half of the study population reported symptoms of distress (45%). 63% of the population worked below skill level. 12-months prevalence of violence at the workplace was 14%. After adjustment, working below skill level was statistically significantly related to distress (odds ratio 2.80; 95% confidence interval 1.58-4.95). Working below skill level is common in Latin American migrants in Germany and may result in poor psychosocial well-being.

Nickel allergy is associated with wheezing and asthma in a cohort of young German adults: results from the SOLAR study

Background

Nickel allergy is the most prevalent contact allergy. It belongs to a different hypersensitivity type to asthma and rhinoconjunctivitis. The aim of this analysis was to assess whether self-reported nickel allergy is associated with incident wheezing, asthma and rhinoconjunctivitis in young German adults, taking into account potential effect modification by sex.

Methods

In total, 2051 (70.6%) participants aged 19–24 years took part in the second phase of SOLAR (Study on Occupational Allergy Risks), a follow-up study of ISAAC II (the second phase of the International Study of Asthma and Allergies in Childhood) in Germany. Self-reported nickel allergy, as well as having pierced ears, and the three outcomes incident wheezing, asthma and rhinoconjunctivitis, were analysed stratified for sex. Logistic regression adjusted for potential confounders was performed.

Results

An association between self-reported nickel allergy and incident wheezing was observed for men and women, while only in males did pierced ears show a significant association with the outcome (adjusted OR 2.26, 95% CI 1.10–4.62). Also only in males, self-reported nickel allergy was associated with elevated odds for incident asthma (adjusted OR 4.34, 95% CI 1.22–15.41). Neither in men nor in women was a significant association observed for incident rhinoconjunctivitis.

Conclusion

Our results suggest that self-reported nickel allergy is associated with incident wheezing. Whether this association is due to environmental or genetic predisposition, or due to an overlap of the mechanisms of type I and type IV hypersensitivity, needs to be elucidated.

Self-reported nickel allergy is associated with incident wheezing in young German males and females, and with incident asthma in males, whereas no significant association was observed for self-reported nickel allergy and incident rhinoconjunctivitishttp://bit.ly/2YHmwBA

Do wastewater treatment plants increase antibiotic resistant bacteria or genes in the environment? Protocol for a systematic review

BACKGROUND

Antibiotic resistance is a global public health threat. Water from human activities is collected at wastewater treatment plants where processes often do not sufficiently neutralize antibiotic resistant bacteria and genes, which are further shed into the local environment. This protocol outlines the steps to conduct a systematic review based on the Population, Exposure, Comparator and Outcome (PECO) framework, aiming at answering the question "Are antimicrobial-resistant enterobacteriaceae and antimicrobial resistance genes present (O) in air and water samples (P) taken either near or downstream or downwind or down-gradient from wastewater treatment plants (E), as compared to air and water samples taken either further away or upstream or upwind or up-gradient from such wastewater treatment plant (C)?" Presence of antimicrobial-resistant bacteria and genes will be quantitatively measured by extracting their prevalence or concentration, depending on the reviewed study.

METHODS

We will search PubMed, EMBASE, the Cochrane database and Web of Science for original articles published from 1 Jan 2000 to 3 Sep 2018 with language restriction. Articles will undergo a relevance and a design screening process. Data from eligible articles will be extracted by two independent reviewers. Further, we will perform a risk of bias assessment using a decision matrix. We will synthesize and present results in narrative and tabular form and will perform a meta-analysis if heterogeneity of results allows it.

DISCUSSION

Antibiotic resistance in environmental samples around wastewater treatment plants may pose a risk of exposure to workers and nearby residents. Results from the systematic review outlined in this protocol will allow to estimate the extend of exposure, to inform policy making and help to design future studies.

Investigating the association between occupational exposure to asbestos and ovarian carcinoma: results from a pilot study in Germany

Background

The aim of this pilot study was to assess the feasibility of a large-scale epidemiologic investigation elucidating the quantitative association between occupational exposure to asbestos and ovarian cancer in former German asbestos workers.

Methods

Between December 2017 and May 2018, a random sample of one thousand insured woman registered at the health service of a German trade association as formerly occupationally exposed to asbestos were invited to participate in a pilot study. Participation included a phone interview using a standardised questionnaire. The feasibility of the project was evaluated using a priori defined criteria. They included response, number of cases, eligibility of the questionnaire data for exact estimation of asbestos fibre-years, and availability of relevant medical documentation (imaging procedures, medical reports, and histologic materials).

