Human papillomavirus (HPV) vaccination can dramatically reduce the incidence of HPV-associated cancers. However, HPV vaccination coverage in rural areas is lower than in urban areas, and overall HPV vaccination coverage in the United States remains lower than other adolescent vaccines. We conducted 20 qualitative interviews with adolescent healthcare providers and clinic staff in urban and rural Minnesota and assessed their perspectives on HPV vaccination. Guiding interview topics included: strategies to persuade families to vaccinate their children, the impact of the patient-provider relationship and the clinical environment on vaccination uptake, and provider perceptions of parents' vaccine attitudes. In thematic analysis, all participants reported using common vaccination strategies, such as framing the HPV vaccine in terms of cancer prevention. The analysis also revealed three themes described as occurring uniquely or more intensely in rural communities than urban communities: the rural value of choice or independence, the spread of misinformation, and close-knit, multifaceted patient-provider relationships in clinical practice. Interventions aimed at increasing HPV vaccination should consider the distinctive circumstances of rural healthcare providers and patients.

PURPOSE: This study assessed efficacy of one-time COVID-19 booster reminder/recall for booster eligible adolescents in a health-care system in Wisconsin. METHODS: COVID-19 booster eligible patients aged 12-17 years were randomized 1:1 to receive one reminder/recall message from the health-care system using the parent's preferred communication method (intervention) or no reminder/recall (usual care) in May 2022. RESULTS: Reminder/recall was sent to 2,146/4,296 (50%) adolescent patients. During the 90-day evaluation period following randomization, booster dose receipt was 2.0 percentage points (CI: 0.3%-3.7%) higher in the intervention (10.0%) versus usual care groups (8.0%). Among patients with ≥1 preventive visit during the evaluation period, uptake was 7.5 percentage points higher in the intervention (16.4%) versus usual care groups (8.9%). DISCUSSION: A single COVID-19 booster dose reminder/recall resulted in a small but statistically significant increase in booster dose receipt, though uptake overall was low. Additional strategies are needed to increase uptake.

BACKGROUND: The human papillomavirus (HPV) vaccine is recommended for all adolescents age 11-12 years. HPV vaccine coverage remains suboptimal in the United States though, particularly in rural areas. We surveyed adolescent immunization providers in two Midwestern states to assess rural vs. urban differences in HPV vaccine resources, practices, and attitudes. METHODS: A cross-sectional survey was sent to all licensed adolescent care providers in a subset of urban and rural counties in Minnesota and Wisconsin during 2019. Multivariable regression was used to identify attitudes and practices that differentiated rural vs. urban providers. RESULTS: There were 437 survey respondents (31% rural). Significantly fewer rural providers had evening/weekend adolescent vaccination appointments available (adjusted odds ratio (aOR) = 0.21 [95% confidence interval (CI): 0.12, 0.36]), had prior experience with adolescent vaccine quality improvement projects (aOR = 0.52 [95% CI: 0.28, 0.98]), and routinely recommended HPV vaccine during urgent/acute care visits (aOR = 0.37 [95% CI: 0.18, 0.79]). Significantly more rural providers had standing orders to administer all recommended adolescent vaccines (aOR = 2.81 [95% CI: 1.61, 4.91]) and reported giving HPV vaccine information to their patients/families before it is due (aOR = 3.10 [95% CI: 1.68, 5.71]). CONCLUSIONS: Rural vs. urban differences in provider practices were mixed in that rural providers do not implement some practices that may promote HPV vaccination, but do implement other practices that promote HPV vaccination. It remains unclear how the observed differences would affect HPV vaccine attitudes or adolescent vaccination decisions for parents in rural areas.

BACKGROUND: Studies have shown that adolescent vaccination rates with human papillomavirus (HPV) and quadrivalent meningococcal conjugate (MenACWY) vaccines are lower in rural areas of the U.S. than in urban areas. We sought to determine factors associated with vaccine acceptance in these two settings. METHODS: We conducted a cross-sectional survey of 536 parents or guardians of teens age 13 through 15 years in select rural and urban counties of Minnesota and Wisconsin. We collected information on demographic variables, receipt of adolescent vaccines, and attitudes toward HPV vaccine in particular. Multivariable logistic regression models were used to assess associations between covariates and outcomes of interest (HPV vaccine receipt and MenACWY receipt). RESULTS: Of the 536 respondents, 267 (50%) resided in a rural county. Most respondents were female (78%) and non-Hispanic White (88%). About half (52%) of teens of the surveyed parents received the three vaccines recommended specifically for adolescents: 90% received tetanus-diphtheria-acellular pertussis (Tdap), 84% received MenACWY, and 60% received one or more doses of HPV vaccine. Rural and urban parents surveyed differed on several covariates relating to teen's health services, parent's demographics, and household characteristics. Parent's perception of the importance that their healthcare providers placed on vaccination with HPV and MenACWY were independently associated with receipt of each of those vaccines (odds ratio [OR] 6.37, 95% confidence interval [CI] 2.90-13.96 and OR 2.15, 95% CI 1.07-4.31, respectively). Parents of vaccinated teens were less likely to report concerns about potential harm from the HPV vaccine or having heard stories about health problems caused by the HPV vaccine. CONCLUSION: Teen receipt of HPV vaccine and MenACWY appears to be influenced by parents' perception of vaccine importance, provider recommendations, and concerns regarding potential harm from the HPV vaccine. Continued education of providers and parents of the importance of adolescent vaccinations is warranted.

