Mina Suh

Quantitative risk assessments of inhaled hexavalent chromium (CrVI) have primarily relied on studies of two chromate production worker cohorts, involving male workers exposed to high concentrations of airborne CrVI that caused an exposure-dependent increase in lung cancer and elicited severe respiratory irritation. An additional larger cohort of CrVI-exposed aerospace workers, including women, and with lower intensity exposures, was recently updated with a longer follow-up period and reconstructed cumulative exposure estimates. A risk assessment was conducted using a pooled analysis of individual-level dose-response information from three cohorts, including the aerospace workers, to generate lung cancer inhalation unit risk estimates (IURs). IURs are estimates of the upper-bound of lifetime increased cancer risk from continuous inhalation exposure to 1 µg/m³ and are commonly used in quantitative risk assessment. Use of the pooled cohort broadens the range for dose-response analysis due to the comparatively low exposures to CrVI in the aerospace cohort; moreover, sex-specific risks could be expanded with the inclusion of female workers. Standardized logistic regression using person-year-specific weighted cumulative exposures was used to estimate the probability of lung cancer mortality, with varied weighting approaches. The primary model included male workers from all cohorts with a minimum of one year of CrVI exposure; secondary analyses examined the impacts of sex and short-term exposure. The best fit dose-response function was a Michaelis-Menten relationship. The IUR from the primary model was 0.01 (95%CI: 0.006-0.01) per µg/m³. Best estimates of the three IURs from secondary analyses, which removed the respiratory use adjustment factors, included females from the aerospace cohort and added workers with less than one year of exposure from the chromate production cohorts, were relatively consistent with the primary analyses, ranging from 0.008 to 0.03 per µg/m³. Use of this pooled IUR estimate allows for inclusion of a broader dose-response range and reduced uncertainty through use of a larger population, additional years of follow-up, and incorporation of broader geographical and cohort characteristics with improved relevancy to the general population.

Hexavalent chromium (CrVI) is known to cause lung cancer among workers exposed to high concentrations in certain historical industries. It is also a toxic air contaminant considered to pose a potentially significant cancer risk at comparatively low concentrations in urban air. However, very limited data currently exist to quantify risk at low-concentration occupational or environmental exposures. This study reconstructs individual-level exposures using a job-exposure matrix (JEM) and examines mortality among 3,723 CrVI-exposed aircraft manufacturing workers, including 440 women with long-term low-level CrVI exposures and long-term follow-up. The JEM used Bayesian methods with industrial hygiene data to calculate cumulative worker exposures from 1960 to 1998. A retrospective cohort mortality study was also conducted to calculate standardized mortality ratios (SMRs) by population demographics and to conduct an internally referenced dose-response analysis. CrVI-exposed painters, electroplaters, and aircraft assembly workers, with 1 to 37 years of exposure (median: 8 years) had mean and median cumulative exposures of 16 µg/m³-yrs and 2.9 µg/m³-yrs, respectively. Based on 1,758 observed deaths, mortality from cancer overall (SMR 1.24; 95% CI 1.13-1.36), smoking-related cancers (SMR 1.31; 95% CI 1.15-1.49), and lung cancer (SMR 1.39; 95% CI 1.17-1.63) were significantly elevated and more highly elevated among women (lung cancer SMR 2.61; 95% CI:1.66-3.92). Internal analyses revealed no dose-response relationship between cumulative exposure and lung cancer mortality. Data available for 12% of CrVI-exposed workers showed smoking prevalence higher than general population norms, especially for women. The absence of a dose-response relationship with cumulative exposure suggests that elevated cancer risks are primarily smoking-related in this cohort, and possibly as a consequence, any increased risk associated with CrVI exposure is not observable. Although an association between lung cancer risk and CrVI exposure was not found, this study provides significant new observations in the low exposure range, and among women, which may be useful for quantitative risk assessment.

