BACKGROUND: During the COVID-19 pandemic, the US President's Emergency Plan for AIDS Relief supported oral caregiver-assisted HIV self-testing (CG-HIVST) to address the gap in HIV diagnosis of children. We aimed to investigate caregiver uptake, results return, acceptability, and potential social harms of CG-HIVST. METHODS: This prospective, interventional, study was done at 32 health facilities in Uganda and 15 health facilities in Zambia. Caregivers aged 18 years and older (plus emancipated minors aged 15-17 years in Uganda) living with HIV who were currently accessing HIV care and considered index cases, with no positive responses to an intimate partner violence screen, and with one or more children aged 18 months to 14 years with unknown HIV status were eligible to participate. Eligible caregivers were offered oral HIVST kits to screen their children and primary outcomes were described by caregiver and child characteristics. Following HIVST kit administration, caregivers were surveyed using a standardised questionnaire to document their perceptions, adverse events, and social harm. Primary outcomes were the uptake of HIVST and the number and proportion of returned screening test results, reactive results, reactive screens with confirmatory HIV testing, confirmatory testing with a positive result, and children who were confirmed HIV-positive who were linked to treatment. This study was registered with ClinicalTrials.gov, NCT04774666 and NCT04754386, and is completed. FINDINGS: From Feb 1 to Oct 31, 2021, 12 998 interested caregivers were screened for eligibility, 4023 of whom were eligible. 3903 (97·0%) accepted HIVST kits to screen their child for HIV (1609 [41·2%] in Zambia and 2294 [58·8%] in Uganda). Among caregivers, 3094 (79·3%) of 3903 were female, and 809 (20·7%) were male. 7601 children were enrolled (3779 [49·7%] were female and 3822 [50·3%] were male). 4766 (97·9%) of 4866 test results were returned in Uganda and 2647 (96·8%) of 2735 in Zambia. 119 (1·6%) of 7413 children had reactive HIVST results, requiring confirmatory testing. Of 116 children with confirmatory testing, 43 were confirmed HIV-positive (HIV prevalence 0·7% [n=32] in Uganda and 0·4% [n=11] in Zambia) and 100% were linked to antiretroviral therapy. Adverse events were rare (11 [0·4%] of 2720) and minor, and there were no reports of social harm or violence. Caregivers surveyed reported the HIVST kit was easy to use (2637 [97·0%] of 2718), they would use it again (2650 [99·1%] of 2674), and they would recommend it to other parents (2615 [97·8%] of 2674). INTERPRETATION: Our findings suggest that oral CG-HIVST is acceptable, feasible, and safe, with no reports of social harm, and has the potential to expand access to HIV testing for children while reducing the service delivery burden on health facilities. FUNDING: US President's Emergency Plan for AIDS Relief and Wellcome Trust.

IMPORTANCE: Less than half of the US population with any mental health condition receives services. Cost is the most commonly cited barrier to treatment. OBJECTIVE: To examine whether service use and out-of-pocket expenditures among Medicare beneficiaries with depression changed after Medicare implemented equal cost-sharing for outpatient mental health and medical services (Medicare parity). DESIGN, SETTING, AND PARTICIPANTS: This economic evaluation used a single-group, interrupted time series design and examined data from the Medical Expenditure Panel Survey Household Component from 2008 to 2019. The sample included Medicare beneficiaries aged 65 years or older with depression. Data were analyzed from June 2, 2023, to June 17, 2024. EXPOSURE: Under the Medicare Improvements for Patients and Providers Act of 2008, beneficiary cost-sharing for outpatient mental health services decreased from 50% prior to 2010 to 20% in 2014, creating parity with equivalent medical care. MAIN OUTCOMES AND MEASURES: The primary outcomes were outpatient mental health service use, as assessed by mean use, proportion of beneficiaries with any use, and intensity of use (ie, mean use among users), and out-of-pocket expenditures. RESULTS: The analysis included 5831 Medicare beneficiaries. Using the Medical Expenditure Panel Survey person-level survey weights, this number corresponded to a nationally representative sample of 72 436 656 beneficiaries (median [IQR] age, 72 [68-79] years; 64.2%-72.2% female per study year). After Medicare parity, mean use of outpatient mental health services among beneficiaries with depression increased by 0.54 visits per year (95% CI, 0.31-0.76 visits per year), and proportion of use increased by 6.61% per year (95% CI, 2.23%-10.99% per year). Intensity of use decreased at parity by a factor of 0.90 (95% CI, 0.82-1.00) and increased after parity by a multiple of 1.07 per year (95% CI, 1.04-1.10 per year). Mean out-of-pocket expenditures for these services increased after parity by $12.25 per year (95% CI, $2.42-$22.08 per year). Sensitivity analysis using the 2016 US Preventive Services Task Force recommendation for routine adult depression screening indicated that the proportion of use increased 28.26% (95% CI, 24.33%-32.19%) once the recommendation was issued. CONCLUSIONS AND RELEVANCE: In this economic evaluation of Medicare parity, implementation of Medicare parity coupled with routine adult depression screening was associated with significant increases in outpatient mental health service use among Medicare beneficiaries with depression. These findings suggest that parity policies alone may not be sufficient to effectively address multiple barriers to mental health care but in tandem with physician screening, diagnosis, and referral practices, may increase the accessibility of mental health services.

Racial misclassification on death certificates leads to inaccurate mortality data for American Indian and Alaska Native (AI/AN) populations. We describe methods for correcting for racial misclassification among non-Hispanic AI/AN (NH-AI/AN) populations using data from the year 2020. We linked National Death Index (NDI) records with the Indian Health Service (IHS) patient registration database to identify AI/AN decedents. Matches were then linked to the National Vital Statistics System (NVSS) mortality data to identify AI/AN individuals that had been misclassified as another race on their death certificates. Analyses were limited to NH-AI/AN and purchased/referred care delivery areas (PRCDA) or urban areas. We compared death rates and counts pre- and post- linkage and calculated sensitivity and classification ratios by region, sex, age, cause of death (COD) and urban area. Racial misclassification on death certificates among NH-AI/AN varied by geographic region. Some of the highest racial misclassification occurred in the Southern Plains and Pacific Coast. Death rates for NH-AI/AN people and differences between NH-AI/AN and Non-Hispanic White (NHW) people were larger using the linked data. Improving AI/AN mortality data using linkages between vital statistics data and IHS strengthens data quality and can help address health disparities through public health planning efforts.