OBJECTIVE: This prospective study assessed the risk of developing rotator cuff syndrome (RCS) with separate or specific combinations of biomechanical exposures measures, controlling for individual confounders. BACKGROUND: Compared with other musculoskeletal disorders, rates of work-related shoulder musculoskeletal disorders have been declining more slowly. METHOD: We conducted up to 2 years of individual, annual assessments of covariates, exposures, and health outcomes for 393 U.S. manufacturing and healthcare workers without RCS at baseline. Task-level biomechanical exposures assessed exposure to forceful exertions (level, exertion rates, duty cycles), vibration, and upper arm postures (flexion, abduction). Hazard ratios (HRs) were calculated with Cox proportional hazard models. RESULTS: We observed 39 incident RCS cases in 694 person-years (incidence rate = 5.62 per 100 person-years). Adjusting for confounders, we found increased risk of incident RCS associated with forceful hand exertions per minute for three upper arm posture tertiles: flexion ≥45° (≥28.2% time, HR = 1.11, CI [1.01, 1.22]), abduction ≥30° (11.9-21.2%-time, HR = 1.18, CI [1.04, 1.34]), and abduction >60° (≥4.8% time, HR = 1.16, CI [1.04, 1.29]). We failed to observe statistically significant effects for other interactions or any separate measures of biomechanical exposure. CONCLUSION: This study highlights the importance of assessing combinations of exposure to forceful repetition and upper arm elevation when developing interventions for preventing RCS. APPLICATION: Based on these results, interventions that reduce exposure to forceful repetition (i.e., lower force levels and/or slower exertion rates) may reduce the risk of RCS, especially when upper arm elevation cannot be avoided.

INTRODUCTION: When it is not possible to capture direct measures of occupational exposure or conduct biomonitoring, retrospective exposure assessment methods are often used. Among the common retrospective assessment methods, assigning exposure estimates by multiple expert rater review of detailed job descriptions is typically the most valid, but also the most time-consuming and expensive. Development of screening protocols to prioritize a subset of jobs for expert rater review can reduce the exposure assessment cost and time requirement, but there is often little data with which to evaluate different screening approaches. We used existing job-by-job exposure assessment data (assigned by consensus between multiple expert raters) from a large, population-based study of women to create and test screening algorithms for polycyclic aromatic hydrocarbons (PAHs) that would be suitable for use in other population-based studies. METHODS: We evaluated three approaches to creating a screening algorithm: a machine-learning algorithm, a set of a priori decision rules created by experts based on features (such as keywords) found in the job description, and a hybrid algorithm incorporating both sets of criteria. All coded jobs held by mothers of infants participating in National Birth Defects Prevention Study (NBDPS) (n = 35,424) were used in developing or testing the screening algorithms. The job narrative fields considered for all approaches included job title, type of product made by the company, main activities or duties, and chemicals or substances handled. Each screening approach was evaluated against the consensus rating of two or more expert raters. RESULTS: The machine-learning algorithm considered over 30,000 keywords and industry/occupation codes (separate and in combination). Overall, the hybrid method had a similar sensitivity (87.1%) as the expert decision rules (85.5%) but was higher than the machine-learning algorithm (67.7%). Specificity was best in the machine-learning algorithm (98.1%), compared to the expert decision rules (89.2%) and hybrid approach (89.1%). Using different probability cutoffs in the hybrid approach resulted in improvements in sensitivity (24-30%), without the loss of much specificity (7-18%). CONCLUSION: Both expert decision rules and the machine-learning algorithm performed reasonably well in identifying the majority of jobs with potential exposure to PAHs. The hybrid screening approach demonstrated that by reviewing approximately 20% of the total jobs, it could identify 87% of all jobs exposed to PAHs; sensitivity could be further increased, albeit with a decrease in specificity, by adjusting the algorithm. The resulting screening algorithm could be applied to other population-based studies of women. The process of developing the algorithm also provides a useful illustration of the strengths and potential pitfalls of these approaches to developing exposure assessment algorithms.

