Electric vehicles and health: A scoping review.

BACKGROUND: The health impacts of the rapid transition to the use of electric vehicles are largely unexplored. We completed a scoping review to assess the state of the evidence on use of battery electric and hybrid electric vehicles and health. METHODS: We conducted a literature search of MEDLINE, Embase, Global Health, CINAHL, Scopus, and Environmental Science Collection databases for articles published January 1990 to January 2024. We included articles if they presented observed or modeled data on the association between battery electric or hybrid electric cars, trucks, or buses and health-related outcomes. We abstracted data and summarized results. RESULTS: Out of 897 reviewed articles, 52 met our inclusion criteria. The majority of included articles examined transitions to the use of electric vehicles (n = 49, 94%), with fewer studies examining hybrid electric vehicles (n = 11, 21%) or plug-in hybrid electric vehicles (n = 8, 15%). The most common outcomes examined were premature death (n = 41, 79%) and monetized health outcomes such as medical expenditures (n = 33, 63%). We identified only one observational study on the impact of electric vehicles on health; all other studies reported modeled data. Almost every study (n = 51, 98%) reported some evidence of a positive health impact of transitioning to electric or hybrid electric vehicles, although magnitudes of association varied. There was a paucity of information on the environmental justice implications of vehicle transitions. CONCLUSIONS: The results of the current literature on electric vehicles and health suggest an overall positive health impact of transitioning to electric vehicles. Additional observational studies would help expand our understanding of the real-world health effects of electric vehicles. Future research focused on the environmental justice implications of vehicle fleet transitions could provide additional information about the extent to which the health benefits occur equitably across populations.

Asthma-Associated Emergency Department Visits During the Canadian Wildfire Smoke Episodes - United States, April- August 2023.

During April 30-August 4, 2023, smoke originating from wildfires in Canada affected most of the contiguous United States. CDC used National Syndromic Surveillance Program data to assess numbers and percentages of asthma-associated emergency department (ED) visits on days with wildfire smoke, compared with days without wildfire smoke. Wildfire smoke days were defined as days when concentrations of particulate matter (particles generally ≤2.5 µm in aerodynamic diameter) (PM2.5) triggered an Air Quality Index ≥101, corresponding to the air quality categorization, "Unhealthy for Sensitive Groups." Changes in asthma-associated ED visits were assessed across U.S. Department of Health and Human Services regions and by age. Overall, asthma-associated ED visits were 17% higher than expected during the 19 days with wildfire smoke that occurred during the study period; larger increases were observed in regions that experienced higher numbers of continuous wildfire smoke days and among persons aged 5-17 and 18-64 years. These results can help guide emergency response planning and public health communication strategies, especially in U.S. regions where wildfire smoke exposure was previously uncommon.

Using Randomized Controlled Trials to Estimate the Effect of Community Interventions for Childhood Asthma.

INTRODUCTION: The Centers for Disease Control and Prevention's Controlling Childhood Asthma and Reducing Emergencies initiative aims to prevent 500,000 emergency department (ED) visits and hospitalizations within 5 years among children with asthma through implementation of evidence-based interventions and policies. Methods are needed for calculating the anticipated effects of planned asthma programs and the estimated effects of existing asthma programs. We describe and illustrate a method of using results from randomized control trials (RCTs) to estimate changes in rates of adverse asthma events (AAEs) that result from expanding access to asthma interventions. METHODS: We use counterfactual arguments to justify a formula for the expected number of AAEs prevented by a given intervention. This formula employs a current rate of AAEs, a measure of the increase in access to the intervention, and the rate ratio estimated in an RCT. RESULTS: We justified a formula for estimating the effect of expanding access to asthma interventions. For example, if 20% of patients with asthma in a community with 20,540 annual asthma-related ED visits were offered asthma self-management education, ED visits would decrease by an estimated 1,643; and annual hospitalizations would decrease from 2,639 to 617. CONCLUSION: Our method draws on the best available evidence from RCTs to estimate effects on rates of AAEs in the community of interest that result from expanding access to asthma interventions.

