Exposure to perfluoroalkyl and polyfluoroalkyl substances and pediatric obesity: a systematic review and meta-analysis.

INTRODUCTION: Perfluoroalkyl and polyfluoroalkyl substances (PFAS) are potentially obesogenic for children. We undertook a systematic review to synthesize this literature and explore sources of heterogeneity in previously published epidemiological studies. METHODS: Studies that collected individual-level PFAS and anthropometric data from children up to 12 years of age were identified by searching six databases. We excluded studies that only evaluated obesity measures at the time of birth. A full-text review and quality assessment of the studies was performed using the Office of Health Assessment and Translation (OHAT) criteria. Forest plots were created to summarize measures of association and assess heterogeneity across studies by chemical type and exposure timing. Funnel plots were used to assess small-study effects. RESULTS: We identified 24 studies, of which 19 used a cohort design. There were 13 studies included in the meta-analysis examining various chemicals and outcomes. Overall prenatal exposures to four different types of PFAS were not statistically associated with changes in body mass index (BMI) or waist circumference. In contrast, for three chemicals, postnatal exposures were inversely related to changes in BMI (i.e., per log10 increase in PFOS: BMI z-score of -0.16 (95% CI: -0.22, -0.10)). There was no substantial heterogeneity in the reported measures of association within prenatal and postnatal subgroups. We observed modest small-study effects, but correction for these effects using the Trim and Fill method did not change our summary estimate(s). CONCLUSION: Our review found no evidence of a positive association between prenatal PFAS exposure and pediatric obesity, whereas an inverse association was found for postnatal exposure. These findings should be interpreted cautiously due to the small number of studies. Future research that can inform on the effects of exposure mixtures, the timing of the exposure, outcome measures, and the shape of the exposure-response curve is needed.

Neighborhood greenness and participation in specific types of recreational physical activities in the Sister Study.

BACKGROUND: Urban green spaces have been consistently shown to have important human health benefits across a range of outcomes. These benefits are thought to be achieved, in part, because urban greenness provides opportunities for participation in recreational activity. However, the findings from studies that have assessed links between exposure to greenness and physical activity have been mixed. To date, few studies have examined association between greenness and specific types of recreational physical activities. OBJECTIVE: We evaluated associations between measures of greenness and specific types of recreational physical activities. Moreover, we explored the extent to which these associations were modified by socioeconomic conditions, and regionally. METHODS: We analyzed cross-sectional data from 49,649 women in the Sister Study and assigned three residentially-based measures of greenness based on national land cover data at buffer distances of 250 m and 500 m. Data on participation in up to ten specific recreational physical activities, including time spent in each activity were collected. Logistic regression was used to estimate odds ratios (OR) and their 95% confidence intervals (CI) controlling for confounders. RESULTS: Compared to those in the lowest tertile of greenness, participants in the upper tertile of greenness within a 500 m buffer, were more likely to garden (OR = 1.46, 95% CI = 1.25,1.69), participate in sports (OR = 1.28, 95% CI = 1.19,1.38), run (OR = 1.15, 95% CI = 1.04,1.27), walk (OR = 1.11, 95% CI = 1.06,1.16), and engage in conditioning exercises (OR = 1.10, 95% CI = 1.05,1.16) at least once a week for at least one month over the past year. These associations were modified by household income and US region. DISCUSSION: Our findings suggest a beneficial effect of greenness on physical activity and provide additional information to inform planning of green environments that contribute to better health and wellbeing.

Residential surrounding greenness and the incidence of childhood asthma: Findings from a population-based cohort in Ontario, Canada.

Several epidemiological studies have investigated the possible role that living in areas with greater amounts of greenspace has on the incidence of childhood asthma. These findings have been inconsistent, and few studies explored the relevance of timing of exposure. We investigated the role of residential surrounding greenness on the risk of incident asthma using a population-based retrospective cohort study. We included 982,131 singleton births in Ontario, Canada between 2006 and 2013. Two measures of greenness, the Normalized Difference Vegetation Index (NDVI) and the Green View Index (GVI), were assigned to the residential histories of these infants from pregnancy through to 12 years of age. Longitudinally-based diagnoses of asthma were determined by using provincial administrative health data. The extended Cox hazards model was used to characterize associations between greenness measures and asthma (up to age 12 years) while adjusting for several risk factors. In a fully adjusted model, that included a term for traffic-related air pollution (NO2), we found no association between an interquartile range increase (0.08) of the NDVI during childhood and asthma incidence (HR = 0.99; 95 % CI = 0.99-1.01). In contrast, we found that an 0.08 increase in NDVI during childhood reduced the risk of asthma in children 7-12 years of age by 14 % (HR = 0.86, 95 % CI:0.79-0.95). Seasonal differences in the association between greenness and asthma were noted. Our findings suggest that residential proximity to greenness reduces the risk of asthma in children aged 7-12.

