Ambient Air Pollution and Variation in Multiple Domains of Asthma Morbidity among Peruvian Children.

RATIONALE: A large portion of asthma morbidity occurs in low- and middle-income countries, and Peru suffers particularly high asthma prevalence. Ambient air exposures are also high, and likely play a role. Most studies of environmental exposures focus on understanding contributors to health care utilization or mortality risk; however, less severe outcomes may still impact quality of life (QOL). OBJECTIVES: To study the association between multiple pollutants and several asthma domains in Peruvian children. METHODS: A total of 484 children aged 9-19 years with asthma were followed for 6-9 months, and evaluated for asthma control, asthma-related QOL, missed school days, and health care utilization. We used geographically distributed monitors to estimate air pollutant concentrations and multivariable generalized linear mixed models to model asthma outcomes as a function of pollutants. RESULTS: A total of 67% of children had moderate to severe persistent asthma. In multipollutant models, higher particulate matter less than 2.5 µm in aerodynamic diameter (PM2.5), black carbon, and nitrogen dioxide concentrations were independently associated with worse asthma control. For each interquartile range increase in PM2.5 or nitrogen dioxide concentration, there was a 59% or 34% higher odds of uncontrolled asthma, respectively. If the proportion of PM2.5 that was black carbon increased, there were increased odds of uncontrolled asthma. Similarly, pollutants were independently associated with worse asthma-related QOL, and PM exposure was associated with increased risk of health care utilization. CONCLUSIONS: Our study highlights the importance of pollutant exposures on multiple domains of asthma morbidity among Peruvian children, including not only acute exacerbations, but also on general asthma burden, such as worse asthma symptom control and QOL.

Association of traffic air pollution and rhinitis quality of life in Peruvian children with asthma.

BACKGROUND: Air pollution exposure may contribute to rhinoconjunctivitis morbidity in children with underlying airways disease. Prior studies have not assessed rhinoconjunctivitis-related quality of life (QOL) in children with asthma chronically exposed to air pollution. METHODS: Children ages 9-19 years with asthma from peri-urban Peru, self-reporting rhinoconjunctivitis symptoms (n = 484), were administered the Rhinoconjunctivitis QOL Questionnaire (RQLQ) at repeated intervals over one year, with scores dichotomized into bothered (>0) and not bothered (= 0). Individual weekly exposures to particulate matter<2.5µm (PM2.5) and its black carbon (BC) component were estimated by inverse distance weighted methods. Generalized estimating equations, adjusting for covariates, estimated associations of PM2.5 and BC with QOL. RESULTS: Participants were on average 13 years old, 55% female, and majority were atopic (77%). Mean (SD) PM2.5 and BC concentrations were 21(3.2) µg/m3 and 4.4(1.5) µg/m3, respectively. In adjusted multi-pollutant models, each 10µg/m3 increase in PM2.5 was associated with increased odds of worse rhinoconjunctivitis QOL (OR;[95% CI]: 1.83;[1.33,2.52]). A 10% increase in the BC proportion was associated with higher rhinitis burden (OR;[95% CI]: 1.80;[1.22,2.66]), while increases in the non-BC component of PM did not significantly impact rhinoconjunctivitis QOL. Associations were similar regardless of atopy. CONCLUSION: Higher PM2.5 and BC exposure is associated with worse rhinitis QOL among asthmatic children.

"The disease is mine, the body is mine, I decide": Individual, interpersonal, and institutional barriers and facilitators among survivors of women's cancers in Andean countries.

Recent national cancer plans address high cancer mortality in Latin America, particularly in Andean countries. Little is known about which individual, interpersonal, and institutional facilitators and barriers persist, particularly from the perspective of cancer survivors. We conducted 15 semi-structured interviews with survivors of breast and cervical cancers during and after a Pan American Health Organization sponsored conference on women's cancers in Lima, Peru. We analyzed data using an inductive content analysis approach. Patients reported primarily psychosocial barriers and facilitators at individual, interpersonal, and institutional levels. Additionally, survivors provided recom-mendations to refine existing policy to improve the cancer care experience for patients.

