The January/February 2024 issue of the Journal of Environmental Health (Volume 87, Number 6), published by the National Environmental Health Association.
Environmental Health To build, sustain, and empower an effective environmental health workforce Volume 87, No. 6 January/February 2025 Journal of
neha.org
Published by the National Environmental Health Association
Environmental Health To build, sustain, and empower an effective environmental health workforce Volume 87, No. 6 January/February 2025 Journal of
ADVANCEMENT OF THE SCIENCE
ABOUT THE COVER
Preventing foodborne illness within military operations is essen- tial to maintain the security and defense capabili- ties of units. This month’s cover article evaluated
A Retrospective, Time-Stratified, Case-Crossover Study of the Eect of PM 2.5 on Asthma Exacerbations in Rural Counties in Wisconsin........................................................8
Bloodborne Pathogen Exposure and the Culture of Reporting Sharps Injuries at a Large Academic Institution................................................................................................14
Relationship Between Employee Food Safety Training and Food Safety Risk Factors at Fort Liberty Military Installation in North Carolina.............................................................20
the status of food safety training for the person- in-charge and other food service employees at Fort Liberty—the largest Army installation in the U.S.—in North Carolina. The authors also evaluated the extent to which training related to the Centers for Disease Control and Preven- tion’s five foodborne illness risk factors identi- fied during inspections. Overall, the study reinforces the need to maintain food safety training by managers and employees to reduce the potential for foodborne illnesses. See page 20. Cover images © iStockphoto: Hispanolistic/GreenTana
ADVANCEMENT OF THE PRACTICE
Direct From CDC/Environmental Health Services: Using Games to Foster Collaboration and Inclusivity in Emergency Preparedness ........................................................... 28
The Practitioner's Tool Kit: Complexities and Strategies for Controlling Contamination ............. 32
ADVANCEMENT OF THE PRACTITIONER
Environmental Health Calendar ...............................................................................................34
ADVERTISERS INDEX
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Spotlight on NEHA Resources: Supporting Your Credential Journey .......................................... 38
YOUR ASSOCIATION
President’s Message: The Importance of Environmental Health Education and Development .................. 6
NEHA 2025 AEC.......................................................................................................................40
Special Listing...........................................................................................................................42
A Tribute to Our 2024 Peer Reviewers......................................................................................44
NEHA News..............................................................................................................................47
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January/February 2025 • Journal of Environmental Health
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An open access journal published monthly (except bimonthly in January/ February and July/August) by the National Environmental Health Association (NEHA), 1400 S. Colorado Blvd., Ste. 325, Denver, CO 80222-3622. Phone: (303) 802-2200; Internet: www.neha.org. E-mail: jeh@neha.org. Volume 87, Number 6. Yearly print subscription rates: $160 (U.S.) and $200 (international). Single print copies: $15, if available. Claims must be filed within 30 days domestic, 90 days foreign, © Copyright 2025, NEHA (no refunds). Opinions and conclusions expressed in articles, columns, and other contributions are those of the authors only and do not reflect the policies or views of NEHA. NEHA and the Journal of Environmental Health are not liable or responsible for the accuracy of, or actions taken on the basis of, any information stated herein. NEHA and the Journal of Environmental Health reserve the right to reject any advertising copy. Advertisers and their agencies will assume liability for the content of all advertisements printed and also assume responsibility for any claims arising therefrom against the publisher. Advertising rates available at www.neha.org/jeh. The Journal of Environmental Health is indexed by Clarivate, EBSCO (Applied Science & Technology Index), Elsevier (Current Awareness in Biological Sciences), Gale Cengage, and ProQuest. The Journal of Environmental Health is archived by JSTOR (www.jstor.org/journal/ jenviheal). Full electronic issues from present to 2012 available at www.neha.org/jeh. All technical manuscripts submitted for publication are subject to peer review. Visit www.neha.org/jeh for submission guidelines and instructions for authors. To submit a manuscript, visit https://jeh.msubmit.net. Direct all questions to jeh@neha.org. Periodicals postage paid at Denver, Colorado, and additional mailing offices. POSTMASTER: Send address changes to Journal of Environmental Health , 1400 S. Colorado Blvd., Ste. 325, Denver, CO 80222-3622.
