>> Okay, hello, everyone. Good morning, good afternoon, and good evening, from wherever you are in the world. We'd like to welcome you to the NORA Chronic Disease Council webinar for this month, and it is entitled "Stress and Cardiovascular Disease among First Responders, Data from the Buffalo Cardio-Metabolic Occupational Police Stress Study, also known as the BCOPS Study." Just to give you a little bit of background on NORA, NORA is the National Occupational Research Agenda, and it is divided into industry sectors and also cross sectors, looking at occupational disease in the American workplace. The CRC, also known as the Cancer, Reproductive, Cardiovascular, and Other Chronic Disease Cross Sector Council is a partnership between NIOSH as a steward, and other partners, including industry, labor, trade, professional organizations, and academia, that are really focused on chronic disease and occupational causes of chronic disease in the American workplace. We partner across multiple different groups to really look at occupational chronic disease, and this helps steer our ideas for research into occupational chronic disease, identify intervention and prevention strategies, communicate those intervention and prevention strategies. And today's webinar is a new example of that, and then we also try to identify and implement solutions with stakeholders, workers, labor organization, industry, academics, and government organizations. And in this effort, we hope to reduce occupational chronic disease. My name is Todd Stueckel. I am a co-coordinator for the CRC Cross Sector, and my partner in crime, Raquel Velasquez-Cronin, is also the other co-coordinator. And I'd like to turn the floor over to you -- to her to go over some ground rules for today's webinar. Raquel?

>> Thanks, Todd. This presentation is being recorded, and an archived copy of the full webinar, including the presentations and the live Q&A session, will be available at a later date on the CDC YouTube channel. And with that, I'd like to turn the floor over to Stephen James.

>> I'm honored to be moderating today. When I started my graduate education in 2009, there were two names I considered giants in the field of police stress research. One was my mentor, Brian Baila, who focused on the impact of stressors, such as shift working fatigue on performance. The other was John Violanti, who focused on the impact of stressors on officer health. Even a decade later, Dr. Violante's work with the BCOPS team is still at the vanguard of police health research. So what is the BCOPS Study? It's the Buffalo Cardio-Metabolic Occupational Police Stress Study, or BCOPS. In truth, it's a unicorn in police health research. I am unaware of any other police health study that has both the length, more than two decades, and depth -- examples. The study has been examining the early health consequences of stress in police officers in Buffalo, New York's police department. It started with a pilot study of 100 officers back in 2001. A police health study with an n of 100 in any other context would not be considered a pilot. This speaks to the magnitude of the undertaking John and his team have successfully managed. Since the pilot, the BCOPS study has been open to the entire population of the Buffalo police department. The study seeks to identify associations between officers' exposures to shift work, and traumatic incidents, for example, and health outcomes, body measurements, cardiovascular disease, et cetera. The range of parameters collected by the study is is simply staggering -- stress biomarkers, psychosocial factors, behavioral habits, shift work experiences, and markers of adverse health outcomes. As I said, it isn't just the scope of the project in terms of the population, an entire police department, or all it measures that's impressive. It's also the longevity of the project. The BCOPS Study started with 100 officers in 2001, with the support of the National Institute of Occupational Safety and Health, and ran for two years. Population cohort data collection started in 2004, and ran to 2009. The first wave of follow-up data, between 2011 and 2015, and the second wave of data between 2015 and 2019. The project is continuing with recent funding from the National Institute of Justice. So why is this work so critical? Well, quite simply, policing is a corrosive occupation. The BCOPS study has shown that just being a police officer can take years, even a decade, off your life, if the stresses of the job go unchecked. If you are in any way connected to police wellness or police leadership, I urge you to read Dr. Violanti's book. The stressors officers are exposed to have real consequences. In this time of staff shortages and difficulties in recruiting, police leaders need to make every effort to support and maintain the officers still on the job, and I believe we have an ethical obligation to minimize the harm policing has on those who serve. When it is time for the women and men who give their best years to their communities, when it's time for them to ride off into the sunset, they should do so in the best physical and mental health possible. So we have four speakers for you today who are answering just that call. They're wonderful researchers who have dedicated decades to serving, through science, those that serve us. First is Dr. John Violanti. He is a full research professor in the Department of Epidemiology and Environmental Health, the School of Public Health and Health Professions, the University of Buffalo, New York. He is a police veteran, serving with New York State Police for 23 years as a trooper, a criminal investigator, and later as a coordinator for the State Police Psychological Assistance Program. Dr. Violanti has authored over 150 peer-reviewed articles on shift work, stress, and PTSD. He's also written and edited 20 books on the topic of stress, trauma, and suicide. His newly-funded projects, including the effects of PTSD on decision-making among police officers, and mental health outcomes associated with COVID-19. In truth, John's work has been an inspiration to my own. Next, we have Dr. Michael Andrew, who serves as the chief of the bioanalytics branch of the Health Effects Laboratory division at the National Institute of Occupational Safety and Health, or NIOSH. Before joining NIOSH in 2002, Dr. Andrew was a professor of preventative medicine at the University of Mississippi Medical Center, where he collaborated on clinical and epidemiological studies, including the -- in risk in communities study, and the Jackson Heart Study. Dr. Andrew has 30 years of experience in statistical methods for clinical and epidemiological study design, analysis, and publication, and his research interests include workplace stress, autonomic function, and cardiovascular disease. Next, we have Dr. Samantha Riedy. She's a senior statistician at the Walter Reed Army Institute of Research. She focuses on the mathematical modeling of sleep and fatigue in law enforcement. Dr. Riedy and I go back about six years or so. She completed her Ph.D. in experimental psychology with us at Washington State University. It was apparent to me from the start that she was a rising star in sleep research. She had multiple offers from very prestigious schools for her post-doc, eventually landing at the University of Pennsylvania, before then moving on to Walter Reed. Dr. James Burch has been engaged in scholarly work in environmental occupation and molecular epidemiology for more than 25 years. He posses a Ph.D. in environmental health sciences, with a specialization in epidemiology, and a master's degree in pharmaceutical sciences. He is currently a professor of epidemiology in the Department of Family Medicine and Population Health in the School of Medicine at Virginia Commonwealth University. He also has an appointment in the University of South Carolina's Cancer Prevention and Control Program. He serves as a principal investigator or a co-investigator on numerous extramural-funded research grants. In addition to this BCOPS study, he also serves as a PI for a National Cancer Institute-sponsored case control study that will examine whether behavioral, psychological, genetic, or epigenetic factors related to the disruption of circadian rhythms and sleep are associated with gastrointestinal inflammation among patients receiving a screening colonoscopy for cancer. I am going to hand you over now to the speakers for a series of short prepared talks before we come back for the live portion of this event, the Q&A.