Starting in the 1970s with robots that were physically isolated from contact with their human co-workers, robots now collaborate with human workers towards a common task goal in a shared workspace. This type of robotic device represents a new era of workplace automation. Industrial robotics is rapidly evolving due to advances in sensor technology, artificial intelligence (AI), wireless communications, mechanical engineering, and materials science. While these new robotic devices are used mainly in manufacturing and warehousing, human-robot collaboration is now seen across multiple goods-producing and service-delivery industry sectors. Assessing and controlling the risks of human-robot collaboration is a critical challenge for occupational safety and health research and practice as industrial robotics becomes a pervasive feature of the future of work. Understanding the physical, psychosocial, work organization, and cybersecurity risks associated with the increasing use of robotic technologies is critical to ensuring the safe development and implementation of industrial robotics. This commentary provides a brief review of the uses of robotic technologies across selected industry sectors; the risks of current and future industrial robotic applications for worker and employer alike; strategies for integrating human-robot collaboration into a health and safety management system; and the role of robotic safety standards in the future of work.

Antiretroviral therapy (ART) has been adopted as a form of HIV treatment and prevention. This study assesses rapid ART initiation using clinical outcomes such as viral load (VL) and CD4+ T lymphocytes count. Over the course of one year, the progress of newly diagnosed people living with HIV who started ART early in a hospital in Panama City was followed. The evaluation of early initiation of ART in achieving viral suppression (VL <200 copies/ml) was analyzed using descriptive statistics. Additionally, the cost difference between early (first 7 days) and late initiation of ART was evaluated from the perspective of the service provider. In total, 209 people were followed up during the study; 85% were male, 70% started ART on same day from hospital arrival, 80% had suppressed viral load at 6 months, and the median count of CD4 increased from 285 (IQR: 166-429) to 509 (IQR: 373-696) over 12 months. Starting ART early led to a 42% increase for the provider in terms of staffing costs; however, the clients had the opportunity to decrease absenteeism in daily activities. The results reveal that early initiation of ART generates clinical and economic benefits for the person in treatment.

During August-October 2020, United States federal, state, and Canadian partners investigated an outbreak of Salmonella Enteritidis infections, in the U.S. and Canada, linked to fresh, whole peaches packed and supplied by a grower and packer with multiple orchards (Farm A). In the U.S., a total of 101 ill people and 28 hospitalizations were reported in 17 states, while in Canada, 57 ill people and 12 hospitalizations were reported in two Canadian provinces. The U.S. traceback investigation included 14 points of service (POS), representing 18 illnesses in eight states. Multiple distributors, packinghouses, and orchards supplied bagged and loose peaches during the timeframe of interest to identified POS, with peaches and packinghouses linked to Farm A being the primary source. Orchards of interest were identified for peach fruit, orchard tree leaf, and soil-drag swab sample collection using traceback and geospatial analysis. Geospatial analyses showed that several orchards were in proximity to animal operations. While none of the Salmonella isolates recovered matched the outbreak strain, Salmonella Alachua was recovered from peaches and leaf samples, and Salmonella Montevideo was recovered from orchard tree leaves. Whole genome sequencing indicated that these Salmonella isolates were closely related to historical poultry and cattle isolates. Farm A voluntarily recalled loose peaches sold from June 1 to August 3, 2020, and bagged Brand A conventional and organic peaches sold from June 1 to August 19, 2020. Recalled products were likely distributed to at least 14 different countries. Findings suggest that adjacent animal operations may be a potential contributing factor to Salmonella contamination of peaches, with windborne or fugitive dust as a possible route. The findings from this first reported international outbreak of Salmonella linked to peaches grown in the U.S. highlight the importance of grower awareness of adjacent land use.

PURPOSE: Per- and polyfluoroalkyl substances (PFAS) are associated with multiple health effects including pregnancy-induced hypertension and pre-eclampsia, increased serum hepatic enzymes, increased in serum lipids, decreased antibody response to vaccines, and decreased birth weight. Millions of US workers are exposed to PFAS at their workplaces. Our objective was to estimate the serum levels of the five PFAS that are most frequently detected in the US general population(perfluorooctane sulfonic acid (PFOS), perfluorooctanoic acid (PFOA), perfluorohexane sulfonic acid (PFHxS), perfluorodecanoic acid (PFDA), and perfluorononanoic acid (PFNA)) among US adult workers. METHODS: Participants were 4476 workers aged ≥ 20 years with PFAS analyte results available who participated in the National Health and Nutrition Examination Survey (NHANES), 2005-2014. Geometric mean serum levels of PFAS (ng/mL) were obtained across industry and occupation groups using the PFAS subsample weight in SAS-callable SUDAAN V11. RESULTS: Among 21 industry groups, the highest geometric mean PFAS levels (ng/mL) were observed in Construction (PFOS = 12.61 ng/mL, PFOA = 3.76, PFHxS = 2.10, PFNA = 1.23, and PFDA = 0.33), followed by Utilities (PFOS = 12.46), and Real Estate/Rental/Leasing (PFOS = 12.15). The lowest geometric mean PFAS levels were seen in Private Households (PFOS = 6.34, PFOA = 2.12, PFHxS=0.75, PFNA = 0.86, and PFDA = 0.25). Among 22 occupation groups, the highest geometric mean PFAS levels were observed in Life/Physical/Social Science occupations (PFOS = 13.19, PFOA = 3.54, PFHxS= 1.69, PFNA = 1.23, and PFDA = 0.33), followed by Installation/Maintenance/Repair occupations (PFOS = 12.75), and Construction/Extraction occupations (PFOS = 12.15). The lowest geometric mean PFAS levels were found in Personal Care/Service occupations (PFOS = 7.25, PFOA = 2.43, PFHxS = 1.07, PFNA = 0.94, and PFDA = 0.25). CONCLUSIONS: Some industry and occupation groups had higher geometric mean levels of PFAS in serum compared to others. Further investigation of these industries and occupations may result in a better understanding of the sources and degree of occupational exposure to PFAS.

