An urgent call to address work-related psychosocial hazards and improve worker well-being

Work-related psychosocial hazards are on the verge of surpassing many other occupational hazards in their contribution to ill-health, injury, disability, direct and indirect costs, and impact on business and national productivity. The risks associated with exposure to psychosocial hazards at work are compounded by the increasing background prevalence of mental health disorders in the working-age population. The extensive and cumulative impacts of these exposures represent an alarming public health problem that merits immediate, increased attention. In this paper, we review the linkage between work-related psychosocial hazards and adverse effects, their economic burden, and interventions to prevent and control these hazards. We identify six crucial societal actions: (1) increase awareness of this critical issue through a comprehensive public campaign; (2) increase etiologic, intervention, and implementation research; (3) initiate or augment surveillance efforts; (4) increase translation of research findings into guidance for employers and workers; (5) increase the number and diversity of professionals skilled in preventing and addressing psychosocial hazards; and (6) develop a national regulatory or consensus standard to prevent and control work-related psychosocial hazards.

Types of COVID-19 Disaster Work and Psychological Responses in National Guard Service Members

INTRODUCTION

The National Guard (NG) served as a critical component of the U.S. response to the coronavirus disease 2019 pandemic. Understanding the impact of types of pandemic-related disaster work on mental health responses can aid in sustaining NG service members' health and preparation for subsequent activations and future pandemics.

MATERIALS AND METHODS

We surveyed 1,363 NG unit (NGU) service members (88% Army; 80% enlisted; 32% 30 to 39 years old; 84% male) following activation in response to the pandemic. Surveys were administered between August and December 2020, which was approximately 2 to 3 months post-activation. Surveys assessed overall activation stress, participation in different types of disaster work, probable post-traumatic stress disorder (PTSD), anxiety and depression, and anger. A disaster work stress scale assessed different types of disaster work during activation and associated stress levels. For each individual, we calculated an overall work task stress (WTS) scaled score, with a maximum score of 100. Logistic regression analyses were conducted to examine the relationship of high-stress disaster work tasks to post-activation PTSD, anxiety and depression, and anger, adjusting for socio-demographic and service-related variables. The study was approved by the Institutional Review Board of the Uniformed Services University (USU) in Bethesda, MD.

RESULTS

Among NGU service members, 12.7% (n = 172) described their activation as very/extremely stressful. The work tasks with the highest scaled scores were as follows: (1) Patient transportation (WTS scaled score = 100); (2) working with the dead (WTS = 82.2); and (3) working with families of coronavirus disease 2019 patients (WTS = 72.7). For each individual's work tasks, we identified the work task associated with the highest WTS score. The top one-third of WTS scores were classified as the high-stress group. Approximately 9% of participants (n = 111) had probable PTSD, 6.7% (n = 85) had clinically significant anxiety and depression, and 12.3% (n = 156) had high anger. Multivariable logistic regression analyses, adjusting for covariates, found that NGU service members exposed to the highest level of disaster WTS were more likely to report PTSD (odds ratio [OR] = 1.48 [95% confidence interval [CI] = 1.13-1.94], χ2 = 7.98), anxiety and depression (OR = 1.91 [95% CI = 1.17-3.13]; χ2 = 6.67), and anger (OR = 1.63 [95% CI = 1.13-2.37]; χ2 = 6.66) post-activation.

CONCLUSIONS

Identifying work tasks associated with high levels of stress can help detect individuals at risk for adverse mental health responses post-exposure. Distinguishing features of high-stress work conditions can be generalized to other types of work conditions and disaster response and are important targets for planning and preventive efforts.

Telemedicine Trends and Lessons Learned During the COVID-19 Pandemic-World Trade Center Health Program, 2020-2021

The World Trade Center (WTC) Health Program, a limited federal health care program for eligible people exposed to the terrorist attacks on September 11, 2001, expanded telemedicine services during the COVID-19 pandemic (2020-2021). We analyzed service use trends from January 2020 through December 2021 to describe how the program implemented telemedicine services. About three-quarters (75%) of telemedicine visits were for mental health-related services. In the second quarter of 2020 (April-June), the number of telemedicine visits per 1000 members (n = 367) increased, exceeding in-person visits (n = 152) by 1.4-fold. The number of telemedicine visits per 1000 members decreased gradually during the rest of the study period but still represented 38% of total visits by the end of 2021. Changes in telemedicine visits were offset by comparable changes for in-person visits, such that the rate of total visits was essentially constant during the study period. Multivariate logistic regression models showed differences in telemedicine visit rates by member type and by demographic characteristics. Survivor members (vs responder members), those self-identified as non-Hispanic Other races (vs non-Hispanic White), those with preferred language not English (vs preferred language English), and those not living in the New York metropolitan area (vs living in the New York metropolitan area) were less likely to use telemedicine. Implementing telemedicine services in the WTC Health Program during the COVID-19 pandemic underscored the importance of extensive collaboration among partners, the capacity to rapidly develop necessary technical guidance, and the flexibility to address frequent regulatory guidance updates in a timely fashion. These lessons learned may guide similar health care providers posed with time-sensitive disruptions of in-person services.

The World Trade Center Health Program: Twenty years of health effects research

It has been 20 years since the devastating terrorist attacks on September 11, 2001. Thousands were injured or killed during the attacks and many more are at risk of adverse health stemming from physical, psychological, and emotional stressors born out of the attacks. Private, federal, state, and local resources were gathered soon after the attacks to address impacts to the community, including the health and well-being of both responders and survivors. Many of these efforts are now largely consolidated under the federally mandated World Trade Center (WTC) Health Program. This program provides medical monitoring and treatment of qualifying conditions among the 9/11-exposed population and supports related physical and mental health research. In this commentary, we describe the WTC Health Program, with emphasis on the health-effects research it has funded since inception in 2011. We describe sentinel research publications, and how science has impacted the program. We provide examples relating studies in this special issue to important roles in the WTC Health Program research agenda. Finally, we provide a perspective on future research needs.

The World Trade Center Health Program: Petitions for adding qualifying health conditions

The federally mandated World Trade Center Health Program provides limited health benefits for qualifying health conditions related to the 9/11 terrorist attacks. A qualifying health condition is an illness or health condition for which the member's exposure to airborne toxins, any other hazard, or any other adverse condition resulting from the 9/11 terrorist attacks is considered substantially likely to be a significant factor in aggravating, contributing to, or causing the illness or health condition. These qualifying health conditions are listed in federal regulations. The regulations also provide a process for amending this list. This commentary describes the methods developed for adding health conditions to the list of qualifying health conditions and discusses changes to the list that have occurred during the Program's 2011-2020 period.