Assessing asthma self-management education among US children with current asthma, Asthma Call-back Survey (ACBS) 2015-2017.

OBJECTIVE: Asthma self-management education (AS-ME) is an effective strategy to help children with asthma achieve better asthma control and outcome. The objective of this study is to assess the association between the prevalence of receiving AS-ME curriculum components and sociodemographic characteristics among children with current asthma. METHODS: Behavioral Risk Factor Surveillance System, child Asthma Call-back Survey 2015-2017 aggregated data were used. Multivariable logistic regression models were used to assess associations of each AS-ME component question and sociodemographic characteristic, adjusting for sample weighting. RESULTS: Among 3,213 children with current asthma, 52% of children reported ever being given an asthma action plan by a doctor or other healthcare professional. After adjusting for other variables, boys and Non-Hispanic Black children were more likely to report being given an action plan (APR= 1.15[95% CI 1.00-1.32] and APR= 1.28[95% CI 1.07-1.54] respectively). Non-Hispanic Black (APR = 2.15 [95% CI 1.30-3.55]), non-Hispanic, other race (APR = 1.95 [95% CI1.04-3.66]), and Hispanic children (APR = 1.84 [95% CI 1.18-2.89]) were more likely to report taking a course to learn how to manage asthma than non-Hispanic White children. Hispanic children (40.8%) were more likely to report being advised to change home environment compared to non-Hispanic Whites (31.5%) (APR =1.28 [95% CI 1.01-1.63). CONCLUSION: The prevalence of some elements of asthma-self management education was relatively low and there were differences observed in the prevalence of receiving AS-ME by race/ethnicity, parental education, and income. Targeted implementation of asthma self-management components and interventions may improve asthma control and reduce asthma morbidity.

Large-scale agricultural burning and cardiorespiratory emergency department visits in the U.S. state of Kansas.

BACKGROUND: Prescribed agricultural burning is a common land management practice, but little is known about the health effects from the resulting smoke exposure. OBJECTIVE: To examine the association between smoke from prescribed burning and cardiorespiratory outcomes in the U.S. state of Kansas. METHODS: We analyzed a zip code-level, daily time series of primary cardiorespiratory emergency department (ED) visits for February-May (months when prescribed burning is common in Kansas) in the years 2009-2011 (n = 109,220). Given limited monitoring data, we formulated a measure of smoke exposure using non-traditional datasets, including fire radiative power and locational attributes from remote sensing data sources. We then assigned a population-weighted potential smoke impact factor (PSIF) to each zip code, based on fire intensity, smoke transport, and fire proximity. We used Poisson generalized linear models to estimate the association between PSIF on the same day and in the past 3 days and asthma, respiratory including asthma, and cardiovascular ED visits. RESULTS: During the study period, prescribed burning took place on approximately 8 million acres in Kansas. Same-day PSIF was associated with a 7% increase in the rate of asthma ED visits when adjusting for month, year, zip code, meteorology, day of week, holidays, and correlation within zip codes (rate ratio [RR]: 1.07; 95% confidence interval [CI]: 1.01, 1.13). Same-day PSIF was not associated with a combined outcome of respiratory ED visits (RR [95% CI]: 0.99 [0.97, 1.02]), or cardiovascular ED visits (RR [95% CI]: 1.01 [0.98, 1.04]). There was no consistent association between PSIF during the past 3 days and any of the outcomes. SIGNIFICANCE: These results suggest an association between smoke exposure and asthma ED visits on the same day. Elucidating these associations will help guide public health programs that address population-level exposure to smoke from prescribed burning.

Changes in asthma emergency department visits in the United States during the COVID-19 pandemic.

