BACKGROUND: We previously identified a sputum 12-gene methylation panel that predicts lung aging and risk for lung cancer. RESEARCH QUESTION: Can the sputum methylation panel be used as a readout to derive a dietary pattern beneficial for lung health? Is this dietary pattern associated with various subjective and objective lung health phenotypes? Does this relationship vary among people who currently smoke vs previously smoked? STUDY DESIGN AND METHODS: Using the Lovelace Smoker Cohort (LSC), we employed the least absolute shrinkage and selection operator regularized Poisson regression to define a dietary pattern for sputum. Associations of the dietary pattern with objective and subjective lung health measurements were examined using generalized linear and Cox models in the LSC and the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening trial. RESULTS: The Dietary Pattern for Healthy Lung (DiPHeaL) includes low consumption of processed meat, and high consumption of dark green vegetables, tea, alcohol, and fruit juice. In the LSC, a higher DiPHeaL score (1 SD) was associated with better FEV1 (by 96.1 mL/s), FEV1/FVC ratio (by 1.83%), and respiratory quality of life (by 4.9 for activity score), and decreased cardiopulmonary mortality (by 47%) in participants who previously smoked (all P values < .05), but not in participants who currently smoke. Moreover, effect sizes of the DiPHeaL score on respiratory quality of life measures were greater among participants who previously smoked with airway obstruction compared with those without. Associations with cardiovascular and respiratory mortality were replicated in PLCO participants who previously smoked. A higher DiPHeaL score was also associated with lower lung cancer incidence in participants who previously smoked, as well as reduced COPD incidence and lung cancer mortality regardless of smoking status in the PLCO. INTERPRETATION: We defined a novel dietary pattern for lung epigenetic aging, which linked to lung health measurements. Participants who previously smoked, especially those with airway obstruction, may benefit the most from nutritional modification.

Rationale: COVID-19 has heightened the importance of mask-wearing for respiratory disease prevention, yet few studies have examined its effectiveness, especially among high-risk workers outside healthcare settings. Miners are rural essential workers at high risk of COVID-19 infection due to working close distances, inadequate ventilation, and the inability to telecommute and use flexible schedules. This study investigates the association between mask usage outside the workplace and COVID-19 infection rates among rural miners. Methods: This is a cross-sectional analysis of data obtained from a non-randomized controlled clinical trial conducted from February 2021-March 2022, which enrolled 169 miners in New Mexico (intervention cohort) and 61 miners in Wyoming (control cohort) at two remote surface coal mines owned by the same company. Miners at both sites were mandated to have universal mask usage at the workplace, as per company policy. The intervention included point-of-care rapid antigen testing on mid-nasal swabs (NS) self-collected by New Mexico miners. Seropositivity was determined by using the IgG antibody to the nucleocapsid protein of SARS-CoV-2, performed by qualitative chemiluminescent immunoassay on plasma samples at baseline, 3, 6, and 12 months. The predictor variable was the self-reported frequency of mask usage outside the workplace, categorized as sometimes or less, often and very often. The primary study outcome was the cumulative seroprevalence at 12 months. Covariates in multivariable analyses included intervention sites (NM vs. WY). Logistic regression analyses were used. Results: The study included 44% Hispanic and 13% American Indian, predominantly male (88%) miners. Compared to sometimes or less use, often and very often mask use was associated with lower odds of cumulative seropositivity (unadjusted OR=0.59 and 0.20, respectively, overall p<0.001, adjusted OR=0.92 and 0.32, respectively, overall p=0.01, Table). Adjustment of covariates did not change the results. The strength of this protective association was comparable to that of vaccination status at baseline (unadjusted OR=0.45, p=0.03) and of the test intervention (OR=0.24, p<0.001). Similar findings were seen when baseline or incident seropositivity was instead analyzed. Conclusions: Our study findings suggest that more frequent mask usage outside the workplace combined with universal mask usage at the workplace is associated with lower COVID-19 infection levels in high-risk occupational groups like miners. Public health campaigns encouraging consistent mask use and promoting mask adherence among populations with higher risk of respiratory vulnerability could improve health outcomes and significantly reduce COVID-19 transmission rates in rural communities.

