Environmental Exposure Disparities and Neurodevelopmental Risk: a Review.

PURPOSE OF REVIEW: Neurotoxicant exposures are of particular concern in historically marginalized communities. Often a consequence of structural racism, low-income minoritized populations experience a disproportionate burden of hazardous exposures through proximity to industrial facilities, high traffic roads, and suboptimal housing. Here, we summarize reports on exposures and neurodevelopment focused on differences by education, income, race/ethnicity, or immigration status from 2015 to 2022, discuss the importance of such investigations in overburdened communities, and recommend areas for future research. RECENT FINDINGS: We found 20 studies that investigated exposure disparities and neurodevelopment in children. Most were conducted in the USA, and many focused on air pollution, followed by metal exposures and water contamination. Although several studies showed differences in exposure-outcome associations by income and education, many examining differences by race/ethnicity did not report notable disparities between groups. However, measures of individual race and ethnicity are not reliable measures of discrimination experienced as a consequence of structural racism. Our review supports scientific evidence that the reduction of individual and widespread municipal exposures will improve child development and overall public health. Identified research gaps include the use of better indicators of economic status and structural racism, evaluations of effect modification and attributable fraction of outcomes by these factors, and considerations of multidimensional neighborhood factors that could be protective against environmental insults. Considering that vulnerable populations have disparities in access to and quality of care, greater burden of exposure, and fewer resources to incur associated expenses, such populations should be prioritized.

Agreement in extreme precipitation exposure assessment is modified by race and social vulnerability.

Epidemiologic investigations of extreme precipitation events (EPEs) often rely on observations from the nearest weather station to represent individuals' exposures, and due to structural factors that determine the siting of weather stations, levels of measurement error and misclassification bias may differ by race, class, and other measures of social vulnerability. Gridded climate datasets provide higher spatial resolution that may improve measurement error and misclassification bias. However, similarities in the ability to identify EPEs among these types of datasets have not been explored. In this study, we characterize the overall and temporal patterns of agreement among three commonly used meteorological data sources in their identification of EPEs in all census tracts and counties in the conterminous United States over the 1991-2020 U.S. Climate Normals period and evaluate the association between sociodemographic characteristics with agreement in EPE identification. Daily precipitation measurements from weather stations in the Global Historical Climatology Network (GHCN) and gridded precipitation estimates from the Parameter-elevation Relationships on Independent Slopes Model (PRISM) and the North American Land Data Assimilation System (NLDAS) were compared in their ability to identify EPEs defined as the top 1% of precipitation events or daily precipitation >1 inch. Agreement among these datasets is fair to moderate from 1991 to 2020. There are spatial and temporal differences in the levels of agreement between ground stations and gridded climate datasets in their detection of EPEs in the United States from 1991 to 2020. Spatial variation in agreement is most strongly related to a location's proximity to the nearest ground station, with areas furthest from a ground station demonstrating the lowest levels of agreement. These areas have lower socioeconomic status, a higher proportion of Native American population, and higher social vulnerability index scores. The addition of ground stations in these areas may increase agreement, and future studies intending to use these or similar data sources should be aware of the limitations, biases, and potential for differential misclassification of exposure to EPEs. Most importantly, vulnerable populations should be engaged to determine their priorities for enhanced surveillance of climate-based threats so that community-identified needs are met by any future improvements in data quality.

Knowledge, attitudes, and practices of Illinois medical professionals related to ticks and tick-borne disease.