Results

The response (17%) was clearly below the intended number of 60%. With six tumour suspects, of which two could be confirmed by medical documents, the number of cases was within the expected range of two to eleven cases. Exact asbestos fibre-year estimations could be performed for 29% of all interviewees, but only for one suspected case. Medical documentation could be collected for only few participants, while no histology reports could be obtained for all cases. Thus, only the feasibility criterion of the expected number of cases was fulfilled.

Conclusion

The results of the pilot study indicate that the planned project is feasible only to a very limited extent. For further planning of the study, measures to improve recruitment of participants are necessary.

Prevalence of low back pain in migrant construction workers in Mar del Plata, Argentina

BACKGROUND

We aimed to compare employment conditions, psychosocial working conditions, and prevalence of low back pain among migrant and local construction workers in Argentina.

METHODS

In a cross-sectional study among workers from three contracting and eight subcontracting companies as well as 26 construction sites in the region of Buenos Aires, Argentina, 134 out of 150 local (89% response) and 141 out of 150 migrant construction workers (94% response) answered a validated questionnaire. Psychosocial working conditions were evaluated based on an imbalance between efforts and rewards (ERI).

RESULTS

Compared to local workers, migrants were younger, more likely to work without a contract (57% vs 8%), to report ERI (81% vs 18%) and to suffer from low back pain during the 7-days before study (80% vs 42%) (all P < .0001). After mutual adjustment, being a migrant (prevalence ratio 2.1; 95% confidence interval [CI] 1.4-3.0) and working without a contract (1.7; 95% CI, 1.4-2.1) were statistically significant risk factors for low back pain.

CONCLUSIONS

This study describes the precarious situation of migrant workers in the Argentinian construction industry and the potential health consequences. Provision of formal employment relations might help to better protect migrant workers' safety and health. Prospective studies are needed to assess the causes and effects of the findings we describe.

Associations between effort-reward imbalance and health indicators among school teachers in Chuquisaca, Bolivia: a cross-sectional study

OBJECTIVE

To assess the association between effort-reward imbalance (ERI) and health indicators among Bolivian school teachers.

DESIGN

School-based cross-sectional study.

SETTING

Sixty randomly selected schools from rural (33) and urban (27) schools in Chuquisaca, Bolivia.

PARTICIPANTS

A total of 1062 school teachers were invited to participate, of which 597 answered the questionnaire (response 56.2%).

EXPOSURE MEASURE

Psychosocial factors at work were explored through the short version of the Effort-Reward Questionnaire.

PRIMARY AND SECONDARY OUTCOME MEASURES

Health outcomes included self-rated overall health, mental distress (12-item General Health Questionnaire ≥5) and the 7-day prevalence of low back pain (LBP) as well as neck or shoulder pain (Nordic Questionnaire). Crude and adjusted ORs and their 95% CIs for each health outcome were calculated using logistic regression models.

RESULTS

The median value for the effort-reward ratio was 0.91 (range: 0.3-2.3) with higher values for teachers from rural versus urban schools. Overall, about 43% of the teachers reported their overall health as fair or poor; 45% suffered mental distress, 17% reported LBP and 29% neck or shoulder pain. Prevalences were higher for teachers employed at rural schools compared with those at urban schools. After adjusting for potential confounders and school location, ERI was statistically significantly associated with fair/poor self-rated health (adjusted OR 1.7, 95% CI 1.0 to 2.9); mental distress (1.9; 95% CI 1.2 to 3.1) and LBP (2.3; 95% CI 1.3 to 4.1).

CONCLUSION

Our results indicate the urgent need to improve psychosocial working conditions among Bolivian school teachers, in order to promote their health and well-being.

Work-related stress and incident asthma and rhinitis: results from the SOLAR study

OBJECTIVES

This study analyzes the association of work-related stress with incident asthma and rhinitis in young adults with a special focus on gender-specific differences.

METHODS

Incident asthma, wheezing and rhinitis were measured in a cohort of 2051 young German adults (aged 16-18 years at baseline) recruited by the prospective population-based SOLAR study (Study of Occupational Allergy Risks). Work-related stress was measured by the Trier Inventory for the Assessment of Chronic Stress (TICS). Two TICS scales, work overload and work discontent, were analysed. Logistic regression was conducted to calculate odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

In females, the odds for incident asthma were found to be 17% higher for each increase of the work discontent score by one point (OR 1.17, 95% CI 1.04-1.31). In males, no association was statistically significant. Incident rhinitis showed no association with any exposure variable.