Early-life external exposome in children 2-5 years old in Colombia.

Exposome studies are advancing in high-income countries to understand how multiple environmental exposures impact health. However, there is a significant research gap in low- and middle-income and tropical countries. We aimed to describe the spatiotemporal variation of the external exposome, its correlation structure between and within exposure groups, and its dimensionality. A one-year follow-up cohort study of 506 children under 5 in two cities in Colombia was conducted to evaluate asthma, acute respiratory infections, and DNA damage. We examined 48 environmental exposures during pregnancy and 168 during childhood in eight exposure groups, including atmospheric pollutants, natural spaces, meteorology, built environment, traffic, indoor exposure, and socioeconomic capital. The exposome was estimated using geographic information systems, remote sensing, spatiotemporal modeling, and questionnaires. The median age of children at study entry was 3.7 years (interquartile range: 2.9-4.3). Air pollution and natural spaces exposure decreased from pregnancy to childhood, while socioeconomic capital increased. The highest median correlations within exposure groups were observed in meteorology (r = 0.85), traffic (r = 0.83), and atmospheric pollutants (r = 0.64). Important correlations between variables from different exposure groups were found, such as atmospheric pollutants and meteorology (r = 0.76), natural spaces (r = -0.34), and the built environment (r = 0.53). Twenty principal components explained 70%, and 57 explained 95% of the total variance in the childhood exposome. Our findings show that there is an important spatiotemporal variation in the exposome of children under 5. This is the first characterization of the external exposome in urban areas of Latin America and highlights its complexity, but also the need to better characterize and understand the exposome in order to optimize its analysis and applications in local interventions aimed at improving the health conditions and well-being of the child population and contributing to environmental health decision-making.

Exposure to low-dose radiation in occupational settings and ischaemic heart disease: a systematic review and meta-analysis.

Ionising radiation is a human carcinogen, but the evidence is less clear that exposure to low-dose ionising radiation (LDIR) increases the risk of adverse cardiovascular outcomes. We synthesised the literature of chronic occupational exposure to LDIR and cardiovascular disease, particularly for ischaemic heart disease (IHD).The literature search was conducted using three databases including studies published between 1990 and 2022. A quality assessment of the studies was completed using the Office of Health and Assessment and Translation Risk of Bias Rating Tool. We conducted meta-analyses for IHD mortality using random effects models using measures of excess relative risk per sievert (ERR/Sv) obtained from internal cohort comparisons, as well as with standardised mortality ratios (SMRs) from external cohort comparisons.We identified 2189 articles, and of these, 26 provided data on IHD and were retained. Most studies were classified as having a 'moderate' level of risk of bias. Fourteen and 10 studies reporting external radiation doses were included in meta-analyses using SMR and ERR/Sv, respectively. The meta-summary SMR was 0.81 (95% CI 0.74 to 0.89) with evidence of reduced risk but high heterogeneity across studies. For internal cohort measures, the summary ERR/Sv for a lagged exposure of 10 years was 0.10 (95% CI 0.01 to 0.20) with low heterogeneity. The subgroup analysis by lagged exposure time showed the strongest association were for the 15 and 20 years lag.Our findings suggest that occupational exposure to LDIR increases the risk IHD mortality and highlight the relevance of internal cohort comparisons.

Daily changes in ambient air pollution concentrations and temperature and suicide mortality in Canada: Findings from a national time-stratified case-crossover study.

