Effectiveness of a custom-fitted flange and local exhaust ventilation (LEV) system in controlling the release of nanoscale metal oxide particulates during reactor cleanout operations

As the nanotechnology industry expands, facilities engaged in the production and use of engineered nanoscale materials (ENMs) are challenged with determining whether their processes pose a risk for worker inhalation exposure. Although there are neither regulatory exposure limits specific to ENMs nor validated measurement standards for nanomaterials in the workplace, many facilities opt to be proactive in managing uncharacterized ENMs by reducing or eliminating the potential for exposure by controlling their release into the workplace atmosphere. A field study was conducted to evaluate the effectiveness of a portable, HEPA-filtered, local exhaust ventilation system equipped with a custom-fitted flange for controlling the emission of engineered nanoscale metal oxide particulates during reactor cleanout operations. On the basis of the findings of this study, it appears that a properly designed LEV system, coupled with good work practices can be highly effective in controlling nanoscale material emissions during processes of this type.     

Characterizing workforces exposed to current and emerging non-carbonaceous nanomaterials in the U.S.

Objective: Toxicology studies suggest that exposure to certain types of engineered nanomaterials (ENMs) may cause adverse health effects, but little is known about the workforce in the United States that produces or uses these materials. In addition, occupational exposure control strategies in this industry are not well characterized. This study identified U.S. ENM manufacturers and users (other than carbon nanotubes and nanofibers, which have been characterized elsewhere), determined workforce size, characterized types and quantities of materials used, occupational exposure control strategies, and the feasibility of occupational ENM exposure studies.

Methods: Eligible companies were identified and information was collected through phone surveys on nanomaterials produced or used, workforce size, location, work practices, and exposure control strategies. The companies were classified into groups for additional examinations.

Results: Forty-nine companies producing or using ENMs in the U.S. were identified. These companies employed at least 1,500 workers. Most companies produced or used some form of nanoscale metal. More than half of the eligible companies were suppliers for the coatings, composite materials, or general industries. Each company provided information about worker exposure reduction strategies through engineering controls, administrative controls, or personal protective equipment. Production-scale companies reported greater use of specific exposure control strategies for ENMs than laboratory-scale companies.

Conclusions: Workplaces producing or using ENMs report using engineering and administrative controls as well as personal protective equipment to control worker exposure. Industrywide exposure assessment studies appear feasible due to workforce size. However, more effort must be taken to target industries using specific ENMs based on known toxicological effects and health risks.     

Nano-metal oxides: Exposure and engineering control assessment

In January 2007, the National Institute for Occupational Safety and Health (NIOSH) conducted a field study to evaluate process specific emissions during the production of ENMs. This study was performed using the nanoparticle emission assessment technique (NEAT). During this study, it was determined that ENMs were released during production and cleaning of the process reactor. Airborne concentrations of silver, nickel, and iron were found both in the employee's personal breathing zone and area samples during reactor cleaning. At the completion of this initial survey, it was suggested that a flanged attachment be added to the local exhaust ventilation system.

?NIOSH re-evaluated the facility in December 2011 to assess worker exposures following an increase in production rates. This study included a fully comprehensive emissions, exposure, and engineering control evaluation of the entire process. This study made use of the nanoparticle exposure assessment technique (NEAT 2.0). Data obtained from filter-based samples and direct reading instruments indicate that reactor cleanout increased the overall particle concentration in the immediate area. However, it does not appear that these concentrations affect areas outside of the production floor. As the distance between the reactor and the sample location increased, the observed particle number concentration decreased, creating a concentration gradient with respect to the reactor. The results of this study confirm that the flanged attachment on the local exhaust ventilation system served to decrease exposure potential.

?Given the available toxicological data of the metals evaluated, caution is warranted. One should always keep in mind that occupational exposure levels were not developed specifically for nanoscale particles. With data suggesting that certain nanoparticles may be more toxic than the larger counterparts of the same material; employers should attempt to control emissions of these particles at the source, to limit the potential for exposure.     