Background: The rising incidence of tick-borne disease (TBD) underscores the importance of proficiency in TBD diagnosis. Clinicians' knowledge about vector ticks and TBDs in their area may influence whether patients are questioned about potential tick exposure and the consideration of diagnostic testing for TBDs. Objective: Our objective was to assess the knowledge, attitudes, and practices of Illinois clinicians towards ticks and TBDs. The study aimed to 1) identify predictors associated with knowledge, 2) identify knowledge gaps, and 3) evaluate attitudes and practices related to TBDs. Methods: A web-based knowledge, attitudes, and practices survey about Illinois ticks and TBDs was disseminated to physicians, mid-level practitioners, and nurses between August 2020 and February 2022. Poisson regression analysis was conducted to identify predictors of higher scores. Results: Of 346 respondents, 80% correctly identified Lyme disease as endemic to Illinois, and 95% were familiar with diagnostic testing for Lyme. Knowledge of other TBDs present in the state was highest among physicians, yet only 26% of physicians believed Rocky Mountain spotted fever (RMSF) to be present in Illinois, and only 17% believed ehrlichiosis to be endemic. Only 32% of physicians knew the cause of Alpha-gal syndrome and fewer than 18% were aware of available diagnostic testing. Tick or TBD-related education within the past two years was the most significant predictor of higher scores, increasing overall knowledge scores by 26% (RR 1.26, 95% CI 1.13-1.41) and increasing scores specific to TBDs by 42% (RR 1.42, 95% CI 1.19-1.69). Conclusion: Illinois clinicians were informed about Lyme disease but lacked knowledge of other TBDs endemic to the state, including RMSF, ehrlichiosis, and Alpha-gal syndrome. The strongest predictor of knowledge was tick/TBD training in the previous two years, highlighting the importance of frequent region-specific training on ticks and TBDs.

Climate Change, Environmental Disasters, and Health Inequities: The Underlying Role of Structural Inequalities.

PURPOSE OF REVIEW: We review and analyze recent literature in public health, urban planning, and disaster management to better understand the relationships between climate change, natural disasters, and root causes of health disparities in the USA. RECENT FINDINGS: Existing scholarship establishes clear linkages between climate change and increasing occurrences and severity of natural disasters across the USA. The frequency and types of disasters vary by region and impact both short and long-term health outcomes. Current research highlights health inequities affecting lower income and minoritized communities disproportionately, but data-driven studies critically examining the role of structural inequalities in climate-induced health disparities are sparse. Adding to the body of knowledge, our conceptual framework maps how long-standing structural inequalities in policy, practice, and funding shape vulnerability of lower-income, racially and ethnically marginalized individuals. Vulnerability follows three common pathways: disparities in "exposure", "sensitivity", and "resiliency" before, during, and after a climate disaster. We recommend that future research, policy, and practice shift towards solutions that unearth and address the structural biases that cause environmental disaster and health inequities.

Examining the Role of Family History of US Enslavement in Health Care System Distrust Today.

Objective: Black/African American people have long reported high, albeit warranted, distrust of the US health care system (HCS); however, Blacks/African Americans are not a homogenous racial/ethnic group. Little information is available on how the subgroup of Black Americans whose families suffered under US chattel slavery, here called Descendants of Africans Enslaved in the United States (DAEUS), view health care institutions. We compared knowledge of unethical treatment and HCS distrust among DAEUS and non-DAEUS. Design and Setting: A cross-sectional random-digit dialing survey was administered in 2005 to Blacks/African Americans, aged 21-75 years, from the University of Pennsylvania Clinical Practices in Philadelphia, Penn. Participants: Blacks/African Americans self-reported a family history of persons enslaved in the US (DAEUS) or no family history of persons enslaved in the US (non-DAEUS). Main Outcome Measures: HCS distrust was measured by a validated scale assessing perceptions of unethical experimentation and active or passive discrimination. Methods: We compared responses to the HCS distrust scale using Fisher's exact and t-tests. Results: Of 89 respondents, 57% self-reported being DAEUS. A greater percentage of DAEUS reported knowledge of unethical treatment than non-DAEUS (56% vs 21%; P<.001), were significantly more likely to express distrust, and to endorse the presence of covert (eg, insurance-based) than overt forms (eg, race-based) of discrimination by the HCS. Conclusions: DAEUS express greater HCS distrust than non-DAEUS, patterned by awareness of unethical treatment and passive discrimination. Understanding how long-term exposure to US institutions influences health is critical to resolving disparities for all Black/African American groups. Rectifying past injustices through reparative institutional measures may improve DAEUS' trust and engagement with the US HCS.