Household air pollution from wood smoke (WS), contributes to adverse health effects in both low- and high-income countries. However, measurement of WS exposure has been limited to expensive in-home monitoring and lengthy face-to-face interviews. This paper reports on the development and testing of a novel, self-report nine-item measure of WS exposure, called the Household Exposure to Wood Smoke (HEWS). A sample of 149 individuals using household wood stoves for heating from western states in the U.S., completed the HEWS during the winter months (November to March) of 2013 through 2016 with 30 subjects having in-home particle monitoring. Hard copy or online surveys were completed. Cronbach’s alpha (α), intraclass correlations (ICC), exploratory factor analysis (EFA) and tests of associations were done to evaluate reliability and validity of the HEWS. Based on initial analysis, only 9 of the 12 items were retained and entered in the EFA. The EFA did not support a unitary scale as the 9 items demonstrated a 3-factor solution (WS exposure duration, proximity, and intensity) with Cronbach’s α of 0.79, 0.91, and 0.62, respectively. ICC was 0.86 of the combined items with single items ranging from 0.46 to 0.95. WS intensity was associated with symptoms and levoglucosan levels, while WS duration was associated with stove and flume maintenance. The three-dimensional HEWS demonstrated internal consistency and test-retest reliability, structural validity, and initial criterion and construct validity.

Introduction The US Radiation Exposure Compensation Act (RECA) provides compensation to some workers whose health was affected by uranium industry employment. Originally scheduled to terminate in 2022, the US government recently extended RECA benefits for two more years. Another RECA amendment proposes to extend the deadline further, defines additional compensable diseases, and expands eligibility to more contemporary uranium miners. Materials and Methods Researchers at NIOSH conduct extended follow-up on the cohort of US Colorado Plateau uranium miners, and participate in the international Pooled Uranium Miners Analysis (PUMA). Here we apply our recent research findings from both studies to contextualize the health burdens faced by surviving uranium miners, and examine how our research findings relate to the proposed extension and expansion of RECA. Results Former US uranium miners die of silicosis (Standardized Mortality Ratio (SMR)=41.4; 95%CI:30.9–54.3), pneumoconiosis (SMR=39.6; 95%CI:29.3–52.3), idiopathic pulmonary fibrosis (SMR=4.8; 95%CI:3.7–6.1), and lung cancer (SMR=4.5; 95%CI:4.2–4.9) at higher rates than expected. These mortality excesses continue to be observed in recent calendar years. In the PUMA study, uranium miners had higher rates of lung, liver, larynx, stomach, and pleural cancers than expected, and miners hired in later periods also had higher rates of lung and stomach cancer than expected. A positive association between radon exposure and lung cancer mortality is seen in the full PUMA cohort as well as in the sub-cohort of more contemporary miners. Conclusions Recent analyses suggest there be more US uranium miners who develop compensable diseases after the planned termination of RECA benefits in 2024. Uranium miners die at elevated rates from several cancer types that are not currently compensable. Contemporary uranium miners who are ineligible for compensation due to their employment dates experience many of the same health hazards as early-period miners. The proposed amendments to RECA are generally consistent with recent scientific results.

Introduction:The Southwestern United States (SWUS) has an extensive history of coal and metal mining, including uranium (U) mining. Lung diseases, including but not limited to, lung cancer and pulmonary fibrosis, have been studied extensively in miners due to occupational, dust-related exposures. However, high-throughput autoimmune biomarkers are largely understudied in miners, despite the fact that ore miners, such as U-miners, are at an increased risk for the development of autoimmune diseases such as systemic sclerosis and systemic lupus erythematosus (SLE). Additionally, there are current gaps in knowledge regarding which signaling pathways may play a role in occupational exposure-associated autoimmunity. Methods:Most current and former miners in the SWUS live close to their previous workplaces, in remote areas, with limited access to healthcare. In this pilot study, by leveraging a mobile clinical platform for patient care and clinical outreach, we recruited 44 miners who self-identified as either U (n = 10) or non-U miners (n = 34) and received health screenings. Serum IgG and IgM autoantibodies against 128 antigens were assessed using a high-throughput molecular technique, as a preliminary health screening opportunity. Results:Even when adjusting for age as a covariate, there was a significant (p < 0.05) association between self-reported U-mining exposure and biomarkers including IgM alpha-actinin, histones H2B, and H4, myeloperoxidase (MPO) and myelin basic protein. However, adjusting for age did not result in significant associations for IgG autoantibody production in U-miners. Bioinformatic pathway analysis revealed several altered signaling pathways between IgM and IgG autoantibodies among both U and non-U miners. Conclusions:Further research is warranted regarding the mechanistic connection between U-exposure and autoantibody development, especially regarding histone-related alterations and IgM autoantibody production.