CONCLUSION

This study shows a link between work-related stress and incident asthma which seems to be confined to women. This study adds evidence about the association of work-related stress and asthma in young adults and can contribute to prevention for that particular age group.

An educational intervention to improve knowledge about prevention against occupational asthma and allergies using targeted maximum likelihood estimation

PURPOSE

Occupational asthma and allergies are potentially preventable diseases affecting 5-15% of the working population. However, the use of preventive measures is often insufficient. The aim of this study was to estimate the average treatment effect of an educational intervention designed to improve the knowledge of preventive measures against asthma and allergies in farm apprentices from Bavaria (Southern Germany).

METHODS

Farm apprentices at Bavarian farm schools were asked to complete a questionnaire evaluating their knowledge about preventive measures against occupational asthma and allergies (use of personal protective equipment, personal and workplace hygiene measures). Eligible apprentices were randomized by school site to either a control or an intervention group. The intervention consisted of a short educational video about use of preventive measures. Six months after the intervention, subjects were asked to complete a post-intervention questionnaire. Of the 116 apprentices (70 intervention group, 46 control group) who answered the baseline questionnaire, only 47 subjects (41%; 17 intervention group, 30 control group) also completed the follow-up questionnaire. We, therefore, estimated the causal effect of the intervention using targeted maximum likelihood estimation. Models were controlled for potential confounders.

RESULTS

Based on the targeted maximum likelihood estimation, the intervention would have increased the proportion of correct answers on all six preventive measures by 18.4% (95% confidence interval 7.3-29.6%) had all participants received the intervention vs. had they all been in the control group.

CONCLUSIONS

These findings indicate the improvement of knowledge by the educational intervention.

Shift work and cognitive impairment in later life - results of a cross-sectional pilot study testing the feasibility of a large-scale epidemiologic investigation

BACKGROUND

The effect of shift work on impairment of cognition in later life has not yet been sufficiently investigated. Therefore, we aimed at testing the feasibility of a large-scale epidemiologic study examining this putative association in a pilot study.

METHODS

Between January and April 2017, a cross-sectional study invited a random sample of 425 former and current employees of a German university hospital aged 55 years and older to undergo a cognitive test battery (including the Repeatable Battery for the Assessment of Neuropsychological Status, Trail Making Test, Letter-Number Span, and Vocabulary Test) and to complete a self-administered questionnaire on socio-demographic characteristics, chronotype, sleep, occupational history including shift work, and medical history. Fifty percent of the invitees were registered in the hospital's occupational records as currently working or having worked in a shift system. The feasibility of a large-scale study was evaluated by the response of the study sample and the completeness of data. In addition, we calculated the prevalence of shift work and cognitive impairment in the study population.

RESULTS

Seventy five subjects (18%) completed the questionnaire, of whom 47 (11% of the total sample) participated in cognitive testing. In all but four items assessed in the questionnaire, the proportion of missing data was below 10 %, suggesting that the quality of collected data can be considered as high. Eighty percent of the participants reported that they ever worked in a shift system, indicating selective participation by exposure to shift work. With respect to chronotype, the majority of the study subjects rated themselves as rather evening type, while a quarter considered themselves as definite morning type. All cognitive tests could be carried out completely. We observed slight difficulties in at least one of the cognitive tests in 17 participants (36%) while two participants (4%) showed more pronounced signs of cognitive impairment.

CONCLUSION

The present pilot study only partially supported the feasibility of the planned large-scale study. As response rates were low and depended on exposure to shift work, a better way of sampling and recruitment needs to be identified. The questionnaire and the test battery appear to be viable instruments.

Violence at Work and Mental Distress among Firefighters in Guatemala

Background:

Firefighting is a highly physically and mentally demanding occupation. In many countries, firefighters are frequently exposed to critical events, violent threats and assault in their job, however, knowledge about its prevalence is limited. In addition, little is known about the impact of workplace violence against firefighters in the development of mental distress.

Objective:

We aimed to determine the prevalence of mental distress in firefighters exposed to workplace violence.

