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BACKGROUND Disability among women of reproductive age is common; many of these women desire children and do not have impaired fertility. OBJECTIVES To examine the epidemiological literature on perinatal health outcomes among women with physical disabilities. DATA SOURCES We searched Medline and CINAHL for articles published January 2009-April 2020 following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. STUDY SELECTION AND DATA EXTRACTION Eligible studies were observational, quantitative, and reported on physical disabilities in association with prenatal, perinatal, postpartum, and/or infant health outcomes. We included studies that grouped physical and non-physical disabilities, such as surveys that queried only about general daily life limitations. We excluded case reports, descriptive studies without comparison groups, and studies conducted in low- or middle-income countries. Data extraction was done using predefined data fields. SYNTHESIS All authors were involved in screening activities, data extraction, and/or quality assessment (rating and areas for bias). RESULTS A total of 2650 articles were evaluated, of which sixteen met inclusion criteria (8 cross-sectional studies and 8 retrospective cohort studies). Assessments of disability status and perinatal outcomes widely varied across studies. Studies were rated as poor (n = 8) or fair quality (n = 8). Findings suggested that women with physical disabilities were at risk of several adverse outcomes, including caesarean delivery, infections, preterm complications, and maternal post-delivery hospitalisations, while their infants may be at risk of low birthweight and small-for-gestational age. Women classified as having complex/severe disabilities were often observed to be at higher risk of adverse outcomes compared to women with less severe disabilities. CONCLUSIONS Research assessing how physical, functional, and medical restrictions influence health outcomes among women with physical disabilities, from preconception through postpartum, is limited. Longitudinal studies with comprehensive data collection that accurately identify women with physical disabilities are critical to understanding their reproductive health risks and outcomes.

To synthesize current knowledge of the impact of pediatric neuropsychological evaluations on child functioning, we conducted a systematic review of the literature on parents' overall satisfaction with their child's evaluation and perceptions of how helpful the evaluation was for understanding their child's abilities and how useful the evaluation was for providing actionable information to elicit change. Parent satisfaction is important in this context because studies on healthcare consumption indicate a substantial relationship between patient satisfaction with services and implementation of recommendations and follow-up care. We followed PRISMA guidelines to conduct a systematic review of the literature on parent perception of pediatric neuropsychological evaluations for children aged 3-21 years. Using a set of predefined search terms, we identified 1,163 abstracts across PubMed, PsycINFO, Cochrane Library, and Web of Science electronic databases and included 12 studies in our qualitative synthesis. In general, parents reported high levels of satisfaction with their child's evaluation. Feedback from the evaluation was helpful for understanding their child's pattern of strengths and weaknesses and included useful information for obtaining support. Although parents did report improvement in their child's functional participation in home, school, and community settings, they tended to rate the usefulness of the evaluation for eliciting change lower than their overall satisfaction with the evaluation or how helpful the evaluation was for understanding their child's abilities. Additional effort appears to be needed for pediatric neuropsychological evaluations recommendations to result in durable, meaningful change in child functioning.

Context Postpartum depression (PPD) is a serious psychiatric disorder. While causes remain poorly understood, perinatal sex hormone fluctuations are an important factor, and allopregnanolone in particular has emerged as a key determinant. Although synthetic environmental chemicals such as bisphenols and phthalates are known to affect sex hormones, no studies have measured allopregnanolone and the consequences of these hormonal changes on PPD have not been interrogated. Objective To investigate associations of repeated measures of urinary bisphenols and phthalates in early and midpregnancy with serum pregnenolone, progesterone, allopregnanolone, and pregnanolone concentrations in midpregnancy and PPD symptoms at 4 months postpartum. Methods Prospective cohort study of 139 pregnant women recruited between 2016 and 2018. Bisphenols and phthalates were measured in early and midpregnancy urine samples. Serum sex steroid hormone concentrations were measured in midpregnancy. PPD was assessed at 4 months postpartum using the Edinburgh Postnatal Depression Scale (EPDS). Multiple informant models were fit using generalized estimating equations. Serum levels of allopregnanolone, progesterone, pregnanolone, and pregnenolone were examined as log-transformed continuous variables. PPD symptoms were examined as continuous EPDS scores and dichotomously with scores ≥10 defined as PPD. Results Di-n-octyl phthalate (DnOP) and diisononyl phthalate (DiNP) metabolites were associated with reduced progesterone concentrations. Log-unit increases in ∑DnOP and ∑DiNP predicted 8.1% (95% CI –15.2%, –0.4%) and 7.7% (95% CI –13.3%, –1.7%) lower progesterone, respectively. ∑DnOP was associated with increased odds of PPD (odds ratio 1.48; 95% CI 1.04, 2.11). Conclusion Endocrine disrupting chemicals may influence hormonal shifts during pregnancy as well as contribute to PPD.

Background The C8 Science Panel was composed of three epidemiologists charged with studying the possible health effects of PFOA in a highly exposed population in the mid-Ohio Valley. The Panel determined in 2012 there was a ‘probable link’ (i.e., more probable than not based on the weight of the available scientific evidence) between PFOA and high cholesterol, thyroid disease, kidney and testicular cancer, pregnancy-induced hypertension, and ulcerative colitis. Objective Here, former C8 Science Panel members and collaborators comment on the PFOA literature regarding thyroid disorders, cancer, immune and auto-immune disorders, liver disease, hypercholesterolemia, reproductive outcomes, neurotoxicity, and kidney disease. We also discuss developments regarding fate and transport, and pharmacokinetic models, and discuss causality assessment in cross-sectional associations among low-exposed populations. Discussion For cancer, the epidemiologic evidence remains supportive but not definitive for kidney and testicular cancers. There is consistent evidence of a positive association between PFOA and cholesterol, but no evidence of an association with heart disease. There is evidence for an association with ulcerative colitis, but not for other auto-immune diseases. There is good evidence that PFOA is associated with immune response, but uneven evidence for an association with infectious disease. The evidence for an association between PFOA and thyroid and kidney disease is suggestive but uneven. There is evidence of an association with liver enzymes, but not with liver disease. There is little evidence of an association with neurotoxicity. Suggested reductions in birthweight may be due to reverse causality and/or confounding. Fate and transport models and pharmacokinetic models remain central to estimating past exposure for new cohorts, but are difficult to develop without good historical data on emissions of PFOA into the environment. Conclusion Overall, the epidemiologic evidence remains limited. For a few outcomes there has been some replication of our earlier findings. More longitudinal research is needed in large populations with large exposure contrasts. Additional cross-sectional studies of low exposed populations may be less informative.