Evidence-based cessation treatments and tobacco-free policies support and increase smoking cessation, which has positive physical health impacts and is associated with positive behavioral health outcomes. Implementation of these strategies in substance use and mental health treatment facilities (behavioral health treatment facilities) could help decrease tobacco use among persons with behavioral health conditions. Data from the 2023 National Substance Use and Mental Health Services Survey were analyzed to ascertain the number and percentage of behavioral health treatment facilities that offered tobacco-related clinical services and had tobacco-free policies. In 2023, tobacco cessation counseling was the most commonly offered cessation service in facilities treating mental health conditions (53.1%) and substance use disorders (69.9%). Fewer than one half of facilities offered nicotine replacement therapy (35.0% of mental health and 40.2% of substance use facilities) or non-nicotine cessation medication (33.6% of mental health and 35.3% of substance use facilities). Policies prohibiting both smoking and vaping were reported by 53.9% of mental health and 33.9% of substance use facilities. Among facilities with a tobacco-free policy, 64.4% of mental health and 81.8% of substance use facilities offered at least one cessation service. Opportunities remain to improve cessation supports in behavioral health treatment facilities, including tobacco-free policies and integrated tobacco cessation treatment services. These strategies could help decrease tobacco-related disease and improve behavioral health outcomes.

BACKGROUND: Low pressure events (LPEs), defined as a water service disruption that presumably lowers system water pressure, can cause drinking water contamination resulting in increased illness risk to consumers. OBJECTIVES: Examine whether LPEs increase the risk for highly credible acute gastrointestinal illness (HCGI) and acute respiratory illness (ARI) and compare water quality in exposed and unexposed areas in the United States. METHODS: A matched cohort study was conducted during 2015-2019. For each LPE, household survey exposed areas were matched 1:2 with unexposed areas based on water main size and material at the point of repair, as well as the housing type and demographic characteristics of the local population from the most recent census tract. Water samples were collected to monitor physicochemical and microbiological water quality parameters. Households (HHs) were surveyed about water use and illness during the 2 weeks after the LPE. Multivariable log-binomial models clustered on utility and LPE number were used to investigate associations between LPE exposure and HCGI and ARI. RESULTS: Five water utilities reported 58 LPEs, including planned maintenance (76%) and emergency (24%) events. Controlling for livestock near home, private well presence, number of people in HH, and travel away from home, exposed HH were at higher risk of HCGI compared to unexposed HH (risk ratio =1.20; 95%CI: 1.05,1.37). No associations between LPE and ARI were detected. Certain LPEs characteristics like pipe material, size, and depth were associated with an increased HH HCGI risk. HHs experiencing LPEs where low disinfectant residual, high adenosine triphosphate, or general Bacteroidales were detected in water following an LPE repair were also at a higher risk for HCGI. CONCLUSIONS: LPEs were associated with 20% higher risk of HCGI in HHs. Planned improvements to water distribution system infrastructure, adherence to industry standard distribution repair practices, and water monitoring following pipe repairs could supplement community alert systems to reduce illnesses from LPEs. https://doi.org/10.1289/EHP15564.

Norovirus is the most common cause of foodborne illness outbreaks in the United States. In January 2024, local health jurisdictions and the California Department of Public Health (CDPH) identified two concurrent norovirus outbreaks across eight Southern California local health jurisdictions. CDPH was notified in late December 2023 and early January 2024 of gastrointestinal illnesses in persons who consumed raw oysters from food service facilities in San Diego County (outbreak 1). Additional illness reports came from multiple jurisdictions that included Los Angeles County and other areas in Southern California (outbreak 2). In total, approximately 400 persons across eight local health jurisdictions reported gastrointestinal illness after raw oyster consumption. A multiagency investigation confirmed that outbreaks 1 and 2 were unrelated, and implicated oysters were traced to two separate, nonoverlapping harvest regions in Mexico. A total of 179 outbreak-associated cases, including 24 laboratory-confirmed norovirus cases, were identified. Patient samples from both outbreaks identified norovirus genogroups I and II; other enteric viruses (sapovirus, astrovirus, rotavirus, and adenovirus) were also identified from one or both outbreaks. Noroviruses were genetically related by genotype within each outbreak but dissimilar between outbreaks. In outbreak 2, oysters might have been contaminated at a location separate from the original growing area, also known as wet storage. Concurrent outbreaks with similar modes of transmission can be unrelated, and the source for each should be confirmed through traceback. Proper storage and handling of shellfish is essential to maintaining safety of food products to consumers. Cooking oysters to 145°F (62.8°C) is recommended before consumption.

BACKGROUND: Firefighters are at an increased risk of cancer and other health conditions compared with the general population. However, the specific exposures and mechanisms contributing to these risks are not fully understood. This information is critical to formulate and test protective interventions. OBJECTIVE: The purpose of the Fire Fighter Cancer Cohort Study (FFCCS) is to conduct community-engaged research with the fire service to advance the evaluation and reduction of firefighter exposures, along with understanding and mitigating effects leading to an increased risk of cancer and other health conditions. This involves establishing a long-term (>30 years) firefighter multicenter prospective cohort study. METHODS: The structure of the FFCCS includes a fire service oversight and planning board to provide guidance and foster communication between researchers and fire organizations; a data coordinating center overseeing survey data collection and data management; an exposure assessment center working with quantitative exposure data to construct a firefighter job exposure matrix; and a biomarker analysis center, including a biorepository. Together, the centers evaluate the association between firefighter exposures and toxic health effects. Firefighter research liaisons are involved in all phases of the research. The FFCCS research design primarily uses a set of core and project-specific survey questions accompanied by a collection of biological samples (blood and urine) for the analysis of biomarkers of exposure and effect. Data and samples are collected upon entry into the study, with subsequent collection after eligible exposures, and at intervals (eg, 1-2 years) after enrollment. FFCCS data collection and analysis have been developed to evaluate unique exposures for specific firefighter groups; cancer risks; and end points in addition to cancer, such as reproductive outcomes. Recruitment is carried out with coordination from partnering fire departments and eligible participants, including active career and volunteer firefighters in the United States. RESULTS: The FFCCS protocol development was first funded by the US Federal Emergency Management Agency in 2016, with enrollment beginning in February 2018. As of September 2024, >6200 participants from >275 departments across 31 states have enrolled, including recruit and incumbent firefighters. Biological samples have been analyzed for measures of exposure and effect. Specific groups enrolled in the FFCCS include career and volunteer structural firefighters, women firefighters, trainers, fire investigators, wildland firefighters, firefighters responding to wildland-urban interface fires, and airport firefighters. Peer-reviewed published results include measurement of exposures and the toxic effects of firefighting exposure. Whenever possible, research results are provided back to individual participants. CONCLUSIONS: The FFCCS is a unique, community-engaged, multicenter prospective cohort study focused on the fire service. Study results contribute to the evaluation of exposures, effects, and preventive interventions across multiple sectors of the US fire service, with broad implications nationally. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/70522.

