Climate change and health: rethinking public health messaging for wildfire smoke and extreme heat co-exposures.

With the growing climate change crisis, public health agencies and practitioners must increasingly develop guidance documents addressing the public health risks and protective measures associated with multi-hazard events. Our Policy and Practice Review aims to assess current public health guidance and related messaging about co-exposure to wildfire smoke and extreme heat and recommend strengthened messaging to better protect people from these climate-sensitive hazards. We reviewed public health messaging published by governmental agencies between January 2013 and May 2023 in Canada and the United States. Publicly available resources were eligible if they discussed the co-occurrence of wildfire smoke and extreme heat and mentioned personal interventions (protective measures) to prevent exposure to either hazard. We reviewed local, regional, and national governmental agency messaging resources, such as online fact sheets and guidance documents. We assessed these resources according to four public health messaging themes, including (1) discussions around vulnerable groups and risk factors, (2) symptoms associated with these exposures, (3) health risks of each exposure individually, and (4) health risks from combined exposure. Additionally, we conducted a detailed assessment of current messaging about measures to mitigate exposure. We found 15 online public-facing resources that provided health messaging about co-exposure; however, only one discussed all four themes. We identified 21 distinct protective measures mentioned across the 15 resources. There is considerable variability and inconsistency regarding the types and level of detail across described protective measures. Of the identified 21 protective measures, nine may protect against both hazards simultaneously, suggesting opportunities to emphasize these particular messages to address both hazards together. More precise, complete, and coordinated public health messaging would protect against climate-sensitive health outcomes attributable to wildfire smoke and extreme heat co-exposures.

Indoor Air Sources of Outdoor Air Pollution: Health Consequences, Policy, and Recommendations: An Official American Thoracic Society Workshop Report.

Indoor sources of air pollution worsen indoor and outdoor air quality. Thus, identifying and reducing indoor pollutant sources would decrease both indoor and outdoor air pollution, benefit public health, and help address the climate crisis. As outdoor sources come under regulatory control, unregulated indoor sources become a rising percentage of the problem. This American Thoracic Society workshop was convened in 2022 to evaluate this increasing proportion of indoor contributions to outdoor air quality. The workshop was conducted by physicians and scientists, including atmospheric and aerosol scientists, environmental engineers, toxicologists, epidemiologists, regulatory policy experts, and pediatric and adult pulmonologists. Presentations and discussion sessions were centered on 1) the generation and migration of pollutants from indoors to outdoors, 2) the sources and circumstances representing the greatest threat, and 3) effective remedies to reduce the health burden of indoor sources of air pollution. The scope of the workshop was residential and commercial sources of indoor air pollution in the United States. Topics included wood burning, natural gas, cooking, evaporative volatile organic compounds, source apportionment, and regulatory policy. The workshop concluded that indoor sources of air pollution are significant contributors to outdoor air quality and that source control and filtration are the most effective measures to reduce indoor contributions to outdoor air. Interventions should prioritize environmental justice: Households of lower socioeconomic status have higher concentrations of indoor air pollutants from both indoor and outdoor sources. We identify research priorities, potential health benefits, and mitigation actions to consider (e.g., switching from natural gas to electric stoves and transitioning to scent-free consumer products). The workshop committee emphasizes the benefits of combustion-free homes and businesses and recommends economic, legislative, and education strategies aimed at achieving this goal.

Impact of income-based public drug coverage deductibles on adherence to asthma medications.