Background Multiple chronic health conditions have been associated with exposure to the September 11, 2001 World Trade Center (WTC) terrorist attacks (9/11). We assessed whether excess deaths occurred during 2003–2014 among persons directly exposed to 9/11, and examined associations of 9/11-related exposures with mortality risk. Materials and methods Deaths occurring in 2003–2014 among members of the World Trade Center Health Registry, a cohort of rescue/recovery workers and lower Manhattan community members who were exposed to 9/11, were identified via linkage to the National Death Index. Participants’ overall levels of 9/11-related exposure were categorized as high, intermediate, or low. We calculated standardized mortality ratios (SMR) using New York City reference rates from 2003 to 2012. Proportional hazards were used to assess associations of 9/11-related exposures with mortality, accounting for age, sex, race/ethnicity and other potential confounders. Results We identified 877 deaths among 29,280 rescue/recovery workers (3.0%) and 1694 deaths among 39,643 community members (4.3%) during 308,340 and 416,448 person-years of observation, respectively. The SMR for all causes of death was 0.69 [95% confidence interval (CI) 0.65–0.74] for rescue/recovery workers and 0.86 (95% CI 0.82–0.90) for community members. SMRs for diseases of the cardiovascular and respiratory systems were significantly lower than expected in both groups. SMRs for several other causes of death were significantly elevated, including suicide among rescue recovery workers (SMR 1.82, 95% CI 1.35–2.39), and brain malignancies (SMR 2.25, 95% CI 1.48–3.28) and non-Hodgkin's lymphoma (SMR 1.79, 95% CI 1.24–2.50) among community members. Compared to low exposure, both intermediate [adjusted hazard ratio (AHR) 1.36, 95% CI 1.10–1.67] and high (AHR 1.41, 95% CI 1.06–1.88) levels of 9/11-related exposure were significantly associated with all-cause mortality among rescue/recovery workers (p-value for trend 0.01). For community members, intermediate (AHR 1.13, 95% CI 1.01–1.27), but not high (AHR 1.14, 95% CI 0.94–1.39) exposure was significantly associated with all-cause mortality (p-value for trend 0.03). AHRs for associations of overall 9/11-related exposure with heart disease- and cancer-related mortality were similar in magnitude to those for all-cause mortality, but with 95% CIs crossing the null value. Conclusions Overall mortality was not elevated. Among specific causes of death that were significantly elevated, suicide among rescue/recovery workers is a plausible long-term consequence of 9/11 exposure, and is potentially preventable. Elevated mortality due to other causes, including non-Hodgkin's lymphoma and brain cancer, and small but statistically significant associations of 9/11-related exposures with all-cause mortality hazard warrant additional surveillance.

Background: Prior studies have found that rescue and recovery workers exposed to the 9/11 World Trade Center (WTC) disaster have evidence of increased persistent hearing and other ear-related problems. The potential association between WTC disaster exposures and post-9/11 persistent self-reported hearing problems or loss among non-rescue and recovery survivors has not been well studied. Methods: We used responses to the World Trade Center Health Registry (Registry) enrollment survey (2003&ndash, 2004) and first follow-up survey (2006&ndash, 2007) to model the association between exposure to the dust cloud and persistent hearing loss (n = 22,741). Results: The prevalence of post-9/11 persistent hearing loss among survivors was 2.2%. The adjusted odds ratio (aOR) of hearing loss for those who were in the dust cloud and unable to hear was 3.0 (95% CI: 2.2, 4.0). Survivors with persistent sinus problems, headaches, PTSD and chronic disease histories had an increased prevalence of reported hearing problems compared to those without symptoms or chronic problems. Conclusions: In a longitudinal study, we observed an association between WTC-related exposures and post-9/11 self-reported hearing loss among disaster survivors.

Objective To determine if World Trade Center (WTC) exposure is associated with hearing loss. Methods Logistic regression to evaluate the immediate impact of WTC exposure and parametric survival analysis to assess longitudinal outcomes. Results Those arriving on the morning of September 11, 2001 had elevated odds of low-frequency (odds ratio [OR]: 1.24; 95% confidence interval [CI]: 1.04 to 1.47) and high-frequency (OR: 1.16; 95% CI: 1.02 to 1.31) hearing loss at their first post-September 11, 2001 examination. Longitudinally, participants arriving before September 13, 2001 and spending more than or equal to 6 months at the WTC-site had greater risk of hearing loss in the low frequencies (risk ratio [RR]: 1.31; 95% CI: 1.05 to 1.60) and high frequencies (RR: 1.37; 95% CI: 1.22 to 1.54). By 2016, 3194 (37%) had abnormal hearing sensitivity in either ear and 1751 (20%) in both ears. Conclusions More heavily WTC-exposed workers were at increased risk of hearing loss, and group differences persisted for at least 15 years. Those with abnormal hearing sensitivity may benefit from interventions such as hearing aids and other rehabilitation.