Reported associations between World Trade Center (WTC) occupational exposure and chronic obstructive pulmonary disease (COPD) or asthma COPD overlap (ACO) have been inconsistent. Using spirometric case definitions, we examined that association in the largest WTC occupational surveillance cohort. We examined the relation between early arrival at the 2001 WTC disaster site (when dust and fumes exposures were most intense) and COPD and ACO in workers with at least one good quality spirometry with bronchodilator response testing between 2002 and 2019, and no physician-diagnosed COPD before 9/11/2001. COPD was defined spirometrically as fixed airflow obstruction and ACO as airflow obstruction plus an increase of ≥ 400 ml in FEV1 after bronchodilator administration. We used a nested 1:4 case-control design matching on age, sex and height using incidence density sampling. Of the 17,928 study participants, most were male (85.3

Models in the supervised learning framework may capture rich and complex representations over the features that are hard for humans to interpret. Existing methods to explain such models are often specific to architectures and data where the features do not have a time-varying component. In this work, we propose TIME, a method to explain models that are inherently temporal in nature. Our approach (i) uses a model-agnostic permutation-based approach to analyze global feature importance, (ii) identifies the importance of salient features with respect to their temporal ordering as well as localized windows of influence, and (iii) uses hypothesis testing to provide statistical rigor.

Abstract Background The role of wood smoke (WS) exposure in the etiology of chronic obstructive pulmonary disease (COPD), lung cancer (LC), and mortality remains elusive in adults from countries with low ambient levels of combustion-emitted particulate matter. This study aims to delineate the impact of WS exposure on lung health and mortality in adults age 40 and older who ever smoked. Methods We assessed health impact of self-reported “ever WS exposure for over a year” in the Lovelace Smokers Cohort using both objective measures (i.e., lung function decline, LC incidence, and deaths) and two health related quality-of-life questionnaires (i.e., lung disease-specific St. George's Respiratory Questionnaire [SGRQ] and the generic 36-item short-form health survey). Results Compared to subjects without WS exposure, subjects with WS exposure had a more rapid decline of FEV1 (− 4.3 ml/s, P = 0.025) and FEV1/FVC ratio (− 0.093%, P = 0.015), but not of FVC (− 2.4 ml, P = 0.30). Age modified the impacts of WS exposure on lung function decline. WS exposure impaired all health domains with the increase in SGRQ scores exceeding the minimal clinically important difference. WS exposure increased hazard for incidence of LC and death of all-cause, cardiopulmonary diseases, and cancers by > 50% and shortened the lifespan by 3.5 year. We found no evidence for differential misclassification or confounding from socioeconomic status for the health effects of WS exposure. Conclusions We identified epidemiological evidence supporting WS exposure as an independent etiological factor for the development of COPD through accelerating lung function decline in an obstructive pattern. Time-to-event analyses of LC incidence and cancer-specific mortality provide human evidence supporting the carcinogenicity of WS exposure.