>> All right, I'm John Violanti from the School of Public Health and Health Professions at the State University of New York at Buffalo. I'd like to talk to you today about the basic design of our study, the BCOPS study, BCOPS meaning the Buffalo Cardio-Metabolic Occupational Police Stress study, which we initiated back in 1999 with some small pilot studies, and eventually got the entire Buffalo Police Department involved. So this slide is a brief history of the study, which was conducted in collaboration with us, with the bioanalytics branch, Health Effects Laboratory Division at NIOSH in Morgantown, West Virginia. We did a couple of pilot studies back in '99 and '03. At 2004, we took on the entire department, did a baseline, did a follow-up on that, and did a second follow-up on that. So we have data all the way up to 2020 on this study. The chart below shows you our course here, the work-related exposures and lifestyle factors -- traumatic events, stress, diet, exercise and so forth, and the intermediate outcomes, such as the altered stress biology, what happens to your body when stress hits, sleep quality, changes in biomarkers and blood, and to see what sort of effect that might have on future heart disease. And the outcomes, of course, are our measures of cardiovascular disease, sub-clinical cardiovascular disease, meaning that there were factors involved which could lead to future outcomes of heart disease. The thickness of the carotid arteries were one of those factors. The decreased blood flow in artery was another factor. Recently, we added the retinal vessel narrowing in the eye analysis, where we took pictures of the eye, and looked at the vessels within the eye as indicators of possible future heart disease. We looked at metabolic derangement, including glucose intolerance, sugar levels in the blood. We looked at a syndrome called a metabolic syndrome, which has several risk factors for heart disease involved, such as low good cholesterol, high triglycerides, obesity, high glucose, and high blood pressure. We looked at psychological factors, such as depression, PTSD, post-traumatic stress disorder, burnout, resilience, which is a protective factor, and others. We got work history. In order to study shift work, we needed work history on the officers' shifts. We were very fortunate to get day-by-day records of shift work, of absence, which included absence, injury, and the various shifts that the officer worked for this period of time. That became very useful in our analysis. Our study questionnaire booklets were several, and they contained all of the information we requested on psychological and health factors in the officers. Body measures included the pulse, waist and neck circumference, weight, height, abdominal height, the height of your stomach as you're lying down, blood pressure. Blood samples -- we took blood, 10 hours' fasting blood for analysis. We took a lipid panel and a chemistry panel, and a complete blood count. We froze some samples of the blood for future use at minus 80 degrees, and little things called [inaudible]. To test stress, we used a biological test for stress called the cortisol, and it's a hormone in your body. And when you feel stressed, it activates certain hormones in your body. Cortisol is one of the main hormones that it does activate, and it's part of an axis in the body called the HPA axis, which involves a system in the body. Initially, what we did here is, when we took the blood, the venipuncture, we used these little tubes called salivettes, and took a saliva sample before and after the blood sample to see if that was stressful, which it is for a lot of people. Next, at lunchtime, we took a baseline salivette saliva test. Then we gave the officers a high-protein shake, around 65 milligrams of protein. Then we took saliva samples every 15 minutes after that shake to watch the course of the cortisol over time as it took its course. Now, protein basically -- the high protein basically spiked the cortisol, and made it move, and gave us sort of a curve of cortisol that we could measure. We gave the officers some salivettes to take home. We instructed them to take four at awakening, at 15 minutes apart, take one at lunch, one at dinner, take one at bedtime, and then a dexamethasone pill, which is a cortisol suppression, to see whether that was working properly. And when they woke up in the morning, to take four more saliva samples at 15 minutes apart. The sample -- these are the swabs, which they put in their mouth to gather the saliva. To look at the effects of shift work and sleep, we used an ACTO watch. An ACTO watch is basically a movement device that measures all your movements throughout the day. We had the officers wear this watch for 15 days, and we looked at how much they moved during sleep, whether they had interrupted sleep, how long they slept, and various other parameters of sleep quality and quantity. This allowed us to look at the effects of shift work, including injury, accidents, absences, psychological effects, and sleep quality and quantity, as they might be related. Next, we took ultrasound, which is a noninvasive device, as you know, to look at artery health, to look at flexibility of the artery, to look at thickness of the carotid artery in your neck, and this piece can be related to early indications of future heart disease. The artery we looked at in particular was the brachial in your arm. What we'd do there is, we would occlude the artery. We'd cut it off for about four minutes, release the cuff, and see how well the artery reacted. Of course, the better it reacted, the more healthy it's considered, and we can measure that. In terms of the carotid in your neck, we measured its thickness. The more thick it is, the more likely that it's going to cause problems for you. DEXA was a device which measured the bone density and the bone health of the officers. It also measured body fat and lean mass in the officers, and we can use that to look at associations between that and stress. The key messages of this study was that we wanted to see whether or not the stress of this job, this police work job that is so stressful, what these people have to go through. Did it have an effect on their medical health? And we did that through looking at the medical health, and we looked at the psychological evaluation of these officers as well, both in a biological stance, and both in asking questions as well. Some of the basic findings were that we found an increase risk for potential future heart disease in these officers. We found high values of stress related to the organization, related to the lack of support. We found the effects of sleep deprivation, and how it may be related to injuries, and accidents, and absences, and we found that psychological factors, such as PTSD and depression, are very relevant and biological effects on police officers' health. This job is replete with stress, with traumatic experiences, and the increase for cardiovascular disease. Intervention is much needed in this occupation on a proactive basis, and on an ongoing basis. Thank you.