Methods:

In this cross-sectional study, 141 male full-time firefighters of Guatemala City and Metropolitan Area (response 80.4%) were invited to answer an interview-based questionnaire including items on sociodemographics, working conditions and mental health (general health questionnaire GHQ-12). Mental distress was defined as a GHQ-12 score above 4. The item ‘12-months prevalence of violence on the job’ included physical violence or sexual abuse from colleagues or the public. Statistical analysis with Epiinfo 7 included descriptive, bivariate and logistic regression analyses.

Findings:

Exposure to violence at the workplace was common (37%). Prevalence of mental distress was higher in violence-exposed firefighters (54%) than among unexposed firemen (39%; p = 0.08). After adjustment, the odds for distress was not statistically significantly increased for those exposed to violence at the workplace in comparison to the unexposed group (1.87; 0.90–3.87). Especially affected by distress were middle-aged firefighters (40–49 years; adjusted Odds Ratio 2.90; 95% Confidence interval 1.20–7.05) compared to younger firemen (<40 years).

Conclusions:

Exposure to violence at the workplace is common in Guatemalan firefighters. Although limited by small numbers, the association between violence and poor mental health is plausible. Therefore, training programs strengthening resilience among firefighters in areas with high crime prevalence are warranted.

Developing an Awareness Campaign to Reduce Second Hand Smoke Among Disadvantaged Families-A Participatory M-Health Approach

Children from disadvantaged families are particularly exposed to second hand smoke in their home environment. Using a mixed methods participatory approach, we aimed at identifying suitable media channels and appropriate content for a campaign increasing caregivers' knowledge about the risks of second hand smoke (SHS) exposure for their children and appropriate measures for exposure reduction. In the first phase of the mixed method design, we evaluated knowledge and norms about children's SHS and perceived barriers for avoiding it. To this end, we conducted 26 one-to-one interviews with smoking caregivers of children below the age of six years. Subsequently, we developed and illustrated core messages and identified appropriate communication channels. These were evaluated in focus group discussions by 20 of the 26 interview participants. After a final revision, 121 caregivers evaluated the campaign via an online questionnaire. Online social networks were identified as the most suitable media channel. For these, we developed animated photos with voiceovers addressing the potential consequences of SHS for children. The overall rating of the campaign messages was promising. Participants confirmed that it was important to address the issue in social media. However, sharing the pictures was considered unlikely due to the sensitive topic of the campaign, while the importance of doctors or scientists being recognizable as a source was highlighted. Employing a participatory approach, we developed an m-health campaign, which can now be disseminated in social networks to reach the target population. The effectiveness of the campaign should be evaluated.

One's Workplace, Other's Home? Work and Health of Domestic Workers in Argentina

Background:

Domestic workers around the world work and eventually live in private homes where control of working conditions is difficult.

Objective:

The aim of this study was to compare working conditions and its impact on general and mental health in live-in and live-out domestic workers in Argentina.

Methods:

In a cross-sectional study, the Spanish version of the European Workings Condition Survey and an ad hoc questionnaire were applied to 201 domestic workers (response 94%). Twelve months’ prevalence of verbal or physical workplace violence was assessed. Poor general health was defined by general health self-assessed as poor or fair. Symptoms of common mental disorders (CMD) were considered present if Goldberg’s general health score was above 4. Data were analyzed using Chi square’s test and logistic regression models.

Findings:

Live-in workers formed 66% of the participants. They were more likely to take care of the elderly, iron and cook than live-out workers. Workplace violence was reported by 17% of live-in and 24% of live-out workers (p = 0.25). Overall prevalence of poor general health was 23%; 53% reported CMD. After adjustment, violence remained a statistically significant predictor of poor general health (Odds Ratio 7.3; 95% Confidence Interval 2.8–19.1) and CMD (3.2; 1.1–9.3).

Conclusions:

Working conditions of live-in and live-out domestic workers are different. However, exposure to workplace violence is common in both groups and affects general and mental health.

Prevalence and Risk Factors for Hearing Loss in Chilean Shellfish Divers

BACKGROUND

Diving within artisanal fishing is a profession carried out by many men in coastal communities of southern Chile. These shellfish divers use surface supplied air for breathing. Among potential health threats are occupational accidents, decompression sickness and barotrauma. Repeated middle and inner ear barotrauma and decompression sickness of the ear may result in hearing loss.

OBJECTIVE

To determine the prevalence of hearing loss and related risk factors in artisanal shellfish divers.

