The Association of Ambient Temperature with Extremely Preterm Births.

INTRODUCTION: Extremely preterm births (EPT), require complex decision making and significant medical interventions. While environmental factors such as ambient temperature extremes have been associated with preterm births, little is known of the environmental associations with EPT births. The objective of this study is to explore whether ambient temperature is associated with increased risk of EPT birth. METHODS: Birth records for 315,226 infants born in Queensland Australia (2007-2015) were matched to average maximum and minimum temperature for the last month of pregnancy. Odds ratios and 95% confidence intervals were calculated using a generalised linear model. Population attributable risk was calculated for a 5% reduction in maximum temperature. RESULTS: Each one degree increase in maximum [aOR 1.03 (95% CI 1.01, 1.05)] and minimum temperature [aOR 1.02 (95% CI 1.01, 1.04)] was associated with an increase in odds for EPT birth. Increased odds for EPT births was found for maternal smoking [aOR 1.46 (95% CI 1.23, 1.72)], increasing plurality [OR 6.38 (95% CI 5.48, 7.42)] and stillbirth [aOR 342.99 (95% CI 295.53, 398.06)]. When stratified by birth status, the association was only found for live births. DISCUSSION: Higher temperatures are associated with small increases in the odds of delivering an infant in the EPT period. The risk may be enhanced for women who smoke during pregnancy. Women at an increased risk of preterm births should be counselled around methods to reduce their exposure to excessive heat.

Development of a questionnaire-based insecticide exposure assessment method and comparison with urinary insecticide biomarkers in young Australian children.

Environmental and behavioural factors assessed via an online questionnaire were compared to insecticide metabolite concentrations in urine collected from 61 children from South East Queensland, Australia. Metabolite concentrations (µg/L urine) were transformed using the natural logarithm prior to regression analysis and adjusted for age and creatinine. A significant dietary association was reported for vegetable intake and 3-phenoxybenzoic acid (3-PBA) (ß: 1.47 for top quartile of intake versus bottom quartile of intake 95% CI: 0.36, 2.57). Intake of vegetables and fruit were also positively associated with sum non-specific organophosphate metabolites (Æ©nsOP). Æ©nsOP concentrations were lower when fruits and vegetables were always or almost always washed prior to cooking or eating (ß: -0.69 95% CI: -1.25, -0.12). In multivariable modelling 3-PBA concentrations were also associated with hand-washing frequency (ß: 1.69 95% CI: 0.76, 2.61 for <1 day versus > 3 day), presence of a dog in the home (ß: 0.73 95% CI: 0.07, 1.38), frequency of pest-spray use in the summer months (ß: 0.88 95% CI: 0.22, 1.54 weekly versus less than weekly) and season (ß: 0.88 95% CI: 0.32, 1.44 for spring/summer versus winter/autumn). This is the first study in Australia to report dietary, behavioural and environmental factors associated with biomarkers of insecticide exposure in young children.

Concentrations of organophosphate flame retardants and plasticizers in urine from young children in Queensland, Australia and associations with environmental and behavioural factors.

In recent years, the production and usage volumes of organophosphate flame retardants (OPFRs) has increased substantially. Certain OPFRs are suspected reproductive toxins, carcinogenic, and neurotoxic. Insufficient information is available on human exposure pathways to these chemicals, particularly in Australia. We aim to assess the association between OPFR concentrations in the urine of children to environmental and behavioural risk factors. Concentrations of eight OPFRs and eleven metabolites were measured in the urine of 51 children, aged 3-29 months, in Southeast Queensland, Australia and compared to their behavioural and environmental risk factor data obtained by an online questionnaire. Of the 11 OPFR metabolites analysed, 55% were frequently detected in the majority (> 80%) of samples. The most frequently detected metabolite was bis(1,3-dichloroisopropyl) phosphate (BDCIPP) (detected in 100% of samples), followed by 1-hydroxy-2-propyl bis(1-chloro-2-propyl) phosphate (BCIPHIPP) (96%), diphenyl phosphate (DPHP) (94%) and bis(1-chloroisopropyl) phosphate (BCIPP) (86%). In multivariable modelling, age was positively associated with concentrations of bis(2-butoxyethyl) phosphate (BBOEP) and negatively associated with concentrations of BCIPP and BCIPHIPP. Other non-age related factors, including vacuuming frequency, hand-washing frequency and presence and number of some electrical appliances in the home were also associated with concentrations of OPFR metabolites.