BACKGROUND: Cost-related nonadherence to medications can be a barrier to asthma management. OBJECTIVE: To quantify the impact of public drug plan deductibles on adherence to asthma medications. METHODS: We used a quasi-experimental regression discontinuity analysis to determine whether thresholds in deductibles for public drug coverage, determined on the basis of annual household income, decreased medication use among lower-income children and adults with asthma in British Columbia from 2013 to 2018. Using dispensed medication records, we evaluated deductible thresholds at annual household incomes of $15,000 (a deductible increase from 0% to 2% of annual household income), and $30,000 (a deductible increase from 2% to 3% annual household income). We evaluated medication costs, use, the ratio of inhaled corticosteroids-containing controller medications to total medications, excessive use of short-acting ß-agonists, and the proportion of days covered by controller therapies. All costs are reported in 2020 Canadian dollars. RESULTS: Overall, 88,935 individuals contributed 443,847 person-years of follow-up (57% of female sex, mean age 31 years). Public drug subsidy decreased by -$41.74 (95% CI, -$28.34 to -$55.13) at the $15,000-deductible threshold, a 28% reduction, and patient costs increased by $48.45 (95% CI, $35.37-$61.53). The $30,000 deductible threshold did not affect public drug costs (P = .31), but patient costs increased by $27.65 (95% CI, $15.22-$40.09), which is an 11% increase. Asthma-related medication use, inhaled corticosteroids-to-total medication ratio, excessive use of short-acting ß-agonists, and proportion of days covered by controller therapies were not impacted by deductible thresholds. CONCLUSION: Income-based deductibles reduced public drug costs with no effect on asthma-related medication use, adherence to controller therapies, or excessive reliever therapy use in lower-income individuals with asthma.

Family income as a moderator of relations between sleep and physical health during adolescence.

OBJECTIVES: Sleep duration, quality, and consistency are associated with overall physical health in adolescence, yet the effects of sleep on development may be not uniform because both sleep and physical health vary systematically along gradients of family income. To understand "for whom" sleep may be particularly beneficial, the present study tested family income as a moderator of relations between youth sleep and physical health. METHODS: Three hundred twenty-three youth (M age=17.39years; 53% female; 41% Black, 59% White) wore wrist actigraphs for 1week at home. Four well-recognized sleep parameters were derived: minutes, efficiency, long wake episodes, and variability in minutes across the week. Parents reported family income, and mothers rated adolescents' physical health. In independent path models, physical health was regressed onto each indicator of sleep, family income, and Sleep × Family Income interactions to test potential moderation effects. RESULTS: Associations between sleep and physical health were moderated by family income. Lower sleep efficiency, more long wake episodes, and more variability in sleep minutes were associated with poorer physical health among adolescents from lower-income families. At optimal levels of all sleep variables, income-based differences in physical health were mitigated. Youth from higher-income families tended to have better physical health regardless of their sleep. CONCLUSIONS: Findings build evidence that sleep has relations with physical health for low-income youth in particular. Clinicians and other service providers working with youth might benefit from considering the role of sleep in prevention and interventions programs geared toward improving health.

Air Pollution and Diet: Potential Interacting Exposures in Asthma.

PURPOSE OF REVIEW: To provide a review of emerging literature describing the impact of diet on the respiratory response to air pollution in asthma. RECENT FINDINGS: Asthma phenotyping (observable characteristics) and endotyping (mechanistic pathways) have increased the specificity of diagnostic and treatment pathways and opened the doors to the identification of subphenotypes with enhanced susceptibility to exposures and interventions. Mechanisms underlying the airway immune response to air pollution are still being defined but include oxidative stress, inflammation, and activation of adaptive and innate immune responses, with genetic susceptibility highlighted. Of these, neutrophil recruitment and activation appear prominent; however, understanding neutrophil function in response to pollutant exposures is a research gap. Diet may play a role in asthma pathogenesis and morbidity; therefore, diet modification is a potential target opportunity to protect against pollutant-induced lung injury. In particular, in vivo and in vitro data suggest the potential for diet to modify the inflammatory response in the airways, including impacts on neutrophil recruitment and function. Murine models provide compelling results in regard to the potential for dietary components (including fiber, antioxidants, and omega-3 fatty acids) to buffer against the inflammatory response to air pollution in the lung. Precision lifestyle approaches to asthma management and respiratory protection in the context of air pollution exposures may evolve to include diet, pending the results of further epidemiologic and causal investigation and with neutrophil recruitment and activation as a candidate mechanism.

Socioeconomic Disparities, Nighttime Bedroom Temperature, and Children's Sleep.

We investigated associations between family income-to-needs, nighttime bedroom temperature (NBT), and children's sleep. Using a sample of 46 children (M age = 11.5), we recorded NBT and objective sleep parameters via actigraphy nightly for one week to evaluate within- (night-to-night) and between-person associations. We found consistent evidence for a curvilinear association between NBT and sleep variables at the between-person level, indicating that children who slept in rooms that were "too hot" or "too cold" experienced poorer sleep. Moreover, children in lower income-to-needs families had more extreme NBTs. There was some evidence that family income-to-needs is indirectly related to sleep via NBT, but with interpretational caveats. These findings point to NBT as a potentially modifiable variable, which has implications for practical applications to mitigate effects of socioeconomic disparities on children's sleep.