>> The title of this talk is "Correlates of changes in Blood Vessel Function Over Seven Years." Blood vessel function is also thought of as endothelial function, and endothelium is a membrane that lines the inside of blood vessels in the heart, and it regulates the vascular contraction and relaxation, and also then blood flow. Endothelial function is measured as flow mediated brachial diameter reactivity or flow mediated dilation -- we'll call it FMD -- which is an early predictor of the development of cardiovascular disease. So how we measure this is by -- with an ultrasound probe, and we measure the diameter in the brachial artery, in the forearm. And we put a blood pressure cuff on the forearm of a person, and we inflate the cuff. And you can see the pressure increasing here as the cuff is inflated, and then we release the cuff. And that causes a flow challenge, or it causes increased flow in the artery. And so, then we can observe the diameter change, the response of the artery or the endothelium in response to that increased blood flow. And so, a large change indicates a good-functioning artery, and a smaller change, less good. So we tend to take this maximum value diameter, and we subtract from that the baseline, before the procedure, and then we divided by the baseline to obtain what we call the FMD. So here's a slide showing how those calculations work. We do the peak minus the baseline over the baseline times 100 to get it as a percentage. We divide by the baseline, because it tends to correct for differences in baseline artery sizes between people, making the measurements more consistent across baseline diameters. Change in endothelial function over time is this subtracting the baseline, or the first clinic examination, FMD% from the followup seven years later, and then decrease in FMD% over time infers decreased endothelial function, or decreased blood vessel function. What causes these decreases? Well, things like hypertension, smoking, lack of physical activity, and we're going to examine exposure to chronic stress. So our measure of exposure to chronic stress is the cortisol awakening response, and cortisol is a hormone that's thought of as a stress hormone. It helps in dealing with challenges and stressors. It decreases inflammation. It mobilizes energy. Waking up in the morning is considered a challenge. We tend to examine how the stress response system is working by examining challenges over time. So waking is a challenge to that system, and so, we examine the cortisol response at first waking, and then 15 minutes later, 30 minutes later, and 45 minutes later. Lower cortisol response is thought to be from chronic stress exposure, which is thought to be from wear-and-tear on the stress response system. So the way the area under the curve, the AUCI, is calculated, which is going to be our independent variable, is for each individual person, we take the measurements. Then we calculate the area under the curve, and this top curve would be a good, healthy response. And you can see that'll give you a larger number, and for this red curve, where it actually goes down, that's going to be a negative number. And in between here is sort of a middle response. These three curves relate to the lowest, middle, and the highest 33% of the AUCs in this population, and it's used for illustrating what that looks like. So we had a sample of 172 officers present at both the follow-up exam and the baseline exam. We compared the means of the seven-year change in FMD% across the lowest, the medium, and the highest 33% groups of baseline cortisol AUC. And the result was that the lowest third of AUC had a larger decline in FMD or artery function over time, and the highest third had the smallest decline in function. And so, let's go back and look at that graph. You can see here, this is the more healthy-looking response, and this is an average of the samples from the highest third of the people with the highest AUCs. You can see there's a small decline over seven years, which is not unusual. And you can see for this unhealthy-looking, atypical response, you can see a very large decline in artery function over the seven years. And then, in the middle, there's also a decline. These two values are statistically significantly different. Okay, so the key messages here is that abnormal or atypical awakening cortisol pattern at baseline examination predicted worsening FMD over a seven-year period of time, and that this atypical awakening pattern may lead to impaired brachial FMD or impaired artery function in males only. We only found this result in males, not in women. The key recommendations are that stress may be linked to vascular abnormalities and sub clinical cardiovascular disease, and that there's a need for stress reduction strategies in high-stress occupations such as policing. Okay, now we're moving on to the second study that also has FMD or endothelial function as its outcome, a decline over seven years in artery function as the outcomes. In this situation, there was 188 officers, a few more, because there was less missing data for these variables. Shift work was the exposure here, and shift work was determined during the previous year before the examination, and it was classified as the dominant shift worked among the percent time spent on day, afternoon, and night shifts. So whatever was the highest percentage for a person was classified as the dominant shift. These data come from daily electronic work history data from the City of Buffalo payroll records. The outcome, again, was the seven-year change in brachial artery function, and calculated the same way as before. And we found that male officers on the day shift had a smaller mean decrease in FMD, which is this number right here, when compared to those who worked -- male officers who worked the afternoon, which had a larger decrease, or the night shift, which also had a larger decrease in artery function. These comparisons were adjusted for a variety of covariates. And so, shift work status was significantly associated with seven-year change in artery function among male officers only, and the people working the night shift -- the men working the night shift had a much higher decline, and the afternoon shift as well. Here's the reference, if you want to look at some more details. The key messages for this study are that shift work status was significantly associated with a decline over seven years in men only, and the highest declines in afternoon and night shifts. And the larger decreases in FMD suggest greater endothelial dysfunction over time. So the key recommendation here is that there's need for further studies of shift work adaptation among police officers. It's not like you can not work shifts, you know, afternoon and evening shifts. And so, you know, there's a need for further studies about how people can adapt, and maybe be healthier working on shifts. Thank you. The title of this talk is "Police Work Stress and Cardiovascular Disease Risk Factors." I'm going to go over two key studies. These two studies have a common exposures, and two outcomes, heart rate variability and metabolic syndrome, which I will define shortly. The exposure is police stress. And so, how do we measure police stress? In the BCOPS study, we measured it using the Spielberger police stress survey. This is a survey that has 60 items, and it measures the number of times a potentially stressful event happened in the last month, and also separately in the last year. These items were developed, you know, from input from police officers, in terms of making a Q list of the things that officers find stressful on the street and in the workplace. So this also has a score from zero to 100 for each event. The higher the stress score, the more stressful the officer's experience of the item. So we can create exposure indices by multiplying the frequency of an event times the stress score, and those scores are then averaged over the below subscales, over items that make up the below subscales. So we have organizational/administrative pressure, physical/psychological threat, and lack of support, and those are the three variables of interest, the exposure variables that we'll be using here. So the first study includes a cross-sectional association between police work stress and high frequency heart rate variability. High frequency heart rate variability is thought to be a measure of how well the biological brake on the fight-or-flight system is working, but lower HRV is also an early sign of cardiovascular disease. So a little bit of history on this parasympathetic brake, or brake on the fight-or-flight system. Usually, with everyday functioning and everyday situations, we're using social engagement, and when that's happening, this brake on the fight-or-flight system is on. And it can be on, you know, a certain amount, depending on the need. If, you know, we're in a fairly relaxed situation, the brake goes on quite a bit, and then, if something happens and you need to deal with an environmental challenge, that social engagement will allow you to deal with, and the brake comes off a little bit. But it's always on and regulating. Now, when there's an emergency where social engagement isn't going to help with the situation, then the brake goes off, and we have what's called the fight-or-flight response. And then other kinds of things kick in, and so, this HF-HRV is a measure of how healthy or how well this brake is working for people. And so, to measure this, we look at electrocardiogram data, and we look at the time differences between heart beats. And that gives us our heart rate variability series of data points. And then, we extract those and analyze them, and we get what's called the high-frequency component of the resting heart rate variability, which turns out to be between .14 and .4 Hertz. And so, this is a measure of how well the brain is regulating the heart rate relative to putting the brake on the fight-or-flight system. There are a lot of details that go into this, and if you're interested, you can look at the paper. And then, there are reference sin this paper that will lead you in the directions of how to do this kind of study. This was a cross-sectional study of 360 officers from Buffalo, examined at the baseline study '04 to '09. We did not find any significant associations between stress measures and HF-HRV among men. Among women, there was a statistically significant inverse association between the lack of support stressor over the past year and the HF-HRV. And then, the regression coefficient for that was a minus 2.73, which means that as the lack of support goes up, high-frequency heart rate variability, you know, tends to be lower in people. And so, these lack of support stressors have to do with things like lack of supervisor support, lack of coworker support, lack of resources, more local kinds of stressors, whereas the other administrative stressor is more global, police department-wide kinds of things. So all other stress indices were not significantly associated with HF-HRV for men or women. So it was only the lack of support stressor that had an association. So the key message here is that the lack of support structure is associated with the ability to put the brake on for the flight-or-flight response, but in women only. And the key recommendation is that this result could be used to inform potential interventions that may help improve stress regulation and potentially reduce CVD in policewomen. It's a cross-sectional result, so, you know, more studies would need to be done to confirm this. The second study is a cross-sectional association between the same exposures, police work stress, as introduced earlier, and metabolic syndrome. This is a little bit higher sample, because there was less missing data among the metabolic syndrome data. And metabolic syndrome is a clustering of abnormalities associated with increased risk for cardiovascular disease and diabetes, type two diabetes. The components of metabolic syndrome include abdominal obesity, or sort of middle obesity, high triglycerides, reduced good cholesterol, glucose intolerance or high blood sugar, and high blood pressure. And this is defined by the document you can look up there. It's cited here. The presence of metabolic syndrome itself is indicated as three or more of these components. So here's a reference you can look at if you would like to get some more details on this. We compared the number of metabolic syndrome components between lower, middle, and upper thirds, or tertiles, of the police stress indices separately for men and women. So we had the three subscales, organizational/admin pressure, physical/psychological threat, and lack of support. The results were that, among women only, the number of metabolic syndrome components were associated with that lack of support stressor again that we saw before, administrative/organizational stressor, but not the physical and psychological threat stressors. And there were no associations between these variables among men. So the key message here is that lack of support stressors and administrative or organizational stressors are associated with cardiovascular risk factors or metabolic syndrome among women only, and that the physical/psychological stressors were not associated with this outcome. The key recommendation again is that this result can be used to inform potential interventions that may help reduce cardiovascular risk in policewomen. But again, it's a cross-sectional result, so more research is probably needing to be done. Thank you very much for your time and attention.

