Accuracy of self-reported distance to nearest unconventional oil and gas well in Pennsylvania, Ohio, and West Virginia residents and implications for exposure assessment.

Self-reported distances to industrial sources have been used in epidemiology as proxies for exposure to environmental hazards and indicators of awareness and perception of sources. Unconventional oil and gas development (UOG) emits pollutants and has been associated with adverse health outcomes. We compared self-reported distance to the nearest UOG well to the geographic information system-calculated distance for 303 Pennsylvania, Ohio, and West Virginia residents using Cohen's Weighted Kappa. Agreement was low (Kappa = 0.18), and self-reports by Ohioans (39% accuracy) were more accurate than West Virginians (22%) or Pennsylvanians (13%, both p < 0.05). Of the demographic characteristics studied, only educational attainment was related to reporting accuracy; residents with 12-16 years of education were more accurate (31.3% of group) than those with <12 or >16 years (both 16.7%). Understanding differences between objective and subjective measures of UOG proximity could inform studies of perceived exposures or risks and may also be relevant to adverse health effects. IMPACT: We compared objective and self-reported measures of distance to the nearest UOG well for 303 Appalachian Basin residents. We found that residents' self-reported distance to the nearest UOG well had limited agreement with the true calculated distance category. Our results can be used to inform the collection and contextualize the use of self-reported data in communities exposed to UOGD. Self-reported metrics can be used in conjunction with objective assessments and can be informative regarding how potentially exposed populations perceive environmental exposures or risks and could provide insights into awareness of distance-related policies, such as setbacks.

Measuring long-term exposure to wildfire PM2.5 in California: Time-varying inequities in environmental burden.

Wildfires have become more frequent and intense due to climate change and outdoor wildfire fine particulate matter (PM2.5) concentrations differ from relatively smoothly varying total PM2.5. Thus, we introduced a conceptual model for computing long-term wildfire PM2.5 and assessed disproportionate exposures among marginalized communities. We used monitoring data and statistical techniques to characterize annual wildfire PM2.5 exposure based on intermittent and extreme daily wildfire PM2.5 concentrations in California census tracts (2006 to 2020). Metrics included: 1) weeks with wildfire PM2.5 < 5 µg/m3; 2) days with non-zero wildfire PM2.5; 3) mean wildfire PM2.5 during peak exposure week; 4) smoke waves (≥2 consecutive days with <15 µg/m3 wildfire PM2.5); and 5) mean annual wildfire PM2.5 concentration. We classified tracts by their racial/ethnic composition and CalEnviroScreen (CES) score, an environmental and social vulnerability composite measure. We examined associations of CES and racial/ethnic composition with the wildfire PM2.5 metrics using mixed-effects models. Averaged 2006 to 2020, we detected little difference in exposure by CES score or racial/ethnic composition, except for non-Hispanic American Indian and Alaska Native populations, where a 1-SD increase was associated with higher exposure for 4/5 metrics. CES or racial/ethnic × year interaction term models revealed exposure disparities in some years. Compared to their California-wide representation, the exposed populations of non-Hispanic American Indian and Alaska Native (1.68×, 95% CI: 1.01 to 2.81), white (1.13×, 95% CI: 0.99 to 1.32), and multiracial (1.06×, 95% CI: 0.97 to 1.23) people were over-represented from 2006 to 2020. In conclusion, during our study period in California, we detected disproportionate long-term wildfire PM2.5 exposure for several racial/ethnic groups.

Multiple Dimensions of Environmental Justice and Oil and Gas Development in Pennsylvania.