Erratum In the November 2024 Journal of Environmental Health (volume 87, number 4), the author listing for G. Zarus was incorrectly listed in the column, “Computational Modeling Approaches Applied to Public and Environmental Health,” by P. Ruiz, G. Zarus, and S. Desai. The correct listing is: Gregory Zarus, MS. The electronic version of the issue reflects the change at www.neha.org/jeh. in the next Journal of Environmental Health Air Pollution and COVID-19: Exploring the Link Between Pandemic Spread and Pollutants Charting the Path: The Impact of the National Environmental Public Health Internship on Educational and Career Choices Enhanced Hotel Room Cleaning: Environmental Microbiological Sampling Investigation in a Mid- Scale Hotel Property
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Volume 87 • Number 6
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January/February 2025 • Journal of Environmental Health
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PRESIDENT’S MESSAGE
The Importance of Environmental Health Education and Development
CDR Anna Khan, MA, REHS/RS
T he environmental health workforce represents the second largest disci- pline of the public health workforce, second only to nursing. In addition, the 10 Essential Public Health Services describe the public health activities that all communi- ties should have in place and environmental health is part of those activities including “in- vestigate, diagnose, and address health prob- lems and hazards aecting the population” (Centers for Disease Control and Preven- tion, 2024). I find it puzzling and sometimes frustrating that environmental public health is somehow unknown to most people. How do we ensure that people know who environ- mental health professionals are or better yet, that our profession does not fade away? What would be the impact if we no longer exist or if we are blended into another profession that does not emphasize essential elements of life such as clean air, water, and food? In Frank Capra’s classic film, It’s a Wonderful Life , when George discovers a world without his family’s bank, the Baily Brothers Building and Loan, the economically disadvantaged people suered the most. Without environ- mental public health, people who are at the greatest risk would suer the most. Environ- mental health professionals are needed to ensure the health of the whole public. A research brief from the de Beaumont Foundation and Public Health National Cen- ter for Innovation (2021) clearly states the need for public health professionals. The brief emphasizes that state and local health depart- ments need to hire a minimum of 80,000 more full-time equivalent positions to provide adequate infrastructure and public health ser-
so they can engage eectively in conserva- tion eorts and make informed decisions that benefit their communities and the world. By designating a specific day for environmen- tal education, the UN aims to highlight the interconnectedness of human well-being and environmental health, encouraging global participation in sustainability eorts. By equipping people with the knowledge and skills necessary to tackle pressing environ- mental challenges, we not only inform but also mobilize communities around the world to participate in initiatives that promote sus- tainability and ecological balance. The principle of World Environmental Education Day is the belief that education should be inclusive and action-oriented. The UN emphasizes the importance of integrat- ing environmental education into all levels of schooling, fostering critical thinking, and encouraging collaborative problem-solving. And this line of thought brings us to the National Environmental Health Association (NEHA) and what we are doing towards these eorts. As we all know, our mission is to build, sustain, and empower an eective environmental health workforce. While our members might be aware of the countless ways we look to support their empowerment and development, I want to highlight some initiatives and programs that we have in place that focus on environmental health education and development. We have recently created an Office of Student Aairs to support students as they begin their careers. One of those ways is through free student memberships (see Sidebar). Getting an education means more
We will continue to champion environmental health education and
development for all our members.
vices, which is an increase of approximately 80% compared with current stang levels. In addition, among the public health profession- als needed, the brief states that there is a need for 9,500 environmental practitioners. I think this ongoing concern has been exac- erbated since the pandemic. I want, however, to bring to your attention one of the earliest instances of realization of the importance of environmental health workforce education and development. The United Nations (UN) held a conference on the human environment in Stockholm, Sweden, in 1972. The confer- ence was held to bring attention to environ- mental health issues. During this conference, there was a decision to observe a World Envi- ronment Day every June. This conference also led to the establish- ment of a World Environmental Education Day, which is observed every January. It was created to raise awareness about the impor- tance of environmental education. World Environmental Education Day is a way to educate people about environmental issues
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Volume 87 • Number 6
than earning a degree. Employers are look- ing for experience, achievements, and prac- tical knowledge of the profession, all of which we can help our future leaders obtain. Our free student memberships will help stu- dents prepare to enter the workforce on day one. Through our network, student mem- bers also have exclusive access to mentor- ship programs, scholarship opportunities, and discounted rates to attend our Annual Educational Conference & Exhibition. We also recognize that education and learning is a life-long process. So, we have programs in place to help our experienced workforce members continue to grow and develop their skills. One such program is our webinar series of the soft skills of lead- ership (see Sidebar). Through these recorded webinars, you can hear from experts on the current information ecosystem, eective messaging for environmental health profes- sionals, social and emotional skills, and how to work with the media. As we start a new year, it is customary to assess what we have accomplished over the last year and what we hope to attain in the coming several months. While many chal- lenges in environmental public health require
careful coordination, collaboration, and com- promise with our partners and policymakers, we can all agree that professional develop- ment and educational growth should be a priority. Over this year, we will continue to champion environmental health education and development for all our members regard- less of where they are in their environmental health journeys.
Additional Resources
• National Environmental Health Association – Free Student Membership: www.neha.org/students – Leadership: The Hard Facts of Soft Skills: www.neha.org/leadership- webinar-series • 10 Essential Public Health Services: www.cdc.gov/public-health-gateway/ php/about/index.html • Research Brief—Staf ng Up: Workforce Levels Needed to Provide Basic Public Health Services: https:// debeaumont.org/wp-content/uploads/ 2021/10/Staf ng-Up-FINAL.pdf • Report of the United Nations Conference on the Human Environment: https://documents. un.org/doc/undoc/gen/nl7/300/05/ pdf/nl730005.pdf • Workplace Perceptions and Experiences Related to COVID-19 Response Efforts Among Public Health Workers: www.cdc.gov/mmwr/ volumes/71/wr/mm7129a3.htm
akhan@neha.org
References Centers for Disease Control and Prevention. (2024). 10 Essential Public Health Services . https://www.cdc.gov/public-health-gate way/php/about/index.html de Beaumont Foundation, & Public Health National Center for Innovation. (2021, October). Sta ng up: Workforce levels needed to provide basic public health services for all Americans [Research brief]. https://debeau mont.org/wp-content/uploads/2021/10/ Stang-Up-FINAL.pdf
Did You Know?
You can find a listing of our scheduled webinars at www.neha.org/education/ events. We oer a variety of webinars on dierent topics throughout the year. You can also earn continuing education contact hours toward your NEHA credential by attending our webinars.