Background: Infants covered by Medicaid have higher respiratory syncytial virus (RSV) hospitalization rates than those with commercial insurance, but findings are limited to the inpatient setting. This birth cohort study describes healthcare encounters for RSV across all settings among infants covered by Medicaid and the Children's Health Insurance Program. Methods: Medicaid claims for infants born and residing in Arizona (AZ), California (CA), Florida (FL), Michigan (MI), North Carolina (NC), New York (NY), and Texas (TX) were analyzed for first diagnosis of RSV in 2016–2018 using International Classification of Diseases, Tenth Revision codes. Encounters on the day of first diagnosis were examined by setting in 7 states and by setting and race in CA, FL, and NC. Results: A total of 80 945 infants were diagnosed with RSV in 7 states in 2016–2018. The highest encounter rates for first RSV diagnosis were in the emergency department (ED) in 5 states (11.0–33.4 per 1000 in AZ, CA, FL, MI, and NY) and outpatient setting in 2 states (54.8 and 68.5 per 1000 in TX and NC). Significantly higher outpatient encounter rates were found in CA and NC for White infants compared to non-White infants. In NC, ED encounter rates were significantly higher for non-White infants than White infants, whereas in CA, the rates were comparable. In these 2 states, hospitalization rates were similar across groups. In FL, compared with White infants, non-White infants had significantly higher encounter rates in each setting on the day of first RSV diagnosis. Conclusions: This is the first study to describe the burden of RSV by setting and race. Medicaid infants who are newly diagnosed with RSV have the highest burden in ED and outpatient settings.

OBJECTIVES: Since 2002, the Korean government has provided breast cancer screening as part of the National Cancer Screening Program. This study reported trends in the screening rate among Korean women from 2005 to 2020, including organized and opportunistic screening for breast cancer.METHODS: Data from the Korean National Cancer Screening Survey, an annual cross-sectional nationwide survey, were collected using a structured questionnaire between 2005 and 2020. The study population included 23,702 women aged 40-74 years with no history of cancer. We estimated the screening rate based on the current recommendation of biennial mammographic screening for breast cancer. In addition, a joinpoint trend analysis was performed for breast cancer screening rates among various subgroups.RESULTS: In 2020, the breast cancer screening rate was 63.5%, reflecting an annual increase of 7.72% (95% confidence interval 5.53 to 9.95) between 2005 and 2012, followed by non-significant trends thereafter. In particular, a significant decrease in the breast cancer screening rate was observed in the subgroups aged 50-59 years old, with 12-15 years of education, and living in rural areas.CONCLUSIONS: Although there has been substantial improvement in breast cancer screening rates in Korean women, the trend has flattened in recent years. Therefore, continual efforts are required to identify subgroups with unmet needs and solve barriers to the uptake of breast cancer screening.

Lee K, et al. J Gastric Cancer. 2022 Oct;22(4):264-272. https://doi.org/10.5230/jgc.2022.22.e36

Background: Respiratory syncytial virus (RSV) can cause serious illness in those aged <5 years in the United States, but uncertainty remains around which populations receive RSV testing. We conducted a systematic literature review of RSV testing patterns in studies published from 2000 to 2021.Methods: Studies of RSV, medically attended RSV lower respiratory tract infections (LRTIs), and bronchiolitis were identified using standard methodology. Outcomes were clinical decisions to test for RSV, testing frequency, and testing incidence proportions in inpatient (IP), emergency department (ED), outpatient (OP), and urgent care settings.Results: Eighty good-/fair-quality studies, which reported data from the period 1988–2020, were identified. Twenty-seven described the clinical decision to test, which varied across and within settings. Two studies reported RSV testing frequency for multiple settings, with higher testing proportions in IP (n = 2, range: 83%–85%, 1996–2009) compared with ED (n = 1, 25%, 2006–2009) and OP (n = 2, 15%–25%, 1996–2009). Higher RSV testing incidence proportions were observed among LRTI infant populations in the ED (n = 1, 74%, 2007–2008) and OP (n = 2, 54%–69%, 1995–2008). Incidence proportions in LRTI populations were not consistently higher in the IP setting (n = 13). Across studies and time, there was heterogeneity in RSV testing patterns, which may reflect varying detection methods, populations, locations, time periods, and healthcare settings.Conclusions: Not all infants and children with LRTI are tested for RSV, highlighting underestimation of RSV burden across all settings.