Obstructive sleep apnea screening in children with asthma.

RATIONALE: Obstructive sleep apnea is highly prevalent in children with asthma, particularly in obese children. The sleep-related breathing disorder screening questionnaire has low screening accuracy for obstructive sleep apnea in children with asthma. Our goal was to identify the questions on the sleep-related breathing disorder survey associated with obstructive sleep apnea in children with asthma. METHODS: Participants completed the survey, underwent polysomnography and their body mass index z-score was measured. Participants with survey scores above 0.33 were considered high risk for obstructive sleep apnea and those with an apnea-hypopnea index ≥ 2 events/h classified as having obstructive sleep apnea. Logistic regression was used to examine the association of each survey question and obstructive sleep apnea. Positive and negative predictive values were calculated to estimate screening accuracy. RESULTS: The prevalence of obstructive sleep apnea was 40% in our sample (n = 136). Loud snoring, morning dry mouth, and being overweight were the survey questions associated with obstructive sleep apnea. The composite survey score obtained from all 22 questions had positive and negative predictive values of 51.0% and 65.5%, while the combined model of loud snoring, morning dry mouth, and being overweight had positive and negative predictive values of 60.3% and 77.6%. On the other hand, the body mass index z-score alone had positive and negative predictive values of 76.3% and 72.2%. CONCLUSIONS: The body mass index z-score is useful for obstructive sleep apnea screening in children with asthma and should be applied routinely given its simplicity and concerns that obstructive sleep apnea may contribute to asthma morbidity.

PASC in Solid Organ Transplant Recipients With Self-reported SARS-CoV-2 Infection.

BACKGROUND: Postacute sequelae of SARS-CoV-2 infection (PASC) is an increasingly recognized phenomenon and manifested by long-lasting cognitive, mental, and physical symptoms beyond the acute infection period. We aimed to estimate the frequency of PASC symptoms in solid organ transplant (SOT) recipients and compared their frequency between those with SARS-CoV-2 infection requiring hospitalization and those who did not require hospitalization. METHODS: A survey consisting of 7 standardized questionnaires was administered to 111 SOT recipients with history of SARS-CoV-2 infection diagnosed >4 wk before survey administration. RESULTS: Median (interquartile range) time from SARS-CoV-2 diagnosis was 167 d (138-221). Hospitalization for SARS-CoV-2 infection was reported in 33 (30%) participants. Symptoms after the COVID episode were perceived as following: significant trauma (53%), cognitive decline (50%), fatigue (41%), depression (36%), breathing problems (35%), anxiety (23%), dysgeusia (22%), dysosmia (21%), and pain (19%). Hospitalized patients had poorer median scores in cognition (Quick Dementia Rating System survey score: 2.0 versus 0.5, P = 0.02), quality of life (Health-related Quality of Life survey: 2.0 versus 1.0, P = 0.015), physical health (Global physical health scale: 10.0 versus 11.0, P = 0.005), respiratory status (Breathlessness, Cough and Sputum Scale: 1.0 versus 0.0, P = 0.035), and pain (Pain score: 3 versus 0 out of 10, P = 0.003). Among patients with infection >6 mo prior, some symptoms were still present as following: abnormal breathing (42%), cough (40%), dysosmia (29%), and dysgeusia (34%). CONCLUSIONS: SOT recipients reported a high frequency of PASC symptoms. Multidisciplinary approach is needed to care for these patients beyond the acute phase.

Responding to the Disproportionate Impact of COVID-19 Among Latinx Patients in Baltimore: The JHM Latinx Anchor Strategy.

