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ObjectivesRadon is a ubiquitous occupational and environmental lung carcinogen. We aim to quantify the association between radon progeny and lung cancer mortality in the largest and most up-to-date pooled study of uranium miners.MethodsThe pooled uranium miners analysis combines 7 cohorts of male uranium miners with 7754 lung cancer deaths and 4.3 million person-years of follow-up. Vital status and lung cancer deaths were ascertained between 1946 and 2014. The association between cumulative radon exposure in working level months (WLM) and lung cancer was modelled as the excess relative rate (ERR) per 100 WLM using Poisson regression; variation in the association by temporal and exposure factors was examined. We also examined analyses restricted to miners first hired before 1960 and with ResultsIn a model that allows for variation by attained age, time since exposure and annual exposure rate, the ERR/100 WLM was 4.68 (95% CI 2.88 to 6.96) among miners who were less than 55 years of age and were exposed in the prior 5 to ConclusionsThis new large, pooled study confirms and supports a linear exposure–response relationship between cumulative radon exposure and lung cancer mortality which is jointly modified by temporal and exposure factors.

Background: Low-carbohydrate diets decrease hemoglobin A1c among patients with type 2 diabetes mellitus. However, evidence on effects of low-carbohydrate diets on hemoglobin A1c among individuals with prediabetes is limited. Methods: We conducted a randomized parallel-group trial of 150 adults aged 40-70 years with untreated hemoglobin A1c from 6.0-6.9%. Participants were assigned to a healthy low-carbohydrate diet (target Results: Mean age was 59 years; 72% were female and 59% were Black. 95% completed the study. Participants in the low-carbohydrate arm had significantly greater 6-month decrease in hemoglobin A1c (net difference, -0.23% [95% CI, -0.32 to -0.14%]) , fasting plasma glucose (net difference, -10.3 mg/dL [95% CI, -15.7 to -4.9 mg/dL]) , and body weight (net difference, -5.9 kg [95% CI, -7.2 to -4.7 kg]) compared with usual diet arm. At 6 months, 53% in the low-carbohydrate arm and 32% in the usual diet arm had hemoglobin A1c Conclusion: A healthy low-carbohydrate diet led to improvements in glycemic and other cardiometabolic outcomes in adults with elevated hemoglobin A1c and could be recommended for prevention of type 2 diabetes mellitus. Disclosure K.S.Dorans: None. M.J.O'brien: None. G.I.Uwaifo: None. J.He: None. L.A.Bazzano: None. L.Qi: None. H.He: None. J.Chen: None. L.J.Appel: n/a. F.Hu: None. J.Samet: None. K.T.Mills: None. Funding National Institute of General Medical Sciences (1P20GM109036-01A1) . The California Walnut Commission (Folsom, CA) supported the study by providing walnuts. Shakes and bars were donated by The Simply Good Foods Company (Denver, CO) . Sugar replacement samples were provided by Swerve LLC (New Orleans, LA) .

BackgroundDespite reductions in exposure for workers and the general public, radon remains a leading cause of lung cancer. Prior studies of underground miners depended heavily upon information on deaths among miners employed in the early years of mine operations when exposures were high and tended to be poorly estimated.ObjectivesTo strengthen the basis for radiation protection, we report on the follow-up of workers employed in the later periods of mine operations for whom we have more accurate exposure information and for whom exposures tended to be accrued at intensities that are more comparable to contemporary settings.MethodsWe conducted a pooled analysis of cohort studies of lung cancer mortality among 57,873 male uranium miners in Canada, Czech Republic, France, Germany, and the United States, who were first employed in 1960 or later (thereby excluding miners employed during the periods of highest exposure and focusing on miners who tend to have higher quality assessments of radon progeny exposures). We derived estimates of excess relative rate per 100 working level months (ERR/100 WLM) for mortality from lung cancer.ResultsThe analysis included 1.9 million person-years of observation and 1,217 deaths due to lung cancer. The relative rate of lung cancer increased in a linear fashion with cumulative exposure to radon progeny (ERR/100 WLM=1.33; 95% CI: 0.89, 1.88). The association was modified by attained age, age at exposure, and annual exposure rate; for attained ages

Ambient air pollution is a growing public health concern in major African cities, including Addis Ababa (Ethiopia), where little information is available on fine particulate matter (PM2.5, with aerodynamic diameter