Background: Community socioeconomic deprivation (CSD) may be related to higher oil and natural gas development (OGD) exposure. We tested for distributive and benefit-sharing environmental injustice in Pennsylvania's Marcellus Shale by examining (1) whether OGD and waste disposal occurred disproportionately in more deprived communities and (2) discordance between the location of land leased for OGD and where oil and gas rights owners resided. Materials and Methods: Analyses took place at the county subdivision level and considered OGD wells, waste disposal, and land lease agreement locations from 2005 to 2019. Using 2005-2009 American Community Survey data, we created a CSD index relevant to community vulnerability in suburban/rural areas. Results: In adjusted regression models accounting for spatial dependence, we observed no association between the CSD index and conventional or unconventional drilled well presence. However, a higher CSD index was linearly associated with odds of a subdivision having an OGD waste disposal site and receiving a larger volume of waste. A higher percentage of oil and gas rights owners lived in the same county subdivision as leased land when the community was least versus most deprived (66% vs. 56% in same county subdivision), suggesting that individuals in more deprived communities were less likely to financially benefit from OGD exposure. Discussion and Conclusions: We observed distributive environmental injustice with respect to well waste disposal and benefit-sharing environmental injustice related to oil and rights owner's residential locations across Pennsylvania's Marcellus Shale. These results add evidence of a disparity between exposure and benefits resulting from OGD.

An environmental justice analysis of air pollution emissions in the United States from 1970 to 2010.

Over the last decades, air pollution emissions have decreased substantially; however, inequities in air pollution persist. We evaluate county-level racial/ethnic and socioeconomic disparities in emissions changes from six air pollution source sectors (industry [SO2], energy [SO2, NOx], agriculture [NH3], commercial [NOx], residential [particulate organic carbon], and on-road transportation [NOx]) in the contiguous United States during the 40 years following the Clean Air Act (CAA) enactment (1970-2010). We calculate relative emission changes and examine the differential changes given county demographics using hierarchical nested models. The results show racial/ethnic disparities, particularly in the industry and energy generation source sectors. We also find that median family income is a driver of variation in relative emissions changes in all sectors-counties with median family income >$75 K vs. less generally experience larger relative declines in industry, energy, transportation, residential, and commercial-related emissions. Emissions from most air pollution source sectors have, on a national level, decreased following the United States CAA. In this work, we show that the relative reductions in emissions varied across racial/ethnic and socioeconomic groups.

Disparities in preterm birth following the July 1995 Chicago heat wave.

PURPOSE: To evaluate if changes in preterm birth (PTB, <37 weeks of gestation) incidence differed between non-Hispanic (NH) Black and NH white births following the July 1995 Chicago heat wave-among the most severe U.S. heat waves since 1950. METHODS: We used an ecologic study design. We obtained birth data from January 1990-December 1996 from the National Vital Statistics File to calculate the mean monthly PTB incidence in Chicago's Cook County, Illinois. Births between July 1995 and February 1996 were potentially exposed to the heat wave in utero. We generated time series models for NH Black and NH white births, which incorporated synthetic controls of Cook County based on unexposed counties. We ran a secondary analysis considering socioeconomic status (SES). RESULTS: From 1990-1996, the mean monthly PTB incidence among NH Black births was 18.6% compared to 7.8% among NH white births. The mean monthly PTB incidence among NH Black births from August 1995-January 1996 was 16.7% higher than expected (three additional PTBs per 100 live births per month [95% confidence interval (CI): 1, 5]). A similar increase occurred among low-SES NH Black births. No increase appeared among NH white births. CONCLUSIONS: Severe heat waves may increase racial disparities in PTB incidence.

The role of insurance status in the association between short-term temperature exposure and myocardial infarction hospitalizations in New York State.

Myocardial infarction (MI) is a leading cause of morbidity and mortality in the United States and its risk increases with extreme temperatures. Climate change causes variability in weather patterns, including extreme temperature events that disproportionately affect socioeconomically disadvantaged communities. Many studies on the health effects of extreme temperatures have considered community-level socioeconomic disadvantage. Objectives: To evaluate effect modification of the relationship between short-term ambient temperature and MI, by individual-level insurance status (insured vs. uninsured). Methods: We identified MI hospitalizations and insurance status across New York State (NYS) hospitals from 1995 to 2015 in the New York Department of Health Statewide Planning and Research Cooperative System database, using International Classification of Diseases codes. We linked short-term ambient temperature (averaging the 6 hours preceding the event [MI hospitalization]) or nonevent control period in patient residential zip codes. We employed a time-stratified case-crossover study design for both insured and uninsured strata, and then compared the group-specific rate ratios. Results: Over the study period, there were 1,095,051 primary MI admissions, 966,475 (88%) among insured patients. During extremely cold temperatures (<5.8 °C) insured patients experienced reduced rates of MI; this was not observed among the uninsured counterparts. At warmer temperatures starting at the 65th percentile (15.7 °C), uninsured patients had higher rates than insured patients (e.g., for a 6-hour pre-event average temperature increase from the median to the 75th percentile, the rate of MI increased was 2.0% [0.0%-4.0%] higher in uninsured group). Conclusions: Uninsured individuals may face disproportionate rates of MI hospitalization during extreme temperatures.