Environmental risk factors associated with pulmonary isolation of nontuberculous mycobacteria, a population-based study in the southeastern United States.

The prevalence of pulmonary nontuberculous mycobacteria (NTM) disease is increasing in the United States. Associations were evaluated among residents of central North Carolina between pulmonary isolation of NTM and environmental risk factors including: surface water, drinking water source, urbanicity, and exposures to soils favorable to NTM growth. Reports of pulmonary NTM isolation from patients residing in three counties in central North Carolina during 2006-2010 were collected from clinical laboratories and from the State Laboratory of Public Health. This analysis was restricted to patients residing in single family homes with a valid residential street address and conducted at the census block level (n = 13,495 blocks). Negative binomial regression models with thin-plate spline smoothing function of geographic coordinates were applied to assess effects of census block-level environmental characteristics on pulmonary NTM isolation count. Patients (n = 507) resided in 473 (3.4%) blocks within the study area. Blocks with >20% hydric soils had 26.8% (95% confidence interval (CI): 1.8%, 58.0%), p = 0.03, higher adjusted mean patient counts compared to blocks with ≤20% hydric soil, while blocks with >50% acidic soil had 24.8% (-2.4%, 59.6%), p = 0.08 greater mean patient count compared to blocks with ≤50% acidic soil. Isolation rates varied by county after adjusting for covariates. The effects of using disinfected public water supplies vs. private wells, and of various measures of urbanicity were not significantly associated with NTM. Our results suggest that proximity to certain soil types (hydric and acidic) could be a risk factor for pulmonary NTM isolation in central North Carolina.

Extreme Precipitation Events and Infectious Disease Risk: A Scoping Review and Framework for Infectious Respiratory Viruses.

Extreme precipitation events (EPE) change the natural and built environments and alter human behavior in ways that facilitate infectious disease transmission. EPEs are expected with high confidence to increase in frequency and are thus of great public health importance. This scoping review seeks to summarize the mechanisms and severity of impacts of EPEs on infectious diseases, to provide a conceptual framework for the influence of EPEs on infectious respiratory diseases, and to define areas of future study currently lacking in this field. The effects of EPEs are well-studied with respect to enteric, vector-borne, and allergic illness where they are shown to moderately increase risk of illness, but not well-understood in relation to infectious respiratory illness. We propose a framework for a similar influence of EPEs on infectious respiratory viruses through several plausible pathways: decreased UV radiation, increased ambient relative humidity, and changes to human behavior (increased time indoors and use of heating and cooling systems). However, limited work has evaluated meteorologic risk factors for infectious respiratory diseases. Future research is needed to evaluate the effects of EPEs on infectious respiratory diseases using individual-level case surveillance, fine spatial scales, and lag periods suited to the incubation periods of the disease under study, as well as a full characterization of susceptible, vulnerable, and sensitive population characteristics.

Racial Disparities in Hypertension Prevalence within US Gentrifying Neighborhoods.

Racial disparities in hypertension remain a persistent public health concern in the US. While several studies report Black-White differences in the health impacts of gentrification, little is known concerning the impact of living in a gentrifying neighborhood on hypertension disparities. Data from the American Community Survey were used to identify gentrifying neighborhoods across the US from 2006 to 2017. Health and demographic data were obtained for non-Hispanic Black and White respondents of the 2014 Medical Expenditure Panel Survey (MEPS) residing in gentrifying neighborhoods. Modified Poisson models were used to determine whether there is a difference in the prevalence of hypertension of individuals by their race/ethnicity for those that live in gentrifying neighborhoods across the US. When compared to Whites living within gentrifying neighborhoods, Blacks living within gentrifying neighborhoods had a similar prevalence of hypertension. The non-existence of Black-White hypertension disparities within US gentrifying neighborhoods underscores the impact of neighborhood environment on race differences in hypertension.