Real-time monitoring of fine particulate matter (PM(2.5)) concentrations and assessing the health impact are limited in Ethiopia. The objective of this study is to describe current levels of PM(2.5) air pollution in Addis Ababa and examine temporal patterns and to consider the health impact of current PM(2.5) exposure levels. METHODS: PM(2.5) concentrations were measured using a centrally-located Beta Attenuator Monitor (BAM-1022) for 3 years (1 April 2017 to 31 March 2020), with data downloaded biweekly. Deaths attributable to current PM(2.5) concentration levels were estimated using the AirQ+ tool. The daily average was estimated using hourly data. RESULTS: The daily mean (SD) PM(2.5) concentration was 42.4 µg/m(3) (15.98). Two daily extremes were observed: morning (high) and afternoon (low). Sundays had the lowest PM(2.5) concentration, while Mondays to Thursdays saw a continuous increase; Fridays showed the highest concentration. Seasons showed marked variation, with the highest values during the wet season. Concentration spikes reflected periods of intensive fuel combustion. A total of 502 deaths (4.44%) were attributable to current air pollution levels referenced to the 35 µg/m(3) WHO interim target annual level and 2,043 (17.7%) at the WHO 10 µg/m(3) annual guideline. CONCLUSION: PM(2.5) daily levels were 1.7 times higher than the WHO-recommended 24-hour guideline. The current annual mean PM(2.5) concentration results in a substantial burden of attributable deaths compared to an annual mean of 10 µg/m(3). The high PM(2.5) level and its variability across days and seasons calls for citywide interventions to promote clean air.

Since the mid-20th century, the scientific community has substantially improved its understanding of the worldwide tobacco epidemic. Although significant progress has been made, the sheer enormity and scope of the global problem put it on track to take a billion lives this century. Curbing the epidemic will require maximizing the impact of proven tools as well as the development of new, breakthrough methods to help interrupt the spread of nicotine addiction and reduce the downstream morbidity.Members of the Tobacco Action Committee of the American Thoracic Society queried bibliographic databases, including Medline, Embase, and the Cochrane Collaborative, to identify primary sources and reviews relevant to the epidemic. Exploded search terms were used to identify evidence, including tobacco, addiction, smoking, cigarettes, nicotine, and smoking cessation. Evidence was consolidated into three thematic areas: (1) determinants of risk, (2) maternal-fetal exposure, and (3) current tobacco users. Expert panel consensus regarding current gaps in understanding and recommendations for future research priorities was generated through iterative discussion.Although much has been accomplished, significant gaps in understanding remain. Implementation often lags well behind insight. This report identifies a number of investigative opportunities for significantly reducing the toll of tobacco use, including: (1) the need for novel, nonlinear models of population-based disease control; (2) refinement of "real-world" models of clinical intervention in trial design; and (3) understanding of mechanisms by which intrauterine smoke exposure may lead to persistent, tobacco-related chronic disease.In the coming era of tobacco research, pooled talent from multiple disciplines will be required to further illuminate the complex social, environmental and biological codeterminants of tobacco dependence.

Ethiopia produced its Environmental Health Situational Analysis and Needs Assessment (SANA) report in 2010 as part of the global endeavor to characterize and underscore the importance of connecting health and environment. The assessment methods used in SANA 2010 were updated, replicated and used in this SABNA. with a focus on air pollution, occupational safety and health, and climate change.The purpose of the review was to examine national policies and identify gaps in regulations and organizational arrangements that determine Ethiopia's ability to mitigate and eventually prevent the health impacts of air pollution, occupational hazards, and climate change.The national policy and regulatory documents were reviewed. Literature was identified through electronic searches. Hard copies of past reports and policies were reviewed whenever necessary. A semi-structured guideline was used to conduct in-depth interviews aimed at identifying gaps and needs.The Constitution of Ethiopia has policy provisions related to air pollution, occupational safety and health (OSH), and climate change and health. Proclamation No. 300/2002 on Environmental Pollution Control specifies ambient air quality standards and allowable emissions. However, there were no documents that outlined the national or regional strategies that the ministries and agencies could adopt to translate existing policies, legal provisions, or guidelines for air pollution into practical programs. In the same way, a national OSH policy was lacking at the time this review was made on how occupational safety and health should be handled nationally or at lower governing levels as required by the International Occupation Safety and Health and Working Environment Convention No. 155/1981. Ethiopia is a signatory of this Convention.The results of the situational analysis indicate that there are cross-cutting gaps in the various sectors. Among these, addressing the critical shortage of skilled personnel is an urgent priority. Most stakeholders face acute shortages of professionals and poor retention mechanisms. It is therefore important to design interventions that focus on capacity building in, for example, aligning curricula with specific needs of ministries, andequip professionals with the necessary technical skills.In addition, the results indicate that policies and regulations exist in theory, but in practice, there are inadequate implementation strategies to encourage adherence and enforcement of the regulations and policies.