The application of system dynamics modelling to environmental health decision-making and policy - a scoping review.

BACKGROUND: Policy and decision-making processes are routinely challenged by the complex and dynamic nature of environmental health problems. System dynamics modelling has demonstrated considerable value across a number of different fields to help decision-makers understand and predict the dynamic behaviour of complex systems in support the development of effective policy actions. In this scoping review we investigate if, and in what contexts, system dynamics modelling is being used to inform policy or decision-making processes related to environmental health. METHODS: Four electronic databases and the grey literature were systematically searched to identify studies that intersect the areas environmental health, system dynamics modelling, and decision-making. Studies identified in the initial screening were further screened for their contextual, methodological and application-related relevancy. Studies deemed 'relevant' or 'highly relevant' according to all three criteria were included in this review. Key themes related to the rationale, impact and limitation of using system dynamics in the context of environmental health decision-making and policy were analysed. RESULTS: We identified a limited number of relevant studies (n = 15), two-thirds of which were conducted between 2011 and 2016. The majority of applications occurred in non-health related sectors (n = 9) including transportation, public utilities, water, housing, food, agriculture, and urban and regional planning. Applications were primarily targeted at micro-level (local, community or grassroots) decision-making processes (n = 9), with macro-level (national or international) decision-making to a lesser degree. There was significant heterogeneity in the stated rationales for using system dynamics and the intended impact of the system dynamics model on decision-making processes. A series of user-related, technical and application-related limitations and challenges were identified. None of the reported limitations or challenges appeared unique to the application of system dynamics within the context of environmental health problems, but rather to the use of system dynamics in general. CONCLUSIONS: This review reveals that while system dynamics modelling is increasingly being used to inform decision-making related to environmental health, applications are currently limited. Greater application of system dynamics within this context is needed before its benefits and limitations can be fully understood.

Mortality and morbidity in populations in the vicinity of coal mining: a systematic review.

BACKGROUND: Evidence of the association of coal mining with health outcomes such as increased mortality and morbidity in the general population has been provided by epidemiological studies in the last 25 years. Given the diverse sources of data included to investigate different health outcomes in the exposed populations, the International Classification of Diseases (ICD) can be used as a single classification standard to compare the findings of studies conducted in different socioeconomic and geographic contexts. The ICD classifies diagnoses of diseases and other disorders as codes organized by categories and chapters. OBJECTIVES: Identify the ICD codes found in studies of morbidity and/or mortality in populations resident or in proximity of coal mining and assess the methods of these studies conducting a systematic review. METHODS: A systematic database search of PubMed, EMBASE and Scopus following the PRISMA protocol was conducted to assess epidemiological studies from 1990 to 2016. The health outcomes were mapped to ICD codes and classified by studies of morbidity and/or mortality, and the categories and chapters of the ICD. RESULTS: Twenty-eight epidemiological studies with ecological design from the USA, Europe and China were included. The exposed populations had increased risk of mortality and/or morbidity by 78 ICD diagnosis categories and 9 groups of ICD categories in 10 chapters of the ICD: Neoplasms, diseases of the circulatory, respiratory and genitourinary systems, metabolic diseases, diseases of the eye and the skin, perinatal conditions, congenital and chromosomal abnormalities, and external causes of morbidity. Exposed populations had non-increased risk of 9 ICD diagnosis categories of diseases of the genitourinary system, and prostate cancer. CONCLUSIONS: There is consistent evidence of the association of coal mining with a wide spectrum of diseases in populations resident or in proximity of the mining activities. The methods of the studies included in this review can be integrated with individual-level and longitudinal studies to provide further evidence of the exposure pathways linked to increased risk in the exposed populations.

Examination of Child and Adolescent Hospital Admission Rates in Queensland, Australia, 1995-2011: A Comparison of Coal Seam Gas, Coal Mining, and Rural Areas.