Stand out in the crowd. Show the world you are the environmental health expert you know you are with a credential. You might even earn more or get promoted. neha.org/credentials
7
January/February 2025 • Journal of Environmental Health
ADVANCEMENT OF THE SCIENCE
Open Access
A Retrospective, Time-Stratified, Case-Crossover Study of the Effect of PM 2.5 on Asthma Exacerbations in Rural Counties in Wisconsin
Our study’s aim was to investigate the association between PM 2.5 and asthma exac- erbations in rural areas of Wisconsin because most previous studies have focused on urban centers. Assessing time-varying pollutant exposures on asthma exacerbations can be challenging, however, particularly when working with administrative data sets that only include cases. To overcome this chal- lenge, we employed the case-crossover study design, which uses cases and self-matched referent periods to e ectively control for con- founding characteristics (Maclure, 1991). In recent years through public health sur- veillance, we have observed that some rural counties in Wisconsin have experienced increasing rates of asthma-related emergency department visits and hospitalizations, and we hypothesized that poor air quality could be a contributing factor. Given the important role of agriculture in Wisconsin’s rural economy, agricultural practices such as prescribed burn- ing, soil tilling, livestock operations emis- sions, and farm equipment use could gener- ate substantial amounts of PM 2.5 (Domingo et al., 2021; U.S. Environmental Protection Agency, 2024). Additionally, wildfires occur- ring in other U.S. states and Canada can lead to high levels of particulate matter that adversely a ect the air quality in Wisconsin. Our study examined the relationship between PM 2.5 and asthma exacerbations in seven rural counties in Wisconsin. Although one study that spanned both rural and urban popula- tions examined the impact of PM 2.5 on asthma exacerbations (Bozigar et al., 2021), our study is the first to specifically focus on rural popu- lations, contributing to the understanding of the impact of air pollution on asthma exacer- bations in rural areas. Megan Elderbrook, MPH, CHES Wisconsin Asthma Program, Wisconsin Department of Health Services Ron Gangnon, PhD Department of Population Health Sciences and Department of Biostatistics and Medical Informatics, School of Medicine and Public Health, University of Wisconsin-Madison Carrie Tomasallo, MPH, PhD Wisconsin Asthma Program, Wisconsin Department of Health Services
Abstract Air pollution is a pervasive environmental health hazard with the potential to worsen respiratory health outcomes, including asthma exacerbations. The impact of PM 2.5 on asthma exacerbations among rural populations is not well understood. Our analysis used a retrospective, time-stratified, case-crossover study design to examine the relationship be- tween PM 2.5 and asthma exacerbations. We included asthma exacerbations that occurred January 1, 2019–June 30, 2022, among residents of seven ru- ral counties in Wisconsin with a PM 2.5 air monitor. We also used PM 2.5 data collected by the Wisconsin Department of Natural Resources and weather data available from the National Oceanic and Atmospheric Administration (NOAA). Further, we used conditional logistic regression to assess the asso- ciation between asthma exacerbations and lagged PM 2.5 levels, adjusting for maximum daily temperature. We found PM 2.5 levels (µg/m 3 ) 2 days prior to exacerbation were significantly associated with asthma exacerbations (haz- ard ratio 1.184; 95% confidence interval [1.051, 1.344]). Our study dem- onstrated an increased hazard of asthma exacerbations with higher levels of PM 2.5 in rural populations. These findings highlight the need for further research and eorts to mitigate the eects of air pollution in rural areas. Keywords: asthma, respiratory health, air pollution, PM 2.5 , rural health
Introduction Asthma is a prevalent chronic lung disease that a ects approximately 1 in 10 children (Centers for Disease Control and Prevention [CDC], 2023a) and 1 in 7 adults in Wiscon- sin (CDC, 2023b). Asthma symptoms can be triggered by tobacco smoke, dust mites, pests, mold, pets, and outdoor air pollution (CDC, 2024). Outdoor air pollution varies by geography (Strosnider et al., 2017) and
is influenced by seasonal weather patterns (Winquist et al., 2014). PM 2.5 is one of the most ubiquitous pollutants and has been shown to exacerbate asthma symptoms. Mul- tiple epidemiological studies have demon- strated that PM 2.5 levels are positively corre- lated with asthma symptoms (Berhane et al., 2016), emergency department visits (Romieu et al., 1996), hospitalizations (Zheng et al., 2015), and mortality (Atkinson et al., 2014).