The current rapid economic development has brought changes in workplaces in developing countries, including Ethiopia. The organization of occupational health and safety services is not yet resilient enough to handle the growing demands for workers' health in the context of industrialization. There is limited information on the gaps and needs of occupational health services in workplaces in Ethiopia.The present review article describes the existing profile of occupational safety and health services in Ethiopia and identifies the current gaps and needs in the services.Secondary data sources were reviewed using a structured checklist to explore the status of occupational safety, health services and related morbidity. Local literature was consulted in order to describe the type and prevalence of work related hazards, patterns of industries and of workforce. Published articles were searched in Google, Google scholar, PUBMED, and HINARI databases. Relevant heads of stakeholder organizations and experts were interviewed to verify the gaps that were synthesized using desk review.Ethiopia is an agrarian country that is industrializing rapidly with a focus on construction, manufacturing, mining, and road infrastructure. An estimated work force of about two million is currently engaged in the public and private sectors. Males constitute the majority of this workforce. Most of the workforce has basic primary education. Commonly observed hazards in the workplace include occupational noise and dust of various types in manufacturing sectors and chemical exposures in the flower industry. Injury in both the agriculture and the manufacturing sectors is another workplace hazard commonly observed in the country. A lack of information made assessing workplace exposures in detail difficult. The prevalence of noise exposure was found to be high with the potential to seriously impact hearing capacity. Exposure to dust in textile and cement factories greatly exceeded international permissible limits. There is a high level of workplace injuries that often leads to an extended loss of productive working days. Occupational safety and health services were found to be inadequately organized. There is limited practice in exposure assessment and monitoring. This happens to be true despite the existing favorable environment in areas of policies and regulations.There is a severe scarcity of peer-reviewed literature related to workplace exposures and their impact on workplace health and safety. Limited adequately skilled manpower is available. The internal infrastructural capacity is weak and cannot help to identify and assess hazards in the workplace. Monitoring system and laboratory investigation is limited despite the presence of favorable policy and regulatory frameworks. Addressing these gaps is of immediate concern.

