Air pollution and public health vulnerabilities, susceptibilities and inequalities in Wales, UK.

BACKGROUND: Outdoor air pollution is the largest environmental risk to health. Air pollution, deprivation and poor health status are inextricably linked; highlighting issues of environmental injustice, social and health inequalities. METHODS: Air pollution (nitrogen dioxide, NO2 and fine particulate matter, PM2.5), population and deprivation data were identified at Lower Super Output Area level in Wales, UK, for 2012-18. Air pollution data were categorized according to different air pollution concentrations. Population and deprivation data were considered simultaneously to describe population vulnerabilities, susceptibilities and inequalities. Simple statistical analyses were performed using a difference in proportions method with 95% confidence intervals. RESULTS: Over time, the majority of Welsh people transitioned to living in areas of lower NO2 and PM2.5 pollution. Areas of worse air pollution comprised more young people than people aged 65+; both populations are known to be susceptible to air pollution exposure. By 2018, significant socioeconomic inequality gaps were found where 'most deprived' population groups for both pollutants experienced greater disadvantage. CONCLUSION: Air quality in Wales is improving. However, local-level variations in exposure risk still exist. System-wide action must ensure that air quality improvement-related benefits are equitable and acknowledge current evidence about the harms that even low levels of air pollution can have on health.

Cluster of atypical adult Guillain-Barré syndrome temporally associated with neurological illness due to EV-D68 in children, South Wales, United Kingdom, October 2015 to January 2016.

We report a cluster of atypical Guillain-Barré syndrome in 10 adults temporally related to a cluster of four children with acute flaccid paralysis, over a 3-month period in South Wales, United Kingdom. All adult cases were male, aged between 24 and 77 years. Seven had prominent facial diplegia at onset. Available electrophysiological studies showed axonal involvement in five adults. Seven reported various forms of respiratory disease before onset of neurological symptoms. The ages of children ranged from one to 13 years, three of the four were two years old or younger. Enterovirus testing is available for three children; two had evidence of enterovirus D68 infection in stool or respiratory samples. We describe the clinical features, epidemiology and state of current investigations for these unusual clusters of illness.

Interventions for latent autoimmune diabetes (LADA) in adults.

BACKGROUND: Latent autoimmune diabetes in adults (LADA) is a slowly developing type 1 diabetes. OBJECTIVES: To compare interventions used for LADA. SEARCH STRATEGY: Studies were obtained from searches of electronic databases, supplemented by handsearches, conference proceedings and consultation with experts. Date of last search was December 2010. SELECTION CRITERIA: Randomised controlled trials (RCT) and controlled clinical trials (CCT) evaluating interventions for LADA or type 2 diabetes with antibodies were included. DATA COLLECTION AND ANALYSIS: Two authors independently extracted data and assessed risk of bias. Studies were summarised using meta-analysis or descriptive methods. MAIN RESULTS: Searches identified 13,306 citations. Fifteen publications (ten studies) were included, involving 1019 participants who were followed between three months to 10 years (1060 randomised). All studies had a high risk of bias. Sulphonylurea (SU) with insulin did not improve metabolic control significantly more than insulin alone at three months (one study, n = 15) and at 12 months (one study, n = 14) of treatment and follow-up. SU (with or without metformin) gave poorer metabolic control compared to insulin alone (mean difference in glycosylated haemoglobin A1c (HbA1c) from baseline to end of study, for insulin compared to oral therapy: -1.3% (95% confidence interval (CI) -2.4 to -0.1; P = 0.03, 160 participants, four studies, follow-up/duration of therapy: 12, 30, 36 and 60 months; however, heterogeneity was considerable). In addition, there was evidence that SU caused earlier insulin dependence (proportion requiring insulin at two years was 30% in the SU group compared to 5% in conventional care group (P < 0.001); patients classified as insulin dependent was 64% (SU group) and 12.5% (insulin group, P = 0.007). No intervention influenced fasting C-peptide, but insulin maintained stimulated C-peptide better than SU (one study, mean difference 7.7 ng/ml (95% CI 2.9 to 12.5)). In a five year follow-up of GAD65 (glutamic acid decarboxylase formulated with aluminium hydroxide), improvements in fasting and stimulated C-peptide levels (20 µg group) were maintained after five years. Short term (three months) follow-up in one study (n = 74) using Chinese remedies did not demonstrate a significant difference in improving fasting C-peptide levels compared to insulin alone (0.07 µg/L (95% CI -0.05 to 0.19). One study using vitamin D with insulin showed steady fasting C-peptide levels in the vitamin D group but declining fasting C-peptide levels (368 to 179 pmol/L, P = 0.006) in the insulin alone group at 12 months follow-up. Comparing studies was difficult as there was a great deal of heterogeneity in the studies and in their selection criteria. There was no information regarding health-related quality of life, complications of diabetes, cost or health service utilisation, mortality and limited evidence on adverse events (studies on oral agents or insulin reported no adverse events in terms of severe hypoglycaemic episodes). AUTHORS' CONCLUSIONS: Two studies show SU leading to earlier insulin dependence and a meta-analysis of four studies with considerable heterogeneity showed poorer metabolic control if SU is prescribed for patients with LADA compared to insulin. One study showed that vitamin D with insulin may protect pancreatic beta cells in LADA. Novel treatments such as GAD65 in certain doses (20 µg) have been suggested to maintain fasting and stimulated C-peptide levels. However, there is no significant evidence for or against other lines of treatment of LADA.

Protocol of the baseline assessment for the Environments for Healthy Living (EHL) Wales cohort study.