>> Hello. I'm Samantha Riedy. I am a sleep researcher and the contracted senior statistician at Walter Reed Army Institute of Research. Today, I'll be presenting on modeling sleep and fatigue in law enforcement. Before I begin, the opinions or assertions contained herein are the private views of the author, and are not to be construed as official, or as reflecting true views of the Department of the Army, the Department of Defense, or the NIOSH CDC. In the United States, there are more than 12,000 local law enforcement agencies that provide routine patrol services to communities around the clock. While there is substantial variability in the work hour policies and procedures used by each agency to staff offices around the clock, there is a high prevalence of shift work and long work hours, particularly in the form of overtime and mandatory off-duty court appearances. It is well-established that shift work and sleep loss, and maybe secondary to long work hours, increase the likelihood of fatigue and performance impairment, and it's been suggested that absenteeism may represent a self-management strategy for fatigue, thereby signaling reduced operational readiness. There's also recent experimental research that has established a substantial impact of shift work-related fatigue on police officers' encounters with the public. This is important, because these encounters have a major impact on public trust and perceptions of police legitimacy. Citizen complaints are one important indicator of public trust, and the extent to which people believe that they're fairly and respectfully treated by police. We were interested in further exploring the relationships between shift work, sleep loss, fatigue, and police/community relationships, as measured by citizen complaints, and operational readiness, as measured by absenteeism. To do so, we used data from two large-scale law enforcement studies. First was the Tired Cops study that included 379 police officers across four police departments. Each police officer had day-by-day payroll for up to four months, and our analyses focused on the two police departments that were willing to report citizen complaints filed against their officers. The second study was the Buffalo Cardio-Metabolic Occupational Police Stress Study, a.k.a. BCOPS. This study included 367 police officers at one police department. Again, each officer had day-by-day payroll for up to 25 years. We defined absenteeism as taking a single sick day on a regularly scheduled work day. Across the two studies, there are about 530,000 shifts worked by 746 police officers, and despite the vast amount of work data that were available, there was a lack of complementary day-by-day sleep/wake data. To still be able to examine the relationships that we were interested in between shift work, sleep loss, fatigue, and police/community relationships, and operational readiness, we used a sleep and performance prediction model called FAID Quantum. These models are widely used in operational settings, such as rail and aviation, to develop work/rest schedules that help mitigate fatigue, to determine whether fatigue mitigation strategies may be needed, and in aviation, they're also used in safety cases for flights do not fit within the regulations. Essentially, we used the work/rest schedules for these 746 police officers as input to predict their sleep/wake behaviors, and then the temporal profiles of sleepiness across the work/rest schedule. Between the work data in the Tired Cops and BCOPS studies, the public complaint and absenteeism data, and sleep and sleepiness predictions yielded by FAID Quantum, we then had a complete data set. In terms of citizen complaints, we found that police officers who were predicted to obtain less sleep and have greater on-duty sleepiness were significantly more likely to have a citizen complaint filed against them. We found that police officers working night shifts, but particularly consecutive night shifts with daytime court hours interleaved, which reduces their sleep opportunity, are significantly more likely to receive a citizen complaint when compared to day shift officers. For absenteeism, we found that police officers who were predicted to obtain less sleep and have greater on-duty sleepiness were significantly more likely to exhibit absenteeism, particularly for those officers working afternoon or night shifts, and who are predicted to be relatively sleepy. The results suggest that sleep loss reduces operational readiness and impairs performance, and that this may have impacts on police officers, police departments, and the civilians that they protect and serve. With further validation, sleep and performance prediction models could provide a useful tool for studying and helping to mitigate police fatigue and associated consequences in law enforcement.

