Kristin J Cummings

University of Pennsylvania, Philadelphia, Pennsylvania, United States

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Publications (33)116.96 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Rationale: Occupational exposure to indium compounds including indium-tin oxide (ITO) can result in potentially fatal indium lung disease. However, the early effects of exposure on the lungs are not well understood. Objectives: To determine the relationship between short-term occupational exposures to indium compounds and development of early lung abnormalities. Methods: Among ITO production and reclamation facility workers, we measured plasma indium, respiratory symptoms, pulmonary function, chest computed tomography, and serum biomarkers of lung disease. The relationships between plasma indium concentration and health outcome variables were evaluated using restricted cubic spline and linear regression models. Measurements and Main Results: Eighty-seven (93%) of 94 ITO facility workers (median tenure=2 years; median plasma indium=1.0 mcg/L) participated in the study. Spirometric abnormalities were not in excess and few had radiographic evidence of alveolar proteinosis (n=0), fibrosis (n=2), or emphysema (n=4). Compared to participants with plasma indium concentrations <1.0 mcg/L, those with values ≥1.0 mcg/L had more dyspnea, lower mean FEV1% and FVC%, and higher median serum KL-6 and SP-D levels. Spline regression demonstrated non-linear exposure-response, with significant differences occurring at plasma indium concentrations as low as 1.0 mcg/L for FEV1%, FVC%, KL-6, and SP-D compared to the reference. Associations between health outcomes and plasma indium were evident in linear regression models and not explained by age, smoking status, or facility tenure. Conclusions: In ITO facility workers with short-term, low-level exposure, plasma indium concentrations lower than previously reported were associated with lung symptoms, abnormal spirometry, and increased serum biomarkers of lung disease.
    Annals of the American Thoracic Society. 10/2014;
  • Kathleen Kreiss, Kristin J Cummings
    American Journal of Industrial Medicine 06/2014; · 1.97 Impact Factor
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    ABSTRACT: To better understand respiratory symptoms and lung function in flavouring manufacturing workers.
    Occupational and environmental medicine. 06/2014;
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    The Journal of Infectious Diseases 03/2014; · 5.85 Impact Factor
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    ABSTRACT: Occupational exposure to indium compound particles has recently been associated with lung disease among workers in the indium-tin oxide (ITO) industry. Previous studies suggested that excessive alveolar surfactant and reactive oxygen species (ROS) may play a role in the development of pulmonary lesions following exposure to indium compounds. However, toxicity at the cellular level has not been comprehensively evaluated. Thus, the aim of this study was to assess which, if any, compounds encountered during ITO production are toxic to cultured cells and ultimately contribute to the pathogenesis of indium lung disease. The compounds used in this study were collected from eight different processing stages at an ITO production facility. Enhanced dark field imaging showed 5 of the compounds significantly associated with cells within 1 h, suggesting that cellular reactions to the compound particles may be occurring rapidly. To examine the potential cytotoxic effects of these associations, ROS generation, cell viability, and apoptosis were evaluated following exposures in RAW 264.7 mouse monocyte macrophage and BEAS-2B human bronchial epithelial cell lines. Both exhibited reduced viability with exposures, while apoptosis only occurred in RAW 264.7 cells. Our results suggested that excessive ROS production is likely not the predominant mechanism underlying indium-induced lung disease. However, the effects on cell viability reveal that several of the compounds are cytotoxic, and therefore, exposures need to be carefully monitored in the industrial setting.
    Journal of Toxicology and Environmental Health Part A 01/2014; 77(20):1193-209. · 1.73 Impact Factor
  • Kristin J Cummings, Anna-Binney McCague, Kathleen Kreiss
    Epidemiology (Cambridge, Mass.) 01/2014; 25(1):160-1. · 5.51 Impact Factor
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    ABSTRACT: To explore factors associated with fatal accidents among contractors and operators by using the Mine Safety and Health Administration database. Cross-sectional data on 157,410 miners employed by operators or contractors during 1998-2007 were analyzed using logistic regression and multiple imputation. Univariate odds of fatal versus nonfatal accident were 2.8 (95% confidence interval, 2.3 to 3.4) times higher for contractors than operators. In a multivariable model, fatality was associated with contractor, less experience at the current mine, and occurrence at more than 8 hours into the workday (P < 0.05 for each). Differences in odds of fatality by employment type were more pronounced in surface mines. Contractors had a higher proportion of fatal injuries. Fatality also varied by mine experience, the number of hours worked before injury, work location, and mine type.