Impacts of Gentrification on Health in the US: a Systematic Review of the Literature.

Gentrification in the largest 50 US cities has more than doubled since the 1990s. The process of gentrification can bring about improved neighborhood conditions, reduced rates of crime, and property value increases. At the same time, it can equally foster negative conditions associated with poorer health outcomes, such as disrupted social networks from residential displacement and increases in stress. While neighborhood environment is consistently implicated in health outcomes research, gentrification is rarely conceptualized as a public health issue. Though research on gentrification is growing, empirical studies evaluating the health impacts of gentrification in the US are poorly understood. Here we systematically review US population-based empirical studies examining relationships between gentrification and health. Electronic databases (PubMed, Embase, CINAHL, PsycINFO, Scopus, Web of Science, and Academic Search Complete) were searched using a combination of terms to identify peer-reviewed studies published on or before July 9, 2018, reporting associations between gentrification and health. Study title and abstract screenings were followed by full-text review of all studies meeting the following inclusion criteria of: ≥ 1 quantitative measure of association for a health outcome, within the context of gentrification; peer-reviewed research; located in the US; and English language. Of 8937 studies identified, 6152 underwent title and abstract screening, and 50 studies underwent full-text screening, yielding six studies for review. Gentrification exposure measures and health outcomes examined varied widely. Most studies reported little to no overall association between gentrification and health outcomes; however, gentrification was repeatedly associated with undesirable health effects among Black and economically vulnerable residents. Despite seemingly overall null associations between gentrification and health, evidence suggests that gentrification may negatively impact the health of certain populations, particularly Black and low-income individuals. Complexities inherent in operationalizing gentrification point toward the need for validated measures. Additionally, understanding how gentrification-health associations differ across health endpoints, race/ethnicities, socioeconomic status, and life course can provide insight into whether this process contributes to urban inequality and health disparities. As gentrification occurs across the US, it is important to understand how this process impacts health. While aging cities reinvest in the revitalization of communities, empirical research examining relationships between gentrification and health can help inform policy decisions.

Gentrification: A Priority for Environmental Justice and Health Equity Research.

Although gentrification is occurring at increasing rates across the United States, our understanding of what this means for public health is limited. While positive changes, such as increases in property values and reduced crime rates occur, negative consequences, such as residential displacement, also ensue. Individuals living through gentrification experience major changes in social and environmental conditions often in short periods of time, which can result in disrupted social networks and stress, both associated with decrements in health. As neighborhoods across the United States undergo revitalization, understanding health effects of gentrification, positive and negative, is paramount. We posit that gentrification may be beneficial in some aspects of health and detrimental in others. To address current challenges in the gentrification-health literature, we recommend future research: 1) examine the gentrification processes and stages; 2) integrate built, natural, and social environment metrics; and 3) assess mediating and moderating associations. As gentrification expands across the United States, research conducted in this area is poised for timely contributions to equitable development and urban planning policies.

A spatial analysis of climate gentrification in Orleans Parish, Louisiana post-Hurricane Katrina.