>> Good afternoon, everyone. I'm going to be talking today about shift work impacts and adaptation in police officers, and I'd like to thank the organizers for inviting me to participate today. Shift work is very common. About 15 to 30% of all shift workers -- of all workers participate in some form of shift work, usually begins some time after the regular work schedule ends, and continues through the night. In the international range of somewhere between six and 30%, and about 20 to 30% of workers who work shifts are unable to maintain this schedule, and they drop out of the workforce or find another job within two to three years of initiating shift work. Shift work is essential. If you think about people who are involved with shift work, it's some very high profile, high-consequence occupations, including medical care providers, emergency responders, and so forth. It's also very hazardous. Chronic fatigue is a big issue, as is sleep disruption. There are increased accidents and injury rates in shift workers, and also decreased productivity that amounts to hundreds of billions of dollars per year, just in the United States alone. This is a list of some major disasters that have occurred over the last several decades. They all occurred between approximately midnight and 6:00 a.m. So somebody was on a night shift when a lot of these disasters occurred. Doesn't prove cause and effect, but it does show how important night work is, and how people need to be vigilant, no matter what time of day it is, when they're in these high-profile, high-consequence occupations. Shift work also has health impacts, cardiovascular disease, gastrointestinal disorders, reproductive disorders. Cancer is an area that I work in, has also been associated with shift work very recently, this year. The National Toxicology Program did a cancer hazard assessment that pretty much confirmed the conclusions of the IARC probable human carcinogen designation that was given shift work back in 2007. Shift work impacts are preventable, as well. So to prevent the costs and the health impacts, it's important to understand what factors -- how people adapt, and how we can target these adaptation strategies to improve health, and -- of shift workers. So this is a study of shift work adaptation among healthcare workers that we did a number of years ago. These are workers at a regional hospital. To find out about adaptation, we asked them to rate themselves on how well their performance was on their current work schedule, or how content they were with their current work schedule. And we used one validated questionnaire of occupational stress, known as the pressure management indicator, and we combined that with a questionnaire on shift work called the standard shift work index. There were 145 items, and so we used a factor analysis to sort of combine these questions that were statistically related. And so, in interpreting these, you can -- if the odds ratio is above one, then people who are getting adequate rest were more likely to report that their performance was optimal on their current work schedule, and if the odds ratio is less than one, then this characteristic was associated with less, poorer -- less-than-optimal performance on their work schedule, or being less content with their current work schedule. So the important point here is that these factors that are related to sleep were very important, in terms of the individuals reporting whether or not they were adapted to shift work. Fast-forwarding to more recently, to our study of shift work adaptation among police officers and beat cops, we wanted to identify people with and without shift work adaptation, but we didn't have a direct question about that, about whether they were adapted in the questionnaire at the beginning of this study. We have since developed a questionnaire that does ask direct questions, and it asked about strategies for adaptation. And we initiated that survey last year. We will be analyzing the data in the upcoming year, but for this analysis, we wanted to just see if we could group individuals based on their symptoms. And so, we asked a number of symptoms that we thought would be related to adaptation or maladaptation to shift work, and as -- these are the categories of questions that were used in the analysis. And these are the results of that analysis. So the people in the group with the orange lines and dots here represent individuals who had lower levels of these symptoms, and people in the blue category are individuals -- these are all shift workers in this analysis. So the people in the blue were poorly adapted, and the people in the orange category were more well-adapted to shift work. And so, we thought we got pretty good separation here, and so -- but we wanted to sort of confirm these results by comparing these two groups, in terms of different behaviors or personality traits that had been associated with shift work in the past, shift work adaptation in the past. And so, I'm not going to show the results, because we don't have time. But factors related to diet, family conflict, stress response, or sleep differed between these two groups, and that was sort of a confirmation that the strategy that we used to identify these two groups was working. And finally, in this analysis, we wanted to look to see whether or not certain disease biomarkers may differ between these two groups, and so, we had 15 different biomarkers related to metabolic syndrome, or hormonal factors, or immune factors, or measures of heart rate variability, which is a measure of your cardiovascular resilience. And so, these are the results of that analysis. So of those 15 biomarkers, there were four biomarkers that were associated with maladaptation. All of these were higher in the maladapted group relative to either adapted shift work or daytime workers, even after adjusting for potential confounding factors that could be associated with these things. So we thought that this was pretty good evidence that we -- it's not real strong, but it's suggestive that maladapted workers have these differences in these certain factors related to inflammation and metabolic syndrome. We are planning in the upcoming year to do a more definitive analysis, where we'll look at these biomarkers longitudinally to see if maladapted workers have changes in these biomarkers over time, which would be a more definitive association between maladaptation, and these biomarkers of disease. So the key messages from my talk today is that multiple factors, both individual and social, contribute to shift work adaptation. Adequate sleep is very important for shift work adaptation. To understand the relationship between shift work maladaptation and disease progression, we need to do longitudinal studies, and such studies are critical for developing health promotion strategies that are effective for shift workers. So this is both police officers, and in other occupations with shift work. What are those adaptation strategies that can prevent disease? This is our ultimate goal, and we intend to investigate this using a prospective analysis approach in the BCOPS cohort data to identify these targets of disease prevention in this research that is supported by the National Institute of Justice. So, thank you for your attention. These are my collaborators, both students and faculty, as well as sponsors. I'd like to thank sponsors of the research, and here are some key references for you to investigate if you'd like to look into this more carefully. Thank you for your time.