Residential mobility is hypothesized to impact health through changes to the built environment and disruptions in social networks, and may vary by neighborhood deprivation exposure. However, there are few longitudinal investigations of residential mobility in relation to health outcomes. This study examined enrollees from the World Trade Center Health Registry, a longitudinal cohort of first responders and community members in lower Manhattan on September 11, 2001. Enrollees who completed ≥2 health surveys between 2004 and 2016 and did not have diabetes (N = 44,089) or hypertension (N = 35,065) at baseline (i.e., 2004) were included. Using geocoded annual home addresses, residential mobility was examined using two indicators: moving frequency and displacement. Moving frequency was defined as the number of times someone was recorded as living in a different neighborhood; displacement as any moving to a more disadvantaged neighborhood. We fit adjusted Cox proportional hazards models with time-dependent exposures (moving frequency and displacement) and covariates to evaluate associations with incident diabetes and hypertension. From 2004 to 2016, the majority of enrollees never moved (54.5%); 6.5% moved ≥3 times. Those who moved ≥3 times had a similar hazard of diabetes (hazard ratio (HR) = 0.78; 95% Confidence Interval (CI): 0.40, 1.53) and hypertension (HR = 0.99; 95% CI: 0.68, 1.43) compared with those who never moved. Similarly, displacement was not associated with diabetes or hypertension. Residential mobility was not associated with diabetes or hypertension among a cohort of primarily urban-dwelling adults.

Background Asthma, gastroesophageal reflux disease (GERD), posttraumatic stress disorder (PTSD) and depression have each been linked to exposure to the September 11, 2001 World Trade Center (WTC) terrorist attacks (9/11). We described the prevalence and patterns of these conditions and associated health-related quality of life (HRQOL) fifteen years after the attacks. Methods We studied 36,897 participants in the WTC Health Registry, a cohort of exposed rescue/recovery workers and community members, who completed baseline (2003–2004) and follow-up (2015–16) questionnaires. Lower respiratory symptoms (LRS; cough, dyspnea, or wheeze), gastroesophageal reflux symptoms (GERS) and self-reported clinician-diagnosed asthma and GERD history were obtained from surveys. PTSD was defined as a score > 44 on the PTSD checklist, and depression as a score > 10 on the Patient Health Questionnaire (PHQ). Poor HRQOL was defined as reporting limited usual daily activities for > 14 days during the month preceding the survey. Results In 2015–16, 47.8% of participants had ≥1 of the conditions studied. Among participants without pre-existing asthma, 15.4% reported asthma diagnosed after 9/11; of these, 76.5% had LRS at follow up. Among those without pre-9/11 GERD, 22.3% reported being diagnosed with GERD after 9/11; 72.2% had GERS at follow-up. The prevalence of PTSD was 14.2%, and of depression was 15.3%. HRQOL declined as the number of comorbidities increased, and was particularly low among participants with mental health conditions. Over one quarter of participants with PTSD or depression reported unmet need for mental health care in the preceding year. Conclusions Nearly half of participants reported having developed at least one of the physical or mental health conditions studied by 2015–2016; comorbidity among conditions was common. Poor HRQOL and unmet need for health were frequently reported, particularly among those with post-9/11 PTSD or depression. Comprehensive physical and mental health care are essential for survivors of complex environmental disasters, and continued efforts to connect 9/11-exposed persons to needed resources are critical.

Perfluoroalkyl substances (PFAS) were shown to be immunotoxic in laboratory animals. There is some epidemiological evidence that PFAS exposure is inversely associated with vaccine-induced antibody concentration. We examined immune response to vaccination with FluMist intranasal live attenuated influenza vaccine in relation to four PFAS (perfluorooctanoate, perfluorononanoate, perfluorooctane sulfonate, perfluorohexane sulfonate) serum concentrations among 78 healthy adults vaccinated during the 2010 – 2011 influenza season. We measured anti-A H1N1 antibody response and cytokine and chemokine concentrations in serum pre-vaccination, 3 days post-vaccination, and 30 days post-vaccination. We measured cytokine, chemokine, and mucosal IgA concentration in nasal secretions 3 days post-vaccination and 30 days post-vaccination. Adults with higher PFAS concentrations were more likely to seroconvert after FluMist vaccination as compared to adults with lower PFAS concentrations. The associations, however, were imprecise and few participants seroconverted as measured either by hemagglutination inhibition (9%) or immunohistochemical staining (25%). We observed no readily discernable or consistent pattern between PFAS concentration and baseline cytokine, chemokine, or mucosal IgA concentration, or between PFAS concentration and change in these immune markers between baseline and FluMist-response states. The resuts of this study do not support a reduced immune response to FluMist vaccination among healthy adults in relation to serum PFAS concentration. Given the study’s many limitations, however, it does not rule out impaired vaccine response to other vaccines or vaccine components in either children or adults.

Background Rescue and recovery workers responding to the 2001 collapse of the World Trade Center (WTC) sustained exposures to toxic chemicals and have elevated rates of multiple morbidities. Methods Using data from the World Trade Center Health Program and the National Death Index for 2002–2011, we examined standardized mortality ratios (SMR) and proportional cancer mortality ratios (PCMR) with indirect standardization for age, sex, race, and calendar year to the U.S. general population, as well as associations between WTC-related environmental exposures and all-cause mortality. Results We identified 330 deaths among 28,918 responders (SMR 0.43, 95%CI 0.39–0.48). No cause-specific SMRs were meaningfully elevated. PCMRs were elevated for neoplasms of lymphatic and hematopoietic tissue (PCMR 1.76, 95%CI 1.06–2.75). Mortality hazard ratios showed no linear trend with exposure. Conclusions Consistent with a healthy worker effect, all-cause mortality among responders was not elevated. There was no clear association between intensity and duration of exposure and mortality. Surveillance is needed to monitor the proportionally higher cancer mortality attributed to lymphatic/hematopoietic neoplasms. Am. J. Ind. Med. 59:87–95, 2016. © 2016 Wiley Periodicals, Inc.