METHODS

A cross-sectional study including 125 male shellfish divers was carried out in a coastal village in southern Chile. Participants were interviewed using a standard Spanish questionnaire adapted for this population. Hearing loss was assessed through audiometry. Any hearing loss, sensorineural hearing loss and other types of hearing loss (conduction, unilateral and mixed) were used as the outcomes. Bivariate and multiple logistic regression models were carried out to identify risk factors for hearing loss.

FINDINGS

Median duration on the job was 25 years (range 1-52), 64% of divers had a low level of schooling and 52% reported not knowing how to use decompression tables. Most (86%) of the divers dove deeper than 30 meters exceeding the 20 meters permitted by law. The majority (80%) reported having experienced several episodes of type II decompression sickness during their working life. The prevalence of any type of hearing loss was 54.4%: 29.0% presented sensorineural hearing loss and 25.6% presented other types of hearing impairment. After adjustment for age and other potential risk factors, diving more than 25 years was the main predictor for all kinds of hearing loss under study.

CONCLUSIONS

Hearing loss is frequent in artisanal shellfish divers and safety measures are limited. Although based on small numbers and lacking an unexposed comparison group, our results suggest the need for community-based interventions.

Education and Training: Key Factors in Global Occupational and Environmental Health

INTRODUCTION

Education and training in Occupational and Environmental Health (OEH) play an important role in building global capacity and contribute to safer working conditions. The shortage of occupational health professionals, the lack of knowledge and a high number of occupational accidents and diseases stress the demand for providing further education and training in OEH. This need is especially urgent in low and middle-income countries. Three international courses on OEH provide valuable insights on how to develop successful trainings in the field and how to contribute to the creation of healthy and safe workplaces.

METHODOLOGY AND RESULTS

The courses "Global Occupational and Environmental Determinants of Diseases: a multidisciplinary and multicultural approach for prevention" (University of Brescia, Italy), "Advanced International Training Course in OEH" (Chulabhorn Research Institute, Bangkok, Thailand) and "Teaching interventions crossing borders" (Ludwig-Maximillians-Universität, Munich, Germany) offer a unique networking opportunity for health professionals from low-, middle- and high-income countries. Three main characteristics of learning were identified as successful for adult learning in OEH: Interdisciplinary learning allows exchanging skills and knowledge and therefore closes gaps between the several disciplines within OEH. Experiential learning enables participants to reflect on their personal experiences, e.g. through workplace visits. Finally, active learning empowers the learner to take the leading role in the learning process using e.g. problem- or project-based learning approaches.

CONCLUSION

Training and education in OEH should become a higher priority by including it in the standard public health and medical curricula. For this, train the trainer approaches are essential in many countries. Any OEH training should follow the interdisciplinary, experiential and interactive learning approach and should be accessible to participants from all regions.

Prevalence and risk factors for intestinal parasitic infections in pregnant women residing in three districts of Bogotá, Colombia

BACKGROUND

Intestinal parasitic infections (IPI) lead to significant morbidity and mortality in pediatric and adult populations worldwide. Intestinal parasitism during pregnancy is of interest as it may affect the health of pregnant women and their offspring. This study determined the prevalence of IPI in pregnant women living in substandard conditions in three urban districts of Bogotá, Colombia. Associations between prevalence and sociodemographic factors, housing, and living conditions were also evaluated.

METHODS

In a cross-sectional and community-based study, pregnant women were recruited from three districts of Bogotá. A total of 550 participants answered a questionnaire; 331 of these also provided stool samples, with 233 providing one and 98 providing two stool samples. Questionnaire responses were associated with the presence of intestinal parasites, which was determined using a standard combined microscopy technique including direct wet mount and formol-ether concentration. Results were verified by supplementary examination of 48 stool samples by quantitative polymerase chain reaction (qPCR).

RESULTS

Among pregnant women who lived in selected poor residential areas in Bogotá, the overall prevalence of intestinal parasitism was 41% with 9% polyparasitism. Pathogenic parasites were present in 1.2% of the 331 participants including Giardia lamblia and Ascaris lumbricoides. Higher prevalence was found for parasites with debated pathogenicity, including Blastocystis hominis (25%), Endolimax nana (15%), Entamoeba coli (8%), and Iodamoeba butschlii (2%). Entamoeba histolytica/dispar complex was also detected (1.5%). When comparing a subset of stool samples using the combined microscopy technique and qPCR, the latter detected a higher 58.3% overall IPI prevalence. Higher prevalence of infections by any intestinal parasite was found in participants who had never been dewormed (p = 0.01). Higher but not statistically significant associations were found between any parasite and women living with a partner, and intestinal polyparasitism and being from a minority group and not having a water sink.