OBJECTIVE: A better understanding of the impacts of the Coronavirus disease 2019 (COVID-19) pandemic on emergency department (ED) visits for asthma is needed to improve asthma control. METHODS: Using data from the National Syndromic Surveillance Program (NSSP), we assessed changes in average weekly asthma ED visits in the United States in 3 surveillance periods: 1) March 15, 2020-January 2, 2021; 2) January 3, 2021-January 1, 2022; and 3) January 2-March 5, 2022, relative to pre-pandemic comparison periods between December 30, 2018 and December 28, 2019. For each surveillance period, we assessed changes in asthma ED visits by age group and sex. RESULTS: For the surveillance period beginning March 15, 2020, average weekly asthma ED visits declined 31% relative to what was observed during the comparison period - that is, from 45,276 visits/week in 2019 to 31,374 visits/week in 2020. Declines of over 19% and 26% were observed for 2021 and 2022, respectively, relative to the comparison periods. In all surveillance periods, the largest declines occurred among children, especially those ages 0-4 (74%) and 5-11 (66%) years. CONCLUSIONS: The COVID-19 pandemic impacted asthma ED visits in the United States. The impact was greater among children than adults, as ED visits among children were notably lower during all three pandemic surveillance periods than during the corresponding pre-pandemic periods. Additional information about the roles of behaviors of patients with asthma and changes in asthma care might improve our understanding of the reasons underlying these observed changes.

Mental Health Conditions and Severe COVID-19 Outcomes after Hospitalization, United States.

Among 664,956 hospitalized COVID-19 patients during March 2020-July 2021 in the United States, select mental health conditions (i.e., anxiety, depression, bipolar, schizophrenia) were associated with increased risk for same-hospital readmission and longer length of stay. Anxiety was also associated with increased risk for intensive care unit admission, invasive mechanical ventilation, and death.

Communication channels for receiving air quality alerts among adults in the United States.

Exposure to air pollution is associated with respiratory and cardiovascular effects, particularly among people with underlying respiratory and heart disease. It is therefore important for individuals with respiratory and heart disease to be aware of air quality. However, information about the most effective communication channels for disseminating air quality alerts is limited. We assessed communication channels used for receiving air quality alerts among U.S. adults using data from the summer 2020 wave of ConsumerStyles, a nationally representative survey of U.S. adults (n = 4053). We calculated weighted percentages of respondents who received air quality alerts from six communication channels and stratified by demographic and health characteristics. We calculated weighted prevalence ratios (PRs) adjusted for sex, age, race/ethnicity, and education to assess if communication channel use varied by presence of respiratory or heart disease. Sixty-four percent of U.S. adults had heard or read about air quality alerts. Television was the most commonly reported communication channel for receiving alerts (57.5%), followed by app on mobile phone or device (30.2%) and internet or social media (26.4%). Communication channels differed most prominently by age. The proportion of adults receiving alerts from specific communication channels did not notably vary by presence of heart disease. Adults with respiratory disease more often reported receiving alerts from their doctor's office than adults without respiratory disease (PR: 3.10, 95% confidence interval: 1.49, 6.45). These findings can be used by public health officials to increase awareness of poor air quality days and improve the reach of alerts to target populations.

Trends in Clinical Severity of Hospitalized Patients With Coronavirus Disease 2019-Premier Hospital Dataset, April 2020-April 2021.

BACKGROUND: Clinical severity of coronavirus disease 2019 (COVID-19) may vary over time; trends in clinical severity at admission during the pandemic among hospitalized patients in the United States have been incompletely described, so a historical record of severity over time is lacking. METHODS: We classified 466677 hospital admissions for COVID-19 from April 2020 to April 2021 into 4 mutually exclusive severity grades based on indicators present on admission (from most to least severe): Grade 4 included intensive care unit (ICU) admission and invasive mechanical ventilation (IMV); grade 3 included non-IMV ICU and/or noninvasive positive pressure ventilation; grade 2 included diagnosis of acute respiratory failure; and grade 1 included none of the above indicators. Trends were stratified by sex, age, race/ethnicity, and comorbid conditions. We also examined severity in states with high vs low Alpha (B.1.1.7) variant burden. RESULTS: Severity tended to be lower among women, younger adults, and those with fewer comorbidities compared to their counterparts. The proportion of admissions classified as grade 1 or 2 fluctuated over time, but these less-severe grades comprised a majority (75%-85%) of admissions every month. Grades 3 and 4 consistently made up a minority of admissions (15%-25%), and grade 4 showed consistent decreases in all subgroups, including states with high Alpha variant burden. CONCLUSIONS: Clinical severity among hospitalized patients with COVID-19 has varied over time but has not consistently or markedly worsened over time. The proportion of admissions classified as grade 4 decreased in all subgroups. There was no consistent evidence of worsening severity in states with higher vs lower Alpha prevalence.