Emergency medical service (EMS) providers face significant exposure to infectious aerosols during outbreaks like the COVID-19 pandemic. Most ambulances lack ventilation controls to reduce EMS worker exposure to these aerosols. Ambulances are smaller than hospital rooms and handle numerous patients daily, increasing contact with potentially infectious individuals. Ventilation controls such as portable high-efficiency particulate air (HEPA) filtration can mitigate this risk. Few studies have assessed portable HEPA filters in ambulances. This study evaluated two HEPA filter models in an unoccupied, stationary research ambulance at the National Institute for Occupational Safety and Health (NIOSH) in Cincinnati. A tracer aerosol simulated patient aerosol generation, and optical particle counters (OPCs) measured aerosols. The HEPA units were tested individually, placed in the same location, and operated for 50 min. Results showed significant reductions in aerosol concentrations during the generation phase, with performance varying during the decay period. Overall, HEPA units reduced particle concentrations by around 50% during the generation phase and continued to be effective through the decay period. This demonstrates the potential of portable HEPA filters as an affordable and effective option for air cleaning in ambulance patient modules.

BACKGROUND: Public health threats (PHTs) influence how and in what ways managers communicate with employees. Employee resources and information during uncertain times has been noted as a reoccurring gap, especially as it relates to personal protective equipment (PPE). This study explored general and PPE-specific communication practices with 22 healthcare and emergency medical service (EMS) managers to support workers, particularly in the context of preparedness and response. METHODS: Data collection occurred in two phases that involved interviews and small group discussions to identify, examine, and better frame and execute communication practices. Qualitative analysis was informed by the 4i FACT framework and the social ecological model (SEM) to identify relevant communication practices and intervention points within health delivery settings. RESULTS: Results elucidated perceived, effective leadership practices and interpersonal influences in the workplace. Tangible leadership communication practices were identified as important intervention points within the SEM, with a focus on proactive behaviors to procure necessary PPE and disseminate information. Participants emphasized one-on-one interactions with employees, and the use of trusted messengers to share health-related messages. They also highlighted the challenges of PPE shortages and the importance of access to resources across different job roles, organizations, and work settings. CONCLUSIONS/APPLICATION TO PRACTICE: This study contributes insights into communication practices during a public health emergency, offering a nuanced understanding of managerial approaches, PPE-related communication, and the broader contextual factors influencing information dissemination. Further, the integration of frameworks like 4i FACT and SEM provides a structured perspective for future communication strategies, supporting tailored approaches across organizations.

BACKGROUND: Powered equipment for patient handling was designed to alleviate Emergency Medical Service (EMS) clinician injuries while lifting patients. This project evaluated the organizational rationale for purchasing powered equipment and the outcomes from equipment use. METHODS: This project analyzed secondary data obtained via an insurance Safety Intervention Grant (SIG) program in Ohio USA. These data were primarily in reports from EMS organizations. Investigators applied a mixed-methods approach, analyzing quantitative data from 297 grants and qualitative data from a sample of 64 grants. Analysts abstracted data related to: work-related injuries or risk of musculoskeletal-disorders (MSD), employee feedback regarding acceptance or rejection, and impact on quality, productivity, staffing, and cost. RESULTS: A total of $16.67 million (2018 adjusted USD) was spent from 2005 through 2018 for powered cots, powered loading systems, powered stair chairs, and non-patient handling equipment (eg, chest compression system, powered roller). Organizations purchased equipment to accommodate staff demographics (height, age, sex) and patient characteristics (weight, impairments). Grantees were fire departments (n = 254) and public (n = 19) and private (n = 24) EMS organizations consisting of career (45%), volunteer (20%), and a combination of career and volunteer (35%) staff. Powered equipment reduced reported musculoskeletal injuries, and organizations reported it improved EMS clinicians' safety. Organization feedback was mostly positive, and no organization indicated outright rejection of the purchased equipment. Analyst-identified design advantages for powered cots included increased patient weight capacity and hydraulic features, but the greater weight of the powered cot was a disadvantage. The locking mechanism to hold the cot during transportation was reported as an advantage, but it was a disadvantage for older cots without a compatibility conversion kit. Around one-half of organizations described a positive impact on quality of care and patient safety resulting from the new equipment. CONCLUSION: Overall, organizations reported improved EMS clinicians' safety but noted that not all safety concerns were addressed by the new equipment.

BACKGROUND: Persons with end stage kidney disease (ESKD) on dialysis are at high risk for severe COVID-19 disease. In September 2023, 2023-2024 COVID-19 vaccination was recommended in the United States for all persons aged ≥6 months. Due to possible immune dysfunction, advanced age, and high prevalence of additional underlying conditions, including immunocompromising conditions, among individuals with ESKD, reduced vaccine effectiveness (VE) is a concern. Understanding effectiveness of 2023-2024 COVID-19 vaccine among persons with ESKD can inform COVID-19 vaccine recommendations for this population. METHODS: A retrospective cohort investigation was conducted among Medicare fee-for-service beneficiaries aged ≥18 years with ESKD receiving dialysis using Medicare enrollment and claims records. Follow-up began on September 17, 2023, and continued until the earliest occurrence of claim for a COVID-19-associated outcome, other censoring event, or end of follow-up. A marginal structural Cox model was used to estimate VE (calculated as [1 - hazard ratio]*100 %), interpreted as the benefit of 2023-2024 COVID-19 vaccination compared with no 2023-2024 vaccine dose. VE was estimated by presence of additional immunocompromising conditions, age group, and time since vaccination. RESULTS: During September 17, 2023 - April 13, 2024, 17,749/112,250 (16 %) Medicare beneficiaries aged ≥18 years with ESKD without additional immunocompromising conditions received a 2023-2024 COVID-19 vaccine dose, with a maximum 209 days of follow-up since vaccination. During the follow-up period 6539 medically attended COVID-19 events, including 3605 COVID-19-associated hospitalizations, 789 COVID-19-associated deaths, and 896 COVID-19-associated thromboembolic events, were recorded. VE against COVID-19-associated hospitalization was 55 % (95 % confidence interval [CI]: 42 % - 65 %) at 7-59 days after vaccination and 47 % (95 % CI: 35 % - 57 %) at ≥60 days after vaccination. VE against COVID-19-associated death was 71 % (95 % CI: 46 % - 84 %) at 7-59 days after vaccination and 51 % (95 % CI: 24 % - 69 %) ≥60 days after vaccination. VE against COVID-19-associated thromboembolic events was 44 % (95 % CI, 24 %, 59 %). CONCLUSIONS: The 2023-2024 COVID-19 vaccines provided protection against COVID-19-associated hospitalization, death, and thromboembolic events among adults with ESKD. These data support the recommendation that adults with ESKD receive the updated COVID-19 vaccine.