Urbanization and Daily Exposure to Biomass Fuel Smoke Both Contribute to Chronic Bronchitis Risk in a Population with Low Prevalence of Daily Tobacco Smoking.

OBJECTIVE: Risk factors beyond tobacco smoking associated with chronic bronchitis are not well understood. We sought to describe the prevalence and risk factors of chronic bronchitis across four distinct settings in Peru with overall low prevalence of tobacco smoking yet varying degrees of urbanization, daily exposure to biomass fuel smoke and living at high altitude. METHODS: We analyzed data of 2,947 participants from rural and urban Puno, Lima and Tumbes including spirometry, blood samples, anthropometry and administered questionnaires about respiratory symptoms. We used multivariable Poisson regression to assess biologic, socioeconomic and environmental risk factors associated with chronic bronchitis. RESULTS: Overall prevalence of chronic bronchitis was 5.9% (95%CI 5.1%-6.9%) with variation by setting: prevalence was lower in semi-urban Tumbes (1.3%) vs. highly urbanized Lima (8.9%), urban Puno (7.0%) and rural Puno (7.8%; p < 0.001). Chronic bronchitis was more common among participants with vs. without COPD based on FEV1/FVC< LLN (12.1% vs 5.6%, p < 0.01) and it was associated with increased reporting of dyspnea on exertion (p < 0.001), hospitalization (p = 0.003) and workdays missed due to respiratory symptoms (p < 0.001). Older age (Prevalence ratio [PR] = 1.23 for each 10-years of age, 95%CI 1.09-1.40) past history of asthma (PR = 2.87, 95%CI 1.80-4.56), urbanization (PR = 3.34, 95%CI 2.18-5.11) and daily exposure to biomass fuel smoke (PR = 2.00, 95%CI 1.30-3.07) were all associated with chronic bronchitis. CONCLUSIONS: We found important variations in the prevalence of chronic bronchitis across settings. Prevalence increased with both urbanization and with daily exposure to biomass fuel smoke. Having chronic bronchitis was also associated with worse patient-centered outcomes including dyspnea, hospitalization and missed workdays.

Influence of Insurance Status and Demographic Features on Recognition of Symptomatic and Asymptomatic Gonorrhea Cases.

A random sample of individuals diagnosed as having gonorrhea from 2009 to 2013 were interviewed. Demographic and clinical features for asymptomatic and symptomatic individuals were examined to elucidate trends in medical care. Age, race, and sexually transmitted disease history had no association with the absence of symptoms (e.g., infection found by screening), whereas insurance coverage did for women.

The continuum of hepatitis C testing and care.

UNLABELLED: A hepatitis C virus (HCV)-infected person will ideally have access to quality health care and move through the HCV continuum of care (CoC) from HCV antibody (Ab) screening, HCV-RNA confirmation, engagement and retention in medical care, and treatment. Unfortunately, studies show that many patients do not progress through this continuum. Because these studies may not be generalizable, we assessed the HCV CoC in Philadelphia from January 2010 to December 2013 at the population level. The expected HCV seroprevalence in Philadelphia during 2010-2013 was calculated by applying National Health and Nutrition Examination Survey prevalences to age-specific census data approximations and published estimates of homeless and incarcerated populations. HCV laboratory results reported to the Philadelphia Department of Public Health and enhanced surveillance data were used to determine where individuals fell on the continuum. HCV CoC was defined as follows: stage 1: HCV Ab screening; stage 2: HCV Ab and RNA testing; stage 3: RNA confirmation and continuing care; and stage 4: RNA confirmation, care, and HCV treatment. Of approximately 1,584,848 Philadelphia residents, 47,207 (2.9%) were estimated to have HCV. Positive HCV results were received for 13,596 individuals, of whom 6,383 (47%) had a positive HCV-RNA test. Of these, 1,745 (27%) were in care and 956 (15%) had or were currently receiving treatment. CONCLUSION: This continuum provides a real-life snapshot of how this disease is being managed in a major U.S. urban center. Many patients are lost at each stage, highlighting the need to raise awareness among health care professionals and at-risk populations about appropriate hepatitis testing, referral, support, and care.