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Volume 87 • Number 6
Resources, n.d.-a). We used the daily average of PM 2.5 in our analyses as both a continuous variable and categorical variable using Air Quality Index (AQI) categories (Wisconsin Department of Natural Resources, n.d.-b). To handle the small number of random missing PM 2.5 values, we imputed missing values with the mean of nearby daily values (1 day before and 1 day after), as done by Chi et al. (2019). Gaps of more than 1 day were not imputed. Meteorological Exposures We downloaded weather data from the National Oceanic and Atmospheric Adminis- tration (NOAA) for the dates December 18, 2018–July 14, 2022, for the seven rural coun- ties included in this analysis. We included an additional 2 weeks before and after the case date range as potential control dates. We used only the maximum daily temperature from this data set. To handle the small number of missing values, we imputed missing values with the mean of nearby daily values (1 day before and 1 day after). As temperature data for Forest County were unavailable, we used temperatures from the adjacent Vilas County for Forest County measurements. Statistical Analysis We used a retrospective, time-stratified, case- crossover study design to test for associations between PM 2.5 exposures and asthma exac- erbations. We applied conditional logistic regression for multivariate analyses to produce hazard ratios (HR) and 95% confidence inter- vals (CI) (SAS PHREG with TIES=BRESLOW; Wang et al., 2011). We combined clinical encounter data with daily PM 2.5 measure- ments and daily maximum temperature from each county. Control exposure periods were selected by matching the day of the week for 1–2 weeks prior to and 1–2 weeks after the exposure date for each exacerbation ( n = 3–4). We created lag days for PM 2.5 exposures on the day of the exacerbation (lag0) and 1–6 days prior to the exacerbation (lag1–6). We also included a 7-day PM 2.5 average to represent the total exposure to PM 2.5 in the 7-day period prior to the exacerbation. All models were adjusted for daily maxi- mum temperature (°F). In secondary analy- ses, we assessed potential e¥ect modification by sex, race and ethnicity, age, season, and county of residence. Race and ethnicity were evaluated as potential e¥ect modifiers given
TABLE 1
Main Characteristics of Asthma Exacerbations Among Residents From Ashland, Dodge, Forest, Grant, Sauk, Taylor, and Vilas Counties in Wisconsin
Characteristic
# (%) or Mean ± SD
Exacerbations
1,424 (100)
Type of exacerbation
Emergency department visit
1,267 (89.0)
Hospitalization
80 (5.6) 77 (5.4)
Observation stay
PM 2.5 (µg/m
3 ) Mean: All possible days Mean: Exacerbation days
6.7 ± 4.7 7.5 ± 4.8 35 ± 21.7
Mean age at time of exacerbation (years)
Age group (years) 0–4
103 (7.2)
5–17
231 (16.2) 406 (28.5) 525 (36.9) 159 (11.2)
18–34 35–64
≥65
Race and ethnicity Asian
5 (0.4)
Black
57 (4.1) 77 (5.5) 74 (5.3)
Hispanic
Native American
White
1,179 (84.7)
Not provided
32
continued on page 10
Methods
sin Department of Natural Resources. Rural county classifications were based on the Fed- eral Oce of Rural Health Policy data files (Health Resources and Services Adminis- tration, 2024). Second encounters for cases occurring within 7 days of a prior exacerba- tion and exacerbations with missing PM 2.5 data were excluded from the analysis. PM 2.5 Exposure We used PM 2.5 data collected by the Wis- consin Department of Natural Resources from all rural counties with air monitors ( n = 7). Throughout Wisconsin, the Wisconsin Department of Natural Resources operates a network of air monitors that use feder- ally approved methods for measuring air quality (Wisconsin Department of Natural
Case Definition of Asthma Exacerbation
To identify asthma exacerbations, we used hospital discharge data collected by the Wis- consin Hospital Association that had been shared with the Wisconsin Department of Health Services. We defined an asthma exac- erbation as any emergency department visit, hospitalization, or observation stay with an ICD-10 (International Classification of Dis- ease, 10th revision) code of J45 that occurred during January 1, 2019–June 30, 2022. We restricted our analysis to Wisconsin residents of seven rural counties (Ashland, Dodge, Forest, Grant, Sauk, Taylor, and Vilas) with PM 2.5 air monitors operated by the Wiscon-
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January/February 2025 • Journal of Environmental Health
ADVANCEMENT OF THE SCIENCE
the substantial asthma disparities observed among Black and Native American popula- tions compared with Asian and White popu- lations in Wisconsin (Wisconsin Department of Health Services, 2020). All analyses were conducted using SAS version 9.4.
Main Characteristics of Asthma Exacerbations Among Residents From Ashland, Dodge, Forest, Grant, Sauk, Taylor, and Vilas Counties in Wisconsin TABLE 1 continued
Results
Characteristic
# (%) or Mean ± SD
Characteristics of Asthma Exacerbations
Sex
Male
604 (42.4) 820 (57.6)
A total of 1,424 asthma exacerbations were identified during the study period among residents of seven Wisconsin rural counties, including 1,267 (89%) emergency depart- ment visits, 80 (6%) hospitalizations, and 77 (5%) observation stays (Table 1). The mean age at the time of exacerbation was 35 years, and 820 (58%) of the cases were female patients. Most of the patients were White (85%), and 5% were Native American, 5% were Hispanic, 4% were Black, and <1% were Asian. A relatively even distribution of exacerbations was observed across the sea- sons, with spring (32%) having the highest proportion, followed by fall (26%), winter (22%), and summer (21%). The mean PM 2.5 level for all possible days in the study period was 6.7 µg/m 3 (±4.7), and the mean level on exacerbation days was 7.5 µg/m 3 (±4.8).