Severe Outcomes, Readmission, and Length of Stay Among COVID-19 Patients with Intellectual and Developmental Disabilities.

OBJECTIVES: The aim of this study was to evaluate the association between intellectual and developmental disabilities (IDDs) and severe COVID-19 outcomes, 30-day readmission, and/or increased length of stay (LOS) using a large electronic administrative database. METHODS: Patients hospitalized with COVID-19 were identified between March 2020 and June 2021 from more than 900 hospitals in the United States. IDDs included intellectual disability, cerebral palsy, Down syndrome, autism spectrum disorder (ASD), and other intellectual disabilities. Outcomes included intensive care unit (ICU) admission, invasive mechanical ventilation (IMV), 30-day readmission, mortality, and LOS. RESULTS: Among 643,765 patients with COVID-19, multivariate models showed that patients with any IDD were at a significantly greater risk of at least 1 severe outcome, 30-day readmission, or longer LOS than patients without any IDD. Compared with those without any IDD, patients with Down syndrome had the greatest odds of ICU admission (odds ratio [OR] and 95% confidence interval [CI]: 1.96 [1.73-2.21]), IMV (OR: 2.37 [2.07-2.70]), and mortality (OR: 2.33 [2.00-2.73]). Patients with ASD and those with Down syndrome both had over a 40% longer mean LOS. Patients with intellectual disabilities had a 23% (12-35%) increased odds of 30-day readmission. CONCLUSIONS: Results suggest that patients hospitalized with COVID-19 with IDD have a significantly increased risk of severe outcomes, 30-day readmission, and longer LOS.

Uncontrolled asthma and household environmental exposures in Puerto Rico.

OBJECTIVE: To describe asthma control and household environmental exposures among adults and children with asthma in Puerto Rico. METHODS: A cross-sectional analysis was conducted using data from the 2014-2016 Behavioral Risk Factor Surveillance System Asthma Call-back Survey on 931 adults and 177 children with current asthma in Puerto Rico. These data were analyzed to assess the prevalence of uncontrolled asthma in Puerto Rico and potential associations with household environmental exposure to cockroaches, smoke, and mold. Asthma control was classified using daytime and nighttime symptoms, activity limitation, and short-acting beta agonist use. Prevalence and prevalence ratios were calculated, adjusting for sample weighting. RESULTS: An estimated 53% of adults with asthma and 29% of children with asthma in Puerto Rico have uncontrolled asthma. Among adults with asthma, in the past 30 days, 29% had seen or smelled mold and 50% had seen cockroaches; in the past week, 12% reported having someone smoke in their home. Adults with uncontrolled asthma were 1.4 times more likely to have observed mold in their homes than were those with controlled asthma when adjusting for age, sex, education, and income (prevalence ratio [95% confidence interval]: 1.4 [1.1, 1.8]). Children with uncontrolled asthma were also more likely to have mold observed in their home than were children with controlled asthma (adjusted PR [95% CI]: 3.0 [1.3, 7.1]). CONCLUSIONS: Uncontrolled asthma is common among adults and children with asthma in Puerto Rico. These results suggest potential differences in household mold exposure by asthma control status.

Clinical outcomes among hospitalized US adults with asthma or chronic obstructive pulmonary disease, with or without COVID-19.