BACKGROUND: Hurricane Katrina made landfall in New Orleans, Louisiana as a Category 3 storm in August 2005. Storm surges, levee failures, and the low-lying nature of New Orleans led to widespread flooding, damage to over 70% of occupied housing, and evacuation of 80-90% of city residents. Only 57% of the city's black population has returned. Many residents complain of gentrification following rebuilding efforts. Climate gentrification is a recently described phenomenon whereby the effects of climate change, most notably rising sea levels and more frequent flooding and storm surges, alter housing values in a way that leads to gentrification. OBJECTIVE: To examine the climate gentrification following hurricane Katrina by (1) estimating the associations between flooding severity, ground elevation, and gentrification and (2) whether these relationships are modified by neighborhood level pre- and post-storm sociodemographic factors. METHODS: Lidar data collected in 2002 were used to determine elevation. Water gauge height of Lake Ponchartrain was used to estimate flood depth. Using census tracts as a proxy for neighborhoods, demographic, housing, and economic data from the 2000 decennial census and the 2010 and 2015 American Community Survey 5-year estimates US Census records were used to determine census tracts considered eligible for gentrification (median income < 2000 Orleans Parish median income). A gentrification index was created using tract changes in education level, population above the poverty limit, and median household income. Proportional odds ordinal logistic regression was used with product terms to test for effect measure modification by sociodemographic factors. RESULTS: Census tracts eligible for gentrification in 2000 were 80.2% black. Median census tract flood depth was significantly lower in areas eligible to undergo gentrification (0.70 m vs. 1.03 m). Residents of gentrification-eligible tracts in 2000 were significantly more likely to be black, less educated, lower income, unemployed, and rent their home rather than own. In 2015 in these same eligible tracts, areas that underwent gentrification became significantly whiter, more educated, higher income, less unemployed, and more likely to live in a multi-unit dwelling. Gentrification was inversely associated with flood depth and directly associated with ground elevation in eligible tracts. Marginal effect modification was detected by the effect of pre-storm black race on the relationships of flood depth and elevation with gentrification. CONCLUSIONS: Gentrification was strongly associated with higher ground elevation in New Orleans. These results provide evidence to support the idea of climate gentrification described in other low-elevation major metropolitan areas like Miami, FL. High elevation, low-income, demographically transitional areas in particular - that is areas that more closely resemble high-income area demographics, may be vulnerable to future climate gentrification.

Ambient air pollution as a mediator in the pathway linking race/ethnicity to blood pressure elevation: The multi-ethnic study of atherosclerosis (MESA).

BACKGROUND: Racial/ethnic disparities in blood pressure and hypertension have been evident in previous studies, as were associations between race/ethnicity with ambient air pollution and those between air pollution with hypertension. The role of air pollution exposure to racial/ethnic differences in hypertension has not been explored. OBJECTIVE: To assess the potential mediating effects of ambient air pollution on the association between race/ethnicity and blood pressure levels. METHODS: We studied 6,463 White, Black, Hispanic and Chinese adults enrolled across 6 US cities. Systolic (SBP) and diastolic blood pressure (DBP) were measured at Exam 1 (2000-2002) and Exam 2 (2002-2004). Household-level annual average concentrations of fine particulate matter (PM2.5), oxides of nitrogen (NOX), and ozone (O3) for the year 2000 were estimated for participants. RESULTS: The difference in SBP levels by race/ethnicity that was related to higher PM2.5 concentrations compared with White men ("indirect associations") was 0.3 (95% CI: 0.1, 0.6) mmHg for Black men, 0.3 (95% CI: 0.1, 0.6) mmHg for Hispanic men and 1.0 (95% CI: 0.2, 1.8) mmHg for Chinese men. Findings were similar although not statistically significant for women. PM2.5 did not mediate racial/ethnic differences in DBP. Indirect associations were significant for O3 for SBP among women and men and for DBP among men. In contrast, racial/ethnic disparities were attenuated due to exposure to NOX. CONCLUSION: Racial disparities in blood pressure were reduced after accounting for PM2.5 and ozone while increased after accounting for NOX.

Application of diagnostic criteria for non-tuberculous mycobacterial disease to a case series of mycobacterial-positive isolates.

