Sarah Zimmerman

Mortality among Hardmetal Production Workers: German Historical Cohort Study

Objective: The aim of this study was to investigate a cohort in German hardmetal industry, especially relationship between exposures to cobalt, with and without tungsten, and risks of total and cause-specific mortality. Methods: The cohort comprises blue-collar workers at three German plants who were employed in hardmetal processing. Individual cumulative exposures and long-term average concentrations were estimated for cobalt, nickel, tungsten, respirable, and inhalable dust. Standardized mortality ratios (SMRs) were calculated for external comparisons. Time-dependent multivariable Cox models were performed for internal analyses. Results: Elevated SMRs were found for all-cause, heart diseases, and nonmalignant respiratory diseases mortality, but not for lung cancer. Internal analyses did not show increased risks for any endpoints, and no exposure–response relationship was indicated. Conclusions: This study does not provide evidence for elevated lung cancer risks. Methodologic limitations, incomplete ascertainment of death causes in particular, impede conclusions about exposure effects.

Mortality Among Hardmetal Production Workers: Occupational Exposures

Objective: To generate quantitative exposure estimates for use in retrospective occupational cohort mortality studies of the hardmetal industry. Methods: Job-exposure matrices (JEMs) were constructed for cobalt, tungsten, and nickel over the time period 1952 to 2014. The JEMs consisted of job class categories, based on job titles and processes performed, and exposure estimates calculated from available company industrial hygiene measurements. Results: Exposure intervals of one-half order magnitude were established for all three agents. Eight job classes had significantly decreasing time trends for cobalt exposure; no significant time trends were detected for tungsten or nickel exposures. Conclusions: The levels of exposures determined for this study were similar to or lower than those previously reported for the hardmetal industry during the 1952 to 2014 study period.

Mortality Among Hardmetal Production Workers: UK Cohort and Nested Case–Control Studies

Objective: The aim of this study was to characterize the mortality at two hardmetal production factories in the United Kingdom as part of an international study. Methods: Standardized mortality ratios (SMRs) were calculated on the basis of mortality rates for England and Wales, and local rates. A nested case–control study of lung cancer was undertaken. Results: The cohort comprised 1538 workers, with tracing complete for 94.4%. All-cause mortality was statistically significantly low for all cancers and nonmalignant respiratory disease, and for lung cancer was nonsignificantly low. The SMR for lung cancer for maintenance workers was elevated, based on only six deaths. The odds ratio for lung cancer per year of exposure to hardmetal was 0.93 (0.76 to 1.13). Conclusions: In this small study, there is no evidence to support that working in the UK hardmetal manufacturing industry increased mortality from any cause including lung cancer.

Mortality Among Hardmetal Production Workers : The Swedish Cohort.

Background: The mortality pattern was determined in a cohort of 16,999 white and blue-collar workers in the Swedish hardmetal industry, particularly for cobalt exposure and lung cancer. Methods: The mortality follow-up analysis in the Swedish Mortality register covered the period from 1952 to 2012. The exposure measures were ever/never exposed, duration of exposure, cumulative, and mean cobalt concentrations. Results: The mortality of all causes was significantly increased, highly associated with the short-term employed workers. A negative exposure–response was found for lung cancer and duration of exposure. An exposure–response was determined for cumulative and mean cobalt exposures analyzed by quartiles, but not for exposure classes. Internal comparison analysis using proportional hazard showed no exposure–response. Conclusions: The cohort lung cancer mortality showed no correlation to cobalt, nickel, or tungsten exposure.

Mortality among Hardmetal Production Workers: Pooled Analysis of Cohort Data from an International Investigation

Objectives: Based on a pooled analysis of data from an international study, evaluate total and cause-specific mortality among hardmetal production workers with emphasis on lung cancer. Methods: Study members were 32,354 workers from three companies and 17 manufacturing sites in five countries. We computed standardized mortality ratios and evaluated exposure-response via relative risk regression analysis. Results: Among long-term workers, we observed overall deficits or slight excesses in deaths for total mortality, all cancers, and lung cancer and found no evidence of any exposure-response relationships for lung cancer. Conclusions: We found no evidence that duration, average intensity, or cumulative exposure to tungsten, cobalt, or nickel, at levels experienced by the workers examined, increases lung cancer mortality risks. We also found no evidence that work in these facilities increased mortality risks from any other causes of death.