World Trade Center Health Program - United States, 2012-2020

PROBLEM/CONDITION

After the September 11, 2001, terrorist attacks on the United States, approximately 400,000 persons were exposed to toxic contaminants and other factors that increased their risk for certain physical and mental health conditions. Shortly thereafter, both federal and nonfederal funds were provided to support various postdisaster activities, including medical monitoring and treatment. In 2011, as authorized by the James Zadroga 9/11 Health and Compensation Act of 2010, the CDC World Trade Center (WTC) Health Program began providing medical screening, monitoring, and treatment of 9/11-related health conditions for WTC responders (i.e., persons who were involved in rescue, response, recovery, cleanup, and related support activities after the September 11, 2001, terrorist attacks) and affected WTC survivors (i.e., persons who were present in the dust or dust cloud on 9/11 or who worked, lived, or attended school, child care centers, or adult day care centers in the New York City disaster area).

REPORTING PERIOD COVERED

2012-2020.

DESCRIPTION OF SYSTEM

The U.S. Department of Health and Human Services WTC Health Program is administered by the director of CDC's National Institute for Occupational Safety and Health. The WTC Health Program uses a multilayer administrative claims system to process members' authorized program health benefits. Administrative claims data are primarily generated by clinical providers in New York and New Jersey at the Clinical Centers of Excellence and outside those states by clinical providers in the Nationwide Provider Network. This report describes WTC Health Program trends for selected indicators during 2012-2020.

RESULTS

In 2020, a total of 104,223 members were enrolled in the WTC Health Program, of which 73.4% (n = 76,543) were responders and 26.6% (n = 27,680) were survivors. WTC Health Program members are predominantly male (78.5%). The median age of members was 51 years (interquartile range [IQR]: 44-57) in 2012 and 59 years (IQR: 52-66) in 2020. During 2012-2020, enrollment and number of certifications of WTC-related health conditions increased among members, with the greatest changes observed among survivors. Overall, at enrollment, most WTC Health Program members lived in New York (71.7%), New Jersey (9.3%), and Florida (5.7%). In 2020, the total numbers of cancer and noncancer WTC-related certifications among members were 20,612 and 50,611, respectively. Skin cancer, male genital system cancers, and in situ neoplasms (e.g., skin and breast) are the most common WTC-related certified cancer conditions. The most commonly certified noncancer conditions are in the aerodigestive and mental health categories. The average number of WTC-related certified conditions per certified member is 2.7. In 2020, a total of 40,666 WTC Health Program members received annual monitoring and screening examinations (with an annual average per calendar year of 35,245). In 2020, the total number of WTC Health Program members who received treatment was 41,387 (with an annual average per calendar year of 32,458).

INTERPRETATION

Since 2011, the WTC Health Program has provided health care for a limited number of 9/11-related health conditions both for responders and survivors of the terrorist attacks. Over the study period, program enrollment and WTC certification increased, particularly among survivors. As the members age, increased use of health services and costs within the WTC Health Program are expected; chronic diseases, comorbidities, and other health-related conditions unrelated to WTC exposures are more common in older populations, which might complicate the clinical management of WTC-related health conditions.

PUBLIC HEALTH ACTION

Analysis of administrative claims data in the context of WTC research findings can better clarify the health care use patterns of WTC Health Program members. This information guides programmatic decision-making and might also help guide future disaster preparedness and response health care efforts. Strengthening the WTC Health Program health informatics infrastructure is warranted for timely programmatic and research decision-making.

A Workshop on Cognitive Aging and Impairment in the 9/11-Exposed Population

The terrorist attacks on 11 September 2001 potentially exposed more than 400,000 responders, workers, and residents to psychological and physical stressors, and numerous hazardous pollutants. In 2011, the World Trade Center Health Program (WTCHP) was mandated to monitor and treat persons with 9/11-related adverse health conditions and conduct research on physical and mental health conditions related to the attacks. Emerging evidence suggests that persons exposed to 9/11 may be at increased risk of developing mild cognitive impairment. To investigate further, the WTCHP convened a scientific workshop that examined the natural history of cognitive aging and impairment, biomarkers in the pathway of neurodegenerative diseases, the neuropathological changes associated with hazardous exposures, and the evidence of cognitive decline and impairment in the 9/11-exposed population. Invited participants included scientists actively involved in health-effects research of 9/11-exposed persons and other at-risk populations. Attendees shared relevant research results from their respective programs and discussed several options for enhancements to research and surveillance activities, including the development of a multi-institutional collaborative research network. The goal of this report is to outline the meeting's agenda and provide an overview of the presentation materials and group discussion.

A comparative assessment of major international disasters: the need for exposure assessment, systematic emergency preparedness, and lifetime health care

BACKGROUND

The disasters at Seveso, Three Mile Island, Bhopal, Chernobyl, the World Trade Center (WTC) and Fukushima had historic health and economic sequelae for large populations of workers, responders and community members.

METHODS

Comparative data from these events were collected to derive indications for future preparedness. Information from the primary sources and a literature review addressed: i) exposure assessment; ii) exposed populations; iii) health surveillance; iv) follow-up and research outputs; v) observed physical and mental health effects; vi) treatment and benefits; and vii) outreach activities.

RESULTS

Exposure assessment was conducted in Seveso, Chernobyl and Fukushima, although none benefited from a timely or systematic strategy, yielding immediate and sequential measurements after the disaster. Identification of exposed subjects was overall underestimated. Health surveillance, treatment and follow-up research were implemented in Seveso, Chernobyl, Fukushima, and at the WTC, mostly focusing on the workers and responders, and to a lesser extent on residents. Exposure-related physical and mental health consequences were identified, indicating the need for a long-term health care of the affected populations. Fukushima has generated the largest scientific output so far, followed by the WTCHP and Chernobyl. Benefits programs and active outreach figured prominently in only the WTC Health Program. The analysis of these programs yielded the following lessons: 1) Know who was there; 2) Have public health input to the disaster response; 3) Collect health and needs data rapidly; 4) Take care of the affected; 5) Emergency preparedness; 6) Data driven, needs assessment, advocacy.

CONCLUSIONS

Given the long-lasting health consequences of natural and man-made disasters, health surveillance and treatment programs are critical for management of health conditions, and emergency preparedness plans are needed to prevent or minimize the impact of future threats.