Internal and international migration impacts family structure, parent–child relationships, and child care arrangements for the world’s ∼1 billion migrants.1 When parents migrate without their children, this experience of prolonged separation has profound repercussions on children’s development and well-being. Because international migration disrupts family systems globally, internal migration, such as rural-to-urban migration in low- and middle-income countries, also has massive impacts. In China alone, 61 million rural children are living apart from their parents who have migrated to urban areas.2 These so-called “left-behind children” comprise 34% of all rural children and 22% of the total child population in China.2 The well-being of children who are affected by parental migration has raised concerns worldwide. Although labor-related migration tends to improve a family’s socioeconomic circumstances, a prolonged separation from migrant parents can place children at an increased risk for psychosocial disorders.3 Even reunification with parents may lead to additional distress because of an abrupt restructuring of family dynamics.4,5 Despite the many clinical implications of parental migration and family separation, little information is available to help clinicians understand how parental migration may affect mental and behavioral development in children. Migrant parents often leave their children behind in the pursuit of employment even in Asian cultures, in which family connection is emphasized as the major source of identity and protection. Factors that prevent migrant parents from bringing their children along include residence permit policies, a high cost of living, and a lack of access to child care and education. … Address correspondence to Chenyue Zhao, PhD, Department of Child and Adolescent Psychiatry, School of Medicine, New York University, 1 Park Ave, 7th Floor, New York, NY 10016. E-mail: chenyue.zhao{at}nyumc.org

Perfluoroalkyl and polyfluoroalkyl substances (PFAS) are immunotoxic in laboratory studies. Human studies of immune effects are inconsistent. Using the US National Health and Nutrition Examination Survey (NHANES), we examined PFAS serum concentration and indicators of prevalent immune function among 12–19-y-old children. In this cross-sectional study, we examined PFAS serum concentration in relation to measles, mumps, and rubella antibody concentrations in NHANES 1999–2000 and 2003–2004 (n = 1,191) and to allergic conditions and allergic sensitization in NHANES 2005–2006 (n = 640). In adjusted, survey-weighted models, a doubling of perfluorooctane sulfonate (PFOS) concentration among seropositive children was associated with a 13.3% (95% confidence interval (CI): −19.9, −6.2) decrease in rubella antibody concentration and a 5.9% decrease in mumps antibody concentration (95% CI: −9.9, −1.6). We observed no adverse association between exposure and current allergic conditions, including asthma. Children with higher PFOS concentration were less likely to be sensitized to any allergen (odds ratio (OR): 0.74; 95% CI: 0.58, 0.95). Increased exposure to several PFAS was associated with lower levels to mumps and rubella antibody concentrations, especially among seropositive individuals. These lower antibody concentrations may indicate a less robust response to vaccination or greater waning of vaccine-derived immunity over time.

To examine the association between 9/11-related exposures and self-reported hearing problems among 16,579 rescue/recovery workers in the World Trade Center (WTC) Health Registry.Using Registry Waves 1 (2003 to 2004) and 2 (2006 to 2007), we modeled the association between two metrics of 9/11-related exposures and hearing difficulties.The prevalence of incident, persistent hearing problems was 4.4%. In a fully adjusted model, workers with higher environmental hazards scores were twice as likely (interquartile range OR 2.1; 95% confidence interval [CI] 1.8, 2.5) to report hearing problems. Based on the same fully adjusted model, workers unable to hear in the dust cloud were 2.3 (95% CI 1.8, 3.0) times more likely to report hearing problems as compared with workers not in the dust cloud.We observed a consistent association between WTC-related exposures and self-reported hearing problems among rescue/recovery workers.

Perfluorooctanoate (PFOA) is a perfluorinated compound (PFC) that has been widely used in numerous consumer products since the 1950s.1–3 Human exposure typically occurs through transfer from food packaging, bioaccumulation in the food chain, and inhalation of household dust 4. PFOA is almost always detectable in serum5 and has been found in amniotic fluid,6, 7 maternal and umbilical cord blood,8, 9 and breast milk.10–13 Epidemiologic evidence on PFOA exposure and child development is limited, with variation in exposure timing and specific endpoints. In the Danish National Birth Cohort (n=1,400), prenatal PFOA levels were unrelated to maternal reports of child development through age 7.14, 15 Three cross-sectional studies observed divergent associations among measures of attention in school-age children. In the National Health and Nutrition Examination Survey (NHANES; n=571), higher PFOA levels were associated with increased odds of parent-reported Attention Deficit/Hyperactivity Disorder (ADHD).16 In New York State, higher levels of several PFCs – although not PFOA – were associated with impulsivity (n=79).17 Using C8 Health Project data (n=10,546), the parent study of the present report, Stein and Savitz reported reduced odds of ADHD at the highest PFOA exposure level.18 We recently examined the children in the present report in a prospective study (n=320) of PFOA exposure and performance on neuropsychological tests.19 With increased childhood PFOA exposure there was a modest increase in intelligence quotient (IQ), decrease in behaviors typical of ADHD, and null associations with reading skills, math skills, and neuropsychological functioning. The current study complements the existing literature by providing a prospective examination of childhood PFOA concentration and mother and teacher report of child behavior assessed 3 – 4 years later at ages 6 – 12. In 2001, a group of residents from the West Virginia and Ohio communities surrounding a chemical plant near Parkersburg, West Virginia filed a class action lawsuit alleging health damage from drinking water supplies drawing from PFOA-contaminated groundwater.20 Geometric mean PFOA levels in this population were approximately 5 times the national average; exposure to most other PFCs reflected typical background levels. We invited a subset of children in the C8 Health Project to participate in a follow-up study assessing neurobehavioral development.