INTRODUCTION: Worldwide, approximately 1900 people die by suicide daily. Daily elevations in air pollution and temperature have previously been linked to a higher risk of death from suicide. To date, there have been relatively few studies of air pollution and suicide, particularly at a national level. National analyses play an important role in shaping health policy to mitigate against adverse health outcomes. METHODS: We used a time-stratified case-crossover study design to investigate the influence of short-term (i.e., day to day) interquartile range (IQR) increases in air pollutants (nitrogen dioxide [NO2], ozone [O3], and fine particulate matter [PM2.5]) and temperature on suicide mortality in Canada between 2002 and 2015. For air pollution models, odds ratios (ORs) derived from conditional logistic regression models were adjusted for average daily temperature, and holidays. For temperature models, ORs were adjusted for holidays. Stratified analyses were undertaken by suicide type (non-violent and violent), sex, age, and season. RESULTS: Analyses are based on 50,800 suicide deaths. Overall, temperature effects were stronger than those for air pollution. A same day IQR increase in temperature (9.6 °C) was associated with a 10.1% increase (95% confidence interval (CI): 9.0%-11.2%) of death from suicide. For 3-day average increase of O3 (IQR = 14.1 ppb), PM2.5 (IQR = 5.6 µg/m3) and NO2 (IQR = 9.7 ppb) the corresponding risks were 4.7% (95% CI: 3.9, 5.6), 3.4% (95% CI: 3.0, 3.8), and 2.0% (95% CI: 1.1, 2.8), respectively. All pollutants showed stronger associations with suicide during the warmer season (April-September). Stratified analyses revealed stronger associations for both temperature and air pollution in women. CONCLUSIONS: Daily increases in air pollution and temperature were found to increase the risk of death from suicide. Females, particularly during warmer season, were most vulnerable to these exposures. Policy decisions related to air pollution and climate change should consider effects on mental health.

Short-term changes in meteorological conditions and suicide: A systematic review and meta-analysis.

BACKGROUND: Suicide is a leading cause of death, particularly for young adults. Suicidal behaviours are influenced by a wide-range of personal, social, and cultural factors. Emerging evidence suggests that daily changes in meteorological conditions, including temperature, increases the risk of suicide. METHODS: We conducted a systematic review and meta-analysis of studies that examined associations between either daily, or weekly, variations for eight meteorological variables and suicide outcomes (attempts, or deaths). Meta-analytic methods were applied to derive summary measures of association using random effect models. We assessed the heterogeneity in these associations by region and biological sex. RESULTS: We identified 29 studies of suicide. Of these, 26 reported associations between temperature, while fewer studies reported on rain (n = 4), solar radiation (n = 4), humidity (n = 3), sunshine (n = 3), atmospheric pressure (n = 2), wind (n = 2) and cloud cover (n = 2). The overall relative risk for suicide deaths/attempts per 1 °C increase in ambient temperature was 1.016 (95% CI: 1.013-1.019). Subgroup analysis of temperature found stronger associations with suicide when using the maximum rather than the mean daily temperature, among men, and for completed suicides relative to attempts. Regionally, the strongest associations were found in the East Asia and Pacific region. While associations were found for solar radiation and cloud coverage and suicide, we did not undertake a meta-analysis for these exposures as it was not possible to standardize measures of association across studies. Statistically significant associations were not observed for other identified meteorological variables. CONCLUSIONS: Our findings suggest that daily increases in temperature increase the risk of suicide, particularly, among men and in the East Asia and Pacific region.

Avoidable mortality due to long-term exposure to PM2.5 in Colombia 2014-2019.

OBJECTIVE: To compare estimates of spatiotemporal variations of surface PM2.5 concentrations in Colombia from 2014 to 2019 derived from two global air quality models, as well as to quantify the avoidable deaths attributable to the long-term exposure to concentrations above the current and projected Colombian standard for PM2.5 annual mean at municipality level. METHODS: We retrieved PM2.5 concentrations at the surface level from the ACAG and CAMSRA global air quality models for all 1,122 municipalities, and compare 28 of them with available concentrations from monitor stations. Annual mortality data 2014-2019 by municipality of residence and pooled effect measures for total, natural and specific causes of mortality were used to calculate the number of annual avoidable deaths and years of potential life lost (YPLL) related to the excess of PM2.5 concentration over the current mean annual national standard of 25 µg/m3 and projected standard of 15 µg/m3. RESULTS: Compared to surface data from 28 municipalities with monitoring stations in 2019, ACAG and CAMSRA models under or overestimated annual mean PM2.5 concentrations. Estimations from ACAG model had a mean bias 1,7 µg/m3 compared to a mean bias of 4,7 µg/m3 from CAMSRA model. Using ACAG model, estimations of total nationally attributable deaths to PM2.5 exposure over 25 and 15 µg/m3 were 142 and 34,341, respectively. Cardiopulmonary diseases accounted for most of the attributable deaths due to PM2.5 excess of exposure (38%). Estimates of YPLL due to all-cause mortality for exceeding the national standard of 25 µg/m3 were 2,381 years. CONCLUSION: Comparison of two global air quality models for estimating surface PM2.5 concentrations during 2014-2019 at municipality scale in Colombia showed important differences. Avoidable deaths estimations represent the total number of deaths that could be avoided if the current and projected national standard for PM2.5 annual mean have been met, and show the health-benefit of the implementation of more restrictive air quality standards.