Workplace Interventions and Vaccination-Related Attitudes Associated With Influenza Vaccination Coverage Among Healthcare Personnel Working in Long-Term Care Facilities, 2015‒2016 Influenza Season

ObjectivesInfluenza vaccination of healthcare personnel working in long-term care (LTC) facilities can reduce influenza-related morbidity and mortality among healthcare personnel and among resident populations who are at increased risk for complications from influenza and who may respond poorly to vaccination. The objective of this study was to investigate workplace interventions and healthcare personnel vaccination-related attitudes associated with higher influenza vaccination coverage among healthcare personnel working in LTC facilities.Setting and participantsData were obtained from an online survey of healthcare personnel conducted in April 2016 among a nonprobability sample of 2258 healthcare personnel recruited from 2 preexisting national opt-in Internet panels. Respondents were asked about influenza vaccination status, workplace vaccination policies and interventions, and their attitudes toward vaccination. Analyses were restricted to the 332 healthcare personnel who worked in nursing homes, assisted living facilities, or other LTC facilities.MeasuresLogistic regression models were used to assess the independent associations between each workplace intervention and higher influenza vaccination coverage compared with referent levels, controlling for occupation, age, and race/ethnicity. Prevalence ratios were calculated under the assumption of simple random sampling.ResultsApproximately 77% of healthcare personnel working in LTC facilities reported receiving influenza vaccination in the 2015?2016 influenza season. Influenza vaccination was independently associated with an employer vaccination requirement (prevalence ratio (PR) [95% confidence interval] = 1.28 [1.11, 1.47]), being offered free onsite vaccination (PR = 1.20 [1.04, 1.39]), and employers publicizing vaccination coverage level to employees (PR = 1.24 [1.09, 1.41]). Vaccination was most highly associated with a combination of 3 or more workplace interventions. Most healthcare personnel working in LTC facilities reported positive attitudes toward the safety and effectiveness of influenza vaccination.Conclusions/ImplicationsImplementing employer vaccination interventions in LTC facilities, including employer vaccination requirements and free on-site influenza vaccination that is actively promoted, could increase influenza vaccination among healthcare personnel.     

ONE Nano: NIEHS’s Strategic Initiative on the Health and Safety Effects of Engineered Nanomaterials

Background: The past decade has seen tremendous expansion in the production and application of engineered nanomaterials (ENMs). The unique properties that make ENMs useful in the marketplace also make their interactions with biological systems difficult to anticipate and critically important to explore. Currently, little is known about the health effects of human exposure to these materials.Objectives: As part of its role in supporting the National Nanotechnology Initiative, the National Institute of Environmental Health Sciences (NIEHS) has developed an integrated, strategic research program—“ONE Nano”—to increase our fundamental understanding of how ENMs interact with living systems, to develop predictive models for quantifying ENM exposure and assessing ENM health impacts, and to guide the design of second-generation ENMs to minimize adverse health effects.Discussion: The NIEHS’s research investments in ENM health and safety include extramural grants and grantee consortia, intramural research activities, and toxicological studies being conducted by the National Toxicology Program (NTP). These efforts have enhanced collaboration within the nanotechnology research community and produced toxicological profiles for selected ENMs, as well as improved methods and protocols for conducting in vitro and in vivo studies to assess ENM health effects.Conclusion: By drawing upon the strengths of the NIEHS’s intramural, extramural, and NTP programs and establishing productive partnerships with other institutes and agencies across the federal government, the NIEHS’s strategic ONE Nano program is working toward new advances to improve our understanding of the health impacts of engineered nanomaterials and support the goals of the National Nanotechnology Initiative.     

中国城市地区成年人二手烟暴露水平及相关知识和态度调查

目的 了解中国城市地区成年人二手烟暴露水平及其相关知识态度.方法 利用全球成人烟草调查中国调查(GATS)、国际烟草控制政策评估项目中国调查(ITC)中有关二手烟暴露、禁烟规定、二手烟相关知识态度的变量,使用SAS软件计算率及其95％CI.结果 2项调查中调查对象报告的工作场所室内全面禁烟的比例均低于40％.调查对象报告在餐厅看到吸烟现象比例在各类场所中最高(83.4％ ～ 95.6％),其次为工作场所(53.3％ ～ 84.0％),在医疗卫生机构、学校、公共交通工具看到吸烟现象的比例较低.GATS调查中60.6％的吸烟者和68.5％的非吸烟者知晓二手烟导致肺癌,但只有三分之一的调查对象知晓二手烟导致成年人心脏病.ITC调查对象对二手烟危害的知晓率高于GATS,但知晓二手烟导致成年人心脏病的比例仅有58.2％.ITC调查对象对学校、出租车、医院、政府机构全面禁烟的支持率较高(＞70％),但对工作场所全面禁烟的支持率仅有50.9％和60.9％.结论 中国城市地区室内工作场所全面禁烟的比例较低,二手烟暴露情况严重,公众对二手烟危害的认识以及对工作场所全面禁烟的支持率有待提高.     