Background: Surveillance in 2020–2021 showed that seasonal respiratory illnesses were below levels seen during prior seasons, with the exception of interseasonal respiratory syncytial virus (RSV). Methods: Electronic health record data of infants aged <1 year visiting the Duke University Health System from 4 October 2015 to 28 March 2020 (pre–COVID-19) and 29 March 2020 to 30 October 2021 (COVID-19) were assessed. International Classification of Diseases-Tenth Revision (ICD-10) codes for RSV (B97.4, J12.1, J20.5, J21.0) and bronchiolitis (RSV codes plus J21.8, J21.9) were used to detail encounters in the inpatient (IP), emergency department (ED), outpatient (OP), urgent care (UC), and telemedicine (TM) settings. Results: Pre–COVID-19, 88% of RSV and 92% of bronchiolitis encounters were seen in ambulatory settings. During COVID-19, 94% and 93%, respectively, occurred in ambulatory settings. Pre–COVID-19, the highest RSV proportion was observed in December–January (up to 38% in ED), while the peaks during COVID-19 were seen in July–September (up to 41% in ED) across all settings. RSV laboratory testing among RSV encounters was low during pre–COVID-19 (IP, 51%; ED, 51%; OP, 41%; UC, 84%) and COVID-19 outside of UC (IP, 33%; ED, 47%; OP, 47%; UC, 87%). Full-term, otherwise healthy infants comprised most RSV encounters (pre–COVID-19, up to 57% in OP; COVID-19, up to 82% in TM). Conclusions: With the interruption of historical RSV epidemiologic trends and the emergence of interseasonal disease during COVID-19, continued monitoring of RSV is warranted across all settings as the changing RSV epidemiology could affect the distribution of health care resources and public health policy.

Background: A systematic literature review was conducted to summarize the mortality (overall and by disease severity factors) of US infants and children aged <5 years with respiratory syncytial virus (RSV) or all-cause bronchiolitis (ACB). Methods: Comprehensive, systematic literature searches were conducted; articles were screened using prespecified eligibility criteria. A standard risk of bias tool was used to evaluate studies. Mortality was extracted as the rate per 100 000 or the case fatality ratio (CFR; proportion of deaths among RSV/ACB cases). Results: Among 42 included studies, 36 evaluated inpatient deaths; 10 used nationally representative populations updated through 2013, and only 2 included late-preterm/full-term otherwise healthy infants and children. The RSV/ACB definition varied across studies (multiple International Classification of Diseases [ICD] codes; laboratory confirmation); no study reported systematic testing for RSV. No studies reported RSV mortality rates, while 3 studies provided ACB mortality rates (0.57–9.4 per 100 000). CFRs ranged from 0% to 1.7% for RSV (n = 15) and from 0% to 0.17% for ACB (n = 6); higher CFRs were reported among premature, intensive care unit-admitted, and publicly insured infants and children. Conclusions: RSV mortality reported among US infants and children is variable. Current, nationally representative estimates are needed for otherwise healthy, late-preterm to full-term infants and children.

Background: The burden and health care utilization (HCU) of respiratory syncytial virus (RSV) in US infants aged <1 year across health care settings are not well characterized. Methods: We systematically reviewed studies of RSV and bronchiolitis published 2000–2021 (data years, 1979–2020). Outcomes included RSV hospitalization (RSVH)/bronchiolitis hospitalization rates, emergency department (ED)/outpatient (OP) visit rates, and intensive care unit (ICU) admissions or mechanical ventilation (MV) use among RSV-/bronchiolitis-hospitalized infants. Study quality was determined using standard tools. Results: We identified 141 good-/fair-quality studies. Five national studies reported annual average RSVH rates (range, 11.6 per 1000 per year among infants aged 6–11 months in 2006 to 50.1 per 1000 per year among infants aged 0–2 months in 1997). Two national studies provided RSVH rates by primary diagnosis for the entire study period (range, 22.0–22.7 per 1000 in 1997–1999 and 1997–2000, respectively). No national ED/OP data were available. Among 11 nonnational studies, RSVH rates varied due to differences in time, populations (eg, prematurity), and locations. One national study reported that RSVH infants with high-risk comorbidities had 5-times more MV use compared to non–high-risk infants in 1997-2012. Conclusions: Substantial data variability was observed. Nationally representative studies are needed to elucidate RSV burden and HCU.