Flooding and Emergency Room Visits for Gastrointestinal Illness in Massachusetts: A Case-Crossover Study

Introduction

Floods and other severe weather events are anticipated to increase as a result of global climate change. Floods can lead to outbreaks of gastroenteritis and other infectious diseases due to disruption of sewage and water infrastructure and impacts on sanitation and hygiene. Floods have also been indirectly associated with outbreaks through population displacement and crowding.

Methods

We conducted a case-crossover study to investigate the association between flooding and emergency room visits for gastrointestinal illness (ER-GI) in Massachusetts for the years 2003 through 2007. We obtained ER-GI visits from the State of Massachusetts and records of floods from the National Oceanic and Atmospheric Association’s Storm Events Database. ER-GI visits were considered exposed if a flood occurred in the town of residence within three hazard periods of the visit: 0–4 days; 5–9 days; and 10–14 days. A time-stratified bi-directional design was used for control selection, matching on day of the week with two weeks lead or lag time from the ER-GI visit. Fixed effect logistic regression models were used to estimate the risk of ER-GI visits following the flood.

Results and Conclusions

A total of 270,457 ER-GI visits and 129 floods occurred in Massachusetts over the study period. Across all counties, flooding was associated with an increased risk for ER-GI in the 0–4 day period after flooding (Odds Ratio: 1.08; 95% Confidence Interval: 1.03–1.12); but not the 5–9 days (Odds Ratio: 0.995; 95% Confidence Interval: 0.955–1.04) or the 10–14 days after (Odds Ratio: 0.966, 95% Confidence Interval: 0.927–1.01). Similar results were observed for different definitions of ER-GI. The effect differed across counties, suggesting local differences in the risk and impact of flooding. Statewide, across the study period, an estimated 7% of ER-GI visits in the 0–4 days after a flood event were attributable to flooding.     

Precipitation and Primary Health Care Visits for Gastrointestinal Illness in Gothenburg,Sweden

Background

The river Göta Älv is a source of freshwater for the City of Gothenburg, Sweden, and we recently identified a clear influence of upstream precipitation on concentrations of indicator bacteria in the river water, as well as an association with the daily number of phone calls to the nurse advice line related to acute gastrointestinal illnesses (AGI calls). This study aimed to examine visits to primary health-care centers owing to similar symptoms (AGI visits) in the same area, to explore associations with precipitation, and to compare variability in AGI visits and AGI calls.

Methods

We obtained data covering six years (2007–2012) of daily AGI visits and studied their association with prior precipitation (0–28 days) using a distributed lag nonlinear Poisson regression model, adjusting for seasonal patterns and covariates. In addition, we studied the effects of prolonged wet and dry weather on AGI visits. We analyzed lagged short-term relations between AGI visits and AGI calls, and we studied differences in their seasonal patterns using a binomial regression model.

Results

The study period saw a total of 17,030 AGI visits, and the number of daily visits decreased on days when precipitation occurred. However, prolonged wet weather was associated with an elevated number of AGI visits. Differences in seasonality patterns were observed between AGI visits and AGI calls, as visits were relatively less frequent during winter and relatively more frequent in August, and only weak short-term relations were found.

Conclusion

AGI visits and AGI calls seems to partly reflect different types of AGI illnesses, and the patients’ choice of medical contact (in-person visits versus phone calls) appears to depend on current weather conditions. An association between prolonged wet weather and increased AGI visits supports the hypothesis that the drinking water is related to an increased risk of AGI illnesses.     

School-Located Influenza Vaccination Reduces Community Risk for Influenza and Influenza-Like Illness Emergency Care Visits

Background

School-located influenza vaccination (SLIV) programs can substantially enhance the sub-optimal coverage achieved under existing delivery strategies. Randomized SLIV trials have shown these programs reduce laboratory-confirmed influenza among both vaccinated and unvaccinated children. This work explores the effectiveness of a SLIV program in reducing the community risk of influenza and influenza-like illness (ILI) associated emergency care visits.