Latinx immigrants have been profoundly impacted by COVID-19. As the Johns Hopkins Health System faced a surge in admissions of limited English proficiency patients with COVID-19, it became evident that an institutional strategy to address the needs of this patient population was needed. The Johns Hopkins Medicine (JHM) Latinx Anchor Strategy was established in April 2020 with diverse stakeholder engagement to identify the most urgent community needs and develop timely solutions. The JHM Latinx Anchor Strategy provided a platform for information sharing to promote equitable access to resources for Latinxs with limited English proficiency who were impacted by COVID-19. Leveraging institutional, community, and government resources and expertise, the JHM Latinx Anchor Strategy helped establish interventions to improve access to COVID-19 testing and care for low-income immigrants without a primary care doctor and helped mitigate economic vulnerability through the distribution of food for 2,677 individuals and cash to 446 families and 95 individuals (May to August 2020). Expanded linguistic and culturally competent communication through webinars and livestream events reached more than 10,000 community members and partners. Over 7,500 limited English proficiency patients received linguistically congruent direct patient services through the Esperanza Center bilingual hotline, community testing resulting efforts, and inpatient consultations. The first stage of the JHM Latinx Anchor Strategy relied heavily on volunteer efforts. Funding for a sustainable response will be required to address ongoing COVID-19 needs, including expansion of the bilingual/bicultural healthcare workforce, expanded access to primary care, and investments in population health strategies addressing social determinants of health.

Spatial analysis of tobacco outlet density on secondhand smoke exposure and asthma health among children in Baltimore City.

RATIONALE: Tobacco outlets are concentrated in low-income neighbourhoods; higher tobacco outlet density is associated with increased smoking prevalence. Secondhand smoke (SHS) exposure has significant detrimental effects on childhood asthma. We hypothesised there was an association between higher tobacco outlet density, indoor air pollution and worse childhood asthma. METHODS: Baseline data from a home intervention study of 139 children (8-17 years) with asthma in Baltimore City included residential air nicotine monitoring, paired with serum cotinine and asthma control assessment. Participant addresses and tobacco outlets were geocoded and mapped. Multivariable regression modelling was used to describe the relationships between tobacco outlet density, SHS exposure and asthma control. RESULTS: Within a 500 m radius of each participant home, there were on average six tobacco outlets. Each additional tobacco outlet in a 500 m radius was associated with a 12% increase in air nicotine (p<0.01) and an 8% increase in serum cotinine (p=0.01). For every 10-fold increase in air nicotine levels, there was a 0.25-point increase in Asthma Therapy Assessment Questionnaire (ATAQ) score (p=0.01), and for every 10-fold increase in serum cotinine levels, there was a 0.54-point increase in ATAQ score (p<0.05). CONCLUSIONS: Increased tobacco outlet density is associated with higher levels of bedroom air nicotine and serum cotinine. Increasing levels of SHS exposure (air nicotine and serum cotinine) are associated with less controlled childhood asthma. In Baltimore City, the health of children with asthma is adversely impacted in neighbourhoods where tobacco outlets are concentrated. The implications of our findings can inform community-level interventions to address these health disparities.

Cognitive Dysfunction, Psychiatric Distress, and Functional Decline After COVID-19.

BACKGROUND: There is a limited understanding of the cognitive and psychiatric sequelae of COVID-19 during the post-acute phase, particularly among racially and ethnically diverse patients. OBJECTIVE: We sought to prospectively characterize cognition, mental health symptoms, and functioning approximately four months after an initial diagnosis of COVID-19 in a racially and ethnically diverse group of patients. METHODS: Approximately four months after COVID-19 diagnosis, patients in the Johns Hopkins Post-Acute COVID-19 Team Pulmonary Clinic underwent a clinical telephone-based assessment of cognition, depression, anxiety, trauma, and function. RESULTS: Most Johns Hopkins Post-Acute COVID-19 Team patients assessed were women (59%) and members of racial/ethnic minority groups (65%). Of 82 patients, 67% demonstrated ≥1 abnormally low cognitive score. Patients requiring intensive care unit (ICU) stays displayed greater breadth and severity of impairment than those requiring less intensive treatment. Processing speed (35%), verbal fluency (26%-32%), learning (27%), and memory (27%) were most commonly impaired. Among all patients, 35% had moderate symptoms of depression (23%), anxiety (15%), or functional decline (15%); 25% of ICU patients reported trauma-related distress. Neuropsychiatric symptoms and functional decline did not differ by post-ICU versus non-ICU status and were unrelated to global cognitive composite scores. CONCLUSIONS: At approximately 4 months after acute illness, cognitive dysfunction, emotional distress, and functional decline were common among a diverse clinical sample of COVID-19 survivors varying in acute illness severity. Patients requiring ICU stays demonstrated greater breadth and severity of cognitive impairment than those requiring less intensive treatment. Findings help extend our understanding of the nature, severity, and potential duration of neuropsychiatric morbidity after COVID-19 and point to the need for longitudinal assessment of cognitive and mental health outcomes among COVID-19 survivors of different demographic backgrounds and illness characteristics.