OBJECTIVE: This study assesses the risk of severe clinical outcomes during hospitalizations of adults with asthma and/or COPD plus COVID-19 and compares those risks with those during hospitalizations of adults with asthma and/or COPD without COVID-19. METHODS: We used data from 877 U.S. hospitals from the Premier Healthcare Database during March 2020-March 2021. Hospitalizations (n = 311,215) among patients aged ≥18 years with an ICD-10-CM diagnosis involving asthma or COPD were classified into three groups: adults with asthma (but not COPD), adults with COPD (but not asthma), and adults with both asthma and COPD. We used multivariable Poisson regression to assess associations of severe clinical outcomes [intensive care unit (ICU) admission, use of invasive mechanical ventilation (IMV), and death] and COVID-19 status. RESULTS: The percentage of hospitalizations among patients with asthma and COVID-19 resulting in ICU admission, IMV, and death were 46.9%, 14.0%, and 8.0%, respectively. These risks were higher than those among patients with asthma without COVID-19 (adjusted risk ratio [aRR], 1.17 [95% confidence interval (CI), 1.14-1.21], 1.61 [95% CI, 1.50-1.73], and 5.56 [95% CI, 4.89-6.32]), respectively. Risks of ICU admission, IMV, and death were also high among patients with COPD and COVID-19 and exceeded the corresponding risks among patients with COPD without COVID-19. CONCLUSION: Hospitalizations among patients with asthma and/or COPD with COVID-19 had a more severe clinical course than hospitalizations for asthma and/or COPD exacerbations without COVID-19.Supplemental data for this article is available online at at www.tandfonline.com/ijas .

Estimation of Coronavirus Disease 2019 Hospitalization Costs From a Large Electronic Administrative Discharge Database, March 2020-July 2021.

BACKGROUND: Information on the costs of inpatient care for patients with coronavirus disease 2019 (COVID-19) is very limited. This study estimates the per-patient cost of inpatient care for adult COVID-19 patients seen at >800 US hospitals. METHODS: Patients aged ≥18 years with ≥1 hospitalization during March 2020-July 2021 with a COVID-19 diagnosis code in a large electronic administrative discharge database were included. We used validated costs when reported; otherwise, costs were calculated using charges multiplied by cost-to-charge ratios. We estimated costs of inpatient care per patient overall and by severity indicator, age, sex, underlying medical conditions, and acute complications of COVID-19 using a generalized linear model with log link function and gamma distribution. RESULTS: The overall cost among 654673 patients hospitalized with COVID-19 was $16.2 billion. Estimated per-patient hospitalization cost was $24 826. Among surviving patients, estimated per-patient cost was $13 090 without intensive care unit (ICU) admission or invasive mechanical ventilation (IMV), $21 222 with ICU admission alone, and $59 742 with IMV. Estimated per-patient cost among patients who died was $27 017. Adjusted cost differential was higher among patients with certain underlying conditions (eg, chronic kidney disease [$12 391], liver disease [$8878], cerebrovascular disease [$7267], and obesity [$5933]) and acute complications (eg, acute respiratory distress syndrome [$43 912], pneumothorax [$25 240], and intracranial hemorrhage [$22 280]). CONCLUSIONS: The cost of inpatient care for COVID-19 patients was substantial through the first 17 months of the pandemic. These estimates can be used to inform policy makers and planners and cost-effectiveness analysis of public health interventions to alleviate the burden of COVID-19.

Trends in COVID-19 Cases, Emergency Department Visits, and Hospital Admissions Among Children and Adolescents Aged 0-17 Years - United States, August 2020-August 2021.