Ecotoxicity test methods for engineered nanomaterials: practical experiences and recommendations from the bench

Ecotoxicology research is using many methods for engineered nanomaterials (ENMs), but the collective experience from researchers has not been documented. This paper reports the practical issues for working with ENMs and suggests nano-specific modifications to protocols. The review considers generic practical issues, as well as specific issues for aquatic tests, marine grazers, soil organisms, and bioaccumulation studies. Current procedures for cleaning glassware are adequate, but electrodes are problematic. The maintenance of exposure concentration is challenging, but can be achieved with some ENMs. The need to characterize the media during experiments is identified, but rapid analytical methods are not available to do this. The use of sonication and natural/synthetic dispersants are discussed. Nano-specific biological endpoints may be developed for a tiered monitoring scheme to diagnose ENM exposure or effect. A case study of the algal growth test highlights many small deviations in current regulatory test protocols that are allowed (shaking, lighting, mixing methods), but these should be standardized for ENMs. Invertebrate (Daphnia) tests should account for mechanical toxicity of ENMs. Fish tests should consider semistatic exposure to minimize wastewater and animal husbandry. The inclusion of a benthic test is recommended for the base set of ecotoxicity tests with ENMs. The sensitivity of soil tests needs to be increased for ENMs and shortened for logistics reasons; improvements include using Caenorhabditis elegans, aquatic media, and metabolism endpoints in the plant growth tests. The existing bioaccumulation tests are conceptually flawed and require considerable modification, or a new test, to work for ENMs. Overall, most methodologies need some amendments, and recommendations are made to assist researchers.     

Understanding Workplace Processes and Factors that Influence Exposures to Engineered Nanomaterials

Abstract

There is a critical need to understand the factors that influence engineered nanomaterial (ENM) exposures in the workplace. Such an understanding would aid in: identifying and prioritizing control measures; targeting future exposure measurements; and predicting worker exposures for work scenarios. This information could also be used in epidemiological studies. We propose a multitiered model in which information on exposure factors can be obtained at the macrolevel (examining differences in exposures between different ENM sectors or product types); the midlevel (examining differences in exposures between workplaces within the same ENM sector or product type); and the microlevel (examining differences in exposure between tasks or between ENM types during the same task). Further, within the microlevel, potential exposure factors are defined by a source-receptor model. We recommend that auxiliary data be collected systematically, along with exposure measurements, to enable analysis of exposure factors as well as the pooling of data across studies.     

Exposure characterization of metal oxide nanoparticles in the workplace

This study presents exposure data for various metal oxides in facilities that produce or use nanoscale metal oxides. Exposure assessment surveys were conducted at seven facilities encompassing small, medium, and large manufacturers and end users of nanoscale (particles <0.1 μm diameter) metal oxides, including the oxides of titanium, magnesium, yttrium, aluminum, calcium, and iron. Half- and full-shift sampling consisting of various direct-reading and mass-based area and personal aerosol sampling was employed to measure exposure for various tasks. Workers in large facilities performing handling tasks had the highest mass concentrations for all analytes. However, higher mass concentrations occurred in medium facilities and during production for all analytes in area samples. Medium-sized facilities had higher particle number concentrations in the air, followed by small facilities for all particle sizes measured. Production processes generally had the highest particle number concentrations, particularly for the smaller particles. Similar to particle number, the medium-sized facilities and production process had the highest particle surface area concentration. TEM analysis confirmed the presence of the specific metal oxides particles of interest, and the majority of the particles were agglomerated, with the predominant particle size being between 0.1 and 1 μm. The greatest potential for exposure to workers occurred during the handling process. However, the exposure is occurring at levels that are well below established and proposed limits.     