Biomass fuel smoke, secondhand smoke, and oxides of nitrogen are common causes of household air pollution (HAP). Almost 2.4 billion people worldwide use solid fuels for cooking and heating, mostly in low-and middle-income countries. Wood combustion for household heating is also common in many areas of high-income countries, and minorities are particularly vulnerable. HAP in low-and middle-income countries is associated with asthma, acute respiratory tract infections in adults and children, chronic obstructive pulmonary disease, lung cancer, tuberculosis, and respiratory mortality. Although wood smoke exposure levels in high-income countries are typically lower than in lower-income countries, it is similarly associated with accelerated lung function decline, higher prevalence of airflow obstruction and chronic bronchitis, and higher all-cause and respiratory cause -specific mortality. Household air cleaners with high-efficiency particle filters have mixed effects on asthma and chronic obstructive pulmonary disease outcomes. Biomass fuel interventions in low-income countries include adding chimneys to cookstoves, improving biomass fuel combustion stoves, and switching fuel to liquid petroleum gas. Still, the impact on health outcomes is inconsistent. In high-income countries, strategies for reducing biomass fuel -related HAP are centered on community-level woodstove changeout pro-grams, although the results are again inconsistent. In addi-tion, initiatives to encourage home smoking bans have mixed success in households with children. Environmental solutions to reduce HAP have varying success in reducing pollutants and health problems. Improved understanding of indoor air quality factors and actions that prevent degradation or improve polluted indoor air may lead to enhanced environ-mental health policies, but health outcomes must be rigor-ously examined. (c) 2022 American Academy of Allergy, Asthma & Immunology (J Allergy Clin Immunol Pract

Occupational lung diseases (OLDs) are caused, aggravated or exacerbated by exposures at the workplace. OLDs encompass a wide range of respiratory diseases similar to that found outside the work environment. Occupational asthma is the most commonly diagnosed OLD. Other OLDs may include acute and chronic conditions, ranging from hypersensitivity pneumonitis to chronic obstructive pulmonary disease (COPD) to pulmonary fibrosis. Historically, research into OLDs has centered on diseases resulting from exposures relevant to high-income countries and more obvious hazardous occupations, such as silicosis in coal miners. Peer-reviewed publications in 2019 have broadened the focus to include low- and middle-income countries and once-overlooked occupations such as dry cleaning and animal husbandry. Technological advances and greater understanding of disease etiology have allowed researchers and clinicians to implement improved risk analysis, screening and mitigation strategies to not only treat disease once it occurs, but to identify at-risk populations and institute protections to prevent or limit the negative impacts of workplace hazards. As recognition of OLDs as a worldwide threat in a variety of occupations increases, research is allowing for the development of better treatments and preventive measures that advance workers' rights and ensure their continued good health.

Strengthening Digital Health Technology Capacity in Navajo Communities to Help Counter the COVID-19 Pandemic Melissa Begay, Monika Kakol, Akshay Sood, and Dona Upson* DivisionofPulmonary,CriticalCare,SleepandAllergy, Miners’WellnessTele–Extension forCommunityHealthOutcomes,andOfficeof FacultyAffairsandCareerDevelopment,SchoolofMedicine,UniversityofNewMexico,Albuquerque,NewMexico;NewMexicoVeterans Affairs Health Care Services, Albuquerque, NewMexico; Division of Pulmonary andCritical CareMedicine, StanfordUniversityMedical Center, Stanford University, Stanford, California; and Miners Colfax Medical Center, Raton, NewMexico

Background Diesel exhaust (DE) is a major source of ultrafine particulate matters (PM) in ambient air and contaminates many occupational settings. Airway remodeling assessed using computerized tomography (CT) correlates well with spirometry in patients with obstructive lung diseases. Structural changes of small airways caused by chronic DE exposure is unknown. Wall and lumen areas of 6th and 9th generations of four candidate airways were quantified using end-inhalation CT scans in 78 diesel engine testers (DET) and 76 non-DETs. Carbon content in airway macrophage (CCAM) in sputum was quantified to assess the dose-response relationship. Results Environmental monitoring and CCAM showed a much higher PM exposure in DETs, which was associated with higher wall area and wall area percent for 6th generation of airways. However, no reduction in lumen area was identified. No study subjects met spirometry diagnosis of airway obstruction. This suggested that small airway wall thickening without lumen narrowing may be an early feature of airway remodeling in DETs. The effect of DE exposure status on wall area percent did not differ by lobes or smoking status. Although the trend test was of borderline significance between categorized CCAM and wall area percent, subjects in the highest CCAM category has a 14% increase in wall area percent for the 6th generation of airways compared to subjects in the lowest category. The impact of DE exposure on FEV1 can be partially explained by the wall area percent with mediation effect size equal to 20%, P perm = 0.028). Conclusions Small airway wall thickening without lumen narrowing may be an early image feature detected by CT and underlie the pathology of lung injury in DETs. The pattern of changes in small airway dimensions, i.e., thicker airway wall without lumen narrowing caused by occupational DE exposure was different to that (i.e., thicker airway wall with lumen narrowing) seen in our previous study of workers exposed to nano-scale carbon black aerosol, suggesting constituents other than carbon cores may contribute to such differences. Our study provides some imaging indications of the understanding of the pulmonary toxicity of combustion derived airborne particulate matters in humans.