Latent typologies of posttraumatic stress disorder in World Trade Center responders

Posttraumatic stress disorder (PTSD) is a debilitating and often chronic psychiatric disorder. Following the 9/11/2001 World Trade Center (WTC) attacks, thousands of individuals were involved in rescue, recovery and clean-up efforts. While a growing body of literature has documented the prevalence and correlates of PTSD in WTC responders, no study has evaluated predominant typologies of PTSD in this population. Participants were 4352 WTC responders with probable WTC-related DSM-IV PTSD. Latent class analyses were conducted to identify predominant typologies of PTSD symptoms and associated correlates. A 3-class solution provided the optimal representation of latent PTSD symptom typologies. The first class, labeled "High-Symptom (n = 1,973, 45.3%)," was characterized by high probabilities of all PTSD symptoms. The second class, "Dysphoric (n = 1,371, 31.5%)," exhibited relatively high probabilities of emotional numbing and dysphoric arousal (e.g., sleep disturbance). The third class, "Threat (n = 1,008, 23.2%)," was characterized by high probabilities of re-experiencing, avoidance and anxious arousal (e.g., hypervigilance). Compared to the Threat class, the Dysphoric class reported a greater number of life stressors after 9/11/2001 (OR = 1.06). The High-Symptom class was more likely than the Threat class to have a positive psychiatric history before 9/11/2001 (OR = 1.7) and reported a greater number of life stressors after 9/11/2001 (OR = 1.1). The High-Symptom class was more likely than the Dysphoric class, which was more likely than the Threat class, to screen positive for depression (83% > 74% > 53%, respectively), and to report greater functional impairment (High-Symptom > Dysphoric [Cohen d = 0.19], Dysphoric > Threat [Cohen d = 0.24]). These results may help inform assessment, risk stratification, and treatment approaches for PTSD in WTC and disaster responders.

Risk, coping and PTSD symptom trajectories in World Trade Center responders

Trajectories of disaster-related posttraumatic stress disorder (PTSD) symptoms are often heterogeneous, and associated with common and unique risk factors, yet little is known about potentially modifiable psychosocial characteristics associated with low-symptom and recovering trajectories in disaster responders. A total of 4487 rescue and recovery workers (1874 police and 2613 non-traditional responders) involved during and in the aftermath of the unprecedented World Trade Center (WTC) attacks, were assessed an average of 3, 6, 8, and 12 years post-9/11/2001. Among police responders, WTC-related PTSD symptoms were characterized by four trajectories, including no/low-symptom (76.1%), worsening (12.1%), improving (7.5%), and chronic (4.4%) trajectories. In non-traditional responders, a five-trajectory solution was optimal, with fewer responders in a no/low-symptom trajectory (55.5%), and the remainder in subtly worsening (19.3%), chronic (10.8%), improving (8.5%), and steeply worsening (5.9%) trajectories. Consistent factors associated with symptomatic PTSD trajectories across responder groups included Hispanic ethnicity, pre-9/11 psychiatric history, greater WTC exposure, greater medical illness burden, life stressors and post-9/11 traumas, and maladaptive coping (e.g., substance use, avoidance coping). Higher perceived preparedness, greater sense of purpose in life, and positive emotion-focused coping (e.g., positive reframing, acceptance) were negatively associated with symptomatic trajectories. Findings in this unique cohort indicate considerable heterogeneity in WTC-related PTSD symptom trajectories over 12 years post-9/11/2001, with lower rates of elevated PTSD symptoms in police than in non-traditional responders. They further provide a comprehensive risk prediction model of PTSD symptom trajectories, which can inform prevention, monitoring, and treatment efforts in WTC and other disaster responders.

Posttraumatic stress symptoms and smoking among World Trade Center disaster responders: A longitudinal investigation

PURPOSE

The current longitudinal study examined posttraumatic stress disorder (PTSD) symptom severity in relation to smoking abstinence and reduction over time among responders to the World Trade Center (WTC) disaster.

METHOD

Participants were 763 police and 1881 non-traditional (e.g., construction workers) WTC responders who reported being smokers at an initial examination obtained between July 2002 and July 2011 at the WTC Health Program (WTC-HP). WTC responders were reassessed, on average, 2.5 years later.

RESULTS

For police WTC responders, higher levels of WTC-related PTSD symptoms at the initial visit were associated with a decreased likelihood of smoking abstinence (OR=0.98, p=.002) and with decreased smoking reduction (β=-.06, p=.012) at the follow-up visit. WTC-related PTSD symptom severity was not related to likelihood of smoking abstinence or change in number of cigarettes smoked among non-traditional responders. Post hoc analyses suggested that for police, hyperarousal PTSD symptoms were predictive of decreased abstinence likelihood at the follow-up visit (OR=0.56, p=.006).

DISCUSSION

The present findings suggest that PTSD symptoms may be differentially related to smoking behavior among police and non-traditional WTC responders in a naturalistic, longitudinal investigation. Future work may benefit from exploring further which aspects of PTSD (as compared to each other and to common variance) explain smoking maintenance.

World Trade Center disaster and sensitization to subsequent life stress: A longitudinal study of disaster responders

PURPOSE

The current study examined the role of World Trade Center (WTC) disaster exposure (hours spent working on the site, dust cloud exposure, and losing friend/loved one) in exacerbating the effects of post-disaster life stress on posttraumatic stress disorder (PTSD) symptoms and overall functioning among WTC responders.

METHOD

Participants were 18,896 responders (8466 police officers and 10,430 non-traditional responders) participating in the WTC Health Program who completed an initial examination between July, 2002 and April, 2010 and were reassessed an average of two years later.

RESULTS

Among police responders, there was a significant interaction, such that the effect of post-disaster life stress on later PTSD symptoms and overall functioning was stronger among police responders who had greater WTC disaster exposure (β's=.029 and .054, respectively, for PTSD symptoms and overall functioning). This moderating effect was absent in non-traditional responders. Across both groups, post-disaster life stress also consistently was related to the dependent variables in a more robust manner than WTC exposure.

DISCUSSION

The present findings suggest that WTC exposure may compound post-disaster life stress, thereby resulting in a more chronic course of PTSD symptoms and reduced functioning among police responders.

Post-disaster stressful life events and WTC-related posttraumatic stress, depressive symptoms, and overall functioning among responders to the World Trade Center disaster

BACKGROUND

The current study examined contributions of post-disaster stressful life events in relation to the maintenance of WTC-related posttraumatic stress, depressive symptoms, and overall functioning among rescue, recovery, and clean-up workers who responded to the September 11, 2001 World Trade Center (WTC) terrorist attacks.

METHODS

Participants were 18,896 WTC responders, including 8466 police officers and 10,430 non-traditional responders (85.8% male; 86.4% Caucasian; M(age) = 39.5, SD = 8.8) participating in the WTC Health Program who completed an initial examination between July, 2002 and April, 2010 and who were reassessed, on average, 2.5 years later.