In animal studies, perfluorinated compounds affect fetal growth, development, viability, and postnatal growth. The limited epidemiologic findings on child neurobehavioral development are mixed.We recruited and evaluated 320 children who participated in the C8 Health Project, a 2005-2006 survey in a Mid-Ohio Valley community highly exposed to perfluorooctanoate (PFOA) through contaminated drinking water. We examined associations among estimated in utero PFOA exposure, measured childhood PFOA serum concentration, and subsequent performance on neuropsychological tests 3-4 years later at ages 6-12 years. We assessed Intelligence Quotient (IQ) reading and math skills, language, memory and learning, visual-spatial processing, and attention. All multivariable linear regression models were adjusted for age, sex, home environment, test examiner, and maternal IQ. Models with measured childhood PFOA were additionally adjusted for child body mass index.Children in the highest as compared with lowest quartile of estimated in utero PFOA had increases in Full Scale IQ (β 4.6, 95% confidence interval [CI] = 0.7-8.5) and decreases in characteristics of attention deficit/hyperactivity disorder as measured by the Clinical Confidence Index of Connors' Continuous Performance Test-II (β -8.5, 95% CI = -16.1 to -0.8). There were negligible associations between PFOA and reading or math skills or neuropsychological functioning.These results do not suggest an adverse association between the levels of PFOA exposure experienced by children in this cohort and their performance on neuropsychological tests.

BACKGROUND: Perfluorooctanoic acid (PFOA) is a potential cause of adverse pregnancy outcomes, but previous studies have been limited by low exposures and small study size. OBJECTIVES: Using birth certificate information, we examined the relation between estimated PFOA exposure and birth outcomes in an area of West Virginia and Ohio whose drinking water was contaminated by a chemical plant. METHODS: Births in the study area from 1990 through 2004 were examined to generate case groups of stillbirth (n = 106), pregnancy-induced hypertension (n = 224), preterm birth (n = 3,613), term low birth weight (n = 918), term small-for-gestational-age (SGA) (n = 353), and a continuous measure of birth weight among a sample of term births (n = 4,534). A 10% sample of term births ≥ 2,500 g were selected as a source of controls (n = 3,616). Historical estimates of serum PFOA were derived from a previously developed fate and transport model. In a second study, we examined 4,547 area births linked to a survey with residential history data. RESULTS: In the analysis based only on birth records, we found no consistent evidence of an association between estimated PFOA exposure and stillbirth, pregnancy-induced hypertension, preterm birth, or indices of fetal growth. In the analysis of birth records linked to the survey, PFOA was unrelated to pregnancy-induced hypertension or preterm birth but showed some suggestion of an association with early preterm birth. Measures of growth restriction showed weak and inconsistent associations with PFOA. CONCLUSIONS: Based on the analysis using the health survey, these results provide little support for an effect of PFOA exposure on most pregnancy outcomes, except for early preterm birth and possibly fetal growth restriction.

Purpose Smoking during pregnancy is strongly associated with increased risk of small for gestational age (SGA) and low birth weight, whereas elevated prepregnancy body mass index (BMI) is associated with a decreased risk of SGA and greater birth weight. We investigated the combined effect of prenatal smoking and prepregnancy BMI on risk of SGA and on birth weight. Methods A total of 34,928 singleton, term pregnancies in residents of New York City between 1995 and 2003 were evaluated in multivariable regression models of birth weight and risk of SGA. Results Increasing prepregnancy BMI reduced the risk of SGA and increased birth weight. The effect of prenatal smoking on birth weight and SGA diminished in women as their prepregnancy BMI increased, such that prenatal smoking did not significantly impact the risk of SGA among women who were overweight or obese before pregnancy. Prenatal smoking decreased mean birth weight by 187 g (95% confidence interval [CI] −337, −37) among underweight women, by 129 g(95% CI −170, −87) among normal weight women, by 46 g (95% CI −113, +20) among overweight women, and by 75 g (95% CI −162, +11) among obese women. Conclusions This study suggests that the effect of smoking during pregnancy on SGA and birth weight is present in underweight and normal weight women but markedly reduced among obese and overweight women.

Background: Perfluorinated compounds (PFCs) are persistent environmental pollutants. Toxicology studies demonstrate the potential for perfluorooctanoic acid (PFOA) and other PFCs to affect human growth and development. Attention deficit/hyperactivity disorder (ADHD) is a developmental disorder with suspected environmental and genetic etiology. Objectives: We examined the cross-sectional association between serum PFC concentration and parent or self-report of doctor-diagnosed ADHD with and without current ADHD medication. Methods: We used data from the C8 Health Project, a 2005–2006 survey in a Mid-Ohio Valley community highly exposed to PFOA through contaminated drinking water, to study non-Hispanic white children 5–18 years of age. Logistic regression models were adjusted for age and sex. Results: Of the 10,546 eligible children, 12.4% reported ADHD and 5.1% reported ADHD plus ADHD medication use. We observed an inverted J-shaped association between PFOA and ADHD, with a small increase in prevalence for the second quartile of exposure compared with the lowest, and a decrease for the highest versus lowest quartile. The prevalence of ADHD plus medication increased with perfluorohexane sulfonate (PFHxS) levels, with an adjusted odds ratio of 1.59 (95% confidence interval, 1.21–2.08) comparing the highest quartile of exposure to the lowest. We observed a modest association between perfluorooctane sulfonate and ADHD with medication. Conclusions: The most notable finding for PFOA and ADHD, a reduction in prevalence at the highest exposure level, is unlikely to be causal, perhaps reflecting a spurious finding related to the geographic determination of PFOA exposure in this population or to unmeasured behavioral or physiologic correlates of exposure and outcome. Possible positive associations between other PFCs and ADHD, particularly PFHxS, warrant continued investigation.

The obesity epidemic raises concerns about the impact of excessive and insufficient weight gain during pregnancy.We examined the association between gestational weight gain (GWG) and preterm birth, term small- and large-for-gestational-age (SGA and LGA), term birthweight, and term primary Cesarean delivery, considering prepregnancy body mass index (BMI) and ethnicity in a cohort of 33,872 New York City residents who gave birth between 1995 and 2003 and delivered in hospitals elsewhere in New York State.Preterm birth (37 weeks' gestation) showed a modest U-shaped relationship, with projected GWG of10 kg and 20+ kg associated with odds ratios of 1.4 and 1.3, respectively, relative to 10 to 14 kg. The pattern was stronger for preterm birth32 weeks' and for underweight women with low GWG and overweight/obese women with high GWG. Term SGA decreased and term LGA and birthweight increased monotonically with increasing GWG. Primary Cesarean delivery followed the same pattern as LGA, but less strongly.Although the study is limited by potential selection bias and measurement error, our findings support the contention that GWG may be a modifiable predictor of pregnancy outcome that warrants further investigation, particularly randomized trials, to assess whether the relation is causal.

