Inequalities in rural communities: adapting national deprivation indices for rural settings.

Background: Deprivation indices have been widely used in healthcare research and planning in the United Kingdom. Existing indices, however, are dominated by characteristics of urban populations that may be less relevant in capturing the nature of rural deprivation. We explore if deprivation indices can be modified to make them more sensitive to displaying rural disadvantage in England. Methods: The analysis focussed on the 2011 Carstairs Index (Carstairs2011) and the 2010 English Index of Multiple Deprivation (IMD2010). We removed all urban areas as identified by the Office for National Statistics Rural-Urban Area Classifications and mapped the Carstairs2011 and IMD2010 across the remaining rural areas using rural-specific quintiles. Results: Our method was effective in displaying much greater heterogeneity in rural areas than was apparent in the original indices. We received positive feedback from Directors of Public Health who confirmed that the observed patterns mirror their experiences and first-hand knowledge on the ground. Conclusions: Our maps of Carstairs2011 and IMD2010 for rural areas might strengthen the evidence base for rural planning and service provision. The modified deprivation indices, however, were not specifically formulated for rural populations and further work is needed to explore alternative input variables to produce a more rural-specific measure of deprivation.

On fine particulate matter and COVID-19 spread and severity: An in vitro toxicological plausible mechanism.

COVID-19 pandemic had a significant impact on global public health. The spread of the disease was related to the high transmissibility of SARS-CoV-2 virus but incidence and mortality rate suggested a possible relationship with environmental factors. Air pollution has been hypothesized to play a role in the transmission of the virus and the resulting severity of the disease. Here we report a plausible in vitro toxicological mode of action by which fine particulate matter (PM2.5) could promote a higher infection rate of SARS-CoV-2 and severity of COVID-19 disease. PM2.5 promotes a 1.5 fold over-expression of the angiotensin 2 converting enzyme (ACE2) which is exploited by viral particles to enter human lung alveolar cells (1.5 fold increase in RAB5 protein) and increases their inflammatory state (IL-8 and NF-kB protein expression). Our results provide a basis for further exploring the possible synergy between biological threats and air pollutants and ask for a deeper understanding of how air quality could influence new pandemics in the future.

Small-area methods for investigation of environment and health.

Small-area studies offer a powerful epidemiological approach to study disease patterns at the population level and assess health risks posed by environmental pollutants. They involve a public health investigation on a geographical scale (e.g. neighbourhood) with overlay of health, environmental, demographic and potential confounder data. Recent methodological advances, including Bayesian approaches, combined with fast-growing computational capabilities, permit more informative analyses than previously possible, including the incorporation of data at different scales, from satellites to individual-level survey information. Better data availability has widened the scope and utility of small-area studies, but has also led to greater complexity, including choice of optimal study area size and extent, duration of study periods, range of covariates and confounders to be considered and dealing with uncertainty. The availability of data from large, well-phenotyped cohorts such as UK Biobank enables the use of mixed-level study designs and the triangulation of evidence on environmental risks from small-area and individual-level studies, therefore improving causal inference, including use of linked biomarker and -omics data. As a result, there are now improved opportunities to investigate the impacts of environmental risk factors on human health, particularly for the surveillance and prevention of non-communicable diseases.

Estimating Aspergillus fumigatus exposure from outdoor composting activities in England between 2005 and 14.

Bioaerosols, ubiquitous in ambient air, are released in elevated concentrations from composting facilities with open-air processing areas. However, spatial and temporal variability of bioaerosols, particularly in relation to meteorology, is not well understood. Here we model relative concentrations of Aspergillus fumigatus at each postcode-weighted centroid within 4 km of 217 composting facilities in England between 2005 and 2014. Facilities were geocoded with the aid of satellite imagery. Data from existing bioaerosol modelling literature were used to build emission profiles in ADMS. Variation in input parameters between each modelled facility was reduced to a minimum. Meteorological data for each composting facility was derived from the nearest SCAIL-Agriculture validated meteorological station. According to our results, modelled exposure risk was driven primarily by wind speed, direction and time-varying emissions factors incorporating seasonal fluctuations in compostable waste. Modelled A.fumigatus concentrations decreased rapidly from the facility boundary and plateaued beyond 1.5-2.0 km. Where multiple composting facilities were within 4 km of each other, complex exposure risk patterns were evident. More long-term bioaerosol monitoring near facilities is needed to help improve exposure estimation and therefore assessment of any health risks to local populations.