RESULTS

Path analyses were conducted to evaluate contributions of life events to the maintenance of WTC-related posttraumatic stress, depressive symptoms, and overall functioning. These analyses were stratified by police and non-traditional responder groups and adjusted for age, sex, time from 9/11 to initial visit, WTC exposures (three WTC contextual exposures: co-worker, friend, or a relative died in the disaster; co-worker, friend, or a relative injured in the disaster; and responder was exposed to the dust cloud on 9/11), and interval from initial to first follow-up visit. In both groups, WTC-related posttraumatic stress, depressive symptoms, and overall functioning were stable over the follow-up period. WTC exposures were related to these three outcomes at the initial assessment. WTC-related posttraumatic stress, depressive symptoms, and overall functioning, at the initial assessment each predicted the occurrence of post-disaster stressful life events, as measured by Disaster Supplement of the Diagnostic Interview Schedule. Post-disaster stressful life events, in turn, were associated with subsequent mental health, indicating partial mediation of the stability of observed mental health.

CONCLUSIONS

The present findings suggest a dynamic interplay between exposure, post-disaster stressful life events, and WTC-related posttraumatic stress, depressive symptoms, and overall functioning among WTC disaster responders.

Dimensional structure and course of post-traumatic stress symptomatology in World Trade Center responders

BACKGROUND

Post-traumatic stress disorder (PTSD) in response to the World Trade Center (WTC) disaster of 11 September 2001 (9/11) is one of the most prevalent and persistent health conditions among both professional (e.g. police) and non-traditional (e.g. construction worker) WTC responders, even several years after 9/11. However, little is known about the dimensionality and natural course of WTC-related PTSD symptomatology in these populations.

METHOD

Data were analysed from 10 835 WTC responders, including 4035 police and 6800 non-traditional responders who were evaluated as part of the WTC Health Program, a clinic network in the New York area established by the National Institute for Occupational Safety and Health. Confirmatory factor analyses (CFAs) were used to evaluate structural models of PTSD symptom dimensionality; and autoregressive cross-lagged (ARCL) panel regressions were used to examine the prospective interrelationships among PTSD symptom clusters at 3, 6 and 8 years after 9/11.

RESULTS

CFAs suggested that five stable symptom clusters best represent PTSD symptom dimensionality in both police and non-traditional WTC responders. This five-factor model was also invariant over time with respect to factor loadings and structural parameters, thereby demonstrating its longitudinal stability. ARCL panel regression analyses revealed that hyperarousal symptoms had a prominent role in predicting other symptom clusters of PTSD, with anxious arousal symptoms primarily driving re-experiencing symptoms, and dysphoric arousal symptoms primarily driving emotional numbing symptoms over time.

CONCLUSIONS

Results of this study suggest that disaster-related PTSD symptomatology in WTC responders is best represented by five symptom dimensions. Anxious arousal symptoms, which are characterized by hypervigilance and exaggerated startle, may primarily drive re-experiencing symptoms, while dysphoric arousal symptoms, which are characterized by sleep disturbance, irritability/anger and concentration difficulties, may primarily drive emotional numbing symptoms over time. These results underscore the importance of assessment, monitoring and early intervention of hyperarousal symptoms in WTC and other disaster responders.

Trajectories of PTSD risk and resilience in World Trade Center responders: an 8-year prospective cohort study

BACKGROUND

Longitudinal symptoms of post-traumatic stress disorder (PTSD) are often characterized by heterogeneous trajectories, which may have unique pre-, peri- and post-trauma risk and protective factors. To date, however, no study has evaluated the nature and determinants of predominant trajectories of PTSD symptoms in World Trade Center (WTC) responders.

METHOD

A total of 10835 WTC responders, including 4035 professional police responders and 6800 non-traditional responders (e.g. construction workers) who participated in the WTC Health Program (WTC-HP), were evaluated an average of 3, 6 and 8 years after the WTC attacks.

RESULTS

Among police responders, longitudinal PTSD symptoms were best characterized by four classes, with the majority (77.8%) in a resistant/resilient trajectory and the remainder exhibiting chronic (5.3%), recovering (8.4%) or delayed-onset (8.5%) symptom trajectories. Among non-traditional responders, a six-class solution was optimal, with fewer responders in a resistant/resilient trajectory (58.0%) and the remainder exhibiting recovering (12.3%), severe chronic (9.5%), subsyndromal increasing (7.3%), delayed-onset (6.7%) and moderate chronic (6.2%) trajectories. Prior psychiatric history, Hispanic ethnicity, severity of WTC exposure and WTC-related medical conditions were most strongly associated with symptomatic trajectories of PTSD symptoms in both groups of responders, whereas greater education and family and work support while working at the WTC site were protective against several of these trajectories.

CONCLUSIONS

Trajectories of PTSD symptoms in WTC responders are heterogeneous and associated uniquely with pre-, peri- and post-trauma risk and protective factors. Police responders were more likely than non-traditional responders to exhibit a resistant/resilient trajectory. These results underscore the importance of prevention, screening and treatment efforts that target high-risk disaster responders, particularly those with prior psychiatric history, high levels of trauma exposure and work-related medical morbidities.

Sleep and arousal as risk factors for adverse health and work performance in public health workers involved in the 2004 Florida hurricane season

BACKGROUND

We examined the relation of sleep disturbance and arousal to work performance, mental and physical health, and day-to-day functioning in Florida Department of Health (FDOH) employees 9 months after the 2004 Florida hurricane season.

METHODS

FDOH employees were contacted via e-mail 9 months after the 2004 hurricanes. Participants (N = 2249) completed electronic questionnaires including measures of sleep disturbance, arousal, work performance, physical health, mental health, day-to-day function, hurricane injury, and work demand.

RESULTS

More than 18% of FDOH employees reported ≥ 25% reduced work performance and 11% to 15.3% reported ≥ 7 "bad" mental or physical health days in the past month. Sleep disturbance and elevated arousal were strongly associated with impaired work performance (odds ratios [ORs] 3.33 and 3.34, respectively), "bad" mental health (ORs 3.01 and 3.64), "bad" physical health (ORs 3.21 and 2.01), and limited day-to-day function (ORs 4.71 and 2.32), even after adjusting for sex, race, age, education, and marital status.

CONCLUSIONS

Among public health workers exposed to the 2004 hurricanes, sleep disturbance and arousal were associated with personal and work impairment. Future research should continue to examine the effect of repeated exposure to disasters in first responders.