Living in a socioeconomically deprived neighborhood has been associated with an increased risk of adverse birth outcomes. However, variation in the effect of neighborhood deprivation among diverse ethnic groups has not been studied.Using linked hospital discharge and birth data for 517,994 singleton live births in New York City from 1998 through 2002, we examined the association between neighborhood deprivation, preterm birth (PTB), and term low birthweight (TLBW) (or=37 weeks and2500g). Adjusted odds ratios (aORs) for PTB (32 and 33-36 weeks) and TLBW were estimated using logistic regression.The aOR for PTB of less than 32 weeks for the highest quartile of deprivation compared to the lowest was 1.24 (95% confidence limit [CL] = 1.13, 1.36), for PTB 33-36 weeks was 1.06 (95% CL = 1.01, 1.11), and for TLBW was 1.19 (95% CL = 1.11, 1.27). Measures of association varied by ethnicity; aORs of the greatest magnitude for PTB were found among Hispanic Caribbean women (PTB32 weeks: aOR = 1.63, 95% CL = 1.27, 2.10; PTB 33-36 weeks: aOR = 1.32, 95% CL = 1.02, 1.70), and for TLBW among African women (aOR = 1.47, 95% CL = 1.02, 2.13).The mechanisms linking neighborhood deprivation to adverse birth outcomes may differ depending on individual ethnicity and/or cultural context and should be investigated in future research.

A number of previous studies have reported an inverse association between maternal smoking and preeclampsia. Additionally, some have suggested that smokers who develop preeclampsia have worse maternal and fetal outcomes than nonsmokers who develop preeclampsia. The authors examined the relation of smoking to preeclampsia among 674,250 singleton pregnancies in New York City between 1995 and 2003. Although smoking was associated with a reduced risk of preeclampsia overall (adjusted odds ratio = 0.88, 95% confidence interval: 0.82, 0.94), no association was found for preeclampsia superimposed on chronic hypertension (adjusted odds ratio = 1.04, 95% confidence interval: 0.90, 1.21). Furthermore, the apparent protection conferred by maternal smoking was restricted to women agedor =30 years. Contrary to previous reports, the authors found evidence of a negative interaction between smoking and preeclampsia with respect to preterm delivery and birth weight; smokers who developed preeclampsia had a lower risk of preterm delivery, and a lower adjusted mean difference in birth weight, than would have been expected based on the independent effects of smoking and preeclampsia. These data suggest that smoking is only protective against preeclampsia without pre gestational hypertension, and even then principally among younger women. Additionally, smokers who develop these disorders have no increased risk of adverse birth outcomes relative to nonsmokers who develop the same conditions.

Purpose Community-based testing may identify young adults in the general population with sexually transmitted chlamydial infection. To develop selective screening guidelines appropriate for community settings, the authors conducted a cross-sectional analysis of the National Longitudinal Study of Adolescent Health Wave III (April 2, 2001, to May 9, 2002). Methods Separately for women and men, we developed three predictive models by using unconditional multiple logistic regression for survey data. To account for racial/ethnic disparity in prevalence, initial models included identical predictor characteristics plus information on 1) respondent's race/ethnicity; or 2) respondent's most recent partner's race/ethnicity; or 3) no information on race/ethnicity. Results Chlamydia trachomatis diagnosis was available for 10,928 (88.6%) of the sexually experienced respondents. A combination of five characteristics for women and six characteristics for men identified approximately 80% of infections when testing ≤50% of the population. Information regarding race/ethnicity dramatically affected algorithm performance. Conclusion The use of race/ethnicity in any screening algorithm is problematic and controversial, but the model without race information missed many diagnoses in the minority groups. Universal screening in high-prevalence regions and selective screening in low-prevalence regions may be one method of reaching the affected populations while avoiding the stigma of guidelines incorporating race/ethnicity.

High level occupational exposure to metals such as manganese (Mn), arsenic (As), and Cadmium (Cd) causes neurological disease in adults. The impact of low level environmental exposure to these meta...

Influenza is an acute viral respiratory infection that results in high morbidity and significant mortality in humans, producing significant health and economical burdens worldwide [1]. Annual vaccination has been the most effective strategy to reduce the impact of influenza virus infection [2]. As a consequence, significant effort has been made to produce effective vaccines that will reduce the incidence and severity of natural infections. In the United States, the use of intramuscular trivalent inactivated influenza vaccine (TIV) is recommended to induce protective immunity through the induction of serum antibodies. Recently, a live attenuated influenza vaccine (LAIV) delivered by intranasal spray was licensed [3–5]. LAIV induces an immune response that more closely resembles natural immunity than the response elicited by the intramuscular vaccine [6, 7]. This vaccine provides comparable levels of protection against laboratory-documented influenza in adults (85% efficacy), compared with TIV [8, 9], but the mechanism of action might be different. Lower serum hemagglutination-inhibition (HAI) titers are seen with LAIV, and they are accompanied by a higher level of immunoglobulin A (IgA) antibodies in nasal wash [8–11], suggesting that other immunological contributors may be involved in the protection following vaccination with LAIV. Although systems biology approaches have been used to predict the immunogenicity of the vaccine YF-17D against yellow fever [12] and, more recently, of TIV and LAIV against influenza [13], the latter study did not examine the mucosal response to LAIV. The present study extends what is known about the systemic response and provides information about the local response to LAIV. To identify factors associated with LAIV vaccination, we performed a study during the 2010–2011 influenza season. We developed a protocol to evaluate the immunological changes in systemic and local (upper respiratory tract) immune responses and collected blood samples and nasal secretions from 79 healthy adult subjects who were vaccinated with LAIV. Our study indicates that LAIV receipt induces a local inflammatory response, triggering nasal release of interferon (IFN) and granulocyte colony-stimulating factor (G-CSF) 2–3 days after vaccination, followed by specific IgA antibody production, with little changes in systemic immunity.