Patterns and predictors of air purifier adherence in children with asthma living in low-income, urban households.

OBJECTIVE: Black children and children from low-income communities are disproportionately affected by asthma, attributed partly to pollution exposure. Air purifiers reduce indoor air pollution and improve asthma symptoms in children. In order to implement air purifier interventions, an understanding of patterns of use and potential barriers is necessary. METHODS: In a home intervention study, 127 children with asthma living in Baltimore were randomized to receive two active or two placebo air purifiers. The 16-week study period included: baseline clinic visit, home visit for air purifier installation (active or placebo) with instruction to use the high or turbo settings, and electronic adherence monitoring of air purifiers. Determinants of adherence were identified using linear regression models. RESULTS: Air purifiers were used 80% of the time, and participants demonstrated adherence to high or turbo settings for 60% of the time. In an adjusted model, season was the major determinant of air purifier adherence, with 21% lower use in the winter (p = 0.025) attributed to the cold draft generated by the machine. CONCLUSION: In a clinical trial with electronic adherence monitoring, air purifier use was high and participants were adherent to use of high or turbo settings the majority of the time. Addressing practical barriers to consistent use, such as draft during the winter, in addition to financial barriers may improve air purifier adherence among children with asthma living in low-income, urban households. CLINICAL TRIALS REGISTRY NUMBER: NCT02763917.

Obesity, tidal volume, and pulmonary deposition of fine particulate matter in children with asthma.

BACKGROUND: Obese children with asthma are more vulnerable to air pollution, especially fine particulate matter (PM2.5), but reasons are poorly understood. We hypothesised that differences in breathing patterns (tidal volume, respiratory rate and minute ventilation) due to elevated body mass index (BMI) may contribute to this finding. OBJECTIVE: To investigate the association of BMI with breathing patterns and deposition of inhaled PM2.5. METHODS: Baseline data from a prospective study of children with asthma were analysed (n=174). Tidal breathing was measured by a pitot-tube flowmeter, from which tidal volume, respiratory rate and minute ventilation were obtained. The association of BMI z-score with breathing patterns was estimated in a multivariable model adjusted for age, height, race, sex and asthma severity. A particle dosimetry model simulated PM2.5 lung deposition based on BMI-associated changes in breathing patterns. RESULTS: Higher BMI was associated with higher tidal volume (adjusted mean difference (aMD) between obese and normal-range BMI of 25 mL, 95% CI 5-45 mL) and minute ventilation (aMD 453 mL·min-1, 95% CI 123-784 mL·min-1). Higher tidal volumes caused higher fractional deposition of PM2.5 in the lung, driven by greater alveolar deposition. This translated into obese participants having greater per-breath retention of inhaled PM2.5 (aMD in alveolar deposition fraction of 3.4%, 95% CI 1.3-5.5%), leading to worse PM2.5 deposition rates. CONCLUSIONS: Obese children with asthma breathe at higher tidal volumes that may increase the efficiency of PM2.5 deposition in the lung. This finding may partially explain why obese children with asthma exhibit greater sensitivity to air pollution.

Pretreatment Lung Function and Checkpoint Inhibitor Pneumonitis in NSCLC.