A decision process for determining whether to conduct responder health research following large disasters

Disasters often set the stage for scientific inquiry within the field of occupational safety and health. This is especially true when the long-term consequences of exposures associated with a particular disaster are unclear. However, a responder research study can be costly and difficult to design, and researchers must consider whether the proposed study will produce useful, reliable results and is a prudent public health investment. The decision process can be segregated into various components, including scientific rationale that should be formally recognized as critical to efficiently and effectively determine whether a research study is warranted. The scientific rationale includes certain controlling or "gatekeeper" factors that should be present to proceed with research.

Florida Department of Health workers' response to 2004 hurricanes: a qualitative analysis

OBJECTIVE

Examinations of the demands on public health workers after disaster exposure have been limited. Workers provide emergency care while simultaneously risking injury, damage to personal property, and threats to their own and their family's safety. We examined the disaster management experiences of 4323 Florida Department of Health workers 9 months after their response to 4 hurricanes and 1 tropical storm during a 7-week period in August and September of 2004.

METHODS

Participants completed a self-report questionnaire focused on work performance, mental and physical health, daily functioning, sleep disturbance, physiological arousal, and injury and work demand at the time of the hurricanes, and answered open-ended questions that described their experiences in more detail.

RESULTS

A qualitative analysis conducted from the write-in data yielded 4 domains: (1) work/life balance; (2) training for disaster response role; (3) workplace support; and (4) recovery.

CONCLUSIONS

Study findings highlighted a number of concerns that are important to public health workers who provide emergency care after a disaster and, in particular, multiple disasters such as during the 2004 hurricane season. The findings also yielded important recommendations for emergency public health preparedness.

The integration of mental and behavioral health into disaster preparedness, response, and recovery

The close interplay between mental health and physical health makes it critical to integrate mental and behavioral health considerations into all aspects of public health and medical disaster management. Therefore, the National Biodefense Science Board (NBSB) convened the Disaster Mental Health Subcommittee to assess the progress of the US Department of Health and Human Services (HHS) in integrating mental and behavioral health into disaster and emergency preparedness and response activities. One vital opportunity to improve integration is the development of clear and directive national policy to firmly establish the role of mental and behavioral health as part of a unified public health and medical response to disasters. Integration of mental and behavioral health into disaster preparedness, response, and recovery requires it to be incorporated in assessments and services, addressed in education and training, and founded on and advanced through research. Integration must be supported in underlying policies and administration with clear lines of responsibility for formulating and implementing policy and practice.

The H1N1 crisis: a case study of the integration of mental and behavioral health in public health crises

In substantial numbers of affected populations, disasters adversely affect well-being and influence the development of emotional problems and dysfunctional behaviors. Nowhere is the integration of mental and behavioral health into broader public health and medical preparedness and response activities more crucial than in disasters such as the 2009-2010 H1N1 influenza pandemic. The National Biodefense Science Board, recognizing that the mental and behavioral health responses to H1N1 were vital to preserving safety and health for the country, requested that the Disaster Mental Health Subcommittee recommend actions for public health officials to prevent and mitigate adverse behavioral health outcomes during the H1N1 pandemic. The subcommittee's recommendations emphasized vulnerable populations and concentrated on interventions, education and training, and communication and messaging. The subcommittee's H1N1 activities and recommendations provide an approach and template for identifying and addressing future efforts related to newly emerging public health and medical emergencies. The many emotional and behavioral health implications of the crisis and the importance of psychological factors in determining the behavior of members of the public argue for a programmatic integration of behavioral health and science expertise in a comprehensive public health response.

The burden of full and subsyndromal posttraumatic stress disorder among police involved in the World Trade Center rescue and recovery effort

BACKGROUND

This study examined the prevalence, correlates, and perceived mental healthcare needs associated with subsyndromal PTSD in police involved in the World Trade Center (WTC) rescue and recovery effort.

METHODS

A total of 8466 police completed an interview/survey as part of the WTC Medical monitoring and Treatment Program an average of four years after 9/11/2001.

RESULTS

The past month prevalence of full and subsyndromal WTC-related PTSD was 5.4% and 15.4%, respectively. Loss of someone or knowing someone injured on 9/11 (odds ratios [ORs]=1.56-1.86), pre-9/11 stressors (ORs=1.30-1.50), family support (ORs=0.83-0.94), and union membership (ORs=0.50-0.52) were associated with both full and subsyndromal PTSD. Exposure to the dust cloud (OR=1.36), performing search and rescue work (OR=1.29), and work support (OR=0.89) were additionally associated with subsyndromal PTSD. Rates of comorbid depression, panic disorder, and alcohol use problems (ORs=3.82-41.74), and somatic symptoms and functional difficulties (ORs=1.30-1.95) were highest among police with full PTSD, with intermediate rates among police with subsyndromal PTSD (ORs=2.93-7.02; and ORs=1.18-1.60, respectively). Police with full and subsyndromal PTSD were significantly more likely than controls to report needing mental healthcare (41.1% and 19.8%, respectively, versus 6.8% in trauma controls).

CONCLUSIONS

These results underscore the importance of a more inclusive and dimensional conceptualization of PTSD, particularly in professions such as police, as operational definitions and conventional screening cut-points may underestimate the psychological burden for this population. Accordingly, psychiatric clinicians should assess for disaster-related subsyndromal PTSD symptoms in disaster response personnel.

Impact of 2003 Power Outages on Public Health and Emergency Response

Introduction:

In 2003, a major power outage occurred in the midwest and northeast United States affecting some 50 million people. The power outages affected multiple systems in state and local municipalities and, in turn, affected public health.

Methods:

Semi-structured interviews were conducted using open-ended questionnaires, with a convenience sample of state- and locally selected subject matter experts from Ohio, Michigan, and New York. Respondents were interviewed in groups representing one of five areas of interest, including: (1) emergency preparedness; (2) hospital and emergency medical services; (3) municipal environmental systems; (4) public health surveillance and epidemiology; and (5) psychosocial and behavioral issues. The reported positive and negative impacts of the power outage on public health, medical services, and emergency preparedness and response were documented. Responses were categorized into common themes and recommendations were formulated.

Results:

The amount of time that the respondents' locations were without power ranged from <1 hour to 52 hours. Many common themes emerged from the different locations, including communications failures, alternate power source problems, manpower and training issues, and psychosocial concerns. There was minimal morbidity and mortality reported that could be attributed to the event.

Conclusion:

Power outages negatively impacted multiple municipal infrastructures, and affected medical services, emergency response, and public health efforts. Previous federal funding positively impacted public health and emergency response capabilities. Recommendations were made based upon the common themes identified by the respondents.

Recommendations may assist state and local health departments, medical service providers, and emergency responders in planning for future power outage problems.