>> I'd like to talk to you in this presentation about improving police health and well-being, making it better, if you want to use that term. I think the health status of police officers in the United States is compromised in many various aspects, I think, and interventions are needed, as I mentioned in my last presentation. It's important that we intervene on a proactive basis. So what I want to do here is to talk to you about a couple of examples of interventions that have worked, and perhaps may get you to look at the many other interventions out there that are being used by police departments that have been successful. The first one I'd like to talk about is something called SHIELD, the Safety and Health Improvement Enhancing Law Enforcement Departments study done by Dr. Kerry Kuehl. Dr. Kuehl is an M.D.. And what he did -- he realized that fire fighters and police officers are a cohesive work group. So he said, "What might work well is if we try to improve health as a team." And he was correct. It did work very well. The team-based intervention approach does work well in cohesive occupations, and many first-responder occupations are very cohesive, and stick together very well, and work together well. Dr. Kuehl looked at factors that could be modified -- one's diet, one's physical activity, an ideal body weight, dealing with stress, getting proper sleep, and learning sleep hygiene, decreasing one's tobacco and heavy alcohol use. What he found in his study, again using a control and an experimental group, he found that the experimental group increased fruit and vegetable consumption significantly. He found that sleep quality and quantity was improved significantly. He found stress reduced, and he found that in general, there was healthier eating among the group that participated in this SHIELD program. The important thing, I think, about this study is it demonstrates that a team-based -- led by a peer, by the way, forgot to mention that -- health promotion program can be incorporated into a daily work routine, and may be ideally suited for first-responder occupations like police work. It makes a lot of sense that working together works better. In terms of PTSD, or post-traumatic disorder trauma, I think one of the studies I often use as an example is Bengt Arnetz, who did some work with the Detroit Police Department. And what he did was to develop a proactive police trauma training resilience program, and by proactive I mean he had this program in motion before the young officer went out in the street, at the academy level, and he went out in the street. And this is a good idea. The idea is to reduce stress during these terrible things that officers see, these critical incidents, and to teach them how to deal with these incidents, to get them to come down from those incidents before they go out, and come down after they are through these incidents. The test he had involved the 10-week resiliency imagery and skills training program versus a control group, which was training as usual. The protocol involved education of psychological trauma, what it is, what the symptoms are, what to look for, how long they last, and so forth, and an adaptive way to deal with this trauma, how to cope with this trauma. The protocol involved repetitive, intense imagery of police work scenarios. He might present the scenario, for example, of a dead child, or a horrible traffic accident, or a shooting, or a mutilated body, or death scenes, or riots, whatever really happens in police work. He would begin this with a relaxation technique to get them down, something you can learn, and then give him one after -- and one after the scenario to help to bring them down. And with practice, these techniques can help one to come back to a normal state out of stress. It also involved education and practice on strategies to deal with the emotional challenges of trauma. How does it affect you, and your family, and your life, and what goes on with your performance? One year later, Bengt looked at the results of his experiment, and he found significantly less negative mood among the experimental police officers, and better performance throughout the year in those officers that had the training. Trends for reduced stress were noted in this group as well. Now, these officers experienced much of the same factors and trauma that the officers who did not get the training experienced, and yet, they still had reduced negative mood. So it was considered a good technique for dealing with PTSD, by being proactive. The New York State Police developed a program which was -- I thought was rather interesting for cardiovascular disease testing. The Trooper Police Benevolent Association partnered with 300 -- I'm sorry, with 3000 physicians throughout the State of New York, in every major medical institution, and established a free medical benefit for the members. So it didn't cost you a cent to do this. State Trooper Surgeons program is a union-based healthcare navigation service that's focused on top medical outcomes for troops and their family members. So if your spouse or your child has a problem, they can be tested as well. The service operates throughout New York via a mobile van testing center, equipped with everything, with all the testing equipment. They got treadmills, blood testing. You name it, it's in this van, and the van travels throughout the state, wherever it might need. They might take one section of the state at a time where troopers have signed up for the program, do that, go to the next section, and so forth, but they can cover the entire state. What do they test for? They test for -- they give an electrocardiogram. They test carotid, echocardiogram carotid Doppler check for thickness. They test an abdominal aortic ultrasound Doppler to look at the aorta, to see whether it's sturdy enough, and not about to rupture, which is certainly very serious. Transcranial Doppler, which looks at the blood/brain association, lung tests, pulmonary functions, blood pressure testing, heart rate and cholesterol check. If they do find a problem with any of these tests, they can prescribe a calcium test score via a CT scan to look further into it. The belief of many of these physicians is that the calcium test is a good indicator of heart disease. Well, what messages can we take away from these very few examples? That interventions based on education for a healthy lifestyle and coping with stress and trauma should be conducted on a proactive basis, a proactive basis. Now, that's the important factor here. Reactive basis -- it's probably not early enough, or it's too late, if you will, to do anything. Intervention should begin at the basic police academy when that individual comes into this work, and it should also be done throughout the police career at various stages of follow-up. You know, a lot of departments have in-service training every year, or every two years. It should be done at that point again. Policing is cohesive, and has a cohesive work population, as many first-responder organizations are. These team-based, competitive approaches to health and wellness appear to work well, as we say with Dr. Kuehl's study, and I've seen this in the past in the state police, where monetary rewards were given for officers who could maintain a good physical condition, if you will, based on what the department wanted them to be, doing so many push-ups, sit-ups, and so forth. And what I saw happen with that is that there was a competition that evolved through various departments and precincts in the police department, and they were all trying to outdo each other, get in better physical shape so they could get the monetary incentive. And the better shape you got in, the more money you got. So it turned out to be a very interesting test to watch, and it worked very well. And last, I think it's very important for our departments to establish a collaboration with outside agencies and outside groups. Medical profession is a great example -- to help enhance police health. The medical profession, the American Suicide Foundation -- we know that officers -- that police have an increased risk for suicide. The American Psychological Association, the Veterans' PTSD Group, very good group for information, and videos, and all of that. All of these groups can help in a collaborative way, help police deal with the health problems they got because of what they face every day, the stress they face every day, and what that stress does to them, in terms of their physical and psychological health. So, thank you for your attention, and best wishes to you.

>> Well, I think that was great. Thank you so much for your talks. I've been following the BCOPS study for a while, and I still learned something this morning. We have a few questions already in the chat. The first one that was in was from Maria, and that was, "How can we relay this amazing research into police departments, so leadership will change the current scheduling protocols, which cause all these negative effects on the officer and their families?" And that's from Maria Friedman from Badge of Life. John, would that be for you? How do we best get this to effect change in agencies?

>> What we need to do is -- scientific, that we have -- these scientific terms that we have, and somehow translate them into a common language, if you will, that can be better understood by people who are not scientists. If we can do -- translate it in that manner, we could get it into the police officers who better understand these things, and bring about change. Along with that, we need policy, and we need policy at the legislative level, which we do see occurring in --

>> Andrew, there's two questions that are linked, one that you've already responded to, to say you're going to answer -- and that is around the difference between sex and chronic disease. Do you want to speak to those two questions?

>> Sure, that's a really interesting question, and I knew I was going to get it. So one of the questions was about do you think that the differences in HRV and stress, or women have an association and men don't, is about women being bullied or excluded. And the second question is similar, but it's a more general question about what's the biology behind this, and how are men and women different. And so, the paper that I cited in that presentation has a lengthy discussion of possible biology, biological explanations for this. I'll kind of go over it briefly here. There is a theory that's helpful in interpreting these results called the tend-and-befriend theory. And the idea is that women tend, according to this theory, to cope with stressors in a more social way, and men, less so. And so -- and there's papers out there on that, and there are also other papers on the potential biology of that. And so, one possible explanation for the sex interaction in both of those studies is that, particularly in the heart rate variability study, is that lack of support from supervisors and coworkers can actually thwart or inhibit the natural, you know, stress management approach that women tend to use on average. And this is just an interpretation. I mean, the answer is, nobody really knows, but that's one possible explanation. And then, for men, not so much, and then, you can also think of the workplace as being one that may be more excluding of women. And, you know, there may be more bias, and more difficulties for women in policing, and that could also partly answer that question. One thing I wanted to point out is that, in that HRV and stress result, women have higher HRV than men do in just about every study they've looked at. There's a meta-analysis of that out there, and so, women are protected in terms of having that biological brake work, and also protected from cardiovascular disease when they're younger. So what we really saw was that, for women that were under high levels of social lack of support stress, their HRV came down to about the same level as men, and women that had less of that kind of stress actually had higher HRV than men. And so, that's a little bit of a hint there, that women, you know, may be coping in a different way. The paper itself has a long discussion of that, and lots of references. And the biology is complicated, and I did my best to -- I'm not a biologist, but I did my best to kind of summarize it. So take a look at the journal article. If you want to send me an e-mail, we can talk after you've looked at it. So that's a really great question. Thank you.