Methods

For the 2011/12 and 2012/13 influenza seasons, we estimated age-group specific attack rates (AR) for ILI from routine surveillance and census data. Age-group specific SLIV program effectiveness was estimated as one minus the AR ratio for Alachua County versus two comparison regions: the 12 county region surrounding Alachua County, and all non-Alachua counties in Florida.

Results

Vaccination of ∼50% of 5–17 year-olds in Alachua reduced their risk of ILI-associated visits, compared to the rest of Florida, by 79% (95% confidence interval: 70, 85) in 2011/12 and 71% (63, 77) in 2012/13. The greatest indirect effectiveness was observed among 0–4 year-olds, reducing AR by 89% (84, 93) in 2011/12 and 84% (79, 88) in 2012/13. Among all non-school age residents, the estimated indirect effectiveness was 60% (54, 65) and 36% (31, 41) for 2011/12 and 2012/13. The overall effectiveness among all age-groups was 65% (61, 70) and 46% (42, 50) for 2011/12 and 2012/13.

Conclusion

Wider implementation of SLIV programs can significantly reduce the influenza-associated public health burden in communities.     

The impact of weather on influenza and pneumonia mortality in New York City, 1975-2002: a retrospective study

The substantial winter influenza peak in temperate climates has lead to the hypothesis that cold and/or dry air is a causal factor in influenza variability. We examined the relationship between cold and/or dry air and daily influenza and pneumonia mortality in the cold season in the New York metropolitan area from 1975–2002. We conducted a retrospective study relating daily pneumonia and influenza mortality for New York City and surroundings from 1975–2002 to daily air temperature, dew point temperature (a measure of atmospheric humidity), and daily air mass type. We identified high mortality days and periods and employed temporal smoothers and lags to account for the latency period and the time between infection and death. Unpaired t-tests were used to compare high mortality events to non-events and nonparametric bootstrapped regression analysis was used to examine the characteristics of longer mortality episodes. We found a statistically significant (p = 0.003) association between periods of low dew point temperature and above normal pneumonia and influenza mortality 17 days later. The duration (r = −0.61) and severity (r = −0.56) of high mortality episodes was inversely correlated with morning dew point temperature prior to and during the episodes. Weeks in which moist polar air masses were common (air masses characterized by low dew point temperatures) were likewise followed by above normal mortality 17 days later (p = 0.019). This research supports the contention that cold, dry air may be related to influenza mortality and suggests that warning systems could provide enough lead time to be effective in mitigating the effects.     

The Relationship between Same-Day Access and Continuity in Primary Care and Emergency Department Visits

We examined how emergency department (ED) visits for potentially preventable, mental health, and other diagnoses were related to same-day access and provider continuity in primary care using administrative data from 71,296 patients in 22 VHA clinics over a three-year period. ED visits were categorized as non-emergent; primary care treatable; preventable; not preventable; or mental health-related. We conducted multi-level regression models adjusted for patient and clinic factors. More same-day access significantly predicted fewer non-emergent and primary care treatable ED visits while continuity was not significantly related to any type of ED visit. Neither measure was related to ED visits for mental health problems.     

Emergency Department Non-Urgent Visits and Hospital Readmissions Are Associated with Different Socio-Economic Variables in Italy

Objective

The aim of this paper was to evaluate socio-economic factors associated to poor primary care utilization by studying two specific subjects: the hospital readmission rate, and the use of the Emergency Department (ED) for non-urgent visits.

Methods

The study was carried out by the analysis of administrative database for hospital readmission and with a specific survey for non-urgent ED use.

Results

Among the 416,698 sampled admissions, 6.39% (95% CI, 6.32–6.47) of re-admissions have been registered; the distribution shows a high frequency of events in the age 65–84 years group, and in the intermediate care hospitals (51.97%; 95%CI 51.37–52.57). The regression model has shown the significant role played by age, type of structure (geriatric acute care), and deprivation index of the area of residence on the readmission, however, after adjusting for the intensity of primary care, the role of deprivation was no more significant. Non-urgent ED visits accounted for the 12.10%, (95%CI 9.38–15.27) of the total number of respondents to the questionnaire (N = 504). The likelihood of performing a non-urgent ED visit was higher among patients aged <65 years (OR 3.2, 95%CI 1.3–7.8 p = 0.008), while it was lower among those perceiving as urgent their health problem (OR 0.50, 95%CI 0.30–0.90).