CONCLUSIONS

This first study of the prevalence of intestinal parasitism in Bogotá focused on pregnant women living in poverty, found a high prevalence of intestinal parasites of debated pathogenicity, and confirmed a low prevalence of pathogenic intestinal parasites. These results highlight the need for educational interventions to disrupt transmission routes for prevalent parasites.

Recall of mobile phone usage and laterality in young people: The multinational Mobi-Expo study

OBJECTIVE

To study recall of mobile phone usage, including laterality and hands-free use, in young people.

METHODS

Actual mobile phone use was recorded among volunteers aged between 10 and 24 years from 12 countries by the software application XMobiSense and was compared with self-reported mobile phone use at 6 and 18 months after using the application. The application recorded number and duration of voice calls, number of text messages, amount of data transfer, laterality (% of call time the phone was near the right or left side of the head, or neither), and hands-free usage. After data cleaning, 466 participants were available for the main analyses (recorded vs. self-reported phone use after 6 months).

RESULTS

Participants were on average 18.6 years old (IQR 15.2-21.8 years). The Spearman correlation coefficients between recorded and self-reported (after 6 months) number and duration of voice calls were 0.68 and 0.65, respectively. Number of calls was on average underestimated by the participants (adjusted geometric mean ratio (GMR) self-report/recorded = 0.52, 95% CI = 0.47-0.58), while duration of calls was overestimated (GMR=1.32, 95%, CI = 1.15-1.52). The ratios significantly differed by country, age, maternal educational level, and level of reported phone use, but not by time of the interview (6 vs. 18 months). Individuals who reported low mobile phone use underestimated their use, while individuals who reported the highest level of phone use were more likely to overestimate their use. Individuals who reported using the phone mainly on the right side of the head used it more on the right (71.1%) than the left (28.9%) side. Self-reported left side users, however, used the phone only slightly more on the left (53.3%) than the right (46.7%) side. Recorded percentage hands-free use (headset, speaker mode, Bluetooth) increased with increasing self-reported frequency of hands-free device usage. Frequent (≥50% of call time) reported headset or speaker mode use corresponded with 17.1% and 17.2% of total call time, respectively, that was recorded as hands-free use.

DISCUSSION

These results indicate that young people can recall phone use moderately well, with recall depending on the amount of phone use and participants' characteristics. The obtained information can be used to calibrate self-reported mobile use to improve estimation of radiofrequency exposure from mobile phones.

Greenness and job-related chronic stress in young adults: a prospective cohort study in Germany

OBJECTIVES

We aimed to prospectively study the association between normalised difference vegetation index (NDVI) as a measure of greenness around homes and occupational stress.

SETTING

A population-based cohort in Munich and Dresden cities was followed from age 16-18 years to age 20-23 years (n=1632).

PARTICIPANTS

At baseline, all participants attended high-school while at follow-up some had started working and others studying at university. At baseline and in each follow-up, we assigned NDVI based on participants' residential geocoded addresses and categorised it by quartiles.

OUTCOME MEASURES

School-related, university-related or job-related self-reported chronic stress was assessed at the two follow-ups by the Trier Scale for Assessment of Chronic Stress using work discontent and work overload as outcomes. We modelled the association employing ordinal generalised estimating equations model accounting for changes in sociodemographics, non-job-related stress, job history and environmental covariates. Stratified analysis by each city was performed.

RESULTS

NVDI at baseline was higher for participants from Dresden (median=0.36; IQR 0.31-0.41) than Munich (0.31; 0.26-0.34). At follow-up, it decreased only for participants in Dresden (0.34; 0.30-0.40). Higher greenness (quartile 4 vs quartile 1) was associated with less work discontent (OR 0.89; 95% CI 0.80 to 0.99) and less work overload (OR 0.87; 95% CI 0.78 to 0.96). In stratified analyses, results were more consistent for Munich than for Dresden.

CONCLUSIONS

Our results suggest that residential green spaces, using the vegetation index as a proxy for exposure, are inversely associated with two types of job-related chronic stress in German young adults transitioning from school to university or working life.