The regulatory and policy environment surrounding air quality management warrants new types of epidemiological evidence. Whereas air pollution epidemiology has typically informed previous policies with estimates of exposure-response relationships between pollution and health outcomes, new types of evidence can inform current debates about the actual health impacts of air quality regulations. Directly evaluating specific regulatory strategies is distinct from and complements estimating exposure-response relationships; increased emphasis on assessing the effectiveness of well-defined regulatory interventions will enhance the evidence supporting policy decisions. The goal of this report is to provide new analytic perspectives and statistical methods for what we refer to as "direct"-accountability assessment of the effectiveness of specific air quality regulatory interventions. Toward this end, we sharpened many of the distinctions surrounding accountability assessment initially raised by the HEI Accountability Working Group (2003) through discussion, development, and deployment of statistical methods for drawing causal inferences from observational data. The methods and analyses presented here are unified in their focus on anchoring accountability assessment to the estimation of the causal consequences of well-defined actions or interventions. These analytic perspectives are discussed in the context of two direct-accountability case studies pertaining to four different links in the so-called chain of accountability, the related series of events leading from the intervention to the expected outcomes (see Preface; HEI Accountability Working Group 2003).The statistical methods described in this report consist of both established methods for drawing causal inferences from observational data and newly developed methods for assessing causal accountability. We have sharpened the analytic distinctions between studies that directly evaluated the effectiveness of specific policies and those that estimated exposure-response relationships between pollution and health. We emphasized how a potential-outcomes paradigm for causal inference can elevate policy debates by means of more direct evidence of the extent to which complex regulatory interventions affect pollution and health outcomes. We also outlined the potential-outcomes perspective and promoted its use as a means to frame observational studies as approximate randomized experiments. Our newly developed methods for assessing causal accountability draw on propensity scores, principal stratification, causal mediation analysis, spatial hierarchical models, and Bayesian estimation. The first case study made use of health outcomes among approximately four million Medicare beneficiaries living in the Western United States to estimate the causal health impacts of areas designated as being in nonattainment for particulate matter ≤10 μm in aerodynamic diameter (PM10*) according to the 1987 National Ambient Air Quality Standards (NAAQS). The second case study focused on developing and testing our new, advanced methodology for multipollutant accountability assessment by examining the extent to which sulfur dioxide (SO2) scrubbers on coal-fired power plants causally affect emissions of SO2, nitrogen oxides (NO(x)), and carbon dioxide (CO2) as well as the extent to which emissions reductions mediate the causal effect of a scrubber on ambient concentrations of PM2.5. Both case studies were anchored in our compilation of national, linked data on ambient air quality monitoring, weather, population demographics, Medicare hospitalization and mortality outcomes, continuous-emissions monitoring for electricity-generating units (EGUs) in power plants, and a variety of regulatory control interventions. The resulting database has unprecedented accuracy and granularity for conducting the types of accountability assessments presented in this report. A key component of our work was the creation of tools to help distribute our linked database and to facilitate reproducible research.In the first case study, we focused on illustrating the most fundamental features of a causal-inference perspective on direct-accountability assessment. The results indicated that all-cause Medicare mortality and respiratory-related hospitalization rates were causally reduced in areas designated as nonattainment for PM10 during 1990 to 1995 compared with the rates that would have occurred without the designation. In the second case study, which examined power-plant emissions and illustrated our newly developed statistical methods, the results indicated that the presence of an SO2 scrubber causally reduced ambient PM2.5 and that this reduction was mediated almost entirely through causal reductions in SO2 emissions. The results were interpreted in light of the well-documented relationships between scrubbers, power-plant emissions, and PM2.5.By grounding accountability research in a potential-outcomes framework and applying our new methods to our collection of national data sets, we were able to provide additional sound evidence of the health effects of long-term, large-scale air quality regulations. This additional, rigorous evidence of the causal effects of well-defined actions augments the existing body of research and ensures that the highest-level epidemiological evidence will continue to support regulatory policies. Ultimately, our research contributed to the evidence available to support to the U.S. Environmental Protection Agency (U.S. EPA) and other stakeholders for incorporating health outcomes research into policy development.

While many time-series studies of ozone and daily mortality identified positive associations,others yielded null or inconclusive results. We performed a meta-analysis of 144 effect estimates from 39 time-series studies, and estimated pooled effects by lags, age groups,cause-specific mortality, and concentration metrics. We compared results to estimates from the National Morbidity, Mortality, and Air Pollution Study (NMMAPS), a time-series study of 95 large U.S. cities from 1987 to 2000. Both meta-analysis and NMMAPS results provided strong evidence of a short-term association between ozone and mortality, with larger effects for cardiovascular and respiratory mortality, the elderly, and current day ozone exposure as compared to other single day lags. In both analyses, results were not sensitive to adjustment for particulate matter and model specifications. In the meta-analysis we found that a 10 ppb increase in daily ozone is associated with a 0.83 (95% confidence interval: 0.53, 1.12%) increase in total mortality, whereas the corresponding NMMAPS estimate is 0.25%(0.12, 0.39%). Meta-analysis results were consistently larger than those from NMMAPS,indicating publication bias. Additional publication bias is evident regarding the choice of lags in time-series studies, and the larger heterogeneity in posterior city-specific estimates in the meta-analysis, as compared with NMAMPS.

Time series models relating short-term changes in air pollution levels to daily mortality counts typically assume that the effects of air pollution on the log relative rate of mortality do not vary with time. However, these short-term effects might plausibly vary by season. Changes in the sources of air pollution and meteorology can result in changes in characteristics of the air pollution mixture across seasons. The authors develop Bayesian semi-parametric hierarchical models for estimating time-varying effects of pollution on mortality in multi-site time series studies. The methods are applied to the updated National Morbidity and Mortality Air Pollution Study database for the period 1987--2000, which includes data for 100 U.S. cities. At the national level, a 10 micro-gram/m3 increase in PM(10) at lag 1 is associated with a 0.15 (95% posterior interval: -0.08, 0.39),0.14 (-0.14, 0.42), 0.36 (0.11, 0.61), and 0.14 (-0.06, 0.34) percent increase in mortality for winter, spring, summer, and fall, respectively. An analysis by geographical regions finds a strong seasonal pattern in the northeast (with a peak in summer) and little seasonal variation in the southern regions of the country. These results provide useful information for understanding particle toxicity and guiding future analyses of particle constituent data.