Background: Uranium workers are at risk of developing lung disease, characterized by low forced expiratory volume in one second (FEV1) and/or forced vital capacity (FVC). Previous studies have found an association between decreased lung function and depressive symptoms in patients with pulmonary pathologies, but this association has not been well examined in occupational cohorts, especially uranium workers. Methods: This cross-sectional study evaluated the association between spirometric measures and depressive symptoms in a sample of elderly former uranium workers screened by the New Mexico Radiation Exposure Screening & Education Program (NM-RESEP). Race- and ethnicity-specific reference equations were used to determine predicted spirometric indices (predictor variable). At least one depressive symptom [depressed mood and/or anhedonia, as determined by a modified Patient Health Questionnaire-2 (PHQ-2)], was the outcome variables. Chi-square tests and multivariable logistic regression models were used for statistical analyses. Results: At least one depressive symptom was self-reported by 7.6% of uranium workers. Depressed mood was reported over twice as much as anhedonia (7.2% versus 3.3%). Abnormal FVC was associated with at least one depressive symptom after adjustment for covariates. There was no significant interaction between race/ethnicity and spirometric indices on depressive symptoms. Conclusions: Although depressive symptoms are uncommonly reported in uranium workers, they are an important comorbidity due to their overall clinical impact. Abnormal FVC was associated with depressive symptoms. Race/ethnicity was not found to be an effect modifier for the association between abnormal FVC and depressive symptoms. To better understand the mechanism underlying this association and determine if a causal relationship exists between spirometric indices and depressive symptoms in occupational populations at risk for developing lung disease, larger longitudinal studies are required. We recommend screening for depressive symptoms for current and former uranium workers as part of routine health surveillance of this occupational cohort. Such screening may help overcome workers’ reluctance to self-report and seek treatment for depression and may avoid negative consequences to health and safety from missed diagnoses.

Abstract Objective Iron and steel industry workers are exposed to high levels of inhalable dust particles that contain various elements, including metals, and cause occupational lung diseases. We aim to assess the relationship between occupational dust exposure, systemic inflammation, and spirometric decline in a cohort of Chinese iron and steel workers. Methods We studied 7513 workers who participated in a Health Surveillance program at Wugang Institute for Occupational Health between 2008 and 2017. Time-weighted exposure intensity (TWEI) of dust was quantified based on self-reported dust exposure history, the experience of occupational hygienists, and historical data of dust exposure for workers with certain job titles. A linear mixed-effects model was used for association analyses. Results The average annual change of lung function was − 50.78 ml/year in forced expiratory volume in 1 s (FEV1) and − 34.36 ml/year in forced vital capacity (FVC) in males, and − 39.06 ml/year in FEV1 and − 26.66 ml/year in FVC in females. Higher TWEI prior to baseline was associated with lower longitudinal measurements of FEV1 and FVC but not with their decline rates. Higher WBC and its differential at baseline were associated with lower longitudinal measurements and a more rapid decline of FEV1 and FVC in a dose-dependent monotonically increasing manner. Moreover, the increase of WBC and its differential post-baseline was also associated with a more rapid decline of FEV1 and FVC. Conclusions Our findings support the important role of systemic inflammation in affecting the temporal change of lung function in iron and steel industry workers.

Asthma is a prevalent chronic respiratory condition, and acute exacerbations represent a significant fraction of the economic and health-related costs associated with asthma. We present results from a novel study that is focused on modeling asthma exacerbations from data contained in patients' electronic health records. This work makes the following contributions: (i) we develop an algorithm for phenotyping asthma exacerbations from EHRs, (ii) we determine that models learned via supervised learning approaches can predict asthma exacerbations in the near future (AUC ≈ 0.77), and (iii) we develop an approach, based on mixtures of semi-Markov models, that is able to identify subpopula-tions of asthma patients sharing distinct temporal and seasonal patterns in their exacerbation susceptibility.