Methods in Public Health Environmental Justice Research: a Scoping Review from 2018 to 2021.

PURPOSE OF REVIEW: The volume of public health environmental justice (EJ) research produced by academic institutions increased through 2022. However, the methods used for evaluating EJ in exposure science and epidemiologic studies have not been catalogued. Here, we completed a scoping review of EJ studies published in 19 environmental science and epidemiologic journals from 2018 to 2021 to summarize research types, frameworks, and methods. RECENT FINDINGS: We identified 402 articles that included populations with health disparities as a part of EJ research question and met other inclusion criteria. Most studies (60%) evaluated EJ questions related to socioeconomic status (SES) or race/ethnicity. EJ studies took place in 69 countries, led by the US (n = 246 [61%]). Only 50% of studies explicitly described a theoretical EJ framework in the background, methods, or discussion and just 10% explicitly stated a framework in all three sections. Among exposure studies, the most common area-level exposure was air pollution (40%), whereas chemicals predominated personal exposure studies (35%). Overall, the most common method used for exposure-only EJ analyses was main effect regression modeling (50%); for epidemiologic studies the most common method was effect modification (58%), where an analysis evaluated a health disparity variable as an effect modifier. Based on the results of this scoping review, current methods in public health EJ studies could be bolstered by integrating expertise from other fields (e.g., sociology), conducting community-based participatory research and intervention studies, and using more rigorous, theory-based, and solution-oriented statistical research methods.

It's electric! An environmental equity perspective on the lifecycle of our energy sources.

Energy policy decisions are driven primarily by economic and reliability considerations, with limited consideration given to public health, environmental justice, and climate change. Moreover, epidemiologic studies relevant for public policy typically focus on immediate public health implications of activities related to energy procurement and generation, considering less so health equity or the longer-term health consequences of climate change attributable to an energy source. A more integrated, collective consideration of these three domains can provide more robust guidance to policymakers, communities, and individuals. Here, we illustrate how these domains can be evaluated with respect to natural gas as an energy source. Our process began with a detailed overview of all relevant steps in the process of extracting, producing, and consuming natural gas. We synthesized existing epidemiologic and complementary evidence of how these processes impact public health, environmental justice, and climate change. We conclude that, in certain domains, natural gas looks beneficial (e.g., economically for some), but when considered more expansively, through the life cycle of natural gas and joint lenses of public health, environmental justice, and climate change, natural gas is rendered an undesirable energy source in the United States. A holistic climate health equity framework can inform how we value and deploy different energy sources in the service of public health.

Temporal Trends of Racial and Socioeconomic Disparities in Population Exposures to Upstream Oil and Gas Development in California.

People living near oil and gas development are exposed to multiple environmental stressors that pose health risks. Some studies suggest these risks are higher for racially and socioeconomically marginalized people, which may be partly attributable to disparities in exposures. We examined whether racially and socioeconomically marginalized people in California are disproportionately exposed to oil and gas wells and associated hazards. We longitudinally assessed exposure to wells during three time periods (2005-2009, 2010-2014, and 2015-2019) using sociodemographic data at the census block group-level. For each block group and time period, we assessed exposure to new, active, retired, and plugged wells, and cumulative production volume. We calculated risk ratios to determine whether marginalized people disproportionately resided near wells (within 1 km). Averaged across the three time periods, we estimated that 1.1 million Californians (3.0%) lived within 1 km of active wells. Nearly 9 million Californians (22.9%) lived within 1 km of plugged wells. The proportion of Black residents near active wells was 42%-49% higher than the proportion of Black residents across California, and the proportion of Hispanic residents near active wells was 4%-13% higher than their statewide proportion. Disparities were greatest in areas with the highest oil and gas production, where the proportion of Black residents was 105%-139% higher than statewide. Socioeconomically marginalized residents also had disproportionately high exposure to wells. Though oil and gas production has declined in California, marginalized communities persistently had disproportionately high exposure to wells, potentially contributing to health disparities.