OBJECTIVE: Potentially preventable hospitalizations are inpatient admissions for a standard set of selected acute illnesses and chronic conditions that might have been avoided with preventive care or outpatient management. During 2010-2012, Alaska Native adults had higher rates of potentially preventable hospitalizations compared to other adults in Alaska. We evaluated potentially preventable hospitalizations among American Indian/Alaska Native (AI/AN) adults in the United States during 2016-2021. METHODS: We used hospital discharge data from the Indian Health Service National Patient Information Reporting System (NPIRS) to calculate and compare average annual age-adjusted rates of potentially preventable hospitalizations per 1000 AI/AN adults for two acute conditions (community-acquired pneumonia and urinary tract infection) and four chronic conditions (diabetes, heart failure, asthma/chronic obstructive pulmonary disease, and hypertension). RESULTS: Of 310,889 hospitalizations among AI/AN adults, 40,400 (13 %) were defined as potentially preventable for an annual rate of 7.6 per 1000 persons. Rates were stable during 2016-2019 (8.7 per 1000) but declined during 2020-2021 (5.9 per 1000), likely related to the COVID-19 pandemic. Older adults and rural residents had significantly higher rates of potentially preventable hospitalizations across all six conditions assessed, with community-acquired pneumonia having the highest hospitalization rate among adults aged ≥65 years (5.2 per 1000). CONCLUSIONS: Targeted preventive care and appropriate outpatient management for AI/AN elders living in rural areas might help improve health and reduce medical costs through decreased hospitalizations. Vaccination against respiratory infections could have the greatest impact in reducing preventable hospitalizations among AI/AN adults.

Interruption of service events may result in a temporary inability to use equipment or laboratory space, compromise staffing and infrastructure, preclude maintenance or calibration of equipment, and prevent or require extensive disinfection and decontamination. A continuity of operations plan allows a mycobacteriology laboratory to shift efficiently from its regular structure to one that enables timely continuation of testing services. The Continuity of Operations Plan Toolkit for Public Health Mycobacteriology Laboratories was developed to aid continuity of operations planning for mycobacteriology laboratories that offer testing services for diagnosing tuberculosis. The toolkit includes processes for creating, modifying, or implementing mycobacteriology continuity of operations plans, including considerations for leveraging partnerships. Available within the toolkit are various templates and checklists which can be adapted to meet specific local needs. While intended for public health laboratories, the toolkit is applicable for clinical, commercial, and other laboratory types that may perform tuberculosis testing.

PURPOSE: An increase in injection drug use (IDU) has placed new populations at risk for HIV. Understanding the spatial and temporal patterns of HIV diagnoses and care outcomes is crucial to identify gaps in care for people who inject drugs (PWID). METHODS: We analyzed CDC's National HIV Surveillance System (NHSS) data from 2016 to 2022 to examine regional trends and rural-urban differences in linkage to HIV care within one month and viral suppression within six months of diagnosis among individuals aged 13 and older with HIV attributed to IDU. Rural-urban populations were defined using US Department of Agriculture-Economic Research Service (USDA-ERS) Rural-Urban Continuum Codes (RUCC), and trends were assessed using estimated annual percentage change (EAPC). RESULTS: From 2016 to 2022, HIV diagnoses attributed to IDU increased in large rural counties and small to medium urban counties but linkage to care and viral suppression remained unchanged in these areas. Conversely, diagnoses in large urban counties declined while linkage to care and viral suppression increased. CONCLUSIONS: These findings highlight disparities in HIV diagnoses, linkage to care, and viral suppression across rural and urban areas, emphasizing the need to address these gaps to improve care for PWID and inform public health policies.

AIMS: To examine the national trend in per-capita medical expenditures among U.S. adults with diabetes from 2000 to 2022. METHODS: We analyzed data from the Medical Expenditure Panel Survey in U.S. adults aged ≥18 years with self-reported diabetes. We calculated the expenditure in total and by component, including outpatient services, inpatient services, emergency room (ER) visits, prescription drugs, and other medical services. We used joinpoint regression to identify changes in trends. RESULTS: Estimated total per-capita expenditure increased 66 %, from $9,700 (95 % CI $8,736-$10,663) in 2000 to $16,067 (95 % CI $15,049-$17,086) in 2022. Specifically, spending on prescription drugs, outpatient, ER, and other medical services increased by 144 %, 96 %, 122 %, and 135 %, respectively, while inpatient spending decreased by 28 %. Two significant upward trend periods (2000-2004 and 2011-2018) were identified for total expenditure. Spending trends by component varied, with an accelerated increase in prescription drug spending after 2012; by 2022, prescription drugs accounted for the largest share (39 %) of total expenditures. CONCLUSIONS: The economic burden of diabetes on the national health care system has been increasing, with spending changes varying by medical service category. Interventions to prevent diabetes and its complications may help mitigate this growing economic burden.

BACKGROUND: Medicare claims are frequently used to study Clostridioides difficile infection (CDI) epidemiology. However, they lack specimen collection and diagnosis dates to assign location of onset. Algorithms to classify CDI onset location using claims data have been published, but the degree of misclassification is unknown. METHODS: We linked patients with laboratory-confirmed CDI reported to four Emerging Infections Program (EIP) sites from 2016-2021 to Medicare beneficiaries with fee-for-service Part A/B coverage. We calculated sensitivity of ICD-10-CM codes in claims within ±28 days of EIP specimen collection. CDI was categorized as hospital, long-term care facility, or community-onset using three different Medicare claims-based algorithms based on claim type, ICD-10-CM code position, duration of hospitalization, and ICD-10-CM diagnosis code presence-on-admission indicators. We assessed concordance of EIP case classifications, based on chart review and specimen collection date, with claims case classifications using Cohen's kappa statistic. RESULTS: Of 12,671 CDI cases eligible for linkage, 9,032 (71%) were linked to a single, unique Medicare beneficiary. Compared to EIP, sensitivity of CDI ICD-10-CM codes was 81%; codes were more likely to be present for hospitalized patients (93.0%) than those who were not (56.2%). Concordance between EIP and Medicare claims algorithms ranged from 68% to 75%, depending on the algorithm used (κ = 0.56-0.66). CONCLUSION: ICD-10-CM codes in Medicare claims data had high sensitivity compared to laboratory-confirmed CDI reported to EIP. Claims-based epidemiologic classification algorithms had moderate concordance with EIP classification of onset location. Misclassification of CDI onset location using Medicare algorithms may bias findings of claims-based CDI studies.