Female
County
Ashland
139 (9.8)
Dodge Forest Grant Sauk Taylor
449 (31.5)
31 (2.2)
264 (18.5) 336 (23.6)
97 (6.8)
Vilas
108 (7.6)
Unique days (total/possible)
811/1,277 (63.5)
Median exacerbations/day (range)
1 (1–8)
Mean exacerbations/day Exacerbations by season
1.8 ± 0.96
Winter (December–February)
309 (21.7) 454 (31.9) 295 (20.7) 366 (25.7) 57.3 ± 21.2
Spring (March–May)
Summer (June–August)
Fall (September–November)
Association Between PM 2.5 and Asthma Exacerbations
Mean daily maximum temperature (°F)
The number of exacerbations per AQI category of lag0–6 was compared with all days in the study period, which revealed significant dier- ences in lag0–5 ( p < .05; Table 2). There were higher percentages of moderate to unhealthy AQI levels in lag0–5 compared with the whole study period, with lag2 (2 days prior to exac- erbation) having the greatest dierence ( p = .0001). After controlling for maximum daily temperature, conditional logistic regression analysis showed that PM 2.5 levels on lag2 were significantly associated with increased hazard of asthma exacerbations (HR 1.184; 95% CI [1.051, 1.344]; Table 3). Stratified analysis found no eect modifi- cation by sex, race and ethnicity, age, season, or county of residence on lag2 (all p -values >.05; Figure 1). Associations between PM 2.5 and asthma exacerbations, however, were highest among female patients (HR 1.219; 95% CI [1.041, 1.438]); White individuals (HR 1.195; 95% CI [1.041, 1.370]); people
≥65 years (HR 1.524; 95% CI [1.105, 2.119]); exacerbations occurring in spring (HR 1.268; 95% CI [1.020, 1.568]); and residents of Ashland County (HR 1.424; 95% CI [1.062, 1.931]) and Sauk County (HR, 1.331; 95% CI [1.010, 1.757]). Discussion Our case-crossover study aimed to assess the relationship between PM 2.5 and asthma exacer- bations in rural Wisconsin. We identified cases with asthma exacerbations using hospital dis- charge data from the Wisconsin Hospital Asso- ciation among residents of seven rural coun- ties with a PM 2.5 air monitor. We used PM 2.5 data collected by the Wisconsin Department of Natural Resources as the exposure variable, and we included daily maximum temperature data from NOAA in the analysis. When the number of exacerbations per AQI category of lag0–6 was compared with
all days in the study period, significant dif- ferences were revealed in lag0–5, as the per- centage of exacerbations in the moderate to unhealthy AQI levels was significantly higher than the whole study period. After control- ling for maximum daily temperature, PM 2.5 levels on lag2 were significantly associated with an increased hazard of an asthma exac- erbation occurring. The stratified analysis on lag2 found elevated associations among female cases, White individuals, people ≥65 years, exacerbations occurring in spring, and residents of Ashland and Sauk counties. Our findings are consistent with previous studies conducted in urban areas and dem- onstrate that asthma exacerbations are more likely to occur in the days following higher PM 2.5 levels. For instance, a study by Rosser et al. (2022) found a significant association between PM 2.5 and asthma exacerbations on lag days 2 and 3. Similarly, Glad et al. (2012)
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Volume 87 • Number 6
TABLE 2
Number of Exacerbations per Air Quality Index (AQI) Category in Rural Counties in Wisconsin From January 1, 2019–June 30, 2022
AQI Levels of Health Concern for 24-hr PM 2.5 (µg/m 3 )
All Days in Study Period # (%)
Lag0 # (%)
Lag1 # (%)
Lag2 # (%)
Lag3 # (%)
Lag4 # (%)
Lag5 # (%)
Lag6 # (%)
Good (0–12.0)
7,847 (89.3)
1,239 (87.0)
1,222 (86.1)
1,209 (85.5)
1,214 (86.2)
1,224 (86.9)
1,218 (86.4)
1,238 (87.9)
Moderate (12.1–35.4) Unhealthy for sensitive groups (35.5–55.4) Unhealthy (55.5–140.4) Very unhealthy (140.5–210.4)
928 (10.6)
184 (12.9)
194 (13.7)
199 (14.1)
191 (13.6)
184 (13.7)
190 (13.5)
168 (11.9)
12 (0.1)
1 (0.1)
2 (0.1)
3 (0.2)
4 (0.3)
0
1 (0.1)
1 (0.1)
4 (0.05)
0 0 0 0
1 (0.1)
3 (0.2)
0 0 0
0 0 0
1 (0.1)
2 (0.1)
0 0
0 0 5
0 0
0 0
0 0
Hazardous (>210.4)
Missing
148
10
15
16
14
15
Total
8,939
1,424 .0191
1,424 .0064
1,424 .0001
1,424 .0026
1,424 .0096
1,424 .0109
1,424 .1945
p -value
–
reported an eect on the total population on lag day 1 and lag days 1–3 for Black individu- als in their study. Moreover, Chi et al. (2019) found an association between PM 2.5 and mul- tiple respiratory diseases on lag days 3–5. Our study, however, was notable in that we found an elevated hazard of asthma exacerba- tions with PM 2.5 levels for people ≥65 years. Some studies have reported inconsistent find- ings—for example, a study by Bozigar et al. (2021) found no association between PM 2.5 and asthma exacerbations. These discrepancies might be due to dierences in study design, study populations, or exposure assessments. The strengths of our study include the use of a case-crossover study design, which is an eective method for assessing time-varying exposures in administrative data sets with only case data included. This study design is advantageous because it uses self-matched referent periods, which naturally control for confounding factors. Another strength is the inclusion of data from multiple rural coun- ties, expanding our knowledge base on the relationship between PM 2.5 and asthma exac- erbations in rural areas. Our study was limited by the following fac- tors. We included data only from seven rural counties in Wisconsin, thus limiting the gen- eralizability of our results to other rural areas of the state. Additionally, we were unable to include wind speed data due to missing observations or humidity data because they
TABLE 3
Multivariate Analysis of the Relationship Between 10-Unit Increases of PM 2.5 and Asthma Exacerbations by Lag Day
Lag Day
Hazard Ratio
95% CI
p -Value
Main model: 10-unit increases Lag0
1.072
[0.942, 1.219]
.3127
Lag1
1.083
[0.951, 1.231]
.2303
1.207
[1.072, 1.370]
.0024
Lag2
Lag3
1.072
[0.942, 1.219]
.2725
Lag4
0.932
[0.817, 1.062]
.2772
Lag5
0.980
[0.860, 1.116]
.7585
Lag6
0.980
[0.860, 1.116]
.7307
Average: Lag0–6
1.127
[0.904, 1.397]
.2959
Main model: 10-unit increases controlling for maximum temperature Lag0 1.041
[0.914, 1.195]
.5434
Lag1
1.041
[0.914, 1.195]
.5352
1.184
[1.051, 1.344]
.0069
Lag2
Lag3
1.062
[0.932, 1.207]
.3810
Lag4
0.914
[0.801, 1.041]
.1918
Lag5
0.970
[0.851, 1.105]
.6534
Lag6
0.970
[0.851, 1.116]
.7007
Average: Lag0–6
1.072
[0.860, 1.344]
.5542
Note. The bolded values indicate significant results as p < .05. CI = confidence interval.