The American Thoracic Society (ATS) and Infectious Diseases Society of America (IDSA) have provided guidelines to assist in the accurate diagnosis of lung disease caused by nontuberculous mycobacteria (NTM). These microbiologic, radiographic, and clinical criteria are considered equally important and all must be met to make the diagnosis of NTM lung disease. To assess the significance of the three criteria, each was evaluated for its contribution to the diagnosis of NTM lung disease in a case series. Laboratory reports of any specimen positive for NTM isolation were collected between January 1, 2006 and December 31, 2010 at a university medical center. Medical records were reviewed in detail using a standardized form. The total number of patients with a culture from any site positive for NTM was 297 while the number from respiratory specimens during the same period was 232 (78%). Samples from two of these patients also yielded M. tuberculosis complex and were excluded. While 128 of the remaining 230 patients (55.7%) in the cohort met the microbiologic criterion for diagnosis of NTM lung disease, 151 (65.6%) and 189 (78.3%) met the radiologic and clinical criteria respectively. Only 78 patients (33.9%) met all three criteria provided by the ATS/IDSA for diagnosis of NTM lung disease. This evaluation reaffirms that defining NTM lung disease using either one or two of the criteria provided by the 2007 ATS/IDSA guidelines may significantly overestimate the number of cases of NTM lung disease. Based on the experience of defining NTM lung disease in this case series, recommendations for modification of the ATS/IDSA guidelines are provided which include expansion of both radiologic patterns and the list of symptoms associated with NTM lung disease.

Disentangling Race, Poverty, and Place in Disparities in Physical Activity.

Significant racial disparities in physical activity-a key protective health factor against obesity and cardiovascular disease-exist in the United States. Using data from the 1999-2004 National Health and Nutrition Examination Survey and the 2000 United States (US) Census, we estimated the impact of race, individual-level poverty, neighborhood-level poverty, and neighborhood racial composition on the odds of being physically active for 19,678 adults. Compared to whites, blacks had lower odds of being physically active. Individual poverty and neighborhood poverty were associated with decreased odds of being physically active among both whites and blacks. These findings underscore the importance of social context in understanding racial disparities in physical activity and suggest the need for future research to determine specific elements of the social context that drive disparities.

Extreme precipitation and emergency room visits for influenza in Massachusetts: a case-crossover analysis.

BACKGROUND: Influenza peaks during the wintertime in temperate regions and during the annual rainy season in tropical regions - however reasons for the observed differences in disease ecology are poorly understood. We hypothesize that episodes of extreme precipitation also result in increased influenza in the Northeastern United States, but this association is not readily apparent, as no defined 'rainy season' occurs. Our objective was to evaluate the association between extreme precipitation (≥ 99th percentile) events and risk of emergency room (ER) visit for influenza in Massachusetts during 2002-2008. METHODS: A case-crossover analysis of extreme precipitation events and influenza ER visits was conducted using hospital administrative data including patient town of residence, date of visit, age, sex, and associated diagnostic codes. Daily precipitation estimates were generated for each town based upon data from the National Oceanic and Atmospheric Administration. Odds ratio (OR) and 95% confidence intervals (CI) for associations between extreme precipitation and ER visits for influenza were estimated using conditional logistic regression. RESULTS: Extreme precipitation events were associated with an OR = 1.23 (95%CI: 1.16, 1.30) for ER visits for influenza at lag days 0-6. There was significant effect modification by race, with the strongest association observed among Blacks (OR = 1.48 (1.30, 1.68)). CONCLUSIONS: We observed a positive association between extreme precipitation events and ER visits for influenza, particularly among Blacks. Our results suggest that influenza is associated with extreme precipitation in a temperate area; this association could be a result of disease ecology, behavioral changes such as indoor crowding, or both. Extreme precipitation events are expected to increase in the Northeastern United States as climate change progresses. Additional research exploring the basis of this association can inform potential interventions for extreme weather events and influenza transmission.

Epidemiology of nontuberculous mycobacteria isolations among central North Carolina residents, 2006-2010.