Effects of occupational exposure to polychlorinated biphenyls on urinary metabolites of neurotransmitters: A cross-sectional and longitudinal perspective

BackgroundPolychlorinated biphenyls (PCBs) are chemicals which were used for industrial purposes and are known to induce various adverse health effects. They are also known to be neurotoxic and numerous targets within the central nervous system have been identified in previous studies. Specifically, the neurotransmitters dopamine (DA) and norepinephrine (NE) are influenced by PCBs as indicated in studies involving animals. However, limited evidence has been published documenting PCB induced changes in the neurotransmitter system in humans.ObjectiveIn the present study, we examined the association between a higher PCB body burden following occupational exposure and possible changes in human neurotransmitter metabolites.MethodsWithin a medical surveillance programme called HELPcB (Health Effects in High-Level Exposure to PCB) that monitors adverse health effects of occupational PCB exposure, urine samples were obtained (n_T1 = 166; n_T2 = 177 and n_T3 = 141). The urinary concentrations of the metabolites homovanillic acid (HVA; for DA) and vanillylmandelic acid (VMA; for NE) were analyzed. Blood samples were obtained by vena puncture in order to determine the internal exposure to PCBs with human biomonitoring.ResultsA cross-sectional analysis indicated a significant negative effect of PCB exposure on HVA and VMA. Longitudinally, an initially higher exposure to higher chlorinated PCBs was followed by constant reduced HVA level over three consecutive years. Exploratory analyses show different long-term effects for different PCBs according to their chlorination degree. A higher exposure with lower chlorinated PCBs leads to an increase of VMA and HVA. Conversely, a higher exposure to all PCBs results in a reduction of HVA.ConclusionThis study, to our knowledge, is the first to document changes in neurotransmitter metabolites after occupational PCB exposure in humans. This finding advances evidence obtained from past research, and identifies one potential pathomechanism in the central dopaminergic system of humans.     

Engineered nanomaterials: exposures, hazards, and risk prevention

Nanotechnology presents the possibility of revolutionizing many aspects of our lives. People in many settings (academic, small and large industrial, and the general public in industrialized nations) are either developing or using engineered nanomaterials (ENMs) or ENM-containing products. However, our understanding of the occupational, health and safety aspects of ENMs is still in its formative stage. A survey of the literature indicates the available information is incomplete, many of the early findings have not been independently verified, and some may have been over-interpreted. This review describes ENMs briefly, their application, the ENM workforce, the major routes of human exposure, some examples of uptake and adverse effects, what little has been reported on occupational exposure assessment, and approaches to minimize exposure and health hazards. These latter approaches include engineering controls such as fume hoods and personal protective equipment. Results showing the effectiveness - or lack thereof - of some of these controls are also included. This review is presented in the context of the Risk Assessment/Risk Management framework, as a paradigm to systematically work through issues regarding human health hazards of ENMs. Examples are discussed of current knowledge of nanoscale materials for each component of the Risk Assessment/Risk Management framework. Given the notable lack of information, current recommendations to minimize exposure and hazards are largely based on common sense, knowledge by analogy to ultrafine material toxicity, and general health and safety recommendations. This review may serve as an overview for health and safety personnel, management, and ENM workers to establish and maintain a safe work environment. Small start-up companies and research institutions with limited personnel or expertise in nanotechnology health and safety issues may find this review particularly useful.     

Refinement of the Nanoparticle Emission Assessment Technique into the Nanomaterial Exposure Assessment Technique (NEAT 2.0)

Engineered nanomaterial emission and exposure characterization studies have been completed at more than 60 different facilities by the National Institute for Occupational Safety and Health (NIOSH). These experiences have provided NIOSH the opportunity to refine an earlier published technique, the Nanoparticle Emission Assessment Technique (NEAT 1.0), into a more comprehensive technique for assessing worker and workplace exposures to engineered nanomaterials. This change is reflected in the new name Nanomaterial Exposure Assessment Technique (NEAT 2.0) which distinguishes it from NEAT 1.0. NEAT 2.0 places a stronger emphasis on time-integrated, filter-based sampling (i.e., elemental mass analysis and particle morphology) in the worker's breathing zone (full shift and task specific) and area samples to develop job exposure matrices. NEAT 2.0 includes a comprehensive assessment of emissions at processes and job tasks, using direct-reading instruments (i.e., particle counters) in data-logging mode to better understand peak emission periods. Evaluation of worker practices, ventilation efficacy, and other engineering exposure control systems and risk management strategies serve to allow for a comprehensive exposure assessment.     

Cutaneous exposure scenarios for engineered nanoparticles used in semiconductor fabrication: a preliminary investigation of workplace surface contamination

Background:

Numerous studies are ongoing in the fields of nanotoxicology and exposure science; however, gaps remain in identifying and evaluating potential exposures from skin contact with engineered nanoparticles in occupational settings.