Wildfire smoke exposure and emergency department visits for headache: A case-crossover analysis in California, 2006-2020.

OBJECTIVE: To evaluate the association of short-term exposure to overall fine particulate matter of <2.5 µm (PM2.5 ) and wildfire-specific PM2.5 with emergency department (ED) visits for headache. BACKGROUND: Studies have reported associations between PM2.5 exposure and headache risk. As climate change drives longer and more intense wildfire seasons, wildfire PM2.5 may contribute to more frequent headaches. METHODS: Our study included adult Californian members (aged ≥18 years) of a large de-identified commercial and Medicare Advantage claims database from 2006 to 2020. We identified ED visits for primary headache disorders (subtypes: tension-type headache, migraine headache, cluster headache, and "other" primary headache). Claims included member age, sex, and residential zip code. We linked daily overall and wildfire-specific PM2.5 to residential zip code and conducted a time-stratified case-crossover analysis considering 7-day average PM2.5 concentrations, first for primary headache disorders combined, and then by headache subtype. RESULTS: Among 9898 unique individuals we identified 13,623 ED encounters for primary headache disorders. Migraine was the most frequently diagnosed headache (N = 5534/13,623 [47.6%]) followed by "other" primary headache (N = 6489/13,623 [40.6%]). For all primary headache ED diagnoses, we observed an association of 7-day average wildfire PM2.5 (odds ratio [OR] 1.17, 95% confidence interval [CI] 0.95-1.44 per 10 µg/m3 increase) and by subtype we observed increased odds of ED visits associated with 7-day average wildfire PM2.5 for tension-type headache (OR 1.42, 95% CI 0.91-2.22), "other" primary headache (OR 1.40, 95% CI 0.96-2.05), and cluster headache (OR 1.29, 95% CI 0.71-2.35), although these findings were not statistically significant under traditional null hypothesis testing. Overall PM2.5 was associated with tension-type headache (OR 1.29, 95% CI 1.03-1.62), but not migraine, cluster, or "other" primary headaches. CONCLUSIONS: Although imprecise, these results suggest short-term wildfire PM2.5 exposure may be associated with ED visits for headache. Patients, healthcare providers, and systems may need to respond to increased headache-related healthcare needs in the wake of wildfires and on poor air quality days.

Racial, Ethnic, and Socioeconomic Disparities in Multiple Measures of Blue and Green Spaces in the United States.

BACKGROUND: Several studies have evaluated whether the distribution of natural environments differs between marginalized and privileged neighborhoods. However, most studies restricted their analyses to a single or handful of cities and used different natural environment measures. OBJECTIVES: We evaluated whether natural environments are inequitably distributed based on socioeconomic status (SES) and race/ethnicity in the contiguous United States. METHODS: We obtained SES and race/ethnicity data (2015-2019) for all U.S. Census tracts. For each tract, we calculated the Normalized Different Vegetation Index (NDVI) for 2020, NatureScore (a proprietary measure of the quantity and quality of natural elements) for 2019, park cover for 2020, and blue space for 1984-2018. We used generalized additive models with adjustment for potential confounders and spatial autocorrelation to evaluate associations of SES and race/ethnicity with NDVI, NatureScore, park cover, and odds of containing blue space in all tracts (n=71,532) and in urban tracts (n=45,338). To compare effect estimates, we standardized NDVI, NatureScore, and park cover so that beta coefficients presented a percentage increase or decrease of the standard deviation (SD). RESULTS: Tracts with higher SES had higher NDVI, NatureScore, park cover, and odds of containing blue space. For example, urban tracts in the highest median household income quintile had higher NDVI [44.8% of the SD (95% CI: 42.8, 46.8)] and park cover [16.2% of the SD (95% CI: 13.5, 19.0)] compared with urban tracts in the lowest median household income quintile. Across all tracts, a lower percentage of non-Hispanic White individuals and a higher percentage of Hispanic individuals were associated with lower NDVI and NatureScore. In urban tracts, we observed weak positive associations between percentage non-Hispanic Black and NDVI, NatureScore, and park cover; we did not find any clear associations for percentage Hispanics. DISCUSSION: Multiple facets of the natural environment are inequitably distributed in the contiguous United States. https://doi.org/10.1289/EHP11164.