Bayesian spatial modelling for quasi-experimental designs: An interrupted time series study of the opening of Municipal Waste Incinerators in relation to infant mortality and sex ratio.

BACKGROUND: There is limited evidence on potential health risks from Municipal Waste Incinerators (MWIs), and previous studies on birth outcomes show inconsistent results. Here, we evaluate whether the opening of MWIs is associated with infant mortality and sex ratio in the surrounding areas, extending the Interrupted Time Series (ITS) methodological approach to account for spatial dependencies at the small area level. METHODS: We specified a Bayesian hierarchical model to investigate the annual risks of infant mortality and sex-ratio (female relative to male) within 10 km of eight MWIs in England and Wales, during the period 1996-2012. We included comparative areas matched one-to-one of similar size and area characteristics. RESULTS: During the study period, infant mortality rates decreased overall by 2.5% per year in England. The opening of an incinerator in the MWI area was associated with -8 deaths per 100,000 infants (95% CI -62, 40) and with a difference in sex ratio of -0.004 (95% CI -0.02, 0.01), comparing the period after opening with that before, corrected for before-after trends in the comparator areas. CONCLUSION: Our method is suitable for the analysis of quasi-experimental time series studies in the presence of spatial structure and when there are global time trends in the outcome variable. Based on our approach, we do not find evidence of an association of MWI opening with changes in risks of infant mortality or sex ratio in comparison with control areas.

Proportional classifications of COPD phenotypes.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) encompasses a group of disorders characterised by the presence of incompletely reversible airflow obstruction with overlapping subsets of different phenotypes including chronic bronchitis, emphysema or asthma. The aim of this study was to determine the proportion of adult subjects aged >50 years within each phenotypic subgroup of COPD, defined as a post-bronchodilator ratio of forced expiratory volume in 1 s/forced vital capacity (FEV(1)/FVC) <0.7, in accordance with current international guidelines. METHODS: Adults aged >50 years derived from a random population-based survey undertook detailed questionnaires, pulmonary function tests and chest CT scans. The proportion of subjects in each of 16 distinct phenotypes was determined based on combinations of chronic bronchitis, emphysema and asthma, with and without incompletely reversible airflow obstruction defined by a post-bronchodilator FEV(1)/FVC ratio of 0.7. RESULTS: A total of 469 subjects completed the investigative modules, 96 of whom (20.5%) had COPD. Diagrams were constructed to demonstrate the relative proportions of the phenotypic subgroups in subjects with and without COPD. 18/96 subjects with COPD (19%) had the classical phenotypes of chronic bronchitis and/or emphysema but no asthma; asthma was the predominant COPD phenotype, being present in 53/96 (55%). When COPD was defined as a post-bronchodilator FEV(1)/FVC less than the lower limit of normal, there were one-third fewer subjects with COPD and a smaller proportion without a defined emphysema, chronic bronchitis or asthma phenotype. CONCLUSION: This study provides proportional classifications of the phenotypic subgroups of COPD which can be used as the basis for further research into the pathogenesis and treatment of this heterogeneous disorder.

Patterns of domestic exposure to carbon monoxide and particulate matter in households using biomass fuel in Janakpur, Nepal.

Household Air Pollution (HAP) from biomass cooking fuels is a major cause of morbidity and mortality in low-income settings worldwide. In Nepal the use of open stoves with solid biomass fuels is the primary method of domestic cooking. To assess patterns of domestic air pollution we performed continuous measurement of carbon monoxide (CO) and particulate Matter (PM2.5) in 12 biomass fuel households in Janakpur, Nepal. We measured kitchen PM2.5 and CO concentrations at one-minute intervals for an approximately 48-h period using the TSI DustTrak II 8530/SidePak AM510 (TSI Inc, St. Paul MN, USA) or EL-USB-CO data logger (Lascar Electronics, Erie PA, USA) respectively. We also obtained information regarding fuel, stove and kitchen characteristics and cooking activity patterns. Household cooking was performed in two daily sessions (median total duration 4 h) with diurnal variability in pollutant concentrations reflecting morning and evening cooking sessions and peak concentrations associated with fire-lighting. We observed a strong linear relationship between PM2.5 measurements obtained by co-located photometric and gravimetric monitoring devices, providing local calibration factors of 4.9 (DustTrak) and 2.7 (SidePak). Overall 48-h average CO and PM2.5 concentrations were 5.4 (SD 4.3) ppm (12 households) and 417.6 (SD 686.4) µg/m3 (8 households), respectively, with higher average concentrations associated with cooking and heating activities. Overall average PM2.5 concentrations and peak 1-h CO concentrations exceeded WHO Indoor Air Quality Guidelines. Average hourly PM2.5 and CO concentrations were moderately correlated (r = 0.52), suggesting that CO has limited utility as a proxy measure for PM2.5 exposure assessment in this setting. Domestic indoor air quality levels associated with biomass fuel combustion in this region exceed WHO Indoor Air Quality standards and are in the hazardous range for human health.