Objectives:

The aim of this study was to identify potential cutaneous exposure scenarios at a workplace using engineered nanoparticles (alumina, ceria, amorphous silica) and evaluate the presence of these materials on workplace surfaces.

Methods:

Process review, workplace observations, and preliminary surface sampling were conducted using microvacuum and wipe sample collection methods and transmission electron microscopy with elemental analysis.

Results:

Exposure scenarios were identified with potential for incidental contact. Nanoparticles of silica or silica and/or alumina agglomerates (or aggregates) were identified in surface samples from work areas where engineered nanoparticles were used or handled.

Conclusions:

Additional data are needed to evaluate occupational exposures from skin contact with engineered nanoparticles; precautionary measures should be used to minimize potential cutaneous exposures in the workplace.     

Occupational health hazards among health care personnel working in public health facilities in Bhubaneswar,India

Background

Health care personnel working in public health facilities comprise a major part of the health care workforce in India and are exposed to a variety of workplace hazards.

Aim

To assess the occupational health hazards and associated risk factors among health care personnel working in public health facilities in Bhubaneswar.

Subject and methods

A cross-sectional study was conducted involving 172 health care personnel working in 22 urban primary health centers and four community health centers in the Bhubaneswar Block of the Khordha district in the state of Odisha, during the period from January to December 2017. Relevant data were collected using a semi-structured interview schedule.

Results

Overall, 143 (83.1%) of the participants reported experiencing occupational health hazards, with 89 (51.7%) encountering biological hazards and 130 (75.6%) experiencing non-biological hazards. Stress (38.9%), assault (38.4%), needlestick injury (34.3%), and direct contact with contaminated specimens/body fluids (32.6%) were the most frequently experienced occupational hazards. Multivariate regression analysis revealed that female gender, health care personnel other than doctors, working overtime, dissatisfaction with workplace atmosphere, and not using the necessary personal protective equipment (PPE) were independent predictors for experiencing a biological hazard. Similarly, female gender, presence of family conflict, and not using the required PPE were found to be independent predictors for experiencing non-biological hazards.

Conclusion

Health care personnel in public health facilities experience multiple hazards in their workplaces. Results indicate the need for designing and implementing strategies to promote the occupational health of this important section of society.

     

Predicting and classifyng hearing loss in sailors working on speed vessels using neural networks: a field study

Background: Noise-induced hearing loss (NIHL) is one of the main risk factors affecting people''s health and wellbe-ing in the workplace. Analysing NIHL and consequently controlling the causing factors can significantly affect the improvement of working environments. Methods: One hundred and twelve male sailors participated in this study. They were classified into three groups depending on occupational noise exposure: (A) none, i.e., sound pressure level (SPL) lower than 70dBA, (B) exposed to SPL in the range of70-85dBA, and (C) exposed to SPL exceeding 80dBA. In a first phase, hearing loss shaping risk factors were identified and analysed, including hearing loss in different frequencies, age, work experience, sound pressure level (SPL), marital status, and systolic and diastolic blood pressure. Then, neural networks were trained to predict the hearing loss changes of personnel and used to determine the weight ofhearing loss factors. Finally, the accuracy of predicting models was calculated relying on Bayesian statistics. Results and conclusion: In the present study using neural networks, five models were developed. Their accuracy ranged from 92% to 100%. The frequencies of4000Hz and 2000Hz showed the strongest association with the hearing loss of the sailors. Also, including systolic and diastolic blood pressure did not have any impact on predicted hearing loss, indicating that SPL was poorly correlated with extra-auditory effects.     

Urinary Hexane Diamine to Assess Respiratory Exposure to Hexamethylene Diisocyanate Aerosol: A Human Inhalation Study

Abstract

The use of urinary hexane diamine (HDA) as a biomarker to assess human respiratory exposure to hexamethylene diisocyanate (HDI) aerosol was evaluated. Twenty-three auto body shop workers were exposed to HDI biuret aerosol for two hours using a closed exposure apparatus. HDI exposures were quantified using both a direct-reading instrument and a treated-filter method. Urine samples collected at baseline, immediately post exposure, and every four to five hours for up to 20 hours were analyzed for HDA using gas chromatography and mass spectrometry. Mean urinary HDA (μg/ g creatinine) sharply increased from the baseline value of 0.7 to 18.1 immediately post exposure and decreased rapidly to 4.7, 1.9 and 1.1, respectively, at 4,9, and 18 hours post exposure. Considerable individual variability was found. Urinary HDA can assess acute respiratory exposure to HDI aerosol, but may have limited use as a biomarker of exposure in the workplace.     