BACKGROUND: The World Health Organization (WHO) recommends parasite-based diagnosis of malaria before treatment. The use of nucleic-acid amplification (NAAT) for detection of Plasmodium spp. has expanded rapidly in recent years, for epidemiological research globally and clinical care in high-resource settings. Data from NAATs are frequently used to inform policy decisions, so quality control is essential to ensure results are reliable and comparable. Therefore, robust quality control, including an external quality assessment (EQA) scheme targeting malaria NAATs, is essential. The WHO Global Malaria Programme and the UK National External Quality Assessment Service (UK NEQAS) have collaborated since 2017 to implement a global malaria NAAT EQA scheme. METHODS: Panels of specimens containing five major species of human-infecting Plasmodium at various parasite concentrations and negative samples were created in lyophilized blood (LB) and dried blood spot (DBS) formats. Two distributions per year were sent, containing five LB and five DBS specimens. Samples were validated by expert referee laboratories prior to distribution. Between 37 and 51 laboratories participated in each distribution and submitted results online. Participants were scored based on their laboratory's stated capacity to identify Plasmodium species, and individual laboratory reports were sent which included performance comparison with anonymized peers. Change in performance over time was calculated using a generalized mixed model with a logit link function. RESULTS: Participating laboratories were located in 42 countries. Sample format (DBS or LB) and parasite density were found to significantly affect performance, while referee labs performed better at identifying P. falciparum samples than non-referee labs. Performance of laboratories improved significantly over time, especially for lower density and P. falciparum samples. CONCLUSIONS: Results from the first eleven distributions indicate that the EQA scheme has facilitated improved performance of laboratories over time, highlighting the value of implementing such programmes. EQA schemes are critical to safeguarding the reliability of data and diagnoses, especially in situations where NAAT methodologies and protocols are used. In future, funders should make participation in an EQA scheme a requirement for laboratories, and countries can take initiatives to embed such schemes into their own national assessment programmes.

The Pacific Island Health Officers' Association, the World Health Organization, and the Pacific Community co-organized the launch of the Pacific Vector Network (PVN) to address challenges posed by mosquito-borne diseases, including dengue fever, Zika virus disease, chikungunya, malaria, and lymphatic filariasis. The PVN was created as a new initiative under the Pacific Public Health Surveillance Network (PPHSN). This launch was a critical step in the build-up to PVN as a full-service network of PPHSN in the coming years. The Pacific Island Countries and areas (PIC)-led network comprises vector management leadership, officers, and technical partners dedicated to supporting information-sharing to promote evidence-based collective action and innovation. The setup of a Technical Working Body to ensure governance and to steer forward the work of the network was a key deliverable. This manuscript describes the proceedings and discussions of PIC representatives and several regional partners at the inaugural PVN meeting held 5-7 June 2023 in Hawai'i, USA.

BACKGROUND: Dentists, dental hygienist, and veterinary technicians using drills, scalers and polishers are at risk of developing sensorineural deficits in the fingers and hands. The goal of this study was to determine whether exposure to high-frequency vibration contributed to changes in sensory function. METHODS: The tails of rats were exposed to vibration at 1250 Hz (constant acceleration of 49 m/s2) for 4 hours per day, for 10 days. The effects on sensory nerve function, and vascular function were measured. RESULTS: Vibration increased sensitivity to applied pressure and to transcutaneous electrical stimulation at 2000 and 250 Hz. It also resulted in a reduction in blood flow and myogenic tone. CONCLUSIONS: Exposure to high-frequency vibration has detrimental effects on both peripheral sensorineural and vascular function.