BACKGROUND: Nontuberculous mycobacteria (NTM) are environmental mycobacteria associated with a range of infections. Reports of NTM epidemiology have primarily focused on pulmonary infections and isolations, however extrapulmonary infections of the skin, soft tissues and sterile sites are less frequently described. METHODS: We comprehensively reviewed laboratory reports of NTM isolation from North Carolina residents of three counties during 2006-2010. We describe age, gender, and race of patients, and anatomic site of isolation for NTM species. RESULTS: Among 1033 patients, overall NTM isolation prevalence was 15.9/100,000 persons (13.7/100,000 excluding Mycobacterium gordonae). Prevalence was similar between genders and increased significantly with age. Extrapulmonary isolations among middle-aged black males and pulmonary isolations among elderly white females were most frequently detected. Most isolations from pulmonary sites and blood cultures were Mycobacterium avium complex; rapidly growing NTM (e.g. Mycobacterium chelonae, Mycobacterium fortuitum) were most often isolated from paranasal sinuses, wounds and skin. CONCLUSIONS: We provide the first characterization of NTM isolation prevalence in the Southeastern United States (U.S.). Variation in isolation prevalence among counties and races likely represent differences in detection, demographics and risk factors. Further characterization of NTM epidemiology is increasingly important as percentages of immunocompromised individuals and the elderly increase in the U.S.

Air Pollution and Pulmonary Tuberculosis: A Nested Case-Control Study among Members of a Northern California Health Plan.

BACKGROUND: Ecologic analyses, case-case comparisons, and animal experiments suggest positive associations between air pollution and tuberculosis. OBJECTIVES: We evaluated this hypothesis in a large sample, which yielded results that are applicable to the general population. METHODS: We conducted a case-control study nested within a cohort of Kaiser Permanente of Northern California members. All active pulmonary tuberculosis (TB) cases newly diagnosed between 1996 and 2010 (n = 2,309) were matched to two controls (n = 4,604) by age, sex, and race/ethnicity on the index date corresponding with the case diagnosis date. Average individual-level concentrations of carbon monoxide (CO), nitrogen dioxide (NO2), sulfur dioxide (SO2), ozone (O3), and particulate matter with aerodynamic diameter ≤ 2.5 µm (PM2.5) and 10 µm (PM10) for 2 years before diagnosis/entry into the study were estimated using measurements from the California Air Resources Board monitor closest to the participant's residence. RESULTS: In single-pollutant adjusted conditional logistic regression models, the pulmonary TB odds ratios (95% confidence intervals) for the highest quintile (vs. lowest) were 1.50 (95% CI: 1.15, 1.95) for CO and 1.42 (95% CI: 1.10, 1.84) for NO2. Corresponding estimates were higher among never [1.68 (95% CI: 1.26, 2.24)] than ever [1.19 (95% CI: 0.74, 1.92)] smokers for CO. In contrast, for NO2, estimates were higher among ever [1.81 (95% CI: 1.13, 2.91)] than never [1.29 (95% CI: 0.97, 1.71)] smokers. O3 was inversely associated for smokers [0.66 (95% CI: 0.43, 1.02)] and never smokers [0.65 (95% CI: 0.52, 0.81)]. No other consistent patterns were observed. CONCLUSIONS: In this first, to our knowledge, U.S. nested case-control study on air pollution and pulmonary TB, we observed positive associations with ambient CO and NO2, which require confirmation. CITATION: Smith GS, Van Den Eeden SK, Garcia C, Shan J, Baxter R, Herring AH, Richardson DB, Van Rie A, Emch M, Gammon MD. 2016. Air pollution and pulmonary tuberculosis: a nested case-control study among members of a Northern California health plan. Environ Health Perspect 124:761-768; http://dx.doi.org/10.1289/ehp.1408166.

Cigarette smoking and pulmonary tuberculosis in northern California.