>> There's another question in the chat, and it's from Rafael. There are data that compare morbidity and mortality among police officers compared to the general population. What I'm interested in is whether there is or not a healthy worker bias related to the police officer occupation. So are the morbidity and mortality rates for police officers -- are they moderated in some way by the healthy worker effect?

>> Yes, I think that they are, to a degree. I think that when we talk about limitations to our mortality studies between police and the general population, we do mention the healthy worker effect. And what that essentially is, is that people who are employed and healthy have -- to get a disease. So that's one of the factors that's controlled in mortality -- which we just finished one of these, and did happen to mention that, too. But when that is taken care of, when we consider that, the healthy worker effect, we still see high mortality rates among police officers when we compare -- analysis to the general population, and cardiovascular disease is one of those. There are certain cancers that are also higher in the police population than in the general population.

>> And can I add something to that, please? You know, it depends on who the comparison group is, and John Violanti and I, and others, and Mike, published a paper on cancer and shift work in police officers a few years back. And so, if you are compare people with low levels of -- police with low levels of exposure to a given stressor, and then to those with higher, then you kind of have a comparison group that's within the same group of people, and you wouldn't have necessarily to worry about the healthy worker effect. So really boils down to who the comparison group is.

>> You think that's moderated by the high barrier of entry into the profession, with how long it takes to go through background, and academics and so on, that potentially it's retaining people that would otherwise have left shift working, for example?

>> Are you asking -- I guess it's just for the panel. I think it's a tremendously complex and -- you know, issue. There are multiple factors at play. Sex differences are certainly one thing. How individuals adapt, you know, what their adaptation strategies are, both to stress, and to shift work, other types of stressors, you know, their background. Their genetics probably factors in. You know, there's just multiple factors, and of course, there's the social environment as well. And so, trying to understand all these different components, and which ones are really the drivers of the risk, or the reduction in risk, is really what's critical in the work we're trying to do with BCOPS, is really try to identify the most potent thing that we can target to improve police officers' health.

>> Thank you. Another question in the Q&A box is from Yong Soong. Thoughts on using other bio specimens, like head hair, toenails, chest hair to measure cortisol for chronic work-related stress? Why did you go with -- data, or why did you rule out these -- not using these measures?

>> Well, we didn't rule them out. We did try some hair strand analysis. We didn't get too much of a good result with that. We felt that the saliva was probably the easiest way to collect saliva -- to collect the cortisol, and it was only a matter of keeping these dental swabs in your mouth for a few minutes, and putting them in the salivettes. It also worked well when the officers were no longer in the clinic, because we did take cortisol samples for three days. So when they had to leave the clinic, we had to find some way to collect the cortisol at that point. So the salivettes worked well, and the dental swabs also worked well.

>> Also, one more point on that. The hair samples and things like that give you an integrated measure of cortisol over a certain amount of time. I don't know if it's a month or whatever, but much of the information on how the HPA axis is functioning is in the patterns during a challenge. And so, waking is a challenge, and so, this was designed this way on purpose, to capture the challenge to the system of waking, to capture the challenge to the system of a high-protein lunch, and also, you know, the challenge to the system of an ordinary workday, which is one of -- before bedtime. And depending on how you look at that, you know, sometimes it's the before-bedtime data point that's important. Sometimes it's the slope. Sometimes it's the AUC during the waking. So it gives you much more information about how the HPA axis is working to do the saliva samples.. It's also more expensive. So for some studies, the hair analysis, you know, might be the best choice.

>> So we have a question from anonymous, hopefully not the Anonymous, but do we have just a lack of funding to employ wellness, especially mental health at police departments. I hear support from wellness directors for corrective programs, but no funding in their budgets.

>> Well, we don't have direct knowledge of that, but I think that's probably an accurate statement, to the degree that much of the police data, or much of the police funding today goes towards operational aspects, such as vehicles and, you know, equipment like that, and hiring new police officers if possible. So I think sometimes the wellness issues are put on the back burner, if you will, and that's not true everywhere. But there's certain jurisdictions where they just don't have the money to go with secondary -- what they think is secondary problems. Because I don't feel that way, and I think a lot of chiefs out there that don't feel that way. But if the money's not there, it's not there. There needs, again, to be legislation, like most recently President Biden provided money for providing peer support training for police departments throughout the country. It's things like this that are going to help that move along.

>> Okay, Andrew, I think there's a question in the chat for you. Do you want to take that one?

>> I'm sorry, I can't see the question. Sorry.

>> So it says, "Holdemann et. al, published many studies on occupational physical activity PA in relation to CVDs and musculoskeletal disorders, MSDs. He coined the term 'PA paradox,' meaning the occupational PA leads to chronic stress, while leisure time PA does not. Can you comment on the triangular relationship between PA, MSD, and CVDs in particular in the police population?"

>> Okay. I think one of our cohorts did a study on leisure and physical activity. Mike, was that Jack Goo [assumed spelling] that did that study? And found that leisure time was probably more conducive to reducing CVD.

>> Yeah, I mean, leave time was -- I think it was Claudia Ma [assumed spelling], maybe Claudia Ma that did that, and Jack may have done one as well. And we have looked at that. We haven't looked at MSDs along with physical activity and CVD. So I'm not an expert in that triangular relationship. I don't know the literature there, but yeah, we've looked at workplace versus leisure activity. And leisure activity seems to have a positive impact on health in general, and the things we have examined. That's about all I know at this point.

>> Yeah, I think conceptually, you have to think in terms of exercise can become a stressor. It's a stress-reliever, at one level. It's kind of like a biphasic dose response curve. Too much stress can create actually more stress. I mean, too much exercise can create more stress if you, for example, end up with an injury, musculoskeletal disorder, you know, if you have a very physical occupation, and then also are exercising in your leisure time. You know, there's probably some level at which it becomes counterproductive.

>> I'd like to add to that. We do have some researchers on our Chronic Disease Council that are looking at the effects of strenuous physical activity, and some of the recent research coming out of that suggests that strenuous physical activity on the job actually may be a risk factor for cardiovascular disease. There's more research that needs to be done, but those studies were just published in the last year or two. So we're keeping a close eye on that.

>> Well, we have a question from north of the border, from my good friend and colleague, Greg Kratsich [assumed spelling], from RCMP. We are conducting a massive prospective study with 1000 cadets over 12 years, and are using seismocardiography instead of continuous ECG. Does the panel have any thoughts on this measure?