11
January/February 2025 • Journal of Environmental Health
ADVANCEMENT OF THE SCIENCE
FIGURE 1
Hazard Ratios and 95% Confidence Intervals for Potential Effect Modifiers on the Relationship Between 10-Unit Increases of PM 2.5 and Asthma Exacerbations on Lag2
Sex Female Male Race and Ethnicity Native American
p = .56
Asian Black Hispanic White Age 0 – 4 5 – 17
p = .58
18 – 34 35 – 64 ≥ 65
p = .41
County
Ashland Forest Dodge
p = .16
Grant Sauk Vilas Taylor
Season
Winter Spring Summer Fall
p = .55
5.0
0.2
1.0 Hazard Ratio
were not available for the selected rural counties. Furthermore, we lacked informa- tion on individual-level covariates, such as smoking status and comorbidities, which could modify the relationship between PM 2.5 and asthma exacerbations. Conclusion Our study provides valuable insight into the characteristics of asthma exacerbations in rural areas. It also highlights the importance of looking beyond urban centers with the
highest levels of PM 2.5 when developing inter- ventions and policies to prevent asthma exac- erbations. Our findings support the need for eorts to improve a) air quality in rural areas to reduce the burden of asthma exacerbations in these communities and b) communications within rural areas regarding air quality and associations with poor asthma outcomes. Fur- ther research is needed to confirm our results in other rural areas and to identify individual- level risk factors that could modify the relation- ship between PM 2.5 and asthma exacerbations.
The implications of this research are impor- tant, and our findings could enhance targeted interventions in rural areas to improve asthma management and reduce poor outcomes asso- ciated with air pollution. Corresponding Author: Megan Elderbrook, MPH, CHES, Research Scientist–Epidemiolo- gist, Wisconsin Asthma Program, Wisconsin Department of Health Services, 1 West Wil- son, Room 150, Madison, WI 53703. Email: megan.elderbrook@wi.gov
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Volume 87 • Number 6
References
Atkinson, R.W., Kang, S., Anderson, H.R., Mills, I.C., & Walton, H.A. (2014). Epidemiological time series studies of PM 2.5 and daily mortality and hospital admissions: A systematic review and meta-analysis. Thorax , 69 (7), 660–665. https://doi.org/10.1136/ thoraxjnl-2013-204492 Berhane, K., Chang, C.-C., McConnell, R., Gauderman, W.J., Avol, E., Rapapport, E., Urman, R., Lurmann, F., & Gilliland, F. (2016). Association of changes in air quality with bronchitic symptoms in children in California, 1993–2012. JAMA , 315 (14), 1491–1501. https://doi.org/10.1001/jama.2016.3444 Bozigar, M., Lawson, A.B., Pearce, J.L., Svendsen, E.R., & Vena, J.E. (2021). Using Bayesian time-stratified case-crossover models to examine associations between air pollution and “asthma seasons” in a low air pollution environment. PLOS One , 16 (12), e0260264. https://doi.org/10.1371/journal.pone.0260264 Centers for Disease Control and Prevention. (2023a). 2021 child asthma data: Prevalence tables . https://www.cdc.gov/asthma/ brfss/2021/child/tableL1.html Centers for Disease Control and Prevention. (2023b). 2021 adult asthma data: Prevalence tables and maps . https://www.cdc.gov/ asthma/brfss/2021/tableL1.html Centers for Disease Control and Prevention. (2024). Controlling asthma . https://www.cdc.gov/asthma/control/index.html Chi, R., Li, H., Wang, Q., Zhai, Q., Wang, D., Wu, M., Liu, Q., Wu, S., Ma, Q., Deng, F., & Guo, X. (2019). Association of emergency room visits for respiratory diseases with sources of ambient PM 2.5 . Journal of Environmental Sciences , 86 , 154–163. https://doi. org/10.1016/j.jes.2019.05.015 Domingo, N.G.G., Balasubramanian, S., Thakrar, S.K., Clark, M.A., Adams, P.J., Marshall, J.D., Muller, N.Z., Pandis, S.N., Polasky, S., Robinson, A.L., Tessum, C.W., Tilman, D., Tschofen, P., & Hill, J.D. (2021). Air quality-related health damages of food. Proceedings of the National Academy of Sciences , 118 (20), e2013637118. https:// doi.org/10.1073/pnas.2013637118 Glad, J.A., Brink, L.L., Talbott, E.O., Lee, P.C., Xu, X., Saul, M., & Rager, J. (2012). The relationship of ambient ozone and PM 2.5 levels and asthma emergency department visits: Possible influence of gen- der and ethnicity. Archives of Environmental & Occupational Health , 67 (2), 103–108. https://doi.org/10.1080/19338244.2011.598888 Health Resources and Services Administration. (2024). Federal Oce of Rural Health Policy (FORHP) data files . https://www.hrsa. gov/rural-health/about-us/what-is-rural/data-files Maclure, M. (1991). The case-crossover design: A method for study- ing transient eªects on the risk of acute events. American Journal