Space-time clustering of childhood leukemia in Colombia: a nationwide study.

BACKGROUND: Leukemia is the most common cancer in childhood. The estimated incidence rate of childhood leukemia in Colombia is one of the highest in America and little is known about its spatial distribution. PURPOSE: To explore the presence of space-time clustering of childhood leukemia in Colombia. METHODS: We included children less than 15 years of age with confirmed diagnosis of acute leukemia reported to the national surveillance system for cancer between 2009 and 2017. Kulldorff's spatio-temporal scan statistics were used with municipality and year of diagnosis as units for spatial and temporal analysis. RESULTS: There were 3846 cases of childhood leukemia between 2009 and 2017 with a specific mean incidence rate of 33 cases per million person-years in children aged 0-14 years. We identified five spatial clusters of childhood leukemia in different regions of the country and specific time clustering during the study period. CONCLUSION: Childhood leukemia seems to cluster in space and time in some regions of Colombia suggesting a common etiologic factor or conditions to be studied.

A spatial analysis of childhood cancer and industrial air pollution in a metropolitan area of Colombia.

BACKGROUND: Air pollutants are considered carcinogenic to humans. In some European countries, an association between industrial air pollution and childhood cancer has been established. This relationship has not been addressed in Latin America, despite the spatial variability of air pollutants that may limit the extrapolation of the results to other geographical areas. OBJECTIVE: To conduct a spatial analysis of the relationship between childhood cancer and proximity to industrial sources of air pollution in a metropolitan area of Colombia. METHODS: Incident cases of childhood cancers were obtained from the Population-based Cancer Registry of the Metropolitan Area of Bucaramanga during 2000-2015. Local and focused cluster tests were used for the detection of spatial clusters, and the Poisson multivariable model was used to evaluate the combined effects of spatial variables. RESULTS: The Kulldorff's focused test found a significant spatial cluster (P < 0.001) around one industrial agglomerate and the multivariable model results suggests that the distance effect is modified by the directional effect of the wind. CONCLUSION: A spatial cluster of incident cases of childhood cancer occurred in the municipality of Bucaramanga, Colombia. Our finding supports the hypothesis that childhood cancer might be related with industrial air pollution exposure in a Latin American city.

Association between air pollution and suicide: a time series analysis in four Colombian cities.

BACKGROUND: Recent epidemiological studies have suggested that air pollution could be associated with suicide. However, other studies have criticized these results for being analytically weak and not taking into account potential confounding factors. As such, further studies examining the relationship under diverse contexts are necessary to help clarify this issue. This study explored the association between specific air pollutants (NO2, SO2, PM10, PM2.5, CO and O3) and suicide incidence in four Colombian cities after adjusting for climatic variables and holidays. METHODS: A time series of daily suicides among men and women living in Bogota, Medellin, Cali and Bucaramanga was generated using information from the National Administrative Department of Statistics (DANE) for the years 2011-2014. At the same time, the average daily concentration of each air pollutant for each city was obtained from monitoring stations belonging to the National Air Quality Surveillance System. Using this information together, we generated conditional Poisson models (stratified by day, month and year) for the suicide rate in men and women, with air pollutants as the principal explanatory variable. These models were adjusted for temperature, relative humidity, precipitation and holidays. RESULTS: No association was found between any of the examined pollutants and suicide: NO2 (IRR:0.99, 95% CI: 0.95-1.04), SO2 (IRR:0.99, 95% CI: 0.98-1.01), PM10 (IRR:0.99, 95% CI:0.95-1.03), PM2.5 (IRR:1.01, 95% CI: 0.98-1.05), CO (IRR:1.00, 95% CI:1.00-1.00) and O3 (IRR: 1.00, 95% CI: 0.96-1.04). In the same way, no association was found in stratified models by sex and age group neither in lagged and cumulative effects models. CONCLUSIONS: After adjusting for major confounding factors, we found no statistically significant association between air pollution and suicide in Colombia. These "negative" results provide further insight into the current discussion regarding the existence of such a relationship.