Although COVID-19 generally results in milder disease in children and adolescents than in adults, severe illness from COVID-19 can occur in children and adolescents and might require hospitalization and intensive care unit (ICU) support (1-3). It is not known whether the B.1.617.2 (Delta) variant,* which has been the predominant variant of SARS-CoV-2 (the virus that causes COVID-19) in the United States since late June 2021,† causes different clinical outcomes in children and adolescents compared with variants that circulated earlier. To assess trends among children and adolescents, CDC analyzed new COVID-19 cases, emergency department (ED) visits with a COVID-19 diagnosis code, and hospital admissions of patients with confirmed COVID-19 among persons aged 0-17 years during August 1, 2020-August 27, 2021. Since July 2021, after Delta had become the predominant circulating variant, the rate of new COVID-19 cases and COVID-19-related ED visits increased for persons aged 0-4, 5-11, and 12-17 years, and hospital admissions of patients with confirmed COVID-19 increased for persons aged 0-17 years. Among persons aged 0-17 years during the most recent 2-week period (August 14-27, 2021), COVID-19-related ED visits and hospital admissions in the states with the lowest vaccination coverage were 3.4 and 3.7 times that in the states with the highest vaccination coverage, respectively. At selected hospitals, the proportion of COVID-19 patients aged 0-17 years who were admitted to an ICU ranged from 10% to 25% during August 2020-June 2021 and was 20% and 18% during July and August 2021, respectively. Broad, community-wide vaccination of all eligible persons is a critical component of mitigation strategies to protect pediatric populations from SARS-CoV-2 infection and severe COVID-19 illness.

Asthma-Related Emergency Department Visits in North Carolina Following Hurricane Irene.

OBJECTIVE: Previous research suggests that people with asthma may experience a worsening of symptoms following hurricanes due to changes in environmental exposures, discontinuity in chronic disease management, and stress. The objective of this study was to estimate changes in asthma-related emergency department (ED) visits in North Carolina following Hurricane Irene, which made landfall in August 2011. METHODS: Changes in asthma-related ED visits in September to December of 2010 and 2011 were examined using data from the Healthcare Cost and Utilization Project State Emergency Department and Inpatient Databases. A Poisson generalized linear model was used to estimate the association between Federal Emergency Management Agency disaster declarations following Hurricane Irene and county-level asthma-related ED visits controlling for month, year, and county. RESULTS: Following Hurricane Irene, disaster declarations were made for 38 of 100 counties in North Carolina. In September 2010, the rate of asthma-related ED visits for North Carolina was 6 per 10,000 person-months. In September 2011, rates of asthma-related ED visits were similar in counties with and without disaster declarations (7 and 5 per 10,000 person-months, respectively). When adjusting for covariates, there was little or no difference in the rate of asthma ED visits before and after the hurricane between counties with and without a disaster declaration (rate ratio {RR} [95% confidence interval {CI}] = 1.02[0.97, 1.08]). CONCLUSIONS: Although risk factors for asthma exacerbations increase following hurricanes, these results found little evidence of an increase in asthma-related ED visits in North Carolina following Hurricane Irene.

Daycare attendance and asthma control, Asthma Call-back Survey 2012-2014.

OBJECTIVE: To examine the association between daycare attendance and asthma control among children aged 0 to 4 years with asthma. METHODS: We analyzed 2012-2014 data from the Behavioral Risk Factor Surveillance System Asthma Call-back Survey on 388 children with asthma aged 0 to 4 years with information on daycare attendance in the past 12 months. We calculated weighted prevalence ratios to assess the association between daycare attendance and asthma control (categorized based on day-time and nighttime asthma symptoms, activity limitation, and short-acting beta agonist use). Adjusted models controlled for parent or guardian education, household income, race, sex, cost barriers to asthma care, long-term control medication use, and the number of other children in the child's household. RESULTS: In this sample of children with asthma, representative of 520,400 children in 26 U.S. states, 34% attended daycare in the past 12 months. Only 32% of children who attended daycare in the past 12 months reported having an asthma action plan on file at the daycare they most recently attended. Presence of the asthma triggers of pets, mold, and smoking in a child's daycare were reported to be uncommon. Prevalence of uncontrolled asthma was 44% in children who attended daycare in the past 12 months and 68% in children who did not. The adjusted prevalence ratio between daycare attendance and uncontrolled asthma was 0.96 (95% confidence interval 0.73, 1.25). CONCLUSIONS: When adjusting for covariates, we observed no evidence of an association between daycare attendance in early life and uncontrolled asthma.

Smoke Alarms and Carbon Monoxide Alarms in Households With Children, Puerto Rico, 2010.