of Epidemiology , 133 (2), 144–153. https://doi.org/10.1093/oxford journals.aje.a115853 Romieu, I., Meneses, F., Ruiz, S., Sienra, J.J., Huerta, J., White, M.C., & Etzel, R.A. (1996). Eªects of air pollution on the respiratory health of asthmatic children living in Mexico City. American Jour- nal of Respiratory and Critical Care Medicine , 154 (2), 300–307. https://doi.org/10.1164/ajrccm.154.2.8756798 Rosser, F., Han, Y.-Y., Rothenberger, S.D., Forno, E., Mair, C., & Celedón, J.C. (2022). Air quality index and emergency depart- ment visits and hospitalizations for childhood asthma. Annals of the American Thoracic Society , 19 (7), 1139–1148. https://doi. org/10.1513/AnnalsATS.202105-539OC Strosnider, H., Kennedy, C., Monti, M., & Yip, F. (2017). Rural and urban diªerences in air quality, 2008–2012, and community drinking water quality, 2010–2015—United States. Morbidity and Mortality Weekly Report, Surveillance Summaries , 66 (13), 1–10. https://doi.org/10.15585/mmwr.ss6613a1 U.S. Environmental Protection Agency. (2024). Agriculture and air quality . https://www.epa.gov/agriculture/agriculture-and- air-quality Wang, S.V., Coull, B.A., Schwartz, J., Mittleman, M.A., & Wellenius, G.A. (2011). Potential for bias in case-crossover studies with shared exposures analyzed using SAS. American Journal of Epi- demiology , 174 (1), 118–124. https://doi.org/10.1093/aje/kwr038 Winquist, A., Kirrane, E., Klein, M., Strickland, M., Darrow, L.A., Sarnat, S.E., Gass, K., Mulholland, J.A., Russell, A.G., & Tol- bert, P.E. (2014). Joint eªects of ambient air pollutants on pedi- atric asthma emergency department visits in Atlanta, 1998– 2004. Epidemiology , 25 (5), 666–673. https://doi.org/10.1097/ EDE.0000000000000146 Wisconsin Department of Health Services. (2020). Wisconsin asthma burden report 2020 (P-02412-20). https://dhs.wisconsin.gov/publi cations/p02412-20.pdf Wisconsin Department of Natural Resources. (n.d.-a). Air quality mon- itoring . https://dnr.wisconsin.gov/topic/AirQuality/Monitor.html Wisconsin Department of Natural Resources. (n.d.-b). Wisconsin air quality monitoring data: Air Quality Index (AQI) . https://airquality. wi.gov/home/text/538 Zheng, X.-Y., Ding, H., Jiang, L.-N., Chen, S.-W., Zheng, J.-P., Qiu, M., Zhou, Y.-X., Chen, Q., & Guan, W.-J. (2015). Association between air pollutants and asthma emergency room visits and hospital admissions in time series studies: A systematic review and meta-analysis. PLOS One , 10 (9), e0138146. https://doi. org/10.1371/journal.pone.0138146
Did You Know?
The U.S. Environmental Protection Agency has designated January as National Radon Action Month. Radon is the leading cause of lung cancer deaths among nonsmokers in the U.S. Learn more about the eort to take action against radon at www.epa.gov/ radon/national-radon-action-month-information.
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January/February 2025 • Journal of Environmental Health
ADVANCEMENT OF THE SCIENCE
Open Access
Abstract Our study objectives were to describe injuries from sharps and gain insight into the culture of injury reporting among healthcare professionals at an academic medical center. We performed a retrospective chart review and analyzed sharps injuries reported in 2021 using chi- square analysis for categorical variables and t -tests or analysis of variance (ANOVA) tests for continuous variables. The highest rates of sharps injuries were reported by dental students (6.9%) and resident physicians (3.6%), followed by a smaller percentage of nurses, attending physicians, dental faculty, and medical students ( p < .001). The majority of injuries were reported to occur while administering an injection and/or working in the dental clinics (39%). The median number of days to report an injury was 0 days for dental students, 2 days for resident physicians ( p < .001), and 3 days for medical students ( p = .004). We found that sharps injuries continue to occur in the clinical teaching environment and could reflect procedures that confer a higher risk of injury. Further, our study suggests that there is a stronger culture of reporting among dental students. Keywords: needlestick, sharps injuries, reporting culture, dental students, academic medical center Bloodborne Pathogen Exposure and the Culture of Reporting Sharps Injuries at a Large Academic Institution
fessions in our institution. We sought to describe the type of injury, the role (i.e., job title or training level) of the injured individual, the time the injuries were most likely to occur, and the reporting culture in the dierent professions. Methods We performed a retrospective chart review and abstracted all sharps injuries reported in 2021 through the Accident Reporting Data- base maintained by Rutgers Environmental Health & Safety. We included de-identified data from our eight health sciences schools: pharmacy, dental medicine, graduate studies, health professions, nursing, public health, and the two medical schools. We reviewed the types of injuries and excluded the injuries that did not involve sharp instruments. Examples of non-sharps injuries include splashes, bites, scratches, and contact with blood or bodily fluids with- out the involvement of a sharp instrument. Additionally, we abstracted demographic information including gender, age, job title or training level, what activity was occur- ring when the injury was sustained, type of sharp instrument, accident setting, accident timing, and at which school and campus. We tabulated the following: • role within the university of the person injured, • type of injury sustained, • sharp instrument that caused the injury, • activity at the time of injury, • time of day the injury occurred, and • latency to reporting. Julie Caruth, MPH, MD School of Public Health, Environmental and Occupational Health and Justice; Environmental and Occupational Health Sciences Institute, Rutgers, The State University of New Jersey Christeen Abadir School of Graduate Studies, Rutgers, The State University of New Jersey Ping-Hsin Chen, PhD Department of Family Medicine, Rutgers, New Jersey Medical School Noa’a Shimoni, MPH, MD Department of Family Medicine, Rutgers, New Jersey Medical School