>> That's a new one for me. I'll have to read up on that. Thanks for introducing me to the term [laughter].

>> Hopefully, it wasn't just my pronunciation made you unfamiliar with the term, but if anyone on the panel, or any of the attendees don't know Greg Kratsich, he's a good fellow to get to know. I can tell you that. Greg, we'll follow up with you offline on that, once we've done our research.

>> Well, I think the RCMP is a good group, and I think that's going to be a very successful study. We haven't got to that point yet, but it's very interesting.

>> It's interesting that we're struggling with these issues in every nation. I work with Oscar Kilo [assumed spelling] over in the United Kingdom as well, and they're having the same issues with the UK police departments with stress, and sleep, and so on. Dr. Riedy, I have a question for you. What are the next steps, in terms of biomathematical modeling in law enforcement, and where are the limitations?

>> So as I said during the presentation, these models are widely used in aviation and rail to help develop work/rest schedules that can mitigate fatigue -- to help mitigate fatigue, and they may be used to help identify fatigue countermeasures. We're currently working right now on assessing whether these models that have been largely parameterized and validated in rail and aviation can be used to accurately predict the sleep/wake behaviors, sleepiness, and performance of police officers, so that, if so, they can potentially be used to help improve work/rest schedule in this operation. To do so, we're using data from four large-scale studies conducted in three different countries in a couple different biomathematical models. There are several -- so we're essentially assessing the generalizability, and seeing how they could potentially be used in the future in law enforcement. There are different -- there are some limitations to these models. You know, they're built on principles of the two-process model, where sleep regulation, performance, and sleepiness vary by sleep/wake history, or time awake and time of day. There are some models that can account for caffeine consumption, sleep quality, commute times, and so forth, but there are also a lot of physiological and non-physiological factors that are not accounted for, such as age, sleep disorders, family obligations, and so forth. One important factor is that these -- you know, these models can be used to also increase operational flexibility, versus sticking with the traditional hours of service regulations, but they're best incorporated within a larger fatigue risk management system.

>> I have a quick follow-up to that, Samantha. Is it possible to apply models in kind of a real-time setting? We have -- now, and, you know, is there a possibility for, you know -- like, you're getting to a point where we think your fatigue is too far off the charts, you know, and intervene right there, you know, right then and there, in real time?

>> Yeah, and there are some models that have been incorporated into apps in phones, for example, where you can actually enter your caffeine. You can use it to help predict -- or, to help optimize your sleep/wake schedule, and optimize your caffeine consumption. There are some models that can -- or you can continuously monitor sleep/wake activity, and hopefully use that to see where your performance, or effectiveness, or sleepiness might be at. So I think that's certainly a possibility. It was actually proposed in 1990 -- or it was originally proposed in, like, a 1994 article by Greg Bilanky [assumed spelling], where this idea of taking -- continuously monitoring someone's sleep/wake activity via activity -- running it through a sleep and performance model, continuously getting outputs, and being able to track in real time.

>> And, Jim, I've got a study starting in January that will be looking at something similar with stress response, as well as sleep, with real-time alignment to the CAD RMS data, so we can see the call for service the officer is on right now, and their acute stress response to it. So looking at how that both affects the officers, but also the outcome, and the performance of the officer in that call for service, which is exciting. Another question in the chat -- and we're running a little short on time. We've got about five minutes left. My experience with police officers relates to my work with the WTC cohort, 40% of the cohort, and it occurs to me that our work related to morbidity and mortality, particularly cancer, should be occupational-specific, and seek a comparison outside of New York City. Yeah, it's more of a statement than a question, but I think so. Does any of the panel have any thoughts on that comment?

>> John, you're on mute.

>> Sorry about that, keep shutting that thing off. We are doing a study presently to compare the WTC mortality data with the Buffalo police mortality data, to look at the differences between the prevalence and incidence of cancer. So that's in the works now. We're still working on that.

>> From Vesta [assumed spelling], I think there's a study from Jackson Hearts Study [assumed spelling] that shows high occupational PA being a risk factor for CVD. We'll find the article. I believe we have one of the speakers who was on that study. Am I correct?

>> Yeah, I was. That's probably more recent than when I was there, but yeah, Dusty's [assumed spelling] a collaborator. He's a colleague on the BCOPS study, and so, that's a good comment.

>> Right. We have a couple of minutes left if there's any more final questions from the audience. If not, Todd, are you ready to take control again?

>> Sure. Last call for questions.

>> Well, thank you, everyone, for your engagement. I'm going to hand you back to Todd for some housekeeping on how to get hold of the recording and so on.

>> Okay, so if everyone can see the screen, the speakers would like to acknowledge the BCOPS NIOSH study group themselves, but also some very key folks that helped participate in the BCOPS study that is still ongoing, and these are their names. Also, we would like to provide you a list of key references. Some of them were already mentioned in the previous talks, but here they are. There's the first 10, and then another set of nine. And hopefully, you can look for this webinar. It will be archived on the CDC YouTube channel, hopefully sometime in early 2022. I'm going to try and work with the speakers to see if we can't collect the slides from the slideshow, and create a PDF, and somehow get that posted also, so you can look at those slides at your leisure, or refer back to this archived webinar.

>> I have a question.

>> Sure.

>> How many publications have emanated from the BCOPS study, just out of curiosity?

>> That's a great question.

>> More than 100.

>> Yeah, we calculated -- we added them up at one point for the NIJ, or for that application. It was over 120.

>> Yeah.

>> It's a great return on investment for NIOSH, and --

>> Oh, yeah, yeah.

>> Yep, cost two bucks, and it was a real team effort. A lot of the people you see on those acknowledgments, from Tara Hartley, Desta Fekedulegn, and many others here at NIOSH have worked hard on this study for many, many years. So there's Desta, and Jack, Luanna Charles, Anna, Erin, Kathy. Buzz was the branch chief before I was, and he really kind of spearheaded this with John, and Tara was a real serious player until a few years ago, when she moved up to the OD. Diane Miller was our neuroscience person, and then Penelope Allison is an epidemiologist who's done a lot of work with -- and Brian was with us for a long time, and still continues as a collaborator. So everybody on that list has done a lot of work on all of these papers.

>> Okay, and so, if you are interested in the BCOPS study, maybe getting some more information, maybe some feedback from today's webinar, or just on what the -- NORA is doing to address occupational chronic disease, lots of different types of chronic diseases, that's the e-mail that goes directly to me and Raquel. We monitor that daily. Also, there's the website for the Chronic Disease Cross-Sector for NORA, and I'd like to thank you for your time. Enjoy your weekend and your Thanksgiving break. Thank you all.