No effect of mercury exposure on kidney function during ongoing artisanal gold mining activities in Colombia.

This cross-sectional study examined whether people who are exposed to mercury (Hg) vapours in ongoing artisanal gold mining activities have alteration in kidney function monitoring parameters. The study enrolled 164 miners and 127 participant controls. The Hg concentrations for miners and control participants were measured in blood (B-Hg; median 7.0 vs. 2.5 µg/L), urine (U-Hg; median 3.9 vs. 1.5 µg/g creatinine) and hair (H-Hg; median 0.8 vs. 0.4 µg/g hair). The biomarkers of renal function were creatinine, albumin and excretion of ß-2 microglobulin. Glomerular filtration rate (eGFR) was calculated using the chronic kidney disease epidemiology collaboration equation. Significant statistical differences were found in Hg concentrations and eGFR levels between the two study groups ( p < 0.01) but not with the other biomarkers of renal function. A multiple regression model was applied to explore the relationship of eGFR levels and Hg concentrations. However, no association was found between the prevalence of reduced eGFR (<71.96 mL/min/1.73 m2) and the B-Hg or U-Hg levels after adjustment for covariates. Nevertheless, it was observed that having B-Hg levels above 10 µg Hg/L decreased the eGFR by 1.7 mL/min/1.73 m2 (confidence interval 95% -5.1 to 1.7) compared to having levels below 2.0 µg Hg/L. Our results found no support for kidney damage associated with Hg vapour exposure in ongoing artisanal gold mining, whose population has a level of Hg exposure from low to moderate (B-Hg from 3.4 to 11.0 µg/L and U-Hg from 1.3 to 9.6 µg/g creatinine).

Technical efficiency of women's health prevention programs in Bucaramanga, Colombia: a four-stage analysis.

BACKGROUND: Primary Health Care (PHC) is an efficient strategy to improve health outcomes in populations. Nevertheless, studies of technical efficiency in health care have focused on hospitals, with very little on primary health care centers. The objective of the present study was to use the Data Envelopment Analysis to estimate the technical efficiency of three women's health promotion and disease prevention programs offered by primary care centers in Bucaramanga, Colombia. METHODS: Efficiency was measured using a four-stage data envelopment analysis with a series of Tobit regressions to account for the effect of quality outcomes and context variables. Input/output information was collected from the institutions' records, chart reviews and personal interviews. Information about contextual variables was obtained from databases from the primary health program in the municipality. A jackknife analysis was used to assess the robustness of the results. RESULTS: The analysis was based on data from 21 public primary health care centers. The average efficiency scores, after adjusting for quality and context, were 92.4 %, 97.5 % and 86.2 % for the antenatal care (ANC), early detection of cervical cancer (EDCC) and family planning (FP) programs, respectively. On each program, 12 of the 21 (57.1 %) health centers were found to be technically efficient; having had the best-practice frontiers. Adjusting for context variables changed the scores and reference rankings of the three programs offered by the health centers. CONCLUSION: The performance of the women's health prevention programs offered by the centers was found to be heterogeneous. Adjusting for context and health care quality variables had a significant effect on the technical efficiency scores and ranking. The results can serve as a guide to strengthen management and organizational and planning processes related to local primary care services operating within a market-based model such as the one in Colombia.

Intra-urban variability of long-term exposure to PM2.5 and NO2 in five cities in Colombia.

Rapidly urbanizing cities in Latin America experience high levels of air pollution which are known risk factors for population health. However, the estimates of long-term exposure to air pollution are scarce in the region. We developed intraurban land use regression (LUR) models to map long-term exposure to fine particulate matter (PM2.5) and nitrogen dioxide (NO2) in the five largest cities in Colombia. We conducted air pollution measurement campaigns using gravimetric PM2.5 and passive NO2 sensors for 2 weeks during both the dry and rainy seasons in 2021 in the cities of Barranquilla, Bucaramanga, Bogotá, Cali, and Medellín, and combined these data with geospatial and meteorological variables. Annual models were developed using multivariable spatial regression models. The city annual PM2.5 mean concentrations measured ranged between 12.32 and 15.99 µg/m3 while NO2 concentrations ranged between 24.92 and 49.15 µg/m3. The PM2.5 annual models explained 82% of the variance (R2) in Medellín, 77% in Bucaramanga, 73% in Barranquilla, 70% in Cali, and 44% in Bogotá. The NO2 models explained 65% of the variance in Bucaramanga, 57% in Medellín, 44% in Cali, 40% in Bogotá, and 30% in Barranquilla. Most of the predictor variables included in the models were a combination of specific land use characteristics and roadway variables. Cross-validation suggests that PM2.5 outperformed NO2 models. The developed models can be used as exposure estimate in epidemiological studies, as input in hybrid models to improve personal exposure assessment, and for policy evaluation.