PROBLEM/CONDITION: Approximately 800 foodborne illness outbreaks occur in the United States each year. These outbreaks include approximately 15,000 illnesses, 800 hospitalizations, and 20 deaths. Although illnesses from outbreaks account for a small portion of all foodborne illnesses, outbreak investigations reveal how these illnesses originate by offering crucial data through epidemiologic, environmental health, and laboratory analyses and aid in outbreak mitigation and prevention. PERIOD COVERED: 2014-2022. DESCRIPTION OF SYSTEM: The Foodborne Disease Outbreak Surveillance System (FDOSS), via the National Outbreak Reporting System (NORS), captures data from foodborne enteric illness outbreak investigations in the United States. Epidemiology or communicable disease control and environmental health programs of state and local health departments collect and voluntarily report the data to NORS, which is managed by CDC. These data include information about cases (e.g., case counts, symptoms, duration of illness, and health care-seeking behaviors), laboratory specimens, settings of exposure, implicated food items, and contributing factors (i.e., how the outbreak occurred). A foodborne illness outbreak is defined as two or more cases of a similar illness associated with a common exposure (e.g., shared food, venue, or experience). Data collected from an outbreak investigation help the investigator identify contributing factors to the outbreak. Contributing factors are food preparation practices, behaviors, and environmental conditions that lead to pathogens getting into food, growing in food, or surviving in food and are grouped into three categories: contamination (when pathogens and other hazards get into food), proliferation (when pathogens that are already present in food grow), and survival (when pathogens survive a process intended to kill or reduce them). RESULTS: A total of 2,677 (40.5%) foodborne illness outbreaks reported during 2014-2022 with information on contributing factors were included in this analysis. Foodborne outbreak periods were categorized into three time frames: 2014-2016 (first), 2017-2019 (second), and 2020-2022 (third). Of the 2,677 outbreaks, 1,142 (42.7%) occurred during the first time frame, 1,130 outbreaks (42.2%) during the second time frame, and 405 outbreaks (15.1%) during the third time frame. The proportion of bacterial outbreaks increased from the first (41.9%) to the third time frame (48.4%), and the proportion of viral outbreaks decreased (33.3% to 23.2%). Over the three time frames, the proportion of outbreaks with a contamination contributing factor decreased (85.6%, 83.6%, and 81.0%, respectively). The proportion of outbreaks with a proliferation contributing factor category decreased from the first (40.3%) to the second time frame (35.0%), then increased during the third time frame (35.1%), and the proportion of outbreaks with a survival contributing factor category decreased from the first (25.7%) to the second time frame (21.9%), then increased during the third time frame (25.7%). The proportion of outbreaks with aquatic animals as an implicated food item increased from the first (12.0%) to the second time frame (18.5%), then decreased during the third time frame (18.3%). The proportion of outbreaks with land animals as an implicated food item decreased from the first (16.7%) to the second time frame (14.2%), then increased during the third time frame (15.1%).For outbreaks with a contamination contributing factor, the proportion of food contaminated by an animal or environmental source before arriving at the point of final preparation increased over the three time frames (22.2%, 27.7%, and 32.3%, respectively), and the proportion of outbreaks with contamination from an infectious food worker through barehand contact with food decreased (20.5%, 15.2%, and 8.9%, respectively). For the proliferation category, the proportions of outbreaks associated with allowing foods to remain out of temperature control for a prolonged period during preparation and during food service or display decreased over the three time frames (15.2%, 12.2%, and 9.9%, respectively; and 13.6%, 10.4%, and 8.9%, respectively), and the proportion of improper cooling of food decreased from the first (9.4%) to the second time frame (8.8%), then increased during the third time frame (10.9%). For the survival category, the proportion of outbreaks associated with inadequate time and temperature control during initial cooking/thermal processing of food decreased from the first (12.1%) to the second time frame (9.6%) and increased during the third time frame (12.1%).For bacterial outbreaks, cross-contamination of foods was among the top five contributing factors during the first (22.0%) and second time frames (20.8%) but not during the third time frame. Inadequate time and temperature control during initial cooking of food was among the top five contributing factors during all three time frames (23.8%, 20.4% and 20.9%, respectively). Improper cooling was not among the top five contributing factors during the first and second time frames but was during the third time frame (17.3%). For viral outbreaks, contamination from an infectious food worker through barehand contact with food was among the most common contributing factors during the first (47.1%) and second time frames (37.7%) and decreased to the third most common contributing factor during the third time frame (28.7%). Contamination from an infectious food worker through gloved-hand contact with food was among the top five contributing factors during the first (32.1%) and second time frame (25.5%) and was the most common contributing factor during the third time frame (42.5%). INTERPRETATION: Many foodborne illness outbreaks occur because of contamination of food by an animal or environmental source before arriving at the point of final preparation. Most viral outbreaks are caused by contamination from ill food workers. The decrease in the proportion of viral outbreaks and the proportion of outbreaks with a contamination contributing factor during 2020-2022 might be attributed to effects from the COVID-19 pandemic. Nonpharmaceutical interventions (e.g., increased glove use, cleaning and disinfection, and closure of restaurant dining areas) implemented during the COVID-19 pandemic likely led to a reduction in norovirus, which is typically spread by infectious food workers. Two common contributing factors to bacterial outbreaks are allowing foods to remain out of temperature control for a prolonged period and inadequate time and temperature control during cooking. Proper time and temperature controls are needed to effectively eliminate bacterial pathogens from contaminated foods and ensure safe food operations. PUBLIC HEALTH ACTION: Retail food establishments can follow science-based food safety guidelines such as the Food and Drug Administration Food Code and Hazard Analysis and Critical Control Points (HACCP) plans. Restaurant managers can mitigate contamination by ill food workers by implementing written policies concerning ill worker management, developing contingency plans for staffing during worker exclusions, and addressing reasons why employees work while sick. Health department staff members who investigate outbreaks and conduct routine inspections can encourage restaurants to follow their HACCP plans and other verified food safety practices, such as cooling, to prevent outbreaks.

We conducted a demonstration project of telemedicine HIV care services at the University of Florida (UF) College of Medicine, Jacksonville. Our sample focused on members of racial and ethnic minority groups living in an urban setting. As part of the project's evaluation, we conducted 13 focus groups. Focus groups assessed patient, staff, and provider experiences with facilitating or hindering factors to engaging in telemedicine. We also explored the decision-making processes among people with HIV (PWH) to engage or not in telemedicine. The 46 focus group participants included 21 PWH: 12 PWH who accepted and nine who declined participation in telemedicine. The remaining 25 focus group participants were comprised of medical, clinical support, and community-based organization staff who supported the demonstration project. An unexpected finding that emerged in the focus group narratives detailed that some PWH who accepted telemedicine visits appreciated that telemedicine minimized the stigma they have experienced during in-person healthcare encounters. Among PWH who declined a telemedicine visit, they felt the extension of service into their personal world invaded their privacy, created routes for stigma should their HIV status be disclosed outside the healthcare setting, and raised concerns about confidentiality in virtual settings. Like the PWH, the professionals were mixed in their opinions in that some felt telemedicine facilitated care while others raised concerns. Findings point to the importance of allowing PWH to select the format (in-person or via telemedicine) in which their HIV care is rendered and highlight the importance of intervening to decrease healthcare facility-based stigma.

BACKGROUND: Health disparities exist across socioeconomic status levels, yet empirical evidence between financial well-being (FWB) and health are limited. METHODS: This cross-sectional study combined data from 25 370 adults aged ≥18 years in the 2019 National Health Interview Survey with estimated household FWB scores from the Consumer Financial Protection Bureau's 2016 National Financial Well-being Survey. FWB associations with health service visits, biometric screenings, smoking status, body mass index and physical and mental conditions were tested using age-adjusted, sex-adjusted and health insurance coverage-adjusted linear regression analysis. RESULTS: In 2019, the mean FWB for US adults was 56.1 (range 14 (worse) to 95 (best)). With increasing time since the last health service visit or screening, FWB was increasingly lower compared with adults with visits or screenings <1 year (≥10 years or 'never', FWB ranged from -1 (blood sugar check) to -6.5 (dental examination/cleaning) points). FWB was lower with declining general health status (excellent (reference), very good (-0.5 points), good (-3.4 points) and fair/poor (-6.6 points)). Adults with physical health conditions had FWB lower than adults without (range -0.4 (high cholesterol) to -4.6 (disability) points). FWB were lower in adults who have ever been diagnosed with anxiety disorder (-1.8 points) or depression (-2 points). Adults managing their anxiety or depression (no/minimal symptoms currently) had greater FWB (anxiety: 3 points and depression: 4.1 points) than those with symptoms. CONCLUSION: Given the observed associations between FWB and health-related measures, it is crucial to consider FWB in primary and secondary health prevention efforts, recognising the relationship between economics, health and wellness.