Introduction: Although overweight or obesity have been linked to reduced lung function, no study has estimated the effects of lung function on weight in adults. Aim: We investigated the relation between expiratory flow and body size, and vice versa, in a cohort of adults. Methods: Prospective study in 1,329 former World Trade Center (WTC) workers who were included in the WTC Chest Imaging Archive and had a minimum of 2 spirometries between 2002 and 2018 (mean [SD] follow up=7.2 [3.9] years). We used mixed linear models to test for association between change in first-second forced expiratory volume (∆FEV1) or forced vital capacity (∆FVC) and change in body mass index (∆BMI) between sequential visits, and vice versa. All models included sex, race, educational level, age at each visit, smoking status, arrival at the WTC site within 48 hours, baseline value for the predictor of interest (lung function measure or change in body mass index), and intervals between test dates (accounting for unequal intervals). Results: In multivariable analyses, a 200 ml loss in FEV1 or FVC was associated with 0.29 kg/m2 (95% CI=0.26, 0.33) and 0.22 kg/m2 (95% CI=0.20, 0.22) increment in BMI, respectively. On the other hand, a 0.2 kg/m2 gain in BMI between visits was associated with losses of 7 ml (95% CI= -6 to -8 ml) and 9 ml (95% CI= -8 to -1) ml in FEV1 and FVC, respectively. Conclusion: Change in BMI and change in FEV1 or FVC were inversely associated with each other, and this association was bidirectional. Further work is needed to identify the mechanisms underlying these associations.