Introduction Healthcare personnel are at risk for exposure to bloodborne pathogens, including HIV, hep- atitis B, and hepatitis C. The greatest exposure risk is due to needlestick and sharps injuries that occur most commonly in surgical special- ists and trainees (Ouyang et al., 2017). Fre- quent use of sharp instruments increases the risk of injury for surgeons and a lack of expe- rience increases the risk for surgical trainees (Dukka et al., 2021). Dental professionals are also at risk due to their frequent use of sharp instruments and the confined anatomy of a patient’s oral cavity (Lee et al., 2014). The culture of reporting at an academic medical center aects the likelihood that a healthcare worker will report an injury and
seek help for the injury. Multiple studies have shown that surgeons are likely to underreport injuries; the surgeons cite reasons such as lack of time, perceived minimal risk from the injury, and cumbersome or time-consuming reporting processes (Choi et al., 2017; Hirose et al., 2007; McCarthy & Britton, 2000). Trainees might fail to report injuries due to perceived low risk of the injury, embarrass- ment, or intimidation by someone at the aca- demic medical center (Bernard et al., 2013). Our large academic institution maintains a database where students and employees are instructed to report work-related acci- dents and injuries. Our study’s goal was to compare the reported sharps injuries in 2021 across the dierent healthcare pro-
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Volume 87 • Number 6
physicians, nurses, attending physicians, and dental faculty in our system in 2021. Analy- ses were performed using IBM SPSS Statistics (Version 24). Our study was approved by the Rutgers University Institutional Review Board (protocol # Pro2020000988). Results Overall, 122 injuries were reported in 2021. The average age of an injured person was 33 ± 10 years. The majority of injuries were reported by women (58%). The highest rate of needlestick injuries was reported by den- tal students (6.9%) and resident physicians (3.6%), followed by a lower percentage of nurses, attending physicians, dental faculty, and medical students ( p < .001); Figure 1A). Further, 8 employees classified as “other” and 12 clinical support sta were not included in the rate analysis because a) employees in these groups belonged to multiple dier- ent departments and b) lack of data on the population at risk. Other employees included research assistants/associates and gradu- ate students/fellows. Clinical support sta included medical assistants, dental assistants, dental hygienists, and laboratory personnel. The majority of injuries were reported to occur in the dental clinics (39%), followed by in-patient settings (16%) and the operat- ing room (9%). Most injuries were caused by hollow needles (45%), followed by solid needles (19%; Figure 1B). Of the hollow needle injuries, the largest proportion (38%) were caused by dental anesthetic needles. The most common activity performed dur- ing injury was administering an injection, followed by performing a dental procedure, line placement, biopsy, and suturing (Table 1). Injuries were most likely to occur in the afternoon between 12 and 5 p.m. (Figure 1C). Furthermore, 60% of injuries occurred while the sharp instrument was in active use, versus during cleanup. Hollow needle injuries were common across professions, accounting for 100% of nurse injuries, 83% of support sta injuries, 50% of attending physician and dental faculty injuries, and 34% of resident physician inju- ries. The primary source of injury for medi- cal students was solid needles (100%) and for dental students was dental equipment (35%). Of note, the dental equipment that was implicated in most injuries was the den- tal bur (53%). Less commonly, an explorer,
FIGURE 1
Characteristics of Injuries by A) Injuries Reported by Group, B) Instruments Associated With Sharps Injury, and C) Time of Day When the Injury Occurred
A
7 . 0
4. 0
D A Y
v l R o
1. 0
0 . 6
0 . 2
M edical Students ( n = 3/ 1, 4 4 2)
Dental Students ( n = 4 0 / 577)
A ttending P hysi cians and Dental F aculty ( n = 8 / 1, 28 1)
Nurses ( n = 10 / 735)
R esident P hysi cians ( n = 4 1/ 1, 14 2)
G ro up R epo rting a Sharps Injury
B
45
19
18
12
6
Other Sharps ( n = 7)
Hollow Needle ( n = 55)
Dental Equipment ( n = 15)
Scalpel or Blade ( n = 22)
Solid Needle ( n = 23)
Instrument Causing the Injury
continued
We compared the proportion of inju- ries across academic programs using a chi- squared analysis. We also performed t -tests or analysis of variance (ANOVA) tests for
continuous variables. To compare the pro- portion of injuries in the student/trainee and employee groups, we used the total number of medical students, dental students, resident
15
January/February 2025 • Journal of Environmental Health
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