    Journal of occupational and environmental medicine / American College of Occupational and Environmental Medicine 10/2013; · 1.88 Impact Factor
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    American Journal of Industrial Medicine 01/2013; · 1.97 Impact Factor
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    ABSTRACT: Vocal cord dysfunction (VCD) is the intermittent paradoxical adduction of the vocal cords during respiration, resulting in variable upper airway obstruction. Exposure to damp indoor environments is associated with adverse respiratory health outcomes, including asthma, but its role in the development of VCD is not well described. We describe the spectrum of respiratory illness in occupants of 2 water-damaged office buildings. The National Institute for Occupational Safety and Health conducted a health hazard evaluation that included interviews with managers, a maintenance officer, a remediation specialist who had evaluated the 2 buildings, employees, and consulting physicians. In addition, medical records and reports of building evaluations were reviewed. Diagnostic evaluations for VCD had been conducted at the Asthma and Allergy Center of the Medical College of Wisconsin. Two cases of VCD were temporally related to occupancy of water-damaged buildings. The patients experienced cough, chest tightness, dyspnea, wheezing, and hoarseness when in the buildings. Spirometry was normal. Methacholine challenge did not show bronchial hyperreactivity but did elicit symptoms of VCD and inspiratory flow-volume loop truncation. Direct laryngoscopy revealed vocal cord adduction during inspiration. Coworkers developed upper and lower respiratory symptoms; their diagnoses included sinusitis and asthma, consistent with recognized effects of exposure to indoor dampness. Building evaluations provided evidence of water damage and mold growth. VCD can occur with exposure to water-damaged buildings and should be considered in exposed patients with asthma-like symptoms.
    The journal of allergy and clinical immunology in practice. 01/2013; 1(1):46-50.
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    ABSTRACT: BACKGROUND: We evaluated the effectiveness of workplace changes to prevent indium lung disease, using 2002-2010 surveillance data collected by an indium-tin oxide production facility. METHODS: We assessed pulmonary function using lower limits of normal. Blood indium concentration and personal air sampling data were used to estimate exposure. RESULTS: Abnormalities were uncommon at hire. After hire, prevalence of spirometric restriction was 31% (n = 14/45), about fourfold higher than expected. Excessive decline in FEV1 was elevated at 29% (n = 12/41). Half (n = 21/42) had blood indium ≥5 µg/l. More recent hires had fewer abnormalities. There was a suggestion that abnormalities were more common among workers with blood indium ≥5 µg/l, but otherwise an exposure-response relationship was not evident. Peak dust concentrations were obscured by time averaging. CONCLUSIONS: Evolving lung function abnormalities consistent with subclinical indium lung disease appeared common and merit systematic investigation. Traditional measures of exposure and response were not illustrative, suggesting fresh approaches will be needed. Workplace changes seemed to have had a positive though incomplete impact; novel preventive interventions are warranted. Am. J. Ind. Med. Published 2012. This article is a U.S. Government work and is in the public domain in the USA.
    American Journal of Industrial Medicine 10/2012; · 1.97 Impact Factor
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    ABSTRACT: Reports of pulmonary fibrosis, emphysema, and, more recently, pulmonary alveolar proteinosis (PAP) in indium workers suggested that workplace exposure to indium compounds caused several different lung diseases. To better understand the pathogenesis and natural history of indium lung disease, a detailed, systematic, multidisciplinary analysis of clinical, histopathologic, radiologic, and epidemiologic data for all reported cases and workplaces was undertaken. Ten men (median age, 35 years) who produced, used, or reclaimed indium compounds were diagnosed with interstitial lung disease 4-13 years after first exposure (n = 7) or PAP 1-2 years after first exposure (n = 3). Common pulmonary histopathologic features in these patients included intraalveolar exudate typical of alveolar proteinosis (n = 9), cholesterol clefts and granulomas (n = 10), and fibrosis (n = 9). Two patients with interstitial lung disease had pneumothoraces. Lung disease progressed following cessation of exposure in most patients and was fatal in two. Radiographic data revealed that two patients with PAP subsequently developed fibrosis and one also developed emphysematous changes. Epidemiologic investigations demonstrated the potential for exposure to respirable particles and an excess of lung abnormalities among coworkers. Occupational exposure to indium compounds was associated with PAP, cholesterol ester crystals and granulomas, pulmonary fibrosis, emphysema, and pneumothoraces. The available evidence suggests exposure to indium compounds causes a novel lung disease that may begin with PAP and progress to include fibrosis and emphysema, and, in some cases, premature death. Prospective studies are needed to better define the natural history and prognosis of this emerging lung disease and identify effective prevention strategies.