The impact of disasters and their aftermath on mental health

Hurricanes Katrina and Rita were the latest disasters involving trauma to individuals and displacement of significant populations. As a consequence, those of us in health care fields often are affected both as professionals with critical skills and as individuals with families under intense stress. This Commentary, which appears in the January 2006 issue of The Journal of Clinical Psychiatry (2006;67:7-14), provides first-hand insight into the "at-the-front" realities faced by primary care professionals as disasters evolve, as well as the preparations we can make with our families and the key priorities to be addressed in our professional roles with individuals, affected groups of people, and response systems. While it is rare for us to dually publish material, we deem the importance of this information to merit joint publication in The Journal of Clinical Psychiatry and The Companion.-Larry Culpepper, M.D.

ISEA2007 panel: integration of better exposure characterizations into disaster preparedness for responders and the public

An expert panel was convened in October 2007 at the International Society for Exposure Analysis Annual Meeting in Durham, NC, entitled "The Path Forward in Disaster Preparedness Since WTC-Exposure Characterization and Mitigation: Substantial Unfinished Business!" The panel prospectively discussed the critical exposure issues being overlooked during disaster responses and highlighted the needs for an optimal blending of exposure characterizations and hazard controls within disaster settings. The cases were made that effective and timely exposure characterizations must be applied during responses to any disaster, whether terrorist, manmade, or natural in origin. The consistent application of exposure sciences across acute and chronic disaster timelines will assure that the most effective strategies are applied to collect the needed information to guide risk characterization and management approaches. Exposure sciences must be effectively applied across all phases of a disaster (defined as rescue, reentry, recovery, and rehabitation-the four Rs) to appropriately characterize risks and guide risk-mitigation approaches. Failure to adequately characterize and control hazardous exposures increases the likelihood of excess morbidity and mortality. Advancing the infrastructure and the technologies to collect the right exposure information before, during, and immediately after disasters would advance our ability to define risks and protect responders and the public better. The panel provided conclusions, recommendations, and next steps toward effective and timely integration of better exposure science into disaster preparedness, including the need for a subsequent workshop to facilitate this integration. All panel presentations and a summary were uploaded to the ISES(1) website (http://www.iseaweb.org/Disaster_Preparedness/index.php).

Responder safety and health: preparing for future disasters

This article reviews lessons learned about managing the safety and health of workers who were involved in disaster response, recovery, and cleanup after the 2001 World Trade Center (WTC) disaster. The first two sections review ongoing responder health burdens and the tragic toll of this disaster from a worker safety and health perspective. The remaining sections address changes in federal infrastructure, response planning, and resources for protection of response and recovery personnel. Proper preparation includes pre-event and "just-in-time" disaster-worker training on likely hazards, organizational assets for hazard monitoring, and hands-on instruction in the use of assigned protective equipment. Good planning includes predeployment medical review to ensure "fitness for duty" and considers the following: (1) personal risk factors, (2) hazards likely to be associated with particular field locations, and (3) risks involved with assigned tasks (eg, workload and pace, work/rest cycles, available resources, and team/supervisory dynamics). Planning also should address worker health surveillance, medical monitoring, and availability of medical care (including mental health services). Disaster safety managers should anticipate likely hazards within planning scenarios and prepare asset inventories to facilitate making timely safety decisions. Disaster safety management begins immediately and provides ongoing real-time guidance to incident leadership at all levels of government. Robust standards must be met to reliably protect workers/responders. An integrated and measurable multiagency safety management function must be built into the incident command system before an incident occurs. This function delineates roles and responsibilities for rapid exposure assessments, ensuring cross-agency consistency in data interpretation, and timely, effective communication of information and control strategies. The ability to perform this safety management function should be tested and evaluated in exercise simulations and drills at multiple levels. Joint planning and exercising of the safety management plan and its function are effective ways to build interagency relationships and to be more systemic in managing logistics for safety equipment and converging personnel. Planning must include mechanisms to enable safety decisions to be implemented-such as effective and rapid scene control (site access), personnel tracking, and safety enforcement. Worker safety and health preparedness and leadership are essential for protecting workers and promoting resiliency among personnel involved in disaster response, recovery, and cleanup.

Terrorism, trauma, and mass casualty triage: how might we solve the latest mind-body problem?

The global war on terrorism has led to increased concern about the ability of the U.S. healthcare system to respond to casualties from a chemical, biological, or radiological agent attack. Relatively little attention, however, has focused on the potential, in the immediate aftermath of such an attack, for large numbers of casualties presenting to triage points with acute health anxiety and idiopathic physical symptoms. This sort of "mass idiopathic illness" is not a certain outcome of chemical, biological, or radiological attack. However, in the event that this phenomenon occurs, it could result in surges in demand for medical evaluations that may disrupt triage systems and endanger lives. Conversely, if continuous primary care is not available for such patients after initial triage, many may suffer with unrecognized physical and emotional injuries and illness. This report is the result of an expert planning initiative seeking to facilitate triage protocols that will address the possibility of mass idiopathic illness and bolster healthcare system surge capacity. The report reviews key triage assumptions and gaps in knowledge and offers a four-stage triage model for further discussion and research. Optimal triage approaches offer flexibility and should be based on empirical studies, critical incident modeling, lessons from simulation exercises, and case studies. In addition to staging, the proposed triage and longitudinal care model relies on early recognition of symptoms, development of a registry, and use of non-physician care management to facilitate later longitudinal followup and collaboration between primary care and psychiatry for the significant minority of patients who develop persistent idiopathic symptoms associated with reduced functional status.

The Virtual Network Supporting the Front Lines: Addressing Emerging Behavioral Health Problems following the Tsunami of 2004

The devastation wreaked by the 2004 tsunami in the Indian Ocean required extensive multinational and nongovernmental relief efforts to address the massive loss of infrastructure, people, and society. This article addresses approaches to behavioral incident management from a process perspective, through the lens of one official stateside channel of emergency operations. The process highlights the formation and connectivity of multidisciplinary teams that virtually supported the efforts of a seven-person, on-scene, behavioral health team aboard the USNS Mercy as part of Operation Unified Assistance in the Indian Ocean. Frontline health diplomacy and behavioral health relief efforts were greatly augmented by the virtual network of support from leading experts around the globe. Future disaster response and recovery efforts ought to build on the success of such virtual support networks, by planning for appropriate technology, expertise, and mutual aid partnerships.

Incorporating community mental health into local bioterrorism response planning: experiences from the DeKalb County Board of Health

Following a brief introduction to response planning for terrorism and other disasters, the authors present their experiences in developing a grassroots, interdisciplinary group charged with incorporating a mental health response component into the bioterrorism response plan for the metropolitan Atlanta area. This group was organized and supported by the Center for Public Health Preparedness at the DeKalb County Board of Health. Various viewpoints of key participating agencies are presented. Recommendations are provided for other localities and stakeholders who plan to incorporate a community mental health component into local disaster response plans.