Objectives At present, coal seam gas (CSG) is the most common form of unconventional natural gas development occurring in Australia. Few studies have been conducted to explore the potential health impacts of CSG development on children and adolescents. This analysis presents age-specific hospitalisation rates for a child and adolescent cohort in three study areas in Queensland. Methods Three geographic areas were selected: a CSG area, a coal mining area, and a rural area with no mining activity. Changes in area-specific hospital admissions were investigated over the period 1995-2011 in a series of negative binomial regression analyses for 19 International Classification of Diseases (ICD) chapters, adjusting for sociodemographic factors. Results The strongest associations were found for respiratory diseases in 0-4 year olds (7% increase [95% CI 4%, 11%] and 6% increase [95% CI 2%, 10%] in the CSG area relative to the coal mining and rural areas, respectively) and 10-14 year olds (9% increase [95% CI 1%, 18%] and 11% increase [95% CI 1%, 21%] in the CSG area compared to the coal mining and rural areas, respectively). The largest effect size was for blood/immune diseases in 5-9 year olds in the CSG area (467% increase [95% CI 139%, 1244%]) compared to the rural area with no mining activity. Conclusions for Practice Higher rates of hospitalisation existed in the CSG area for certain ICD chapters and paediatric age groups, suggesting potential age-specific health impacts. This study provides insights on associations that should be explored further in terms of child and adolescent health.

Polybrominated diphenyl ether flame retardant concentrations in faeces from young children in Queensland, Australia and associations with environmental and behavioural factors.

The aim of our study was to investigate children's exposure to the flame retardants polybrominated diphenyl ethers (PBDEs) by analysing faecal content, a non-invasive matrix, as well as responses to an exposure-assessment questionnaire. A convenience sample of 61 parents with children (aged >3 months to <2 years) completed an online pre-tested questionnaire and provided faecal samples for analysis by high resolution gas chromatography/mass spectrometry. BDE-209 was the dominant congener in faecal samples adjusted to 8.3ng/g dry weight (dw), with >80% samples above the limit of detection (LOD). BDE-47 (0.23ng/g dw) and BDE-153 (0.03ng/g dw) were each detected above the LOD in approximately 60% of samples. Age was associated with BDE-47 (-7%/month) and BDE-153 (-12%/month) concentrations in faeces, but not BDE-209. Other variables associated with PBDE concentrations included features of the home (carpet, pets) and behaviour (hand-to-mouth, removing shoes, using a car sunshade, frequency of walks outdoors). However, given the small sample size of this study additional research is required to confirm these findings. In this study we demonstrated that faeces may be a viable alternative to monitor human exposure to PBDEs, but further validation studies are required.

Quantification of hookworm ova from wastewater matrices using quantitative PCR.

A quantitative PCR (qPCR) assay was used to quantify Ancylostoma caninum ova in wastewater and sludge samples. We estimated the average gene copy numbers for a single ovum using a mixed population of ova. The average gene copy numbers derived from the mixed population were used to estimate numbers of hookworm ova in A. caninum seeded and unseeded wastewater and sludge samples. The newly developed qPCR assay estimated an average of 3.7×103 gene copies per ovum, which was then validated by seeding known numbers of hookworm ova into treated wastewater. The qPCR estimated an average of (1.1±0.1), (8.6±2.9) and (67.3±10.4) ova for treated wastewater that was seeded with (1±0), (10±2) and (100±21) ova, respectively. The further application of the qPCR assay for the quantification of A. caninum ova was determined by seeding a known numbers of ova into the wastewater matrices. The qPCR results indicated that 50%, 90% and 67% of treated wastewater (1L), raw wastewater (1L) and sludge (~4g) samples had variable numbers of A. caninum gene copies. After conversion of the qPCR estimated gene copy numbers to ova for treated wastewater, raw wastewater, and sludge samples, had an average of 0.02, 1.24 and 67 ova, respectively. The result of this study indicated that qPCR can be used for the quantification of hookworm ova from wastewater and sludge samples; however, caution is advised in interpreting qPCR generated data for health risk assessment.

All-age hospitalization rates in coal seam gas areas in Queensland, Australia, 1995-2011.