    Chest 12/2011; 141(6):1512-21. · 7.13 Impact Factor
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    ABSTRACT: Exposure to soy antigens has been associated with asthma in community outbreaks and in some workplaces. Recently, 135 soy flake processing workers (SPWs) in a Tennessee facility were evaluated for immune reactivity to soy. Allergic sensitization to soy was common and was five times more prevalent than in health care worker controls (HCWs) with no known soy exposure. To characterize sensitization to soy allergens in SPWs. Sera that were positive to soy ImmunoCAP (n=27) were tested in IgE immunoblots. Wild-type (WT) and transgenic (TG) antigens were sequenced using nanoscale Ultra-Performance Liquid Chromatography Tandem Mass Spectrometry (nanoUPLC MS/MS). IgE reactivity towards 5-enolpyruvylshikimate-3-phosphate synthase (CP4-EPSP), a protein found in TG soy, was additionally investigated. De-identified sera from 50 HCWs were used as a control. Immunoblotting of WT and TG soy flake extracts revealed IgE against multiple soy antigens with reactivity towards 48, 54, and 62 kDa bands being the most common. The prominent proteins that bound SPW IgE were identified by nanoUPLC MS/MS analysis to be the high molecular weight soybean storage proteins, β-conglycinin (Gly m 5), and Glycinin (Gly m 6). No specific IgE reactivity could be detected to lower molecular weight soy allergens, Gly m 1 and Gly m 2, in soybean hull (SH) extracts. IgE reactivity was comparable between WT and TG extracts; however, IgE antibodies to CP4-EPSP could not be detected. SPWs with specific IgE to soy reacted most commonly with higher molecular weight soybean storage proteins compared with the lower molecular weight SH allergens identified in community asthma studies. IgE reactivity was comparable between WT and TG soy extracts, while no IgE reactivity to CP4-EPSP was observed. High molecular weight soybean storage allergens, Gly m 5 and Gly m 6, may be respiratory sensitizers in occupational exposed SPWs.
    Clinical & Experimental Allergy 07/2011; 41(7):1022-30. · 4.79 Impact Factor
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    ABSTRACT: In 2008, a company using multiple buttermilk flavorings in the production of dry bakery mixes replaced one liquid flavoring containing 15-20% diacetyl with a proprietary substitute meant to lower occupational risk for diacetyl-related bronchiolitis obliterans. Subsequently, the National Institute for Occupational Safety and Health (NIOSH) evaluated buttermilk flavoring-related exposures at this company's facility, with a focus on measuring ketones by several methods. Volatile organic compounds (VOCs) were evaluated in the headspaces of six bulk flavorings samples, including the substitute buttermilk flavoring. Ketones were evaluated in workplace air via area and personal samples collected during batch preparation of the substitute buttermilk flavoring and production of a bakery mix containing the same flavoring. Air samples were evaluated using five different methods: NIOSH 2549, Modified OSHA PV2118, OSHA 1013, NIOSH Draft Procedure SMP2, and evacuated canisters. Of five buttermilk flavorings from five different flavorings manufacturers, diacetyl was present in four, including the substitute flavoring; acetoin in two; 2,3-pentanedione in four; 2,3-hexanedione in one; and 2,3-heptanedione in three. Among material safety data sheets (MSDS) for four flavorings, only one listed a hazardous ingredient, which was acetoin. The predominant flavoring ingredient identified in the headspace of the substitute flavoring was 2,3-pentanedione; all other chemicals noted above were also present. Diacetyl and 2,3-pentanedione were measured in workplace air via evacuated canisters. In one area and one personal air sample, 2,3-pentanedione was measured by OSHA Method 1013 at concentrations of 78 and 91 ppb, respectively. Without their or the employer's knowledge, workers who used buttermilk flavorings were exposed to substitute ketones from many flavorings manufacturers. Because 2,3-pentanedione, 2,3-hexanedione, and 2,3-heptanedione all share the same functional α-diketone group as diacetyl, these compounds also may share diacetyl's mechanism of toxicity. Until more is known about 2,3-pentanedione and other α-diketone compounds, they should not be assumed to be safe. Companies using artificial buttermilk flavorings should use a precautionary approach that assumes these flavorings pose a health risk and limit exposures through engineering and administrative controls and use of personal protective equipment.