BACKGROUND: Health is a result of influences operating at multiple levels. For example, inadequate housing, poor educational attainment, and reduced access to health care are clustered together, and are all associated with reduced health. Policies which try to change individual people's behaviour have limited effect when people have little control over their environment. However, structural environmental change and an understanding of the way that influences interact with each other, has the potential to facilitate healthy choices irrespective of personal resources. The aim of Environments for Healthy Living (EHL) is to investigate the impact of gestational and postnatal environments on health, and to examine where structural change can be brought about to optimise health outcomes. The baseline assessment will focus on birth outcomes and maternal and infant health. METHODS/DESIGN: EHL is a longitudinal birth cohort study. We aim to recruit 1000 pregnant women in the period April 2010 to March 2013. We will examine the impact of the gestational environment (maternal health) and the postnatal environment (housing and neighbourhood conditions) on subsequent health outcomes for the infants born to these women. Data collection will commence during the participants' pregnancy, from approximately 20 weeks gestation. Participants will complete a questionnaire, undergo anthropometric measurements, wear an accelerometer, compile a food diary, and have environmental measures taken within their home. They will also be asked to consent to having a sample of umbilical cord blood taken following delivery of their baby. These data will be complemented by routinely collected electronic data such as health records from GP surgeries, hospital admissions, and child health and development records. Thereafter, participants will be visited annually for follow-up of subsequent exposures and child health outcomes. DISCUSSION: The baseline assessment of EHL will provide information concerning the impact of gestational and postnatal environments on birth outcomes and maternal and infant health. The findings can be used to inform the development of complex interventions targeted at structural, environmental factors, intended to reduce ill-health. Long-term follow-up of the cohort will focus on relationships between environmental exposures and the later development of adverse health outcomes, including obesity and diabetes.

Using multiple datasets to understand trends in serious road traffic casualties.

Accurate information on the incidence of serious road traffic casualties is needed to plan and evaluate prevention strategies. Traditionally police reported collisions are the only data used. This study investigate the extent to which understanding of trends in serious road traffic injuries is aided by the use of multiple datasets. Health and police datasets covering all or part of Great Britain from 1996-2003 were analysed. There was a significantly decreasing trend in police reported serious casualties but not in the other datasets. Multiple data sources provide a more complete picture of road traffic casualty trends than any single dataset. Increasing availability of electronic health data with developments in anonymised data linkage should provide a better platform for monitoring trends in serious road traffic casualties.

Twenty miles per hour speed limits: a sustainable solution to public health problems in Wales.

BACKGROUND: Prevention, rather than treatment, is the key to longer healthier lives. Identifying interventions that will impact positively on road traffic injuries, air quality and encourage active travel is a significant public health challenge. This paper aimed to explore whether 20 mph limits could be useful in achieving this. METHODS: Research evidence was reviewed to identify the effect of 20 mph zones and limits on health and well-being. The evidence was then used to estimate the effect of a change to a 20 mph limit on road traffic casualties and air pollution. It was then mapped against the seven goals of the Well-being of Future Generations Act (2015). RESULTS: If all current 30 mph limit roads in Wales became 20 mph limits, it is estimated that 6-10 lives would be saved and 1200-2000 casualties avoided each year, at a value of prevention of £58M-£94M. In terms of air pollution, deaths attributed to nitrogen dioxide (NO2) may increase by 63, and years of life lost by 753. However, deaths attributed to particulates (PM2.5) may decrease by 117 and years of life lost by 1400. Evidence review suggests benefits in terms of road traffic casualties, air quality, active travel, noise pollution, greater social inclusion, greater community cohesion and local business viability. CONCLUSIONS: Road traffic injuries, air pollution and obesity are an inter-related, interdependent triad. The challenge facing public health today is identifying robust interventions that will have positive effects on all three as a minimum; default 20 mph limits is the solution to increasing public health problems in Wales.

Local modelling techniques for assessing micro-level impacts of risk factors in complex data: understanding health and socioeconomic inequalities in childhood educational attainments.

Although inequalities in health and socioeconomic status have an important influence on childhood educational performance, the interactions between these multiple factors relating to variation in educational outcomes at micro-level is unknown, and how to evaluate the many possible interactions of these factors is not well established. This paper aims to examine multi-dimensional deprivation factors and their impact on childhood educational outcomes at micro-level, focusing on geographic areas having widely different disparity patterns, in which each area is characterised by six deprivation domains (Income, Health, Geographical Access to Services, Housing, Physical Environment, and Community Safety). Traditional health statistical studies tend to use one global model to describe the whole population for macro-analysis. In this paper, we combine linked educational and deprivation data across small areas (median population of 1500), then use a local modelling technique, the Takagi-Sugeno fuzzy system, to predict area educational outcomes at ages 7 and 11. We define two new metrics, "Micro-impact of Domain" and "Contribution of Domain", to quantify the variations of local impacts of multidimensional factors on educational outcomes across small areas. The two metrics highlight differing priorities. Our study reveals complex multi-way interactions between the deprivation domains, which could not be provided by traditional health statistical methods based on single global model. We demonstrate that although Income has an expected central role, all domains contribute, and in some areas Health, Environment, Access to Services, Housing and Community Safety each could be the dominant factor. Thus the relative importance of health and socioeconomic factors varies considerably for different areas, depending on the levels of each of the other factors, and therefore each component of deprivation must be considered as part of a wider system. Childhood educational achievement could benefit from policies and intervention strategies that are tailored to the local geographic areas' profiles.