International scale implementation of the CNOSSOS-EU road traffic noise prediction model for epidemiological studies.

The EU-FP7-funded BioSHaRE project is using individual-level data pooled from several national cohort studies in Europe to investigate the relationship of road traffic noise and health. The detailed input data (land cover and traffic characteristics) required for noise exposure modelling are not always available over whole countries while data that are comparable in spatial resolution between different countries is needed for harmonised exposure assessment. Here, we assess the feasibility using the CNOSSOS-EU road traffic noise prediction model with coarser input data in terms of model performance. Starting with a model using the highest resolution datasets, we progressively introduced lower resolution data over five further model runs and compared noise level estimates to measurements. We conclude that a low resolution noise model should provide adequate performance for exposure ranking (Spearman's rank = 0.75; p < 0.001), but with relatively large errors in predicted noise levels (RMSE = 4.46 dB(A)).

Prevalence of asthma and respiratory symptoms in children in a low socio-economic status area of Nigeria.

SETTING: Warri and environs in the Niger Delta, in the Southern region of Nigeria. OBJECTIVE: To investigate the burden of respiratory illness in children in the Niger Delta. DESIGN: A cross-sectional survey of 1397 schoolchildren aged 7-14 years in areas of low socio-economic status (SES), using written questionnaires in English based on the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire, with explanation of symptoms. RESULTS: The prevalence of doctor-diagnosed asthma was 0.9% (95%CI 0.4-1.3), and wheeze in the last 12 months was 5.4% (95%CI 4.3-6.6). The prevalence of other respiratory symptoms was high, in particular night cough 23.3% (95%CI 21.1-25.5), rhinitis 19.2% (95%CI 17.1-21.3) and phlegm production 16.6% (95%CI 14.7-18.6). Risk of wheeze in the younger age groups was twice (OR 2.09, 95%CI 1.29-3.39) that of older ages after controlling for sex and geographical area. Risk of asthma in urban children was reduced (OR 0.15, 95%CI 0.05-0.50) compared to rural children after controlling for age and sex. Urban children also had a lower risk of rhinitis, exercise limitations and absenteeism due to respiratory illness than rural children. CONCLUSION: The prevalence of symptoms of allergic disease was lower than in the African centres in the ISAAC surveys conducted in urban centres. Doctor-diagnosed asthma is likely to be a poor indicator of asthma in low SES areas of developing countries due to health care access issues.

Annoyance and other reaction measures to changes in noise exposure - a review.

INTRODUCTION: Noise is increasingly recognised as a potentially important environmental pollutant but most studies on human responses to noise exposure relate to steady state situations. Effects may differ when noise changes rapidly, e.g. after noise mitigation interventions or with changes in road or airport configurations. METHODS: A systematic review of studies on human reactions to changes in environmental noise exposures published from 1980 to March 2011 was conducted. RESULTS: 41 papers satisfied the inclusion criteria. The most commonly studied outcomes were annoyance (23 papers) and sleep disturbance (11 papers). Other reactions were well-being, activity disturbance and use of living environment. No studies including physiological or disease measures were identified. The most commonly used study design was a written survey. Studies were methodologically diverse and it was not possible to conduct a formal meta-analysis. Annoyance was not necessarily decreased by reducing noise exposure. Non-acoustical factors influenced annoyance ratings and some of these were not identical to those in steady state conditions. There was insufficient evidence to recommend sleep disturbance as an alternative measure of reactions in changed noise conditions. CONCLUSIONS: Surveys of health effects in changed noise situations should be conducted both before and after the change. Annoyance as a reaction indicator should be evaluated with caution as non-acoustical factors play an important role in annoyance ratings. Technical interventions reducing noise levels may therefore not have impacts on annoyance proportionate to their impacts on sound levels. Further studies, investigating impacts on health endpoints (e.g. blood pressure) in changed noise situations are needed.