BACKGROUND: Unconventional natural gas development (UNGD) is expanding globally, with Australia expanding development in the form of coal seam gas (CSG). Residents and other interest groups have voiced concerns about the potential environmental and health impacts related to CSG. This paper compares objective health outcomes from three study areas in Queensland, Australia to examine potential environmentally-related health impacts. METHODS: Three study areas were selected in an ecologic study design: a CSG area, a coal mining area, and a rural/agricultural area. Admitted patient data, as well as population data and additional factors, were obtained for each calendar year from 1995 through 2011 to calculate all-age hospitalization rates and age-standardized rates in each of these areas. The three areas were compared using negative binomial regression analyses (unadjusted and adjusted models) to examine increases over time of hospitalization rates grouped by primary diagnosis (19 ICD chapters), with rate ratios serving to compare the within-area regression slopes between the areas. RESULTS: The CSG area did not have significant increases in all-cause hospitalization rates over time for all-ages compared to the coal and rural study areas in adjusted models (RR: 1.02, 95 % CI: 1.00-1.04 as compared to the coal mining area; RR: 1.01, 95 % CI: 0.99-1.04 as compared to the rural area). While the CSG area did not show significant increases in specific hospitalization rates compared to both the coal mining and rural areas for any ICD chapters in the adjusted models, the CSG area showed increases in hospitalization rates compared only to the rural area for neoplasms (RR: 1.09, 95 % CI: 1.02-1.16) and blood/immune diseases (RR: 1.14, 95 % CI: 1.02-1.27). CONCLUSIONS: This exploratory study of all-age hospitalization rates for three study areas in Queensland suggests that certain hospital admissions rates increased more quickly in the CSG study area than in other study areas, particularly the rural area, after adjusting for key sociodemographic factors. These findings are an important first step in identifying potential health impacts of CSG in the Australian context and serve to generate hypotheses for future studies.

Assessing exposure of young children to common endocrine-disrupting chemicals in the home environment: a review and commentary of the questionnaire-based approach.

BACKGROUND: Although infants and young children are particularly vulnerable to endocrine disrupting chemical (EDC) exposure, there is an absence of comprehensive exposure data for this age group. As young children spend the majority of their time indoors, improved methods of exposure assessment are needed to characterise the health risks from exposures in the home environment. Biologic assessment, which has been considered the gold standard for exposure assessment in recent years, is difficult to conduct in young children. Questionnaires are an alternative and indirect method of predicting exposure, which may overcome some of the limitations of direct exposure assessment. RESEARCH PROBLEM: The feasibility of using a questionnaire-based approach to predict exposure of young children to EDCs in the home has yet to be comprehensively reviewed. Moreover, there is no one questionnaire that has been validated for predicting the exposure of infants to common EDCs in the home. AIMS AND OBJECTIVES: The aim of this review is to discuss the use and validation of the questionnaire-based approach to predict exposure of children to chemicals from three common classes of EDCs in the home, namely, plasticisers, flame retardants, and insecticides. We discuss the strengths and weaknesses of the questionnaire-based approach as well as the important pathways of exposure in the home environment, by which to guide the design and validation of future exposure questionnaires. RESULTS: The findings from our review indicate that the questionnaire-based approach is a valuable tool in the prediction of exposure to persistent organic pollutants, as well as to toxicants that have consistent patterns of exposure. With improvements to the design and validation process, the questionnaire-based approach may also prove to be a reliable instrument in predicting exposure to EDCs with short-half lives, including bisphenol A, phthalates, and pyrethroid and organophosphate insecticides.

Household Food Insecurity Negatively Impacts Diet Diversity in the Vietnamese Mekong Delta: A Cross-Sectional Study.

Healthy, diverse diets are vital for life. In low/middle-income countries, however, the focus is more on food quantity rather than diet quality. This study assessed household diet diversity (HDD) in the Vietnamese Mekong Delta and its associations with household food insecurity (HFI) and household food availability (HFA) controlling for socioeconomic factors. Primary food-preparers in 552 randomly selected households in two rural provinces were interviewed about socioeconomic factors, HDD, HFI, and HFA. More than 80% of households predominantly consumed energy-dense foods, whereas less than 20% consumed nutrient-dense foods. Lower HDD was associated with HFI, lower HFA, for the Khmer ethnic minority, and low livelihood capitals (landlessness, low expenditure, debt) and low utensil scores. The study highlighted the need to provide improved food and nutrition policies that increase availability and access to diverse and healthy foods as well as reduce poverty and increase incomes for at-risk rural and ethnic minority groups.