Conclusions

In the Italian context repeated readmissions and ED utilization are linked to different trajectories, besides the increasing age and comorbidity of patients are the factors that are related to repeated admissions, the self-perceived trust in diagnostic technologies is an important risk factor in determining ED visits. Better use of public national health care service is mandatory, since its correct utilization is associated to increasing equity and better health care utilization.     

Discriminatory public policies and the New York City tuberculosis epidemic, 1975-1993

Discriminatory public policies removed over ten percent of the fire companies in New York City from 1972-1975, mainly from poor communities of color with very old multiple-dwellings. Hundreds of thousands of housing units were destroyed between 1972 and 1978. Patterns of housing overcrowding changed rapidly and social networks were broken. Tuberculosis went into obvious epidemic in 1979. The temporal and geographic dynamics of the TB epidemic is described here as are the lessons for Europe with respect to treatment of marginalized populations.     

Weather, Water Quality and Infectious Gastrointestinal Illness in Two Inuit Communities in Nunatsiavut, Canada: Potential Implications for Climate Change

Climate change is expected to cause changes in precipitation quantity, intensity, frequency and duration, which will subsequently alter environmental conditions and might increase the risk of waterborne disease. The objective of this study was to describe the seasonality of and explore associations between weather, water quality and occurrence of infectious gastrointestinal illnesses (IGI) in two communities in Nunatsiavut, Canada. Weather data were obtained from meteorological stations in Nain (2005–2008) and Rigolet (2008). Free-chlorine residual levels in drinking water were extracted from municipal records (2005–2008). Raw surface water was tested weekly for total coliform and E. coli counts. Daily counts of IGI-related clinic visits were obtained from health clinic registries (2005–2008). Analysis of weather and health variables included seasonal-trend decomposition procedures based on Loess. Multivariable zero-inflated Poisson regression was used to examine potential associations between weather events (considering 0–4 week lag periods) and IGI-related clinic visits. In Nain, water volume input (rainfall + snowmelt) peaked in spring and summer and was positively associated with levels of raw water bacteriological variables. The number of IGI-related clinic visits peaked in the summer and fall months. Significant positive associations were observed between high levels of water volume input 2 and 4 weeks prior, and IGI-related clinic visits (P < 0.05). This study is the first to systematically gather, analyse and compare baseline data on weather, water quality and health in Nunatsiavut, and illustrates the need for high quality temporal baseline information to allow for detection of future impacts of climate change on regional Inuit human and environmental health.     

宁波市2002-2009年O～14岁儿童伤害死亡流行病学分析

目的 了解宁波市0～14岁儿童伤害死亡的流行病学特征,为开展儿童伤害的预防工作提供科学依据.方法 利用描述性流行病学的方法对宁波市2002-2009年死亡登记资料进行统计分析.结果 2002-2009年宁波市0～14岁儿童伤害死亡率为21.10/10万,占儿童死亡的31.59％,其中伤害占婴儿死亡的8.27％.农村儿童伤害死亡率(24.05/10万)高于城市儿童(15.89/10万),男童伤害死亡率(27.90/10万)高于女童(14.18/10万),儿童伤害死亡率随着年龄的增加呈下降趋势(P＜0.05).意外机械性窒息是婴儿死亡的首位原因,占婴儿伤害死亡的46.20％.淹溺和机动车辆交通事故是1～14岁儿童伤害死亡的前2位原因,所占比例分别为59.30％和19.23％.儿童伤害YPLL标化率为79.91‰.结论 伤害已成为宁波市0～14岁儿童死亡的首位原因,尤其是淹溺、机动车辆交通事故对儿童的生命健康危害更大,亟待开展预防控制工作.     