In 2017, Puerto Rico sustained extensive damage from Hurricane Maria, increasing the risk of fires and carbon monoxide (CO) poisonings. Using a population-based, in-person survey of households with children less than 6 years old in Puerto Rico, we collected data in 2010 concerning the presence of smoke alarms and CO alarms in these households. We generated national estimates by extrapolating the number of households in each stratum using data from the 2010 Census. We determined which household characteristics predicted the presence of these alarms. Of 355 households analyzed, 31% had functional smoke alarms, or an estimated 109,773 households territory wide. The presence of smoke alarms was associated with living in multifamily housing and no child in the household receiving government medical insurance. Public housing or publicly subsidized housing, as compared to owner-occupied housing and unsubsidized rental housing, was associated with having a functional smoke alarm in households with children aged less than 6 years. Based on only six houses having CO alarms, we estimated only 7685 (2%) households had CO alarms. The low prevalence of functional smoke or CO alarms 7 years before Hurricane Maria is unfortunate and should be remedied by ensuring that such alarms are widely installed in current rebuilding activities.

Characterizing environmental asthma triggers and healthcare use patterns in Puerto Rico.

Objective: Asthma carries a high burden of disease for residents of Puerto Rico. We conducted this study to better understand asthma-related healthcare use and to examine potential asthma triggers.Methods: We characterized asthma-related healthcare use in 2013 by demographics, region, and date using outpatient, hospital, and emergency department (ED) insurance claims with a primary diagnostic ICD-9-CM code of 493.XX. We examined environmental asthma triggers, including outdoor allergens (i.e., mold and pollen), particulate pollution, and influenza-like illness. Analyses included descriptive statistics and Poisson time-series regression.Results: During 2013, there were 550,655 medical asthma claims reported to the Puerto Rico Healthcare Utilization database, representing 148 asthma claims/1,000 persons; 71% of asthma claims were outpatient visits, 19% were hospitalizations, and 10% were ED visits. Females (63%), children aged ≤9 years (77% among children), and adults aged ≥45 years (80% among adults) had the majority of asthma claims. Among health regions, Caguas had the highest asthma claim-rate at 142/1,000 persons (overall health region claim-rate = 108). Environmental exposures varied across the year and demonstrated seasonal patterns. Metro health region regression models showed positive associations between increases in mold and particulate matter <10 microns in diameter (PM10) and outpatient asthma claims.Conclusions: This study provides information about patterns of asthma-related healthcare use across Puerto Rico. Increases in mold and PM10 were associated with increases in asthma claims. Targeting educational interventions on exposure awareness and reduction techniques, especially to persons with higher asthma-related healthcare use, can support asthma control activities in public health and clinical settings.

Urine Bisphenol A and Arsenic Levels in Residents of the Cheyenne River Sioux Tribe, South Dakota, with and without Diabetes.

INTRODUCTION: Diabetes disproportionately affects American Indians/Alaskan Natives (AI/AN). Bisphenol A (BPA) and arsenic (As), environmental toxicants which may be associated with diabetes, have not been well studied in this population. Our objectives were to determine if urinary BPA and As are associated with diabetes among adults in the Cheyenne River Sioux Tribe (CRST), and to compare their urinary levels with the general US population. METHODS: We performed a case-control study among 276 volunteers. We matched our cases (persons with diabetes) and controls (persons without diabetes) using age. We collected questionnaire data and urine samples which were tested for BPA and speciated As analytes. We used paired t tests and McNemar's chi-square test to compare continuous and categorical variables, respectively, between cases and controls and linear regression to assess the association between self-reported exposures and BPA and As levels. We used conditional logistic regression to investigate the association between case status and BPA and As levels. BPA and As levels among participants were compared with those from the 2011-2012 National Health and Nutrition Examination Survey (NHANES). RESULTS: The average age of participants was 46 years. The majority identified as AI/AN race (97%) and 58% were female. The geometric means from CRST participant urine specimens were 1.83 ug/L for BPA and 3.89 ug/L for total As. BPA geometric means of CRST participants were higher than NHANES participants while total As geometric means were lower. BPA and As were not associated with case status. CONCLUSION: The results of this study are consistent with others that have reported no association between diabetes and exposure to BPA or As.