Historic redlining and the siting of oil and gas wells in the United States.

BACKGROUND: The presence of active or inactive (i.e., postproduction) oil and gas wells in neighborhoods may contribute to ongoing pollution. Racially discriminatory neighborhood security maps developed by the Home-Owners Loan Corporation (HOLC) in the 1930s may contribute to environmental exposure disparities. OBJECTIVE: To determine whether receiving worse HOLC grades was associated with exposure to more oil and gas wells. METHODS: We assessed exposure to oil and gas wells among HOLC-graded neighborhoods in 33 cities from 13 states where urban oil and gas wells were drilled and operated. Among the 17 cities for which 1940 census data were available, we used propensity score restriction and matching to compare well exposure neighborhoods that were similar on observed 1940 sociodemographic characteristics but that received different grades. RESULTS: Across all included cities, redlined D-graded neighborhoods had 12.2 ± 27.2 wells km-2, nearly twice the density in neighborhoods graded A (6.8 ± 8.9 wells km-2). In propensity score restricted and matched analyses, redlined neighborhoods had 2.0 (1.3, 2.7) more wells than comparable neighborhoods with a better grade. SIGNIFICANCE: Our study adds to the evidence that structural racism in federal policy is associated with the disproportionate siting of oil and gas wells in marginalized neighborhoods.

The 2021 Texas Power Crisis: distribution, duration, and disparities.

BACKGROUND: Precipitated by an unusual winter storm, the 2021 Texas Power Crisis lasted February 10 to 27 leaving millions of customers without power. Such large-scale outages can have severe health consequences, especially among vulnerable subpopulations such as those reliant on electricity to power medical equipment, but limited studies have evaluated sociodemographic disparities associated with outages. OBJECTIVE: To characterize the 2021 Texas Power Crisis in relation to distribution, duration, preparedness, and issues of environmental justice. METHODS: We used hourly Texas-wide county-level power outage data to estimate geographic clustering and association between outage exposure (distribution and duration) and six measures of racial, social, political, and/or medical vulnerability: Black and Hispanic populations, the Centers for Disease Control and Prevention (CDC) Social Vulnerability Index (SVI), Medicare electricity-dependent durable medical equipment (DME) usage, nursing homes, and hospitals. To examine individual-level experience and preparedness, we used a preexisting and non-representative internet survey. RESULTS: At the peak of the Texas Power Crisis, nearly 1/3 of customers statewide (N = 4,011,776 households/businesses) lost power. We identified multiple counties that faced a dual burden of racial/social/medical vulnerability and power outage exposure, after accounting for multiple comparisons. County-level spatial analyses indicated that counties where more Hispanic residents resided tended to endure more severe outages (OR = 1.16, 95% CI: 1.02, 1.40). We did not observe socioeconomic or medical disparities. With individual-level survey data among 1038 respondents, we found that Black respondents were more likely to report outages lasting 24+ hours and that younger individuals and those with lower educational attainment were less likely to be prepared for outages. SIGNIFICANCE: Power outages can be deadly, and medically vulnerable, socioeconomically vulnerable, and marginalized groups may be disproportionately impacted or less prepared. Climate and energy policy must equitably address power outages, future grid improvements, and disaster preparedness and management.

African American Unemployment and the Disparity in Periviable Births.