Background: Previous research suggests perfluorooctanoic acid (PFOA) and perfluorooctane sulfonate (PFOS) may be associated with adverse pregnancy outcomes. Objective: We conducted a population-based study of PFOA and PFOS and birth outcomes from 2005 through 2010 in a Mid-Ohio Valley community exposed to high levels of PFOA through drinking-water contamination. Methods: Women provided serum for PFOA and PFOS measurement in 2005–2006 and reported reproductive histories in subsequent follow-up interviews. Reported singleton live births among 1,330 women after 1 January 2005 were linked to birth records (n = 1,630) to identify the outcomes of preterm birth (< 37 weeks gestation), pregnancy-induced hypertension, low birth weight (< 2,500 g), and birth weight (grams) among full-term infants. Results: We observed little or no evidence of association between maternal serum PFOA or PFOS and preterm birth (n = 158) or low birth weight (n = 88). Serum PFOA and PFOS were both positively associated with pregnancy-induced hypertension (n = 106), with adjusted odds ratios (ORs) per log unit increase in PFOA and PFOS of 1.27 (95% CI: 1.05, 1.55) and 1.47 (95% CI: 1.06, 2.04), respectively, but associations did not increase monotonically when categorized by quintiles. Results of subanalyses restricted to pregnancies conceived after blood collection were consistent with the main analyses. There was suggestion of a modest negative association between PFOS and birth weight in full-term infants (–29 g per log unit increase; 95% CI: –66, 7), which became stronger when restricted to births conceived after the blood sample collection (–49 g per log unit increase; 95% CI: –90, –8). Conclusion: Results provide some evidence of positive associations between measured serum perfluorinated compounds and pregnancy-induced hypertension and a negative association between PFOS and birth weight among full-term infants. Citation: Darrow LA, Stein CR, Steenland K. 2013. Serum perfluorooctanoic acid and perfluorooctane sulfonate concentrations in relation to birth outcomes in the Mid-Ohio Valley, 2005–2010. Environ Health Perspect 121:1207–1213; http://dx.doi.org/10.1289/ehp.1206372

We assessed the association between perfluorooctanoic acid (PFOA) and pregnancy outcome in an area with elevated exposure to PFOA from drinking water contaminated by chemical plant releases.Serum PFOA was measured, and reproductive and residential histories were obtained during 2005-2006. We estimated serum PFOA levels at the time of pregnancy for 11,737 pregnancies occurring between 1990 and 2006, based on historical information on PFOA releases, environmental distribution, pharmacokinetic modeling, and residential histories. We assessed the association between PFOA and the odds of miscarriage, stillbirth, preeclampsia, preterm birth, term low birthweight, and birth defects, controlling for calendar time, age, parity, education, and smoking. PFOA exposure was evaluated as a continuous measure (with and without log transformation) and in quintiles, combining the lowest 2 quintiles (6.8 ng/mL) as the referent.Measures of association between PFOA and miscarriage, preterm birth, term low birthweight, and birth defects were close to the null. Odds of stillbirth were elevated in the fourth quintile only. For preeclampsia, the odds ratio was 1.13 (95% confidence interval = 1.00-1.28) for an interquartile shift in log-transformed PFOA, and the odds ratios were 1.1-1.2 across the upper 3 quintiles of exposure.In this large, population-based study in a region with markedly elevated PFOA exposure, we found no associations between estimated serum PFOA levels and adverse pregnancy outcomes other than possibly preeclampsia. Conclusions are tempered by inherent limitations in exposure reconstruction and self-reported pregnancy outcome information.

Purpose The purpose of this study is to describe the patterns of hospitalization for depression in the year after delivery in relation to social, demographic, and behavioral characteristics. Methods Data on births were linked to hospitalizations for depression over the subsequent year to describe the frequency and patterns of hospitalized postpartum depression among 2,355,886 deliveries in New York State from 1995 to 2004. We identified “definite postpartum depression” based on International Classification of Diseases (ICD) codes indicative of “mental disorders specific to pregnancy,” and “possible postpartum depression” by ICD codes for hospitalization with any depressive disorders. Results In New York State, we identified 1363 women (5.8 per 10,000) who were hospitalized with definite postpartum depression, and 6041 women (25.6 per 10,000) with possible postpartum depression, with lower risks in the New York City area. Postpartum depression was more common in later years and among mothers who were older, Black, smokers, lacking private insurance, and with multiple gestations, and was rarer among Asians. For possible postpartum depression, socioeconomic gradients were enhanced. Conclusions Risk of hospitalized postpartum depression is strongly associated with socioeconomic deprivation and varies markedly by ethnicity, with direct implications for screening and health services, also providing suggestions for etiologic studies.

To compare the sexual behaviors of young people in South Africa (SA) and the United States (US) with the aim to better understand the potential role of sexual behavior in HIV transmission in these two countries that have strikingly different HIV epidemics.Nationally representative, population-based surveys of young people aged 18-24 years from SA (n = 7,548) and the US (n = 13,451) were used for the present study.The prevalence of HIV was 10.2% in SA and1% in the US. Young women and men in the US reported an earlier age of first sex than those in SA (mean age of coital debut for women: US [16.5], SA [17.4]; for men: US [16.4], SA [16.7]). The median number of lifetime partners is higher in the US than in SA: women: US (4), SA (2); men: US (4), SA (3). The use of condom at last sex is reported to be lower in the US than in SA: women: US (36.1%), SA (45.4%); men: US (48%), SA (58%). On average, young women in SA report greater age differences with their sex partners than young women in the US.Young people in the US report riskier sexual behaviors than young people in SA, despite the much higher prevalence of HIV infection in SA. Factors above and beyond sexual behavior likely play a key role in the ongoing transmission of HIV in South African youth, and thus should be urgently uncovered to develop maximally effective prevention strategies.