A framework for assessing and predicting the environmental health impact of infectious diseases: a case study of leptospirosis.

This article demonstrates the practical application of an integrated environmental health impact assessment (IEHIA)methodology to investigate an infectious disease (leptospirosis)and the value of using such an approach to estimate future health impact. The assessment described the current health impact (using leptospirosis seroprevalence as a proxy measure)and estimated the future health impact based on scenarios that included indicators of different risk factors. The application of an IEHIA methodology to assess the health impact of an infectious disease was shown to enhance the ability to quantify associations between a disease agent and its health impact by taking into account the environmental drivers of transmission, human behaviour, socio economic factors, and the multiple pathways through which exposure and infection could occur.

Assessment of Environmental Impacts on Health: Examples from the Pacific Basin.

Assessing environmental impacts on health in the Pacific Basin is challenged by significantly varying data types - quantities, qualities, and paucities - because of varying geographic sizes, environments, biodiversity, ecological assets, and human population densities, with highly varied and unequal socio-economic development and capacity to respond to environmental and health challenges. We discuss three case-based methodological examples from Pacific Basin environmental health impact assessments. These methods could be used to improve environmental health evidence at all country and regional levels across a spectrum of big data availability to no data. These methods are, 1) a risk assessment of airborne particulate matter in Korea based on the chemical composition of these particulates; 2) the use of system dynamics to appraise the influences of a range of environmental health determinants on child health outcomes in remote Solomon Islands; and 3) precision environmental public health methodologies based on comprehensive data collection, analyses, and modelling (including Bayesian belief networks and spatial epidemiology) increasing precision for good environmental health decision making to prevent and control a zoonotic disease in Fiji Islands. We show that while a common theme across the three examples is the value of high quality and quantity data to support stronger policy decisions and appropriate prioritizing of investment, it is also clear that for many countries in the Pacific Basin, sufficient data will remain a challenge to inform decision makers about environmental impact on health.

Mapping the Morbidity Risk Associated with Coal Mining in Queensland, Australia.

The populations in the vicinity of surface coal mining activities have a higher risk of morbidity due to diseases, such as cardiovascular, respiratory and hypertensive diseases, as well as cancer and diabetes mellitus. Despite the large and historical volume of coal production in Queensland, the main Australian coal mining state, there is little research on the association of coal mining exposures with morbidity in non-occupational populations in this region. This study explored the association of coal production (Gross Raw Output-GRO) with hospitalisations due to six disease groups in Queensland using a Bayesian spatial hierarchical analysis and considering the spatial distribution of the Local Government Areas (LGAs). There is a positive association of GRO with hospitalisations due to circulatory diseases (1.022, 99% CI: 1.002-1.043) and respiratory diseases (1.031, 95% CI: 1.001-1.062) for the whole of Queensland. A higher risk of circulatory, respiratory and chronic lower respiratory diseases is found in LGAs in northwest and central Queensland; and a higher risk of hypertensive diseases, diabetes mellitus and lung cancer is found in LGAs in north, west, and north and southeast Queensland, respectively. These findings can be used to support public health strategies to protect communities at risk. Further research is needed to identify the causal links between coal mining and morbidity in non-occupational populations in Queensland.

Household water and food insecurity negatively impacts self-reported physical and mental health in the Vietnamese Mekong Delta.