Periviable infants (i.e., born before 26 complete weeks of gestation) represent fewer than .5% of births in the US but account for 40% of infant mortality and 20% of billed hospital obstetric costs. African American women contribute about 14% of live births in the US, but these include nearly a third of the country's periviable births. Consistent with theory and with periviable births among other race/ethnicity groups, males predominate among African American periviable births in stressed populations. We test the hypothesis that the disparity in periviable male births among African American and non-Hispanic white populations responds to the African American unemployment rate because that indicator not only traces, but also contributes to, the prevalence of stress in the population. We use time-series methods that control for autocorrelation including secular trends, seasonality, and the tendency to remain elevated or depressed after high or low values. The racial disparity in male periviable birth increases by 4.45% for each percentage point increase in the unemployment rate of African Americans above its expected value. We infer that unemployment-a population stressor over which our institutions exercise considerable control-affects the disparity between African American and non-Hispanic white periviable births in the US.

Climate Justice and California's Methane Superemitters: Environmental Equity Assessment of Community Proximity and Exposure Intensity.

Methane superemitters emit non-methane copollutants that are harmful to human health. Yet, no prior studies have assessed disparities in exposure to methane superemitters with respect to race/ethnicity, socioeconomic status, and civic engagement. To do so, we obtained the location, category (e.g., landfill, refinery), and emission rate of California methane superemitters from Next Generation Airborne Visible/Infrared Imaging Spectrometer (AVIRIS-NG) flights conducted between 2016 and 2018. We identified block groups within 2 km of superemitters (exposed) and 5-10 km away (unexposed) using dasymetric mapping and assigned level of exposure among block groups within 2 km (measured via number of superemitter categories and total methane emissions). Analyses included 483 superemitters. The majority were dairy/manure (n = 213) and oil/gas production sites (n = 127). Results from fully adjusted logistic mixed models indicate environmental injustice in methane superemitter locations. For example, for every 10% increase in non-Hispanic Black residents, the odds of exposure increased by 10% (95% confidence interval (CI): 1.04, 1.17). We observed similar disparities for Hispanics and Native Americans but not with indicators of socioeconomic status. Among block groups located within 2 km, increasing proportions of non-White populations and lower voter turnout were associated with higher superemitter emission intensity. Previously unrecognized racial/ethnic disparities in exposure to California methane superemitters should be considered in policies to tackle methane emissions.

Sociodemographic Inequalities in Urinary Tract Infection in 2 Large California Health Systems.

BACKGROUND: Urinary tract infection (UTI) accounts for a substantial portion of outpatient visits and antibiotic prescriptions in the United States. Few studies have considered sociodemographic factors including low socioeconomic status (SES)-which may increase residential crowding, inappropriate antibiotic prescribing, or comorbidities-as UTI or multidrug-resistant (MDR) UTI risk factors. METHODS: We used 2015-2017 electronic health record data from 2 California health care systems to assess whether 3 sociodemographic factors-use of Medicaid, use of an interpreter, and census tract-level deprivation-were associated with overall UTI or MDR UTI. UTIs resistant to ≥3 antibiotic classes were considered MDR. RESULTS: Analyses included 601 352 UTI cases, 1 303 455 controls, and 424 977 urinary Escherichia coli isolates from Kaiser Permanente Southern California (KPSC) and Sutter Health in Northern California. The MDR prevalence was 10.4% at KPSC and 12.8% at Sutter Health. All 3 sociodemographic factors (ie, use of Medicaid, using an interpreter, and community deprivation) were associated increased risk of MDR UTI. For example, using an interpreter was associated with a 36% (relative risk [RR], 1.36; 95% CI, 1.31 to 1.40) and 28% (RR, 1.28; 95% CI, 1.22 to 1.34) increased risk of MDR UTI at KPSC and Sutter Health, respectively, adjusted for SES and other potential confounding variables. The 3 sociodemographic factors were only weakly associated with UTI overall. CONCLUSIONS: We found low SES and use of an interpreter to be novel risk factors for MDR UTI in the United States.

Environmental hazards, social inequality, and fetal loss: Implications of live-birth bias for estimation of disparities in birth outcomes.