Miners constitute an underserved, isolated, medically vulnerable, and often underinsured, rural population.1 In the southwestern United States (US), most miners are Hispanic or American Indian, and high school dropouts.1 The recent re-emergence of pneumoconioses2 has created a challenge for rural mining communities in the US. Rural residents also experience a higher prevalence of, and deaths from, chronic obstructive pulmonary disease (COPD) than nonrural residents.3 Rural miners similarly are at greater risk for COPD and self-reported dust-related lung disease than non-rural miners.4 The World Health Organization declared coronavirus disease-2019 (COVID-19) a pandemic on March 11, 2020. Although urban areas are disproportionately affected, the disease has spread to rural areas, where its prevention and treatment may be more challenging because of the lower concentration of medical and public health resources.5 Data indicate that men are more susceptible than women, and that smoking affects outcomes adversely.4, 6 Given that miners, mostly men and often smokers, have a dispoportionately high prevalence of hypertension and diabetes (other risk factors for COVID-191, 7), miners may constitute a susceptible population for this disease. The pandemic has caused various professional organizations to support discontinuing routine pulmonary function test (PFT) studies. The American College of Occupational and Environmental Medicine (ACOEM) explains that "spirometry tests require performance of a forced expiratory maneuver, which could spread droplets in the air if an infected person is tested, even if asymptomatic."8 This creates a risk for the health care professional performing the test as well as for subsequent patients. The American Thoracic Society (ATS) similarly states that the risk of transmitting the virus may be significant, and likely varies based on the community prevalence of infection and patient characteristics.9 Similar concerns about transmitting infection are applicable to other studies of lung function. Many test filters are not validated for capturing particles <1 μm (or 1000 nm) in size—virus size in COVID-19 varies from 60 to 140 nm in diameter.10 This means that filters may provide little or no protection from viral transmission. Lung volumes, diffusing capacity, and cardiopulmonary exercise studies require collection of gases within a closed system. The virus could contaminate the inside chambers, requiring time-consuming decontamination. Consequently, a number of rural test laboratories and clinician offices temporarily stopped testing or started performing only urgent studies. With the unknown risk, ATS and ACOEM recommend health care providers don personal protective equipment such as N95 respirators during urgent testing to limit aerosolized droplet acquisition by staff, and enhanced cleaning of the testing space. Although PFTs are infrequently required for making acute clinical decisions in miners, they form the foundation for surveillance, diagnosis, preemployment physical assessment, impairment assessment, and research. These activities are likely to be delayed by months due to the pandemic, causing significant disruption in the care of miners. Fixed and mobile health screening programs for miners have stopped, as institutions shift focus to the surge of acutely ill patients. At our institution, the evaluation of uranium miners for eligibility under the Radiation Exposure Compensation Act (RECA) has been postponed. Given that potential eligibility claims have a deadline of July 10, 2022, the postponement may deny some miners of deserved compensation benefits. Black Lung and Energy Employees Occupational Illness Compensation Program (EEOICP) impairment evaluations have also stopped. Fewer than half of New Mexico (NM) miners in a study did not have a primary care provider (PCP).1 Without a PCP to call, many miners will rely on unverified information, and some will go to the hospital, perhaps unnecessarily; others will wait too long to seek care.11 For those with a PCP, the rapid transition to telemedicine, although welcome, will create new difficulties in communication, particularly for miners with limited English proficiency, those who lack access to videoconferencing, and those with concomitant hearing deficits who rely on visual cues.11, 12 The EEOICP provides home health services to uranium miners and other energy workers, a service that can help keep rural patients away from overburdened hospitals during the pandemic. Home health staff have been constrained by a lack of protective gear and training on its use, inadequate training on the care of potentially infected patients, physical and mental exhaustion, high staff turnover rates, and fear. Teletraining staff can help address several constraints. Although not currently covered by the program payer, it is likely that telemonitoring in home care will receive more attention during the pandemic. Pulmonary rehabilitation is a recognized treatment for chronic lung diseases in miners. Rural mining communities have limited access to these programs3 and many of those that do have access have encountered program closures due to the pandemic. Potential alternatives, such as rehabilitation at home or telehealth rehabilitation with remote online supervision, should be considered.13 Rural local chapters of support groups, such as the American Lung Association Better Breathers Clubs have also shut down. While telehealth can help relieve isolation, support appropriate education, and assist in patient care,14 lack of Internet access still continues to be a barrier in some rural mining communities.15 The professional expertise available to care for miners has decreased over time in the pneumoconiosis mortality hotspot regions of Appalachia and the Mountain West.1, 16 There is a tremendous need to train these rural professionals across the multidisciplinary aspects of the management of complex mining-related diseases. Following the pandemic outbreak, many directors of spirometry courses approved by the National Institute for Occupational Safety and Health (NIOSH) postponed their training programs, based on the concern for transmitting infection.8 Structured longitudinal telementoring of rural health care professionals could create a virtual "community of practice" that would facilitate team management of complex mining-related diseases in rural areas.14 The strategy of "moving knowledge" instead of "moving patients" has been shown to be effective in managing other chronic diseases in medically underserved areas using the Extension for Community Health Outcomes (ECHO) model for telementoring.17-20 Ironically, the NM-based Miners' Wellness Tele-ECHO program temporarily stopped in April 2020 to help meet the high demand for tele-education of rural providers on the management of the COVID-19 infected patients. Key professional conferences such as the May 2020 American Thoracic Society International Conference were canceled. Given that the pandemic is expected to last several months, there is tremendous need to utilize systems that are already in place for rapid scaling of the Miners' Wellness TeleECHO Program and NIOSH approval for virtual spirometry training courses. Laboratory research activities slowed but continued with social distancing measures. On the other hand, clinical research involving miners at our institution was significantly impacted, out of concern for the safety and welfare of human subject participants and research staff. Recruitment for new studies was delayed and existing studies disrupted. Conducting virtual study activities by phone or video conferencing requires additional institutional review board (IRB) approvals. The National Institutes of Health (NIH) noted that research grant recipients were likely to encounter delays to ongoing research.21 The compensation programs for US miners are complex, requiring specialized input from benefits counselors, attorneys, and judges. Infamous for delayed judgements, many claims in the Black Lung program are awarded to widows, long after the death of the miner. Benefits and legal counseling are complex and difficult during social distancing.22 Most Black Lung clinics have suspended testing and face-to-face benefits counseling until further notice. Some attorneys shut down their lobbies or offices and moved to telephonic assistance to promote social distancing. On March 20, 2020, the Office of Administrative Law Judges suspended all hearings and evidentiary deadlines through May 15, 2020 (2020-MIS-00006), which will worsen the case backlog. Given that the virus causing COVID-19 may remain "stable" on cardboard boxes for up to 24 h23 despite a low risk of transmission, and given that staff are not available to receive mail at some government offices, the Benefits Review Board urged all petitions and briefs to be sent in electronically. Electronic uploading of large documents in some rural communities is difficult. According to a 2018 survey by the Federal Communications Commission, only 73% of rural Americans and 67% of Americans living on tribal lands have access to Internet download speeds of 25 Mbps or higher.24 It is likely that the COVID-19 pandemic will adversely impact the clinical, educational, research, and legal/benefits needs of miners and/or professionals taking care of miners in the rural US, with significant setbacks in the fight against the resurgence of pneumoconiosis. Rahm Emanuel, former White House Chief of Staff once said, "You never let a serious crisis go to waste. And what I mean by that it's an opportunity to do things you think you could not do before." The COVID-19 pandemic should prompt us to expand the use of telemedicine, tele-education, telementoring, and telemonitoring in rural mining communities, as was presciently recommended by the 2019 US COPD National Action Plan prior to the pandemic.14