    Journal of Occupational and Environmental Hygiene 02/2011; 8(2):93-103. · 1.28 Impact Factor
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    Saeed Awan, Muazzam Nasrullah, Kristin J Cummings
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    ABSTRACT: Carpet weaving among children is common in rural Pakistan, but little information is available on the health effects of this work. A total of 628 carpet-weaving children and 292 non-working children from 10 rural villages were evaluated with questionnaires and physical exams. Fifty-five home-based and 30 shed-based worksites in these villages were assessed. Girls comprised the majority of working (73%) and non-working (69%) children; the mean age for both boys and girls was 10 years. The mean number of hours worked daily was 7.2 for males and 6.8 for females. Dust exposure in homes was generally higher than in sheds. Working children had significantly greater odds of joint pain (OR = 2.8), dry cough (OR = 2.5), cuts/bruises (OR = 22.1), Phalen's sign (OR = 17.2), and neck/shoulder abnormalities (OR = 14.2). Symptoms and signs of acute and repetitive injury and respiratory symptoms were more common among carpet-weaving children than their non-working peers.
    International journal of occupational and environmental health 04/2010; 16(2):115-21. · 1.18 Impact Factor
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    ABSTRACT: This study aimed to characterise the relationship between adverse health outcomes and occupational risk factors among workers at a soy processing plant. A questionnaire, spirometry, methacholine challenge, immune testing and air sampling for dust and soy were offered. Prevalence ratios (PRs) of respiratory problems from comparisons with the US adult population were calculated. Soy-specific immunoglobulin (Ig)G and IgE among participants and healthcare worker controls were compared. Associations between health outcomes and potential explanatory variables were examined using logistic regression. 147 (52%) out of 281 employees, including 66 (70%) out of 94 production workers, participated. PRs were significantly elevated for wheeze, sinusitis, ever-asthma and current asthma. Participants had significantly higher mean concentrations of soy-specific IgG (97.9 mg·L(-1) versus 1.5 mg·L(-1)) and prevalence of soy-specific IgE (21% versus 4%) than controls. Participants with soy-specific IgE had three-fold greater odds of current asthma or asthma-like symptoms, and six-fold greater odds of work-related asthma-like symptoms; the latter additionally was associated with production work and higher peak dust exposures. Airways obstruction was associated with higher peak dust. Work-related sinusitis, nasal allergies and rash were associated with reported workplace mould exposure. Asthma and symptoms of asthma, but not other respiratory problems, were associated with immune reactivity to soy.
    European Respiratory Journal 04/2010; 36(5):1007-15. · 6.36 Impact Factor
  • Journal of Allergy and Clinical Immunology - J ALLERG CLIN IMMUNOL. 01/2010; 125(2).
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    ABSTRACT: Two cases of pulmonary alveolar proteinosis, including one death, occurred in workers at a facility producing indium-tin oxide (ITO), a compound used in recent years to make flat panel displays. Both workers were exposed to airborne ITO dust and had indium in lung tissue specimens. One worker was tested for autoantibodies to granulocytemacrophage-colonystimulating factor (GM-CSF) and found to have an elevated level. These cases suggest that inhalational exposure to ITO causes pulmonary alveolar proteinosis, which may occur via an autoimmune mechanism.