Persistence of pharmaceutical compounds and other organic wastewater contaminants in a conventional drinking-water-treatment plant

In a study conducted by the US Geological Survey and the Centers for Disease Control and Prevention, 24 water samples were collected at selected locations within a drinking-water-treatment (DWT) facility and from the two streams that serve the facility to evaluate the potential for wastewater-related organic contaminants to survive a conventional treatment process and persist in potable-water supplies. Stream-water samples as well as samples of raw, settled, filtered, and finished water were collected during low-flow conditions, when the discharge of effluent from upstream municipal sewage-treatment plants accounted for 37-67% of flow in stream 1 and 10-20% of flow in stream 2. Each sample was analyzed for 106 organic wastewater-related contaminants (OWCs) that represent a diverse group of extensively used chemicals. Forty OWCs were detected in one or more samples of stream water or raw-water supplies in the treatment plant; 34 were detected in more than 10% of these samples. Several of these compounds also were frequently detected in samples of finished water; these compounds include selected prescription and non-prescription drugs and their metabolites, fragrance compounds, flame retardants and plasticizers, cosmetic compounds, and a solvent. The detection of these compounds suggests that they resist removal through conventional water-treatment processes. Other compounds that also were frequently detected in samples of stream water and raw-water supplies were not detected in samples of finished water; these include selected prescription and non-prescription drugs and their metabolites, disinfectants, detergent metabolites, and plant and animal steroids. The non-detection of these compounds indicates that their concentrations are reduced to levels less than analytical detection limits or that they are transformed to degradates through conventional DWT processes. Concentrations of OWCs detected in finished water generally were low and did not exceed Federal drinking-water standards or lifetime health advisories, although such standards or advisories have not been established for most of these compounds. Also, at least 11 and as many as 17 OWCs were detected in samples of finished water. Drinking-water criteria currently are based on the toxicity of individual compounds and not combinations of compounds. Little is known about potential human-health effects associated with chronic exposure to trace levels of multiple OWCs through routes such as drinking water. The occurrence in drinking-water supplies of many of the OWCs analyzed for during this study is unregulated and most of these compounds have not been routinely monitored for in the Nation's source- or potable-water supplies. This study provides the first documentation that many of these compounds can survive conventional water-treatment processes and occur in potable-water supplies. It thereby provides information that can be used in setting research and regulatory priorities and in designing future monitoring programs. The results of this study also indicate that improvements in water-treatment processes may benefit from consideration of the response of OWCs and other trace organic contaminants to specific physical and chemical treatments.

One-year health assessment of adult survivors of Bacillus anthracis infection

CONTEXT

Little is known about potential long-term health effects of bioterrorism-related Bacillus anthracis infection.

OBJECTIVE

To describe the relationship between anthrax infection and persistent somatic symptoms among adults surviving bioterrorism-related anthrax disease approximately 1 year after illness onset in 2001.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study of 15 of 16 adult survivors from September through December 2002 using a clinical interview, a medical review-of-system questionnaire, 2 standardized self-administered questionnaires, and a review of available medical records.

MAIN OUTCOME MEASURES

Health complaints summarized by the body system affected and by symptom categories; psychological distress measured by the Revised 90-Item Symptom Checklist; and health-related quality-of-life indices by the Medical Outcomes Study 36-Item Short-Form Health Survey (version 2).

RESULTS

The anthrax survivors reported symptoms affecting multiple body systems, significantly greater overall psychological distress (P<.001), and significantly reduced health-related quality-of-life indices compared with US referent populations. Eight survivors (53%) had not returned to work since their infection. Comparing disease manifestations, inhalational survivors reported significantly lower overall physical health than cutaneous survivors (mean scores, 30 vs 41; P =.02). Available medical records could not explain the persisting health complaints.

CONCLUSION

The anthrax survivors continued to report significant health problems and poor life adjustment 1 year after onset of bioterrorism-related anthrax disease.

Development and Use of an ELISA Test to Detect IgE Antibody to Cry9c following Possible Exposure to Bioengineered Corn

BACKGROUND

Starlink(TM), a variety of corn genetically engineered to contain the insecticidal protein Cry9c, had not been approved for human consumption because it possessed some characteristics associated with allergenic proteins. However, in the fall of 2000 CRY9C DNA was detected in several corn-containing products, suggesting that Starlink corn had entered the human food supply. Subsequently, consumers, following consumption of corn products, reported a number of adverse health events, possibly consistent with allergic reaction.

METHODS

To investigate the possibility of allergic reactions due to Cry9c in these consumers an ELISA test was developed for the purpose of detecting IgE antibodies to Cry9c and blood samples were taken from a total of 18 people who self-reported allergic reactions. Sera collected prior to the 1996 development of Starlink were used as negative controls.

RESULTS

None of the adverse event sera were found to be reactive with recombinant Cry9c antigen, based on comparison with normal controls. Although a known human positive control serum containing IgE specific for Cry9c was not available, other controls were incorporated into the ELISA protocol, including the use of sera from subjects allergic to other allergens and their homologous antigens (cat, grass, peanut) to validate the IgE detection reagents.

CONCLUSIONS

While the results do not support the likely occurrence of allergic reactions to Cry9c, such reactions cannot be ruled out, nor can the possibility that sera might react with unique glycosylated epitopes of Cry9c that may be expressed in the corn plant/seed.

Serious adverse events among participants in the Centers for Disease Control and Prevention's Anthrax Vaccine and Antimicrobial Availability Program for persons at risk for bioterrorism-related inhalational anthrax

On 20 December 2001, the Centers for Disease Control and Prevention (CDC) initiated the Anthrax Vaccine and Antibiotic Availability Program (hereafter, the "Program") under an investigational new drug application with the US Food and Drug Administration. This Program provided options for additional preventive treatment for persons at risk for inhalation anthrax as a result of recent bioterrorism attacks who had concluded or were concluding a 60-day course of antimicrobial prophylaxis. Participants were offered an additional 40 days of antibiotic therapy (with ciprofloxacin, doxycycline, or amoxicillin) or antibiotic therapy plus 3 doses of anthrax vaccine. By 11 February 2002, a total of 5420 persons had received standardized education about the Program and 1727 persons (32%) had enrolled. Twelve participants have been identified as having serious adverse events (SAEs). One SAE, which occurred in a participant with ciprofloxacin-induced allergic interstitial nephritis, was considered to be probably associated with treatment received in the Program. No SAEs were associated with anthrax vaccine. CDC will continue to monitor Program participants during the next 2 years.