BACKGROUND: Cardiac rehabilitation (CR) can improve cardiovascular health. We identified whether CR participation was associated with fewer subsequent inpatient hospitalizations and emergency department visits and less Medicare and out-of-pocket expenditures, and whether outcomes varied by amount of participation. METHODS: This retrospective study used Medicare fee-for-service claims data, including beneficiaries with a CR-qualifying event in 2016. Participants attended ≥2 sessions of CR within 365 days of the event. Propensity score matching was used to identify CR-eligible nonparticipants. Difference-in-differences analyses were used to compare differences in outcomes before (2014-2015) and after (2018-2019; 2-year CR period=2016-2017) the CR period between participants and nonparticipants. RESULTS: We identified 57 668 CR-eligible beneficiaries after matching, with equal numbers of participants and nonparticipants. Nearly 65% of beneficiaries had a percutaneous coronary intervention, 33.5% had an acute myocardial infarction, 17.5% had a coronary artery bypass graft, and 16.8% had a heart valve repair/replacement. Compared with nonparticipants, participants had 47.6 fewer subsequent annual inpatient hospitalizations per 1000 beneficiaries (95% CI, -58.8 to -36.3) and $1005 lower subsequent annual Medicare expenditures per beneficiary (95% CI, -$1352 to -$659). Compared with no participation, medium participation (12-23 sessions), high participation (24-35 sessions), and CR completion (≥36 sessions) were associated with fewer inpatient hospitalizations and lower Medicare expenditures per year. CONCLUSIONS: CR was associated with fewer subsequent annual inpatient hospitalizations and lower subsequent annual Medicare expenditures. A higher amount of participation was associated with a further reduction in hospitalizations and expenditures. These findings can inform programs and policies that encourage CR participation.

OBJECTIVES/BACKGROUND: We evaluated patterns of serum concentrations of endocrine disrupting chemicals (EDCs), namely polychlorinated biphenyls (PCBs), organochlorine pesticides (OCPs), and polybrominated diphenyl ethers (PBDEs), in a U.S. military sample by race/ethnicity (R/E) and sex. METHODS: Twenty-three EDCs were measured in stored serum samples obtained between 1995 and 2010 for 708 service members from the Department of Defense Serum Repository. For each EDC, geometric means (GM) were estimated using log-transformed concentrations in a linear regression model, for eight combined R/E/sex groups: non-Hispanic White (NHW), non-Hispanic Black (NHB), non-Hispanic Asian (NHA), and Hispanic men and women, adjusted for age and service branch and stratified by age tertile ("younger age": 17-23, "middle age": 24-30, and "older age": 31-52 years). Comparisons were made between our military sample and the National Health and Nutrition Examination Survey (NHANES) 2003-2004 data for NHW and NHB groups. RESULTS: Within our military sample, the highest PCB concentrations were among older age NHB men and women and highest OCP concentrations among older age NHB women and NHA men. PBDE concentrations were generally highest in middle age Hispanic women and NHA men, though based on small sample size. Generally, NHB men and women had higher concentrations of EDCs in both the military and NHANES. CONCLUSIONS: We found patterns of elevated EDC concentrations among NHB, NHA, and Hispanic groups in the military sample and for NHB men and women in NHANES. There were no consistent patterns of higher or lower EDCs comparing the military to NHANES. Future studies of EDCs and health outcomes should stratify by R/E/sex to account for potential disparities in EDC concentrations.

Key populations (KP), such as female sex workers (FSW) and men who have sex with men (MSM) can engage in multiple behaviors associated with HIV risk, but they are typically categorized by a single defining behavior, i.e., selling sex and sex with a man, respectively. We estimated the prevalence of engaging in multiple KP defining behaviors such as buying/selling sex, receptive anal sex, and injection drug use (IDU) among KP in Uganda. Data were collected at survey offices in four sites (Kampala, Jinja, Mbarara, and Masaka) through respondent-driven sampling. Data across multiple sites were combined and reweighted based on the combined sample size for each population. We fitted weighted multinomial logistic models for additional KP defining behaviors using demographics as predictors, and the simplest plausible model was identified for each KP using the Bayesian Information Criterion. Among FSW and sexually exploited minors under 18 years of age, 21.8% (CI: 20.1-23.5%) ever engaged in anal sex and 12.0% (CI: 10.6-13.3%) ever engaged in IDU in our model. Among MSM, 54.8% (CI: 52.0-57.7%) ever engaged in buying/selling sex and 11.0% (CI: 9.3-12.8%) ever engaged in IDU in the model. While KP are generally viewed as independent groups, our findings demonstrate that KP defining behaviors such as buying/selling sex, anal sex with a man, and IDU are shared across populations, with buying/selling sex particularly common among MSM. Consideration of comprehensive behaviors by outreach and service providers may better inform HIV risk reduction and prevention services for key populations.

Glutaraldehyde (Chemical Abstracts Service [CAS] registry number 111-30-8) has various occupational uses and is associated with adverse health effects including respiratory tract irritation, asthma, and chronic obstructive pulmonary disease. A quantitative risk assessment was conducted to evaluate the likelihood of adverse health effects associated with differing levels of occupational inhalation exposure to glutaraldehyde. Dose-response models were fit to data from a 2-year glutaraldehyde inhalation exposure bioassay conducted by the National Toxicology Program. The benchmark concentration lower bound values of 32 and 44 parts per billion (ppb) were based on bioassay data for female rats and mice that developed squamous epithelium inflammation and respiratory epithelium squamous metaplasia, respectively. These values were used as a point of departure to determine exposure levels relevant to the occupational setting. Extrapolation from rodents to humans assumed a 40-h workweek and an 8-fold uncertainty factor to account for interspecies and interindividual variability. Adjusted benchmark lower bound concentrations of 3 and 4.1 ppb were calculated for inhalation exposure to glutaraldehyde using the endpoints observed in rat and mouse models. Due to the extrapolation parameters used in deriving this result, these findings have applicability for exposure to glutaraldehyde in the occupational setting.