Regional Distribution of Longevity Population and Elements in Drinking Water in Jiangjin District,Chongqing City,China

This study was carried out to determine the protective effects of lithium borate (LTB) on blood parameters and histopathological findings in experimentally induced acute cadmium (Cd) toxicity in rats. Twenty-eight male Wistar albino rats were used, weighing 200–220 g, and they were randomly divided into four groups, including one control and the following three experimental groups: a Cd group (0.025 mmol/kg), a LTB group (15 mg/kg/day orally for 5 days), and a LTB + Cd group (15 mg/kg/day orally for 5 days and Cd 0.025 mmol/kg by intraperitoneal injection on the fifth day). All the rats in the study were anesthetized with ketamine at the end of the sixth day, blood was taken from their hearts, and then the rats were decapitated. The values in the control and LTB group were usually close to each other. White blood cell (WBC), neutrophil %, and C-reactive protein (CRP) levels increased in the Cd and LTB + Cd groups while lymphocyte and monocyte levels decreased in a statistically significant manner, in comparison to the other groups. It was determined that the levels of red blood cells (RBCs), hematocrit (Htc), and hemoglobin (Hb) did not change in the groups. The levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) in the Cd and LTB + Cd groups significantly increased, in comparison to the other groups, while the glucose, alkaline phosphatase (ALP), albumin (ALB), and total protein (TP) levels decreased. According to histopathological findings in the control and LTB groups, the liver and kidney tissues were found to have normal histological structures. In the Cd group, severe necrotic hemorrhagic hepatitis, mild steatosis, and mononuclear cell infiltration were detected in the liver. In the LTB + Cd group, degeneration and mild mononuclear cell infiltration were found in the liver. Regarding the kidney tissue in the Cd group, severe intertubular hyperemia in both kidney cortex and medulla, as well as degeneration and necrosis in the tubulus epithelium, was observed. In the LTB + Cd group, mild interstitial hyperemia and mononuclear cell infiltration was detected. Resultantly, it can be said that LTB at this dose has non-toxic effects and some beneficial effects for liver and kidney damage caused by acute Cd toxicity.     

Associations between Self-Reported Gastrointestinal Illness and Water System Characteristics in Community Water Supplies in Rural Alabama: A Cross-Sectional Study

Background

Community water supplies in underserved areas of the United States may be associated with increased microbiological contamination and risk of gastrointestinal disease. Microbial and health risks affecting such systems have not been systematically characterized outside outbreak investigations. The objective of the study was to evaluate associations between self-reported gastrointestinal illnesses (GII) and household-level water supply characteristics.

Methods

We conducted a cross-sectional study of water quality, water supply characteristics, and GII in 906 households served by 14 small and medium-sized community water supplies in Alabama’s underserved Black Belt region.

Results

We identified associations between respondent-reported water supply interruption and any symptoms of GII (adjusted odds ratio (aOR): 3.01, 95% confidence interval (CI) = 1.65–5.49), as well as low water pressure and any symptoms of GII (aOR: 4.51, 95% CI = 2.55–7.97). We also identified associations between measured water quality such as lack of total chlorine and any symptoms of GII (aOR: 5.73, 95% CI = 1.09–30.1), and detection of E. coli in water samples and increased reports of vomiting (aOR: 5.01, 95% CI = 1.62–15.52) or diarrhea (aOR: 7.75, 95% CI = 2.06–29.15).

Conclusions

Increased self-reported GII was associated with key water system characteristics as measured at the point of sampling in a cross-sectional study of small and medium water systems in rural Alabama in 2012 suggesting that these water supplies can contribute to endemic gastro-intestinal disease risks. Future studies should focus on further characterizing and managing microbial risks in systems facing similar challenges.     

Drugs, sex and HIV: a mathematical model for New York City.