INTRODUCTION: Household food insecurity and inadequate water, sanitation, and hygiene (WASH) contribute to ill health. However, the interactions between household food insecurity, WASH and health have been rarely assessed concurrently. This study investigated compounded impacts of household food insecurity and WASH on self-reported physical and mental health of adults in the Vietnamese Mekong Delta. MATERIALS AND METHODS: This cross-sectional survey interviewed 552 households in one northern and one southern province of the Vietnamese Mekong Delta. The survey incorporated previously validated tools such as the Short Form 12-item Health Survey, Household Food Insecurity Assessment Scale, and the Access and Behavioural Outcome Indicators for Water, Sanitation, and Hygiene. Physical and mental health were quantified using the physical health composite score (PCS) and mental health composite score (MCS), respectively. These measures were the dependent variables of interest for this study. RESULTS: Statistical analysis revealed that household food insecurity and using <50 litres of water per person per day (pppd) were independently associated with lower PCS (p<0.05), after adjusting for socio-economic confounders. Household food insecurity and lack of food availability, using <50 litres of water pppd, and the use of untreated drinking water were associated with lower MCS (p<0.05), with water usage being an effect modifier of the relationship between household food insecurity and MCS. The results indicate that being food insecure and having limited potable quality water had a compounding effect on MCS, compared to being individually either food insecure or having limited water. CONCLUSION: This study is one of only a few that have established a link between potable water availability, food insecurity and poorer physical and mental health. The results also indicate a need to validate national data with fine-scale investigations in less populous regions to evaluate national initiatives with local populations that may be at higher risk. Adopting joint dual-action policies for interventions that simultaneously address water and food insecurity should result in larger improvements in health, particularly mental health, compared to targeting either food or water insecurity in isolation.

Applications of Systems Science to Understand and Manage Multiple Influences within Children's Environmental Health in Least Developed Countries: A Causal Loop Diagram Approach.

Least developed countries (LDCs) are home to over a billion people throughout Africa, Asia-Pacific, and the Caribbean. The people who live in LDCs represent just 13% of the global population but 40% of its growth rate. Characterised by low incomes and low education levels, high proportions of the population practising subsistence living, inadequate infrastructure, and lack of economic diversity and resilience, LDCs face serious health, environmental, social, and economic challenges. Many communities in LDCs have very limited access to adequate sanitation, safe water, and clean cooking fuel. LDCs are environmentally vulnerable; facing depletion of natural resources, the effects of unsustainable urbanization, and the impacts of climate change, leaving them unable to safeguard their children's lifetime health and wellbeing. This paper reviews and describes the complexity of the causal relationships between children's health and its environmental, social, and economic influences in LDCs using a causal loop diagram (CLD). The results identify some critical feedbacks between poverty, family size, population growth, children's and adults' health, inadequate water, sanitation and hygiene (WASH), air pollution, and education levels in LDCs and suggest leverage points for potential interventions. A CLD can also be a starting point for quantitative systems science approaches in the field, which can predict and compare the effects of interventions.

Core Competencies for Health Workers to Deal with Climate and Environmental Change.

Rapid, detrimental climate change and environmental degradation pose real threats to the health, environment, social, economic and technological wellbeing of society (HESET). It has become even more imperative that the health workforce (public health and medical healthcare as well as auxiliary and support workers) be 'climate-environment' competent to fulfil their role in managing the environmental public health risks and impacts as climate and environment inevitably continue to change. We developed a broad six-domain competency framework consisting of (1) climate and environment sciences, (2) drivers of climate change (3) evidence, projections and assessments (4) iterative risk management (5) mitigation, adaptation and health co-benefits and (6) collective strategies-harnessing international/regional/local agreements and frameworks. The framework can be used by health/medical trainers to design cross-sectoral sub-competencies and learning content for training health workers to function at local, regional and global levels. Reaching, maintaining and improving the different levels of competency, the health workforce will be increasingly invaluable partners in intra- as well as inter-sectoral responses to climate and environmental risks and impacts.

The association of fractional cover, foliage projective cover and biodiversity with birthweight.

INTRODUCTION: Environmental exposures can contribute both benefits and risks to human health. Maternal exposure to green space has been associated with improvements in birthweight, among other birth outcomes. Newer measures of green space have been developed, which allows for an exploration of the effect of different ground covers (green, dry and bare earth), as well as measures of biodiversity. This study explores the association of these novel green space measures with birthweight in a large birth cohort in Queensland, Australia. METHODS: Birthweight was acquired from the routine health records. Records were allocated green space values for fractional cover, biodiversity and foliage projective cover. Directed acyclic graphs were developed to guide variable selection. Mixed-effects linear regression and generalised linear mixed-effects models were developed, with random intercepts for maternal residential locality and year of birth. Results are presented as standardised beta coefficients or odds ratios, with 95% confidence intervals. RESULTS: An IQR increase of green cover (29.6 g, 95% CI 13.8-45.5) and foliage projective cover (26.0 g, 95% CI 10.8-41.3) are associated with birthweight in urban areas. An IQR increase in dry cover -34.4 g, 95% CI -60.4 to -8.4) and bare earth (-17.7 g, 95% CI -32.8 to -2.6) are associated with lower birthweight. Mothers living in rural areas had similar results, with an IQR increase in green cover (17.8 g, 95% CI 2.9-32.7) associated with higher birthweight, and bare earth (-27.7 g, 95% CI -45.7 to -9.7) was associated with lower birthweight. The biodiversity measure used in this study was not associated with any birthweight outcomes. CONCLUSION: This study finds that the types of ground cover within the maternal residential locality are associated with small, but significant, changes in estimated birthweight, and these effects are not limited to urban areas.