Restricting to live births can induce bias in studies of pregnancy and developmental outcomes, but whether this live-birth bias results in underestimating disparities is unknown. Bias may arise from collider stratification due to an unmeasured common cause of fetal loss and the outcome of interest, or depletion of susceptibles, where exposure differentially causes fetal loss among those with underlying susceptibility. METHODS: We conducted a simulation study to examine the magnitude of live-birth bias in a population parameterized to resemble one year of conceptions in California (N = 625,000). We simulated exposure to a non-time-varying environmental hazard, risk of spontaneous abortion, and time to live birth using 1000 Monte Carlo simulations. Our outcome of interest was preterm birth. We included a social vulnerability factor to represent social disadvantage, and estimated overall risk differences for exposure and preterm birth using linear probability models and stratified by the social vulnerability factor. We calculated how often confidence intervals included the true point estimate (CI coverage probabilities) to illustrate whether effect estimates differed qualitatively from the truth. RESULTS: Depletion of susceptibles resulted in a larger magnitude of bias compared with collider stratification, with larger bias among the socially vulnerable group. Coverage probabilities were not adversely affected by bias due to collider stratification. Depletion of susceptibles reduced coverage, especially among the socially vulnerable (coverage among socially vulnerable = 46%, coverage among nonsocially vulnerable = 91% in the most extreme scenario). CONCLUSIONS: In simulations, hazardous environmental exposures induced live-birth bias and the bias was larger for socially vulnerable women.

Anomalously warm weather and acute care visits in patients with multiple sclerosis: A retrospective study of privately insured individuals in the US.

BACKGROUND: As the global climate changes in response to anthropogenic greenhouse gas emissions, weather and temperature are expected to become increasingly variable. Although heat sensitivity is a recognized clinical feature of multiple sclerosis (MS), a chronic demyelinating disorder of the central nervous system, few studies have examined the implications of climate change for patients with this disease. METHODS AND FINDINGS: We conducted a retrospective cohort study of individuals with MS ages 18-64 years in a nationwide United States patient-level commercial and Medicare Advantage claims database from 2003 to 2017. We defined anomalously warm weather as any month in which local average temperatures exceeded the long-term average by ≥1.5°C. We estimated the association between anomalously warm weather and MS-related inpatient, outpatient, and emergency department visits using generalized log-linear models. From 75,395,334 individuals, we identified 106,225 with MS. The majority were women (76.6%) aged 36-55 years (59.0%). Anomalously warm weather was associated with increased risk for emergency department visits (risk ratio [RR] = 1.043, 95% CI: 1.025-1.063) and inpatient visits (RR = 1.032, 95% CI: 1.010-1.054). There was limited evidence of an association between anomalously warm weather and MS-related outpatient visits (RR = 1.010, 95% CI: 1.005-1.015). Estimates were similar for men and women, strongest among older individuals, and exhibited substantial variation by season, region, and climate zone. Limitations of the present study include the absence of key individual-level measures of socioeconomic position (i.e., race/ethnicity, occupational status, and housing quality) that may determine where individuals live-and therefore the extent of their exposure to anomalously warm weather-as well as their propensity to seek treatment for neurologic symptoms. CONCLUSIONS: Our findings suggest that as global temperatures rise, individuals with MS may represent a particularly susceptible subpopulation, a finding with implications for both healthcare providers and systems.

Trends from 2008 to 2018 in Electricity-dependent Durable Medical Equipment Rentals and Sociodemographic Disparities.

BACKGROUND: Duration and number of power outages have increased over time, partly fueled by climate change, putting users of electricity-dependent durable medical equipment (hereafter, "durable medical equipment") at particular risk of adverse health outcomes. Given health disparities in the United States, we assessed trends in durable medical equipment rental prevalence and individual- and area-level sociodemographic inequalities. METHODS: Using Kaiser Permanente South California electronic health record data, we identified durable medical equipment renters. We calculated annual prevalence of equipment rental and fit hierarchical generalized linear models with ZIP code random intercepts, stratified by rental of breast pumps or other equipment. RESULTS: 243,559 KPSC members rented durable medical equipment between 2008 and 2018. Rental prevalence increased over time across age, sex, racial-ethnic, and Medicaid categories, most by >100%. In adjusted analyses, Medicaid use was associated with increased prevalence and 108 (95% confidence interval [CI] = 99, 117) additional days of equipment rental during the study period. ZIP code-level sociodemographics were associated with increased prevalence of equipment rentals, for example, a 1 SD increase in percent unemployed and