A Review of Selected Engineered Nanoparticles in the Atmosphere: Sources,Transformations, and Techniques for Sampling and Analysis

Abstract

A state-of-the-science review was undertaken to identify and assess sampling and analysis methods to detect and quantify selected nanomaterials (NMs) in the ambient atmosphere. The review is restricted to five types of NMs of interest to the Office of Research and Development Nanomaterial Research Strategy (US Environmental Protection Agency): cerium oxide, titanium dioxide, carbon nanostructures (carbon nanotubes and fullerenes), zero-valent iron, and silver nanoparticles. One purpose was determining the extent to which present-day ultrafine sampling and analysis methods may be sufficient for identifying and possibly quantifying engineered NMs (ENMs) in ambient air. Conventional sampling methods for ultrafines appear to require modifications. For cerium and titanium, background levels from natural sources make measurement of ENMs difficult to quantify. In cases where field studies have been performed, identification from bulk analysis samples have been made. Further development of methods is needed to identify these NMs, especially in specific size fractions of ambient aerosols.     

A follow-up study on occupational exposure to inhaled anaesthetics in Eastern European surgeons and circulating nurses

Objective: Although no dose-response relationship exists for the health risks associated with the occupational exposure to inhaled anaesthetics, public health authorities recommend threshold values. The aim of the present study was to assess whether and to what extent these threshold values are exceeded in surgeons and circulating nurses of an Eastern European university hospital, before and after measures had been taken to reduce occupational exposure. Methods: At nine workplaces, occupational exposure to nitrous oxide and the volatile anaesthetic used (halothane or isoflurane) was measured within the breathing zones of surgeons and circulating nurses by means of photoacoustic infrared spectrometry. The measurements were carried out in 1996 and were repeated in 1997 after the installation of active scavenging devices at five workplaces, and an air-conditioning system at one workplace. Results: Occupational exposure to nitrous oxide and halothane or isoflurane was lower in 1997 compared with that of 1996. In 1996, 89% of the nitrous oxide values were above the European threshold value of 100 ppm, whereas in 1997 approximately 50% were above this limit. In 1996 the majority of the measurements for the volatile anaesthetics were already below 5 ppm halothane and 10 ppm isoflurane and the number of measurements exceeding these limits was further reduced in 1997. Conclusion: The measures taken were effective in reducing waste gas exposure. Nevertheless, further efforts are necessary, especially for nitrous oxide, to reach Western European standards and to minimise possible health risks. These efforts comprise the installation of (active) scavenging devices, air-conditioning systems and new anaesthesia machines at all workplaces, the use of low-flow anaesthesia, the replacement of inhaled anaesthetics by intravenous anaesthetics and an appropriate working technique. Received: 27 April 2000 / Accepted: 26 July 2000     

Secondary Measures of Access to Abortion Services in the United States, 2011 and 2012: Gestational Age Limits,Cost, and Harassment

BackgroundAspects of U.S. clinical abortion service provision such as gestational age limits, charges for abortion services, and anti-abortion harassment can impact the accessibility of abortion; this study documents changes in these measures between 2008 and 2012.MethodsIn 2012 and 2013, we surveyed all known abortion-providing facilities in the United States (n = 1,720). This study summarizes information obtained about gestational age limits, charges, and exposure to anti-abortion harassment among clinics; response rates for relevant items ranged from 54% (gestational limits) to 80% (exposure to harassment). Weights were constructed to compensate for nonresponding facilities. We also examine the distribution of abortions and abortion facilities by region.FindingsAlmost all abortion facilities (95%) offered abortions at 8 weeks’ gestation; 72% did so at 12 weeks, 34% at 20 weeks, and 16% at 24 weeks in 2012. In 2011 and 2012, the median charge for a surgical abortion at 10 weeks gestation was $495, and $500 for an early medication abortion, compared with $503 and $524 (adjusted for inflation) in 2009. In 2011, 84% of clinics experienced at least one form of harassment, only slightly higher than found in 2009. Hospitals and physicians' offices accounted for a substantially smaller proportion of facilities in the Midwest and South. Clinics in the Midwest and South were exposed to more harassment than their counterparts in the Northeast and West.ConclusionsAlthough there was a substantial decline in abortion incidence between 2008 and 2011, the secondary measures of abortion access examined in this study changed little during this time period.