Human papilloma virus is the primary causative agent for cervical cancer, and vaccination is the primary means of preventing anogenital cancers caused by human papilloma virus infection. Despite the availability of human papilloma virus vaccines for over a decade, coverage rates lag behind the other vaccines. Public concerns regarding safety of human papilloma virus vaccines have been identified as an important barrier to vaccination, including concerns that the human papilloma virus vaccine causes primary ovarian insufficiency, driven in part by isolated reports of ovarian failure following the human papilloma virus vaccine. We summarize published peer-reviewed literature on human papilloma virus vaccines and primary ovarian insufficiency reviewing information contained in the case reports and series. Health care providers should address any patient concerns about primary ovarian insufficiency and the human papilloma virus vaccine by acknowledging the case reports but noting the lack of association found in a recently published epidemiologic study of approximately 60,000 females. Current evidence is insufficient to suggest or support a causal relationship between human papilloma virus vaccination and primary ovarian insufficiency.

Tris(1-chloro-2-propyl) phosphate (TCPP, also referenced as TCIPP), a flame retardant used in spray polyurethane foam insulation, increases cell toxicity and affects fetal development. Spray polyurethane foam workers have the potential to be exposed to TCPP during application. In this study, we determined exposure to TCPP and concentrations of the urinary biomarker bis(1-chloro-2-propyl) phosphate (BCPP) among 29 spray polyurethane foam workers over 2 work days. Work was conducted at residential or commercial facilities using both open-cell (low density) and closed-cell (high density) foam. Study participants provided two personal air samples (Day 1 and Day 2), two hand wipe samples (Pre-shift Day 2 and Post-shift Day 2), and two spot urine samples (Pre-shift Day 1 and Post-shift Day 2). Bulk samples of cured spray foam were also analyzed. Sprayers were found to have significantly higher TCPP geometric mean (GM) concentration in personal air samples (87.1 mug/m(3)), compared to helpers (30.2 mug/m(3); p = 0.025). A statistically significant difference was observed between TCPP pre- and post-shift hand wipe GM concentrations (p = 0.004). Specifically, TCPP GM concentration in post-shift hand wipe samples of helpers (106,000 ng/sample) was significantly greater than pre-shift (27,300 ng/sample; p < 0.001). The GM concentration of the urinary biomarker BCPP (23.8 mug/g creatinine) was notably higher than the adult male general population (0.159 mug/g creatinine, p < 0.001). Urinary BCPP GM concentration increased significantly from Pre-shift Day 1 to Post-shift Day 2 for sprayers (p = 0.013) and helpers (p = 0.009). Among bulk samples, cured open-cell foam had a TCPP GM concentration of 9.23% by weight while closed-cell foam was 1.68%. Overall, post-shift BCPP urine concentrations were observed to be associated with TCPP air and hand wipe concentrations, as well as job position (sprayer vs. helper). Spray polyurethane foam workers should wear personal protective equipment including air-supplied respirators, coveralls, and gloves during application.

Background: Exposure to bisphenol A (BPA) can be assessed using external and internal exposure measures. We examined the relationship between two measures of external BPA exposure (air and hand-wipe samples) and one of internal exposure (total BPA in urine) for a group of US manufacturing workers. Methods: During 2013-2014, we recruited 78 workers from six US companies that made BPA or made products with BPA. We quantified BPA in seven urine samples, two full-shift air samples and in pre- and end-shift hand-wipe samples collected from workers over 2 consecutive days. We examined correlations between creatinine-corrected urinary concentrations of total BPA (total BPACR) and BPA levels in air and hand wipes using Pearson's correlation coefficient. We also applied mixed-effects regression models to examine the relationship between total BPACR with BPA in air (urine~air model) and with BPA in end-shift hand wipes (urine~hand model), separately and together (urine~air+hand model), after adjusting for covariates. Results: End-shift total BPACR strongly correlated with BPA in air (rp = 0.79, P < 0.0001) and nearly as strongly with BPA in end-shift hand wipes (rp = 0.75, P < 0.0001). In mixed-effect models, BPA air concentration and end-shift hand-wipe BPA level were significantly and positively associated with end-shift total BPACR (P < 0.0001 each). We found a significant effect of the Day 1 BPA air concentration on Day 2 total BPACR (P = 0.0104). When BPA air concentration and end-shift hand-wipe BPA level were in the same model, the air concentration (P < 0.0001) was more significant than the hand-wipe level (P = 0.0106). Conclusion: BPA levels in air and end-shift hand wipes strongly correlated with total BPACR, suggesting that both inhalation and dermal contract were likely exposure routes; however, inhalation, on average, appeared to be a more dominant exposure route than dermal contact for these manufacturing workers.