Clinical features that discriminate inhalational anthrax from other acute respiratory illnesses

Inhalational anthrax (IA) is a rapidly progressive disease that frequently results in sepsis and death, and prompt recognition is critical. To distinguish IA from other causes of acute respiratory illness, patients who had IA were compared with patients in an ambulatory clinic who had influenza-like illness (ILI) and with hospitalized patients who had community-acquired pneumonia (CAP) at the initial health care visit. Compared with patients who had ILI, patients who had IA were more likely to have tachycardia, high hematocrit, and low albumin and sodium levels and were less likely to have myalgias, headache, and nasal symptoms. Scoring systems were devised to compare IA with ILI or CAP on the basis of strength of association. For ILI, a score of > or =4 captured all 11 patients with IA and excluded 664 (96.1%) of 691 patients with ILI. Compared with patients who had CAP, patients with IA were more likely to have nausea or vomiting, tachycardia, high transaminase levels, low sodium levels, and normal white blood cell counts. For CAP, a score of > or =3 captured 9 (81.8%) of 11 patients with IA and excluded 528 (81.2%) of 650 patients with CAP. In conclusion, selected clinical features of patients with IA differ from those of patients with ILI and are more similar to those of patients with CAP.

Is home renovation or repair a risk factor for exposure to lead among children residing in New York City?

Children can be lead poisoned when leaded paint is disturbed during home renovation or repair. We conducted a case-control study to assess the association between elevated blood lead levels (BLLs) in children younger than 5 years of age and renovation or repair of homes built before 1950 in New York City. In 1998, we interviewed parents of 106 case children (BLLs >/= 10 micro g/dL) and 159 control children (BLLs </= 5 micro g/dL) living in selected New York City neighborhoods. We then used logistic regression methods to estimate odds ratios (ORs) for elevated BLLs among children living in housing that had undergone various renovations or repairs in the 6 months before the blood lead test, and we adjusted for age and test month. Case children were only slightly more likely than control children to live in a house that had undergone any renovation (OR = 1.2, 95% confidence interval [95% CI] = 0.7, 2.1). Case children were more likely to (1) live in housing that had interior surfaces prepared for painting, especially by hand sanding (OR = 3.5, 95% CI = 1.1, 10.9; population attributable risk [PAR%] = 10.4%, 95% CI = 0.5%, 19.3%); and (2) have work-created dust throughout their housing unit (OR = 6.3, 95% CI = 1.2, 32.3; PAR% = 6.8%, 95% CI = 0.0%, 13.1%). The risk for excess lead exposure is increased by home renovation or repair work involving interior paint preparation or reported dispersal of dust beyond the work area. The proportion of cases related to this exposure is high enough to merit preventive measures.

Lead poisoning among young children in Russia: concurrent evaluation of childhood lead exposure in Ekaterinburg, Krasnouralsk, and Volgograd

The Gore-Chernomyrdin Commission encouraged a binational collaboration to evaluate pediatric lead poisoning in Russia. The study evaluated children in three Russian cities: Krasnouralsk, a small city with minimal traffic centered around a copper smelter; and Ekaterinburg and Volgograd, both of which are large cities with multiple factories and heavy vehicular traffic. This project was the first international use of portable blood lead analysis instruments. In each city, at least 90% of children attending selected neighborhood kindergartens participated. We selected kindergartens on the basis of their proximity to industrial areas and major traffic corridors. We obtained capillary blood samples and analyzed for lead content and hemoglobin (Hgb) levels in the field, and collected environmental samples (i.e., indoor dust, tap water, play area soil, and interior and exterior paint) and analyzed for each participating school and in the homes of about 10% of the children who had elevated blood lead levels (BLLs; greater than or equal to 10 microg/dL). We calculated all age-, sex-, and city-specific geometric means using generalized estimating equations to account for covariance within kindergartens, and used multivariate logistic regression models to identify variables predictive of elevated BLLs. Overall, 23% of study children had elevated BLLs and 2% were anemic, defined as Hgb < 11 g/dL. Krasnouralsk had the highest geometric mean BLL (10.7 microg/dL), the highest percentage of children (60%) with elevated BLLs, and the highest percentage of anemic children (4%). All soil samples in Krasnouralsk had detectable lead levels. Volgograd was the only city that had paint samples with elevated lead levels. We found apparent city-specific differences in the percentages of children with elevated BLLs. Lead-contaminated soil and dust, which can result from lead-based automotive fuel and from lead-related industrial emissions, appear to be the most important routes of lead exposure of those evaluated in this study. Elevated lead levels found in paint samples from Volgograd may indicate old undercoats of lead-based paint that could represent a regionally rather than nationally important source of exposure.

Use of geographic information system technology to aid Health Department decision making about childhood lead poisoning prevention activities

The Centers for Disease Control and Prevention recommend that local public health agencies use local data to identify children at risk for lead exposure to ensure that they receive preventive services. The objective of this study was to demonstrate the usefulness of a geographic information system (GIS) in identifying children at risk for lead exposure. We conducted a descriptive study, using GIS technology, of the blood lead (BPb) levels and residential location of at-risk children screened for lead exposure. "At-risk children" were defined as those children living in housing built before 1950 or in an area with a high proportion of older housing. The study was conducted in Jefferson County, Kentucky, USA. Participants were the cohort of children born in 1995 and screened from 1996 through 1997, and children younger than age 7 years who were screened from 1994 through 1998. Outcome measures were the BPb level and residential location (address or target zone) of at-risk children screened from 1996 through 1997, and the number and location of homes where more than one child had been poisoned by lead from 1994 through 1998. The proportion of children screened who live within zones targeted for universal screening varied from 48% to 53%, while only 50% of the at-risk children in the entire county were screened. Between 1994 and 1998, 79 homes housed 35% of the 524 children with lead poisoning. These housing units were prioritized for lead-hazard remediation. Significant numbers of at-risk children throughout the county were not being tested for lead exposure, even in prioritized areas. GIS can be very useful to health departments in planning lead exposure screening strategies and measuring program performance.

Downsizing, role demands, and job stress

This is a cross-sectional study consisting of self-administered survey instruments to measure psychological distress and stress-inducing work demands after 6 months of rumors about an upcoming corporate downsizing event. The workforce consisted predominantly of white males who were married, college-educated, and nonsmokers. Higher stress levels were seen among older, more educated workers, who had longer company tenure. Role boundary problems, noxious physical environments, and company tenure were retained in the final multivariable model predicting distress level. The ongoing time delay for management to implement the threatened layoff and peer rankings for a new job performance appraisal contributed to a decline in worker solidarity because of concerns about career and job security. These uncertainties reduced worker productivity and effective teamwork.