In utero and childhood polybrominated diphenyl ether (PBDE) exposures and neurodevelopment in the CHAMACOS study.

BACKGROUND: California children's exposures to polybrominated diphenyl ether flame retardants (PBDEs) are among the highest worldwide. PBDEs are known endocrine disruptors and neurotoxicants in animals. OBJECTIVE: Here we investigate the relation of in utero and child PBDE exposure to neurobehavioral development among participants in CHAMACOS (Center for the Health Assessment of Mothers and Children of Salinas), a California birth cohort. METHODS: We measured PBDEs in maternal prenatal and child serum samples and examined the association of PBDE concentrations with children's attention, motor functioning, and cognition at 5 (n = 310) and 7 years of age (n = 323). RESULTS: Maternal prenatal PBDE concentrations were associated with impaired attention as measured by a continuous performance task at 5 years and maternal report at 5 and 7 years of age, with poorer fine motor coordination-particularly in the nondominant-at both age points, and with decrements in Verbal and Full-Scale IQ at 7 years. PBDE concentrations in children 7 years of age were significantly or marginally associated with concurrent teacher reports of attention problems and decrements in Processing Speed, Perceptual Reasoning, Verbal Comprehension, and Full-Scale IQ. These associations were not altered by adjustment for birth weight, gestational age, or maternal thyroid hormone levels. CONCLUSIONS: Both prenatal and childhood PBDE exposures were associated with poorer attention, fine motor coordination, and cognition in the CHAMACOS cohort of school-age children. This study, the largest to date, contributes to growing evidence suggesting that PBDEs have adverse impacts on child neurobehavioral development.

Organophosphate pesticide exposure and attention in young Mexican-American children: the CHAMACOS study.

BACKGROUND: Exposure to organophosphate (OP) pesticides, well-known neurotoxicants, has been associated with neurobehavioral deficits in children. OBJECTIVES: We investigated whether OP exposure, as measured by urinary dialkyl phosphate (DAP) metabolites in pregnant women and their children, was associated with attention-related outcomes among Mexican-American children living in an agricultural region of California. METHODS: Children were assessed at ages 3.5 years (n = 331) and 5 years (n = 323). Mothers completed the Child Behavior Checklist (CBCL). We administered the NEPSY-II visual attention subtest to children at 3.5 years and Conners' Kiddie Continuous Performance Test (K-CPT) at 5 years. The K-CPT yielded a standardized attention deficit/hyperactivity disorder (ADHD) Confidence Index score. Psychometricians scored behavior of the 5-year-olds during testing using the Hillside Behavior Rating Scale. RESULTS: Prenatal DAPs (nanomoles per liter) were nonsignificantly associated with maternal report of attention problems and ADHD at age 3.5 years but were significantly related at age 5 years [CBCL attention problems: ß = 0.7 points; 95% confidence interval (CI), 0.2-1.2; ADHD: ß = 1.3; 95% CI, 0.4-2.1]. Prenatal DAPs were associated with scores on the K-CPT ADHD Confidence Index > 70th percentile [odds ratio (OR) = 5.1; 95% CI, 1.7-15.7] and with a composite ADHD indicator of the various measures (OR = 3.5; 95% CI, 1.1-10.7). Some outcomes exhibited evidence of effect modification by sex, with associations found only among boys. There was also limited evidence of associations between child DAPs and attention. CONCLUSIONS: In utero DAPs and, to a lesser extent, postnatal DAPs were associated adversely with attention as assessed by maternal report, psychometrician observation, and direct assessment. These associations were somewhat stronger at 5 years than at 3.5 years and were stronger in boys.

Organophosphate pesticide exposure and neurodevelopment in young Mexican-American children.