BACKGROUND: A positive association between smoking and increased risk of tuberculosis disease is well documented for populations outside the USA. However, it is unclear whether smoking increases risk of tuberculosis in the USA, where both smoking prevalence and disease rates are much lower than in the countries where previous studies have been conducted. METHODS: To explore the tuberculosis-smoking association in a more generalisable US population-based sample, we conducted a nested case-control study among members of Kaiser Permanente Northern California (KPNC). We identified all newly diagnosed cases of active pulmonary tuberculosis (PTB) disease between 1996 and 2010. Each of the 2380 cases were individually matched to two controls by age, gender and race/ethnicity. ORs and 95% CIs for the association between smoking status and PTB were calculated using conditional logistic regression adjusted for all matching factors. RESULTS: Increased PTB risk was observed among ever-smokers (OR=1.35; 95% CI 1.19 to 1.53), as well as current (OR=1.26; 95% CI 1.08 to 1.48) and past (OR=1.43; 95% CI 1.23 to 1.67) smokers, compared with never-smokers. Increased intensity and duration of smoking were also positively associated with PTB risk. CONCLUSIONS: Our findings among a more generalisable US population support the hypothesis that smoking increases risk of PTB, underscoring the importance of tobacco cessation and prevention programmes in eliminating tuberculosis.

Trends in gastroenteritis-associated mortality in the United States, 1985-2005: variations by ICD-9 and ICD-10 codes.

BACKGROUND: Trends in gastroenteritis-associated mortality are changing over time with development of antibiotic resistant strains of certain pathogens, improved diagnostic methods, and changing healthcare. In 1999, ICD-10 coding was introduced for mortality records which can also affect trends. We assess trends in gastroenteritis-associated mortality and changes associated with coding. METHODS: Trends in gastroenteritis-associated mortality rates in the United States were examined using the National Center for Health Statistics Multiple Cause-of-Death Mortality databases for 1985-2005. All deaths with the underlying cause or any contributing cause included gastroenteritis were included. Cases were selected based on ICD9 (pre-1999) and ICD10 (1999-2005) codes and all analyses were stratified by ICD usage. Annual trends in age adjusted mortality rates were assessed using linear regression spline analysis. Relative risks and 95% confidence intervals (CIs) were calculated using Poisson regression adjusted for age group, sex, race, and region. RESULTS: There were a total of 190,674 deaths related to gastroenteritis in the U.S. from 1985-2005 with an average of 9,080 per year. During this time the percent of deaths related to gastroenteritis more than tripled, increasing from 0.25% to 0.80% of all deaths. Though the time periods varied in length, we demonstrate a significant increase in slope from a 0.0054% annual increase during the period 1985-1998, when ICD-9 coding was used, to a 0.0550% annual increase during 1999-2005, when ICD-10 coding was used. For both time periods, the oldest age group (75+ years) demonstrated the highest risk of death due to gastroenteritis. Additionally, males demonstrated higher risk than females and blacks were at higher risk than whites for death due to gastroenteritis. CONCLUSIONS: This analysis demonstrates the public health burden of gastroenteritis-associated mortality in the United States and changes in trends due to change from ICD-9 to ICD-10 coding. The overall rate of gastroenteritis-associated mortality has more than tripled over the 21-year period from 1985 to 2005 and the primary burden of deaths due to gastroenteritis is in the elderly population.

Particulate air pollution and susceptibility to the development of pulmonary tuberculosis disease in North Carolina: an ecological study.

Although Mycobacterium tuberculosis is the causative agent of pulmonary tuberculosis (PTB), environmental factors may influence disease progression. Ecologic studies conducted in countries outside the USA with high levels of air pollution and PTB have suggested a link between active disease and ambient air pollution. The present investigation is the first to examine the ambient air pollution-PTB association in a country, where air pollution levels are comparatively lower. We used Poisson regression models to examine the association of outdoor air pollutants, PM10 and PM2.5 with rates of PTB in North Carolina residents during 1993-2007. Results suggest a potential association between long-term exposure to particulate matter (PM) and PTB disease. In view of the high levels of air pollution and high rates of PTB worldwide, a potential association between ambient air pollution and tuberculosis warrants further study.