Objectives.The 1998 Master Settlement Agreement (MSA) between 46 states and four major tobacco companies increased tobacco control funding and restricted tobacco marketing. In 2002, New York City (NYC) began a comprehensive tobacco control program that raised the price of cigarettes, banned indoor workplace smoking, and increased access to cessation treatment. We examined the temporal pattern of smoking during pregnancy, including ethnic variation in smoking prevalence, relative to the implementation of the MSA and NYC's comprehensive tobacco control program using birth certificate data.Methods.Using multiple logistic regression, we analyzed NYC birth certificate data to examine prenatal smoking during three time periods: 1995–1998 (pre-MSA), 1999–2002 (post-MSA, pre-NYC tobacco control), and 2003–2005 (post-MSA, post-tobacco control).Results.Overall, 3.0% of 1,136,437 births included were to smoking mothers. The proportion of smoking mothers declined from 4.5% in 1995–1998 to 1.7% in 2003–2005. Compared with non-Hispanic white women, African American women had 2.46 increased odds (95% confidence interval [CI] 2.36, 2.55) of smoking during 1995–1998, and 3.63 increased odds (95% CI 3.39, 3.88) of smoking during 2003–2005, despite an absolute reduction in smoking from 10.4% to 5.0%. Puerto Rican women also smoked considerably more than non-Hispanic white women.Conclusions.These findings document a striking temporal decline in prenatal smoking in NYC concurrent with changing tobacco control policies. Targeted efforts may be required to address the increasing disparity in prenatal smoking between non-Hispanic white and African American and Puerto Rican women.

The authors examined the association of serum perfluorooctanoic acid (PFOA) and perfluorooctane sulfonate (PFOS) with self-reported pregnancy outcome in Mid-Ohio Valley residents (2000-2006) highly exposed to PFOA. Data on 1,845 pregnancies within the 5 years preceding exposure measurement were analyzed for PFOA, and data on 5,262 pregnancies were analyzed for PFOS. Generalized estimating equations were used to calculate adjusted odds ratios and 95% confidence intervals. Neither PFOA nor PFOS showed any association with miscarriage or preterm birth. Preeclampsia was weakly associated with PFOA (adjusted odds ratio = 1.3, 95% confidence interval: 0.9, 1.9) and PFOS (adjusted odds ratio = 1.3, 95% confidence interval: 1.1, 1.7) exposures above the median. PFOA was not associated with an increase in low birth weight, but PFOS showed an increased risk above the median (adjusted odds ratio = 1.5, 95% confidence interval: 1.1, 1.9) and a dose-response gradient. Birth defects were weakly associated with PFOA exposures above the 90th percentile (adjusted odds ratio = 1.7, 95% confidence interval: 0.8, 3.6). This study identified modest associations of PFOA with preeclampsia and birth defects and of PFOS with preeclampsia and low birth weight, but associations were small, limited in precision, and based solely on self-reported health outcomes.

Objective We sought to examine the association between narrowly defined subsets of maternal ethnicity and birth outcomes. Study Design We analyzed 1995–2003 New York City birth certificates linked to hospital discharge data for 949,210 singleton births to examine the multivariable associations between maternal ethnicity and preterm birth, subsets of spontaneous and medically indicated preterm birth, term small for gestational age, and term birthweight. Results Compared with non-Hispanic whites, Puerto Ricans had an elevated odds ratio (1.9; 95% confidence interval, 1.9–2.0) for delivering at 32–36 weeks (adjusted for nativity, maternal age, parity, education, tobacco use, prepregnancy weight, and birth year). We found an excess of adverse outcomes among most Latino groups. Outcomes also varied within regions, with North African infants nearly 100 g (adjusted) heavier than sub-Saharan African infants. Conclusion The considerable heterogeneity in risk of adverse perinatal outcomes is obscured in broad categorizations of maternal race/ethnicity and may help to formulate etiologic hypotheses.

Objectives Sexual partner mixing by age is common among adolescents and adults. Although adolescent girls with older male partners are at increased risk of sexually transmitted infection, the importance of this association in young adults is unclear. Goal To assess the association between partner age difference and prevalence of chlamydial infection among young women. Study design Using Wave III of the National Longitudinal Study of Adolescent Health (April 2, 2001-May 9, 2002), the authors examined the relation between the prevalence of chlamydial infection and the partner age among women aged 18 to 26 years. Results Among women with most recent partners 2 to 8 years younger, the odds of chlamydial infection were approximately 2 times greater [adjusted odds ratio (OR), 1.8; 95% confidence interval (CI), 0.9, 3.5] than among women with partners within 1-year age difference, adjusting for number of partners in the past year. Prevalence of chlamydial infection was only slightly greater for women with partners 2 to 5 years older (adjusted OR, 1.4; 95% CI, 0.9, 2.3) and partners 6 or more years older (adjusted OR, 1.6; 95% CI, 0.9, 2.8), when compared with women with partners within 1-year age difference. The relation between most discordant partner age difference and chlamydial infection seems to vary by women's race/ethnicity, although these stratified estimates are imprecise. Conclusions These findings suggest that among young adult women, in contrast to adolescents, older male partners are only moderately associated with the prevalence of chlamydial infection. Young adult women have the lowest odds of infection with partners within 1 year of age difference.

Antimicrobial resistance to penicillin and macrolides in Streptococcus pneumoniae has increased in the United States over the past decade. Considerable geographic variation in susceptibility necessitates regional resistance tracking. Traditional active surveillance is labor intensive and costly. We collected antibiogram reports from North Carolina hospitals and assessed pneumococcal susceptibility to multiple agents from 1996 through 2000. Susceptibility in North Carolina was consistently lower than the national average. Aggregating antibiogram data is a feasible and timely method of monitoring regional susceptibility patterns and may also prove beneficial in measuring the effects of interventions to decrease antimicrobial resistance.