Barriers and facilitators of academia-government collaboration in the context of the COVID-19 pandemic in Colombia: a qualitative study.

The COVID-19 pandemic highlighted the importance of strengthening collaborations between academia and government. The development and maintenance of these collaborative relationships is a complex and dynamic process, particularly during public health emergencies. This study was aimed at identifying and analysing factors that acted as barriers and facilitators in the collaboration process between academia and government during the COVID-19 pandemic in the five largest cities in Colombia. The study used a qualitative approach based on the systematization of experiences. A total of 25 semi-structured interviews were conducted with local actors from government and academia during 2021. Participants identified a variety of situations that involved individual, institutional and relational factors that acted as barriers and facilitators, and which have been previously reported in other countries and contexts not related to pandemics. Based on participant reports, two additional factors emerged, one corresponding to situations related to the pandemic management process itself and another related to structural or systemic conditions that involved government processes and the Colombian health system. Despite the challenges posed by the pandemic, the health emergency brought about shared feelings of local commitment and a willingness to work through interdisciplinary teams to address the pandemic with the least adverse effects on the community. Other facilitators of the collaborative process that were recognized were the importance of timely access to data and transparent analyses, as well as government decisions being informed by the perspectives of academics. The main barriers identified by both actors were excessive centralization of the pandemic's management and the need for rapid decision-making processes under high levels of uncertainty. In addition, the fragmentation of services in the health system posed a barrier to the interventions that were suggested by the collaborative work. Our results suggest that government-academia collaborations should be implemented as ongoing participatory processes integrating various sectors, actors and disciplines.

Altitude and COVID-19 in Colombia: An updated analysis accounting for potential confounders.

We assessed the relationship between the altitude of municipalities and the incidence, mortality, and fatality from COVID-19 and excess of mortality in Colombia between 2020 and 2022. We conducted an ecologic study including all 1122 municipalities in Colombia and used categories of altitude as main independent variable. We fit multivariable regression models for incidence, mortality, fatality rates, and excess of mortality controlling for several variables at municipality level. There was a higher incidence rate, similar mortality rate and lower case-fatality rate for COVID-19 during 2020-2022 in municipalities in the upper category of altitude (>=2500 masl) compared to the lower category (<1000 masl). The excess of mortality was lower but not statistically different in municipalities in the upper category of altitude, and significantly lower in the intermediate altitude category compared to the lowlands. Our findings provide evidence that municipalities with high altitude had similar mortality rate, and lower case-fatality rate and excess of mortality for COVID-19 compared to lowlands in Colombia.

Intraurban Geographic and Socioeconomic Inequalities of Mortality in Four Cities in Colombia.

Mortality inequalities have been described across Latin American countries, but less is known about inequalities within cities, where most populations live. We aimed to identify geographic and socioeconomic inequalities in mortality within the urban areas of four main cities in Colombia. We analyzed mortality due to non-violent causes of diseases in adults between 2015 and 2019 using census sectors as unit of analysis in Barranquilla, Bogotá, Cali, and Medellín. We calculated smoothed Bayesian mortality rates as main health outcomes and used concentration indexes (CInd) for assessing inequalities using the multidimensional poverty index (MPI) as the socioeconomic measure. Moran eigenvector spatial filters were calculated to capture the spatial patterns of mortality and then used in multivariable models of the association between mortality rates and quintiles of MPI. Social inequalities were evident but not consistent across cities. The most disadvantaged groups showed the highest mortality rates in Cali. Geographic inequalities in mortality rates, regardless of the adults and poverty distribution, were identified in each city, suggesting that other social, environmental, or individual conditions are impacting the spatial distribution of mortality rates within the four cities.