The COVID-19 pandemic presents family physicians with unique opportunities to work with home health providers to combat the pandemic, provide quality care, and ease the burden of fear among patients.

INTRODUCTION The re-emergence of pneumoconiosis, particularly among coal miners (ie black lung), in the USA is a challenge for rural communities because more miners require specialized care while expertise is scarce. The Miners' Wellness TeleECHO (Extension for Community Health Outcomes) Clinic, jointly held by the University of New Mexico and a community hospital in New Mexico, provides structured telementoring to professionals caring for miners, including clinicians, respiratory therapists, home health professionals, benefits counselors, lawyers/attorneys and others, forming a virtual 'community of practice'. This approach has not been utilized and evaluated previously. METHODS The study's bimonthly program uses the ECHO telementoring model, which uses technology to leverage scarce mentoring resources; uses a disease-management model that is proven to improve outcomes in other disease states, by reducing variation in processes of care and sharing best practices; uses the principle of case-based learning with highly contextualized discussions, which fulfils key learning theory principles; creates a virtual community of practice; and uses an internet-based database to monitor outcomes. This 1-year cross-sectional study from September 2018 to September 2019 used geographical mapping of all attendee locations, web-based continuing medical education surveys completed by attendees using iECHO software, and a Research Electronic Data Capture-based survey of a convenience sample of participants, which obtained detailed information on demographics, knowledge, self-efficacy and collective efficacy. Knowledge sharing among participants was examined using insights and methods from social network analysis. Subgroup analysis involved comparisons between clinical and non-clinical professional groups, and between new and existing participants. Groups were compared using Fisher's exact test for categorical variables, and non-parametric Wilcoxon ranked sum test or student's t-test for continuous variables. RESULTS Participants were largely located in pneumoconiosis mortality hotspots of the USA. In a convenience sample of 70 participants, clinical professional groups such as clinicians (29%), home health professionals (20%) and respiratory therapists (17%) constituted the majority of the stakeholders. Participants demonstrated the lowest knowledge score on 'legal pneumoconiosis' among the knowledge areas questioned; reported low self-efficacy with respect to managing miners' conditions and interpreting test results; and rated the learning community highly in terms of trust (86%), willingness to help each other (93%) and being closely knit (87%). Analysis of knowledge sources indicated that participants receive substantial proportions of knowledge from individuals outside of their stakeholder and professional groups, but proportions differ among clinical and non-clinical professional groups, as well as among 'fresh' and existing participants. CONCLUSION The present study demonstrates the successful creation of a virtual multidisciplinary community of practice in pneumoconiosis mortality hotspot rural regions of the USA, with participants reporting multidisciplinary knowledge transfer. The community is regarded highly by participants in relation to trust, willingness to help and being closely knit. This innovative educational approach may help ensure the delivery of high-quality interdisciplinary care to rural miners in pneumoconiosis mortality hotspots in the USA.