BACKGROUND: Flight attendants may have an increased risk of some cancers from occupational exposure to cosmic radiation and circadian disruption. METHODS: The incidence of thyroid, ovarian, and uterine cancer among approximately 6000 female flight attendants compared to the US population was evaluated via life table analyses. Associations of these cancers, melanoma, and cervical cancer with cumulative cosmic radiation dose and metrics of circadian disruption were evaluated using Cox regression. RESULTS: Incidence of thyroid, ovarian, and uterine cancer was not elevated. No significant, positive exposure-response relations were observed. Weak, non-significant, positive relations were observed for thyroid cancer with cosmic radiation and time zones crossed and for melanoma with another metric of circadian disruption. CONCLUSIONS: We found little evidence of increased risk of these cancers from occupational cosmic radiation or circadian disruption in female flight attendants. Limitations include few observed cases of some cancers, limited data on risk factors, and misclassification of exposures.

For decades, bisphenol A (BPA) has been used in making polycarbonate, epoxy, and phenolic resins and certain investment casting waxes, yet published exposure data are lacking for U.S. manufacturing workers. In 2013-2014, BPA air and hand exposures were quantified for 78 workers at six U.S. companies making BPA or BPA-based products. Exposure measures included an inhalable-fraction personal air sample on each of two consecutive work days (n = 146), pre- and end-shift hand wipe samples on the second day (n = 74 each), and surface wipe samples (n = 88). Potential determinants of BPA air and end-shift hand exposures (after natural log transformation) were assessed in univariate and multiple regression mixed models. The geometric mean (GM) BPA air concentration was 4.0 microg/m3 (maximum 920 microg/m3). The end-shift GM BPA hand level (26 microg/sample) was 10-times higher than the pre-shift level (2.6 microg/sample). BPA air and hand exposures differed significantly by industry and job. BPA air concentrations and end-shift hand levels were highest in the BPA-filled wax manufacturing/reclaim industry (GMAir = 48 microg/m3, GMHand-End = 130 microg/sample) and in the job of working with molten BPA-filled wax (GMAir = 43 microg/m3, GMHand-End = 180 microg/sample), and lowest in the phenolic resins industry (GMAir = 0.85 microg/m3, GMHand-End = 0.43 microg/sample) and in the job of flaking phenolic resins (GMAIR = 0.62 microg/m3, GMHand-End = 0.38 microg/sample). Determinants of increased BPA air concentration were industry, handling BPA containers, spilling BPA, and spending ≥50% of the shift in production areas; increasing age was associated with lower air concentrations. BPA hand exposure determinants were influenced by high values for two workers; for all other workers, tasks involving contact with BPA-containing materials and spending ≥50% of the shift in production areas were associated with increased BPA hand levels. Surface wipe BPA levels were significantly lower in eating/office areas (GM = 9.3 microg/100 cm2) than in production areas (GM = 140 microg/100 cm2). In conclusion, worker BPA exposure was associated with tasks and conditions affecting both inhalation and dermal exposure. The potential for BPA-related health effects among these workers is unknown.

Background: Bisphenol A (BPA) toxicity and exposure risk to humans has been the subject of considerable scientific debate; however, published occupational exposure data for BPA are limited. Methods: In 2013–2014, 77 workers at six US companies making BPA, BPA-based resins, or BPA-filled wax provided seven urine samples over two consecutive work days (151 worker-days, 525 samples). Participant information included industry, job, tasks, personal protective equipment used, hygiene behaviors, and canned food/beverage consumption. Total (free plus conjugated) BPA, quantified in urine by mass spectrometry, was detected in all samples. Results:The geometric mean (GM) creatinine-adjusted total BPA (total BPACR) concentration was 88.0 microg g−1 (range 0.78–18900 microg g - 1), approximately 70 times higher than in US adults in 2013–2014 (1.27 microg g-1). GM total BPACR increased during Day 1 (26.6-127 microg g- 1), decreased by pre-shift Day 2 (84.4 microg g - 1) then increased during Day 2 to 178 microg - 1. By industry, baseline and post-baseline total BPACR was highest in BPA-filled wax manufacturing/reclaim (GM = 111 microg g - 1) and lowest in phenolic resin manufacturing (GM = 6.56 microg g-1). By job, total BPACR was highest at baseline in maintenance workers (GM = 157 microg g−1) and post-baseline in those working with molten BPA-filled wax (GM = 441 microg g - 1). Workers in the job of flaking a BPA-based resin had the lowest concentrations at baseline (GM = 4.81 microg g−1) and post-baseline (GM = 23.2 µg g−1). In multiple regression models, at baseline, industry significantly predicted increased total BPACR (P = 0.0248); post-baseline, handling BPA containers (P = 0.0035), taking ≥3 process/bulk samples with BPA (P = 0.0002) and wearing a Tyvek coverall (P = 0.0042) significantly predicted increased total BPACR (after adjusting for total BPACR at baseline, time point, and body mass index). Conclusion: Several work-related factors, including industry, job, and certain tasks performed, were associated with increased urinary total BPACR concentrations in this group of manufacturing workers. The potential for BPA-related health effects among these workers is unknown.