A data-based mathematical model was formulated to assess the epidemiological consequences of heterosexual, intravenous drug use (IVDU) and perinatal transmission in New York City (NYC). The model was analysed to clarify the relationship between heterosexual and IVDU transmission and to provide qualitative and quantitative insights into the HIV epidemic in NYC. The results demonstrated the significance of the dynamic interaction of heterosexual and IVDU transmission. Scenario analysis of the model was used to suggest a new explanation for the stabilization of the seroprevalence level that has been observed in the NYC IVDU community; the proposed explanation does not rely upon any IVDU or sexual behavioural changes. Gender-specific risks of heterosexual transmission in IVDUs were also explored by scenario analysis. The results showed that the effect of the heterosexual transmission risk factor on increasing the risk of HIV infection depends upon the level of IVDU. The model was used to predict future numbers of adult and pediatric AIDS cases; a sensitivity analysis of the model showed that the confidence intervals on these prediction estimates were extremely wide. This prediction variability was due to the uncertainty in estimating the values of the models' thirty variables (twenty biological-behavioural transmission parameters and the initial sizes of ten subgroups). However, the sensitivity analysis revealed that only a few key variables were significant in contributing to the AIDS case prediction variability; partial rank correlation coefficients were calculated and used to identify and to rank the importance of these key variables. The results suggest that long-term precise estimates of the future number of AIDS cases will only be possible once the values of these key variables have been evaluated accurately.     

The Impact of Heat on an Emergency Department in Italy: Attributable Visits among Children,Adults, and the Elderly during the Warm Season

Introduction

Recent studies suggest that heat is associated with an increase in the number of ambulance calls and emergency department visits. We investigated the association between heat and daily number of emergency department visits at the University Hospital of Verona during the warm seasons 2011–2012 and we assessed the magnitude of the impact in terms of attributable events, focusing on the role of age and triage codification.

Materials and methods

We used a Poisson model to analyse the association between daily number of visits and daily mean apparent temperature, accounting for air pollution level and seasonality. The analyses were stratified by age group and were performed both on the total number of emergency department visits and on the subsample of high-priority visits. Impact estimates were obtained only for this subsample, using a Monte Carlo approach to account for sampling variability. Number of attributable events and attributable community rate were calculated.

Results

We found a positive and immediate association between event occurrence and mean apparent temperatures exceeding a threshold located around 28–29°C. The estimated percent change in the total number of visits per 1°C increase of exposure above the threshold was equal to 3.75 (90% CI: 3.01; 4.49). Focusing only on high-priority visits, the estimated percent change was larger and the greatest effect was among children. We estimated that apparent temperatures above the threshold were responsible for 1177 high-priority visits during the study period. Due to the record high temperatures observed in 2012 in Italy and in Europe, the impact in 2012 was much larger than in 2011, and consisted in 34 high-priority visits every 10000 children, 30 every 10000 people aged 15–64, and 38 every 10000 people aged 65 and over.

Discussion

Our results indicate that heat affects not only the elderly, but also children and non-elderly adults, stressing the need for developing public health preparedness plans for the entire community.     

Drinking Water Quality in a Mexico City University Community: Perception and Preferences

EcoHealth - A transversal study was conducted at the University City campus of the National Autonomous University of Mexico (UNAM) in Mexico City, with the goal of estimating the university...     

Differential mortality by ethnicity and nativity: foreign- and native-born Irish, Italians, and Jews in New York City, 1979-1981

This paper compares the mortality experience of foreign- and native-born Irish, Italians, and Jews in New York City in 1979-81. In most cases, denominator data were not available, so proportional mortality analysis was used. An estimation procedure was undertaken to show the degree to which standardized proportional mortality ratios approximate relative standardized mortality measures. Major and lifestyle-related causes of death were examined, as were specific sites of cancer. While no consistent pattern merged which related nativity or ethnicity to the relative distribution of mortality, it does appear that the intra-ethnic patterns of the Irish group were unique relative to those of the Italian and Jewish groups. Overall, this study suggests a number of interesting relationships between ethnicity, nativity, and the distribution of mortality by cause.