INTRODUCTION: Checkpoint inhibitor pneumonitis (CIP) is a serious toxicity of anti-programmed death-(ligand) 1 immunotherapy. Whether pretreatment differences in pulmonary function exist in patients who develop CIP is unknown. We analyzed the pulmonary function tests (PFTs) of patients with NSCLC treated with immune checkpoint inhibitors (ICIs) to evaluate whether pretreatment lung function was associated with CIP development. METHODS: Patients were included if they completed greater than or equal to 1 PFT within 2 years preceding ICI initiation. CIP status (CIP+: developed CIP, CIP-: did not develop CIP) was determined clinically. Generalized estimating equation-based linear regression was used to evaluate the effects of time and CIP on lung function. Primary outcomes included the following: percent-predicted forced expiratory volume in 1 second (FEV1pp), percent-predicted forced vital capacity (FVCpp), and FEV1/FVC. RESULTS: A total of 43 patients (34 CIP-, 9 CIP+) with 79 PFTs (59 CIP-, 20 CIP+) were included. CIP+ patients had a 21.7% lower pretreatment FEV1pp compared with the CIP- group (95% confidence interval: -38.6 to -4.7). No statistically significant differences in FVCpp or FEV1/FVC were observed. The prevalence of obstructive lung disease was similar in both groups at 67% and 62% for the CIP+ and CIP- cohorts, as was the prevalence of current/former smoking at 100% and 93%, respectively. CONCLUSIONS: Pretherapy differences in lung function were evident between patients who did and did not develop CIP, though the prevalence of obstructive lung disease was similar. Prospective studies are needed to validate these findings, inform potential risk factors for CIP, and investigate the effects of ICI treatment and CIP on pulmonary function in patients with NSCLC.

Dexamethasone-Induced FKBP51 Expression in CD4+ T-Lymphocytes Is Uniquely Associated With Worse Asthma Control in Obese Children With Asthma.

Introduction: There is evidence that obesity, a risk factor for asthma severity and morbidity, has a unique asthma phenotype which is less atopic and less responsive to inhaled corticosteroids (ICS). Peripheral blood mononuclear cells (PBMC) are important to the immunologic pathways of obese asthma and steroid resistance. However, the cellular source associated with steroid resistance has remained elusive. We compared the lymphocyte landscape among obese children with asthma to matched normal weight children with asthma and assessed relationship to asthma control. Methods: High-dimensional flow cytometry of PBMC at baseline and after dexamethasone stimulation was performed to characterize lymphocyte subpopulations, T-lymphocyte polarization, proliferation (Ki-67+), and expression of the steroid-responsive protein FK506-binding protein 51 (FKBP51). T-lymphocyte populations were compared between obese and normal-weight participants, and an unbiased, unsupervised clustering analysis was performed. Differentially expressed clusters were compared with asthma control, adjusted for ICS and exhaled nitric oxide. Results: In the obese population, there was an increased cluster of CD4+ T-lymphocytes expressing Ki-67 and FKBP51 at baseline and CD4+ T-lymphocytes expressing FKBP51 after dexamethasone stimulation. CD4+ Ki-67 and FKBP51 expression at baseline showed no association with asthma control. Dexamethasone-induced CD4+ FKBP51 expression was associated with worse asthma control in obese participants with asthma. FKBP51 expression in CD8+ T cells and CD19+ B cells did not differ among groups, nor did polarization profiles for Th1, Th2, Th9, or Th17 percentage. Discussion: Dexamethasone-induced CD4+ FKBP51 expression is uniquely associated with worse asthma control in obese children with asthma and may underlie the corticosteroid resistance observed in this population.

Addressing the post-acute sequelae of SARS-CoV-2 infection: a multidisciplinary model of care.

As of July 31, 2021, SARS-CoV-2 had infected almost 200 million people worldwide. The growing burden of survivorship is substantial in terms of the complexity of long-term health effects and the number of people affected. Persistent symptoms have been reported in patients with both mild and severe acute COVID-19, including those admitted to the intensive care unit (ICU). Early reports on the post-acute sequelae of SARS-CoV-2 infection (PASC) indicate that fatigue, dyspnoea, cough, headache, loss of taste or smell, and cognitive or mental health impairments are among the most common symptoms. These complex, multifactorial impairments across the domains of physical, cognitive, and mental health require a coordinated, multidisciplinary approach to management. Decades of research on the multifaceted needs of and models of care for patients with post-intensive care syndrome provide a framework for the development of PASC clinics to address the immediate needs of both hospitalised and non-hospitalised survivors of COVID-19. Such clinics could also provide a platform for rigorous research into the natural history of PASC and the potential benefits of therapeutic interventions.