Using vital registration and verbal autopsy, Li Liu and colleagues (June 9, p 2151)1 attribute 270 000 deaths worldwide in children younger than 5 years to congenital anomalies (chromosomal disorders and congenital malformations)—3·5% of the total, or 2·0 per 1000 births. Liu and colleagues' comments that medically certified vital registration data are available for only 2·7% of under-5 deaths, and that verbal autopsy methods “are subject to inherent misclassification errors”, are especially applicable to congenital anomalies, since correct diagnosis often requires advanced diagnostic facilities. Consequently, valid mortality rates are obtainable only for high-income settings, where mortality has been greatly reduced by multiple interventions. In lower-income settings, most congenital anomalies remain undiagnosed, and the associated mortality is inevitably mis-attributed. | The Global Burden of Disease Congenital Expert Group (of which we were members), starting from the known birth prevalence of major congenital anomalies (in the absence of intervention) of 22·5 per 1000 births worldwide2, 3, 4 and known mortality in the absence of diagnosis and care, estimated a minimum of 10 under-5 deaths per 1000 births worldwide—ie, more than four times higher than Liu and colleagues' estimate. In Hungary in 1970–80, congenital anomalies caused around 6·5 under-5 deaths per 1000 births even though diagnosis and care were generally available.3 Currently in the UK they cause around 2·5 under-5 deaths per 1000 births.5 Liu and colleagues' estimates are lower than this for almost all WHO regions. (Although their report in fact only covers neonatal deaths, this omission hardly affects the difference between our estimates.)

The external quality assessment of 24-locus mycobacterial interspersed repetitive-unit–variable-number tandem-repeat (MIRU-VNTR) genotyping by de Beer et al. reveals issues with its international performance (5). Detailed analysis of the data was confounded by the complexity of the participants. The five genotyping laboratories in Canada and the United States participating in this study use similar typing protocols based on the standardized protocol proposed by Supply et al. (8) and developed in collaboration with each other. Systems for routine handling of samples and data management are well established. Quality control (QC) and assurance measures include routine testing of the Mycobacterium tuberculosis strain H37Rv and repeat testing of 1% of isolates at an external laboratory. The laboratorians conducting the analysis have at a minimum 5 years of experience performing MIRU-VNTR typing. This cohesiveness allows for a more in-depth analysis of the data collected by de Beer et al. | Each laboratory reported 24-locus MIRU-VNTR results for the proficiency testing panel of 30 DNA samples (including 10 pairs of duplicates), and their performance is summarized in Table 1. Reproducibility as calculated at the sample level and disregarding missing results ranged from 93% to 100%, and typeability as calculated by the percentage of loci with a reportable result ranged from 98.9% to 100%. Here we present a detailed description of the 38 observed discrepancies to provide a more complete understanding of the performance of MIRU-VNTR typing in our laboratories.

Injuries from medical sharps devices and blood-borne pathogen (BBP) exposure are a significant risk to many healthcare workers. Risk awareness communications and sharps safety strategies are key components of BBP exposure prevention efforts. The research reported here includes an evaluation of a large-scale communication intervention aimed at raising awareness among healthcare workers regarding the risks of sharps injuries and BBP exposure, as well as methods of prevention. The Stop Sticks campaign was a multi-media communication intervention targeted at multiple healthcare facilities in Columbia, South Carolina. Following a comprehensive needs assessment in each facility, tailored communications were delivered via several channels. Samples included individual hospital departments, an entire hospital, and a nursing home. Results indicate high levels of knowledge and communication channel recall, minimal attitude and behavior change, and a strong association between sharps-related safety behavior and safety climate. Overall, this research suggests the blitz approach is viable for raising awareness of occupational safety and health issues. Based on these findings, several recommendations are offered for conducting safety campaigns in healthcare facilities.