Domestic water carrying and its implications for health: a review and mixed methods pilot study in Limpopo Province, South Africa.

BACKGROUND: Lack of access to safe water remains a significant risk factor for poor health in developing countries. There has been little research into the health effects of frequently carrying containers of water. The aims of this study were to better understand how domestic water carrying is performed, identify potential health risk factors and gain insight into the possible health effects of the task. METHODS: Mixed methods of data collection from six were used to explore water carrying performed by people in six rural villages of Limpopo Province, South Africa. Data was collected through semi-structured interviews and through observation and measurement. Linear regression modelling were used to identify significant correlations between potential risk factors and rating of perceived exertion (RPE) or self reported pain. Independent t-tests were used to compare the mean values of potential risk factors and RPE between sub-groups reporting pain and those not reporting pain. RESULTS: Water carrying was mainly performed by women or children carrying containers on their head (mean container weight 19.5 kg) over a mean distance of 337 m. The prevalence of spinal (neck or back) pain was 69% and back pain was 38%. Of participants who carried water by head loading, the distance walked by those who reported spinal pain was significantly less than those who did not (173 m 95%CI 2-343; p = 0.048). For head loaders reporting head or neck pain compared to those who did not, the differences in weight of water carried (4.6 kg 95%CI -9.7-0.5; p = 0.069) and RPE (2.5 95%CI -5.1-0.1; p = 0.051) were borderline statistically significant. For head loaders, RPE was significantly correlated with container weight (r = 0.52; p = 0.011) and incline (r = 0.459; p = 0.018) CONCLUSIONS: Typical water carrying methods impose physical loading with potential to produce musculoskeletal disorders and related disability. This exploratory study is limited by a small sample size and future research should aim to better understand the type and strength of association between water carrying and health, particularly musculoskeletal disorders. However, these preliminary findings suggest that efforts should be directed toward eliminating the need for water carrying, or where it must continue, identifying and reducing risk factors for musculoskeletal disorders and physical injury.

An assessment of the costs and benefits of interventions aimed at improving rural community water supplies in developed countries.

We report a cost benefit analyses (CBA) for water interventions in rural populations of developed country sub-regions. A Bayesian belief network was used to estimate the cost benefit ratio using Monte Carlo simulation. Where possible we used input data from recently published primary research or systematic reviews. Otherwise variables were derived from previous work in the peer-reviewed or grey literature. For these analyses we considered the situation of people with small and very small community supplies that may not be adequately managed. For the three developed country sub-regions Amr-A (America region A), Eur-A (European region A) and Wpr-A (Western Pacific region A), we estimate the costs of acute diarrhoeal illness associated with small community supplies to be U$4671 million (95% CI 1721-9592), the capital costs of intervention to be USD 13703 million (95% CI 6670-20735), additional annual maintenance to be USD 804 million (95%CI 359-1247) and the CB ratio to be 2.78 (95%CI 0.86-6.5). However, we also estimated the cost of post infectious irritable bowel syndrome (IBS) following drinking water-associated acute gastroenteritis to be USD 11896 million (95%CI 3118-22657). When the benefits of reduced IBS are added to the analysis the CB ratio increases to 9.87 (95%CI 3.34-20.49). The most important driver of uncertainty was the estimate of the cost of illness. However, there are very few good estimates of costs in improving management of small rural supplies in the literature. Investments in drinking-water provision in rural settings are highly cost beneficial in the developed world. In the developed world, the CB ratio is substantially positive especially once the impact of IBS is included.