What do chronic obstructive pulmonary disease patients die from? A multiple cause coding analysis.

Information on obstructive lung disease (OLD) deaths is generally derived from the underlying cause of death on the death certificate. This neglects information on other conditions mentioned and may underestimate the burden of disease. Descriptive analyses of all conditions mentioned on the death certificate for all decedents where OLD (chronic obstructive pulmonary disease or asthma) was mentioned as a contributing cause of death were conducted for England and Wales for 1993-1999. OLD was mentioned in 312,664 or 8.0% of all deaths. OLD comprised the underlying cause of death in 59.8% of deaths with any mention of OLD. Where OLD was not the underlying cause of death, the leading causes by the International Classification of Disease version 9 chapter were diseases of the circulatory system, neoplasms, and non-OLD diseases of the respiratory system. The top single causes were acute myocardial infarction, other ischaemic heart disease, and lung cancer. The current analysis confirms that using the underlying cause of death underestimates the contribution of obstructive lung disease to mortality in England and Wales, in contrast to myocardial infarction where underlying cause of death captures most (94%) mentions on the death certificate.

An outbreak of Salmonella enteritidis phage type 5a infection in a residential home for elderly people.

The first outbreak of Salmonella enteritidis phage type (PT) 5a infection to be reported occurred after a party in a residential home for elderly people in May 1995. The party was attended attended by 96 residents, staff and guests. S. enteritidis PT5a was isolated from 14 of the 25 clinical cases identified after the party and S. enteritidis PT4 from another clinical case. Two elderly residents with S. enteritidis PT5a infection died. Infection with S. enteritidis PT5a was associated with consumption of prawn in mayonnaise vol-au-vents, sausage rolls, corned beef sandwiches, and sausages. The investigation of this outbreak illustrated the difficulty that elderly people may have in the completion of questionnaires. It also highlighted areas for intervention; such as reminders about basic hygiene precautions to prevent secondary spread and the importance of coordinated reinforcement in the workplace of formal food hygiene training for cooks. The Food Safety Regulations 1995 came into force soon after this outbreak: their implementation would probably have prevented it.

Medical event profiling of COPD patients.

PURPOSE: This analysis proposes appropriate descriptive and analytical statistical techniques to profile medical events requiring GP consultation using the example of chronic obstructive pulmonary disease (COPD). METHODS: Consultation patterns were examined for 1807 cases with a diagnosis compatible with COPD in 1998 and a group of controls matched by sex, age and practice from the General Practice Research Database, a nationally representative UK primary care database. Consulting patterns by Read code chapter and chapter subdivision were examined using cluster analysis, logistic regression and classification and regression trees (CART). RESULTS: CART and multivariate logistic regression analyses suggested that COPD patients were more likely to consult with pulmonary circulatory disease (multivariate OR: 7.46 (95% confidence intervals: 2.05, 20.01) ), non-COPD respiratory diseases (2.77 (2.28, 3.37)), mycoses (2.0 (1.43, 2.71)), 'symptoms or ill-defined conditions' (1.95 (1.68, 2.29)), or other forms of heart disease (1.84 (1.92, 2.64)), and less likely to consult with hypertensive diseases (0.73 (0.57, 0.96)). Regression also showed positive associations with digestive system diseases (OR: 1.31 (1.02, 1.68)) and negative associations with 'other viral or chlamydial disease' (0.16 (0.03, 0.88)). A borderline significance reduced risk for cancers was seen in univariate logistic regression analyses. Cluster analyses were not useful in discriminating between cases and controls. CONCLUSIONS: These analyses provide information about the natural history of COPD and could be used to help interpret or detect adverse drug reactions if repeated before and after introduction of a treatment. COPD can be considered a multicomponent disease with more frequent comorbidities than age- and gender-matched individuals without COPD.