BACKGROUND: Organophosphate (OP) pesticides are widely used in agriculture and homes. Animal studies suggest that even moderate doses are neurodevelopmental toxicants, but there are few studies in humans. OBJECTIVES: We investigated the relationship of prenatal and child OP urinary metabolite levels with children's neurodevelopment. METHODS: Participating children were from a longitudinal birth cohort of primarily Latino farm-worker families in California. We measured six nonspecific dialkylphosphate (DAP) metabolites in maternal and child urine as well as metabolites specific to malathion (MDA) and chlorpyrifos (TCPy) in maternal urine. We examined their association with children's performance at 6 (n = 396), 12 (n = 395), and 24 (n = 372) months of age on the Bayley Scales of Infant Development [Mental Development (MDI) and Psychomotor Development (PDI) Indices] and mother's report on the Child Behavior Checklist (CBCL) (n = 356). RESULTS: Generally, pregnancy DAP levels were negatively associated with MDI, but child measures were positively associated. At 24 months of age, these associations reached statistical significance [per 10-fold increase in prenatal DAPs: beta = -3.5 points; 95% confidence interval (CI), -6.6 to -0.5; child DAPs: beta = 2.4 points; 95% CI, 0.5 to 4.2]. Neither prenatal nor child DAPs were associated with PDI or CBCL attention problems, but both prenatal and postnatal DAPs were associated with risk of pervasive developmental disorder [per 10-fold increase in prenatal DAPs: odds ratio (OR) = 2.3, p = 0.05; child DAPs OR = 1.7, p = 0.04]. MDA and TCPy were not associated with any outcome. CONCLUSIONS: We report adverse associations of prenatal DAPs with mental development and pervasive developmental problems at 24 months of age. Results should be interpreted with caution given the observed positive relationship with postnatal DAPs.

In utero exposure to dichlorodiphenyltrichloroethane (DDT) and dichlorodiphenyldichloroethylene (DDE) and neurodevelopment among young Mexican American children.

OBJECTIVE: We investigated the relationship between prenatal exposure to dichlorodiphenyltrichloroethane (DDT) and dichlorodiphenyldichloroethylene (DDE) and neurodevelopment of Mexican farm-workers' children in California. METHODS: Participants from the Center for the Health Assessment of Mothers and Children of Salinas study, a birth cohort study, included 360 singletons with maternal serum measures of p,p'-DDT, o,p'-DDT, and p,p'-DDE. Psychomotor development and mental development were assessed with the Bayley Scales of Infant Development at 6, 12, and 24 months. RESULTS: We found a approximately 2-point decrease in Psychomotor Developmental Index scores with each 10-fold increase in p,p'-DDT levels at 6 and 12 months (but not 24 months) and p,p'-DDE levels at 6 months only. We found no association with mental development at 6 months but a 2- to 3-point decrease in Mental Developmental Index scores for p,p'-DDT and o,p'-DDT at 12 and 24 months, corresponding to 7- to 10-point decreases across the exposure range. Even when mothers had substantial exposure, breastfeeding was usually associated positively with Bayley scale scores. CONCLUSIONS: Prenatal exposure to DDT, and to a lesser extent DDE, was associated with neurodevelopmental delays during early childhood, although breastfeeding was found to be beneficial even among women with high levels of exposure. Countries considering the use of DDT should weigh its benefit in eradicating malaria against the negative associations found in this first report on DDT and human neurodevelopment.

Outbreak of cyclosporiasis associated with imported raspberries, Philadelphia, Pennsylvania, 2000.

An outbreak of cyclosporiasis occurred in attendees of a wedding reception held in Philadelphia, Pennsylvania, on June 10, 2000. In a retrospective cohort study, 54 (68.4%) of the 79 interviewed guests and members of the wedding party met the case definition. The wedding cake, which had a cream filling that included raspberries, was the food item most strongly associated with illness (multivariate relative risk, 5.9; 95% confidence interval, 3.6 to 10.5). Leftover cake was positive for Cyclospora DNA by polymerase chain reaction analyses. Sequencing of the amplified fragments confirmed that the organism was Cyclospora cayetanensis. The year 2000 was the fifth year since 1995 that outbreaks of cyclosporiasis definitely or probably associated with Guatemalan raspberries have occurred in the spring in North America. Additionally, this is the second documented U.S. outbreak, and the first associated with raspberries, for which Cyclospora has been detected in the epidemiologically implicated food item.