0269 An International Historical Cohort Study of Workers in the Hard-Metal Industry: Mid-Study Epidemiology Update

Objectives A multinational occupational epidemiological study of workers exposed to tungsten carbide with a cobalt binder (WCCo) is underway in the US and Europe. The epidemiological component will investigate total and cause-specific mortality risks and exposure-response relationships with focus on lung cancer. We designed the study to overcome certain limitations of earlier epidemiology studies. Method The epidemiological and exposure assessment components of the study are coordinated by the University of Pittsburgh and the University of Illinois at Chicago, respectively. Our cohort comprises 12 manufacturing sites in the US and nine sites in Europe, and represents three companies, five countries (US, Austria, Germany, Sweden and UK) and multiple manufacturing processes and exposures. Statistical analyses will adjust external and internal mortality rate comparisons for potential co-exposures, including smoking histories obtained via a nested case-control study. The study will include separate and pooled analyses. Results Our data collection effort identified two additional US study sites and additional subjects in the German and Swedish sites. Accordingly, our originally projected cohort size of 21 000 subjects has increased to 35 508 (US-7005; Europe-33 508). Vital status tracing, cause of death determination and identification of subjects for the nested case-control study are ongoing. Conclusions Our study will enable country-specific and pooled analyses of mortality rates and exposure-response relationships among workers from 21 study sites and the opportunity to compare and contrast findings across countries, sites, companies and/or manufacturing processes and exposures involved in this global industry. We will detail progress to date on the US and combined epidemiological component of the study.

0050 An International Historical Cohort Study of Workers in the Hard-Metal Industry: Exposure Assessment

Objectives A multinational occupational epidemiological study is underway to investigate the total and cause-specific mortality of workers exposed to tungsten carbide with a cobalt binder (WCCo). The study includes 12 US and 9 European plants. The objective of the exposure assessment component, coordinated by the University of Illinois at Chicago, is to reconstruct agent-specific exposure estimates for use in the epidemiological analyses. Method Quantitative occupational exposures are being generated through a process of modelling and validation using industrial hygiene data from study plants. Innovative semi-quantitative methods are being developed to extrapolate data for years in which it is missing, and are based on exposure changes due to manufacturing process changes over time (e.g., moving from manual to automated methods). Company work history information is being used to construct a job dictionary. The resulting exposure estimates and job dictionary will form the job-exposure matrix. Results The agents of interest are WCCo, tungsten carbide, tungsten, cobalt, and carbon black. Current and past working environments are being characterised according to products manufactured and operations performed and in relation to potential exposures using sampling data, job descriptions, plant and process histories, and information provided by knowledgeable plant personnel. Conclusions Exposure estimates will be generated for the study plants. The multinational aspect of the study provides the opportunity to pool data and produce exposure estimates for all 21 facilities with potential insight into similarities or differences among countries and/or plants involved in the same global industry. This presentation will detail the progress to date on the exposure assessment effort.

Mortality Among Hardmetal Production Workers : Swedish Measurement Data and Exposure Assessment.

Background: Mortality pattern was determined in a cohort of 16,999 white and blue-collar workers in the Swedish hardmetal industry. Exposure assessment for cobalt is presented. Methods: A historical database (1970 to 2012) of personal and area measurements of cobalt, tungsten, and nickel in the Swedish hardmetal industry was created. Log linear and exponential modeling of cobalt concentrations based on time period, job, and site was performed, and cumulative and mean exposures were calculated. Results: Some 37% of the personal cobalt measurements exceeded 0.02 mg/m3, mostly for powder production, pressing, and shaping. The log linear regression showed statistical differences (P < 0.05) between sites, time periods, and jobs. Some 1.6% of the cobalt cumulative exposures for blue-collar workers exceeded 0.4 mg/m3 years. Conclusion: Low levels of cumulative and mean exposures were determined.

Outcomes of a Seven Practice Pilot in a Pay-for-Performance (P4P)-Based Program in Pennsylvania

ObjectiveThe objective of this study was to examine how targeted six-month interventions impacted best practice/patient outcomes for minority patients receiving primary care in physician practices participating in a pay-for-performance (P4P) program.MethodsP4P practices were invited to participate in a pilot intervention study designed to improve care for minority patients with hypertension, diabetes, or pediatric asthma. The following patient medical records were reviewed to assess how the interventions impacted (n = 7 practices): body mass index, diet and exercise, smoking, compliance with visits as recommended, blood pressure, sodium intake and weight management counseling, medication reconciliation, HbA1c testing, annual lipid profile, and anti-inflammatory medications.ResultsSignificant improvements in various clinical quality measures were observed in all seven practices. Of the 19 specified interventions, 13 were statistically significant at α = 0.05 level and 14 met the target proportion. This suggests that the best practice intervention had a significant impact on some of the health care processes in the physician practices.ConclusionsThe most impactful interventions were those related to face-to-face educational discussions and patient medical chart documentations rather than those pertaining to medication adherence. Improvements in measuring reporting and recording of data at post-intervention were also observed.

Mortality among chemical plant workers exposed to acrylonitrile: 2011 follow-up.

Objectives:To update a cohort study of chemical workers and reevaluate lung cancer mortality in relation to acrylonitrile (AN) exposure. Methods:Subjects were 2096 workers employed during 1955 to 2011. We identified 474 deaths through 2011, and quantitatively estimated worker exposures to AN. Analyses included national and county-based standardized mortality ratios and relative risk regression of internal cohort rates. Results:We found no statistically significant excess mortality risks associated with Lima employment for any cause of death category, including lung cancer and other cancer sites implicated in previous studies. Conclusions:This update provides no evidence that exposure to AN at levels experienced by Lima workers is associated with an increased risk of lung cancer mortality, as suggested in original study. Earlier reported bladder cancer risks decreased to a much lower, not statistically significant level.