    American Journal of Respiratory and Critical Care Medicine 12/2009; 181(5):458-64. · 11.04 Impact Factor
  • Muazzam Nasrullah, Kristin Cummings
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    ABSTRACT: BACKGROUND Honor killing (HK) is a problem of public health concern but published data on the phenomenon are limited. In a separate paper we determined the burden, circumstances and method/weapon used for HK among women in Pakistan from 2004-2007. In this paper we analyzed the recent data from 2008 and described the epidemiological patterns of HK of women in Pakistan. METHODS Human Rights Commission of Pakistan (HRCP) systematically collected data on HK of women using newspaper reports from January-December 2008. We analyzed the aggregated data on HK through December 2008 and estimated the rate of HK. RESULTS A total of 573 HK events occurred in 2008; complete data was not available for all variables. Adults (≥18 years) constituted 83% (233/281) of death toll with 87% (356/407) being married. Alleged extramarital relation was the major reason for the killing (95%;521/548). Minorities were victims of HK in 7 instances (5 Christians, 2 Hindus). Husbands (42%;203/487), brothers (29%;139/487) and close relatives (12%;60/487) were the perpetrators in known HK events. Among the weapons/methods used for killing, firearms (60%;309/515), use of axe (11%;56/515), strangulation (11%;54/515) and edged tool (10%;49/515) were the main means of execution. The annual rate of HK in females (age 15-64 years) was found to be 11.6 per million. CONCLUSIONS Newspaper reports are good source of surveillance when information is limited. We found that adult married women constituted the majority of victims of HK. Ongoing surveillance would serve to better characterize HK in Pakistan and assess the effectiveness of preventive strategies.
    137st APHA Annual Meeting and Exposition 2009; 11/2009
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    ABSTRACT: Background: Fatality and injury rates have been elevated historically for contract miners. This study examined recent trends in fatal and nonfatal injuries among contractors and operators using the Mine Safety and Health Administration database. Methods: Rates were computed using surveillance data on employment and injuries for miners during 1998-2007. Employment data were used to obtain full-time employee equivalents (FTEs) for operators and contractors in coal/noncoal mining and surface/underground locations. Fatal and non-fatal injury rates were calculated for these subgroups. Rate ratios were computed using a binomial probability model. Results: Overall rates of fatality for contractors and operators were 36.5 and 22.6 per 100,000 FTEs, respectively, with a rate ratio for contractors versus operators of 1.62 [95% CI (1.35 1.93)]. Among underground coal miners, fatality rates for contractors and operators were 76.9 and 49.1 per 100,000 FTEs, respectively. In surface non-coal operations, fatality rates for contractors and operators were 37.1 and 15.5 per 100,000 FTEs, respectively. In contrast, injury rates for contractors and operators were 3.4 and 5.1 per 100 FTEs, respectively, with a rate ratio of 0.65 [95% CI (0.64 0.67)]. This injury pattern existed in all subgroups except underground coal mining. Conclusions: Fatality rates were elevated for contractors compared to operators, while injury rates appeared generally higher among operators. Investigation into the reasons for these disparities and subsequent interventions may be beneficial.
    137st APHA Annual Meeting and Exposition 2009; 11/2009
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    ABSTRACT: We compared the results of the tuberculin skin test with the results of the QuantiFERON-TB Gold In-Tube (QFT-GIT) assay among 182 low-risk healthcare workers. Overall agreement and specificity were high, but the tests did not agree on positive results. Only 2 of 5 positive QFT-GIT assay results could be confirmed with repeat analyses. Indeterminate results were associated with potential immunosuppression.
    Infection Control and Hospital Epidemiology 11/2009; 30(11):1123-6. · 4.02 Impact Factor

Publication Stats

207 Citations
116.96 Total Impact Points


  • 2013
    • University of Pennsylvania
      Philadelphia, Pennsylvania, United States
  • 2006–2013
    • Centers for Disease Control and Prevention
      • Division of Respiratory Disease Studies
      Atlanta, MI, United States
  • 2009
    • Aga Khan University Hospital, Karachi
      • Department of Emergency Medicine
      Karachi, Sindh, Pakistan