All-Cause and Cause-Specific Mortality Attributable to Seasonal Influenza: A Nationwide Matched Cohort Study

Background@#Although influenza poses substantial mortality burden, most studies have estimated excess mortality using time-aggregated data. Here, we estimated mortality risk and population attributable fraction (PAF) attributed to seasonal influenza using individual-level data from a nationwide matched cohort. @*Methods@#Individuals with influenza during four consecutive influenza seasons (2013–2017) (n = 5,497,812) and 1:4 age- and sex-matched individuals without influenza (n = 20,990,683) were identified from a national health insurance database. The endpoint was mortality within 30 days after influenza diagnosis. All-cause and cause-specific mortality risk ratios (RRs) attributed to influenza were estimated. Excess mortality, mortality RR, and PAF of mortality were determined, including for underlying disease subgroups. @*Results@#Excess mortality rate, mortality RR, and PAF of all-cause mortality were 49.5 per 100,000, 4.03 (95% confidence interval [CI], 3.63–4.48), and 5.6% (95% CI, 4.5–6.7%). Cause-specific mortality RR (12.85; 95% CI, 9.40–17.55) and PAF (20.7%; 95% CI, 13.2– 27.0%) were highest for respiratory diseases. In subgroup analysis according to underlying disorders, PAF of all-cause mortality was 5.9% (95% CI, 0.6–10.7%) for liver disease, 5.8% (95% CI, 2.9–8.5%) for respiratory disease, and 3.8% (95% CI, 1.4–6.1%) for cancer. @*Conclusion@#Individuals with influenza had a 4-fold higher mortality risk than individuals without influenza. Preventing seasonal influenza may lead to 5.6% and 20.7% reductions in all-cause and respiratory mortality, respectively. Individuals with respiratory disease, liver disease, and cancer may benefit from prioritization when establishing influenza prevention strategies.

Season and Temperature Effects on Bloodstream Infection Incidence in a Korean Tertiary Referral Hospital / 대한임상미생물학회지

BACKGROUND: The weather has well-documented effects on infectious disease and reports suggest that summer peaks in the incidences of gram-negative bacterial infections among hospitalized patients. We evaluated how season and temperature changes affect bloodstream infection (BSI) incidences of major pathogens to understand BSI trends with an emphasis on acquisition sites.METHODS: Incidence rates of BSIs by Staphylococcus aureus, Enterococcus spp., Escherichia coli, Klebsiella pneumoniae, Acinetobacter spp., and Pseudomonas aeruginosa were retrospectively analyzed from blood cultures during 2008–2016 at a university hospital in Seoul, Korea according to the acquisition sites. Warm months (June–September) had an average temperature of ≥20℃ and cold months (December–February) had an average temperature of ≤5℃.RESULTS: We analyzed 18,047 cases, where 43% were with community-onset BSI. E. coli (N = 5,365) was the most common pathogen, followed by Enterococcus spp. (N = 3,980), S. aureus (N = 3,075), K. pneumoniae (N = 3,043), Acinetobacter spp. (N = 1,657), and P. aeruginosa (N = 927). The incidence of hospital-acquired BSI by Enterococcus spp. was weakly correlated with temperature, and the median incidence was higher during cold months. The incidence of community-onset BSI by E. coli was higher in warm months and was weakly correlated with temperature.CONCLUSION: We found seasonal or temperature-associated variation in some species-associated BSIs. This could be a useful information for enhancing infection control and public health policies by taking season or climate into consideration.

Effect of Socioeconomic Status and Underlying Disease on the Association between Ambient Temperature and Ischemic Stroke

PURPOSE: Inconsistent findings have been reported regarding the effect of ambient temperature on ischemic stroke. Furthermore, little is known about how underlying disease and low socioeconomic status influence the association. We, therefore, investigated the relationship between ambient temperature and emergency department (ED) visits for ischemic stroke, and aimed to identify susceptible populations. MATERIALS AND METHODS: Using medical claims data, we identified ED visits for ischemic stroke during 2005–2009 in Seoul, Korea. We conducted piecewise linear regression analyses to find optimum ambient temperature thresholds in summer and winter, and estimated the relative risks (RR) and 95% confidence intervals (CI) per a 1℃ increase in temperature above/below the thresholds, adjusting for relative humidity, holidays, day of the week, and air pollutant levels. RESULTS: There were 63564 ED visits for ischemic stroke. In summer, the risk of ED visits for ischemic stroke was not significant, with the threshold at 26.8℃. However, the RRs were 1.055 (95% CI, 1.006–1.106) above 25.0℃ in medical aid beneficiaries and 1.044 (1.007–1.082) above 25.8℃ in patients with diabetes. In winter, the risk of ED visits for ischemic stroke significantly increased as the temperature decreased above the threshold at 7.2℃. This inverse association was significant also in patients with hypertension and diabetes mellitus above threshold temperatures. CONCLUSION: Ambient temperature increases above a threshold were positively associated with ED visits for ischemic stroke in patients with diabetes and medical aid beneficiaries in summer. In winter, temperature, to a point, and ischemic stroke visits were inversely associated.

Future perspective on international affairs for Korean doctors

The Korean Medical Association (KMA) has been requested to respond proactively and effectively to local agendas reflecting global perspectives in order to lead our society through the dynamic and fast-changing health care environment, which faces issues such as big data, artificial intelligence, and the increasing health-related impacts of climate change and fine particulate matter. Since the KMA joined the World Medical Association (WMA) in 1949 and the Confederation of Medical Associations in Asia and Oceania (CMAAO) in 1956, the KMA has made continuous progress in international affairs. Based on these achievements, the KMA has recently played important roles, such as the chair of the WMA Finance and Planning Committee, a council member in the WMA, and a council chair in the CMAAO. For the next several decades, the WMA and CMAAO are still expected to be the basic channels for sharing trends and visions, discussing health challenges across borders, and developing powerful initiatives that improve people's health. Maintaining current partnerships with the WMA and CMAAO and strengthening strategic collaboration with promising national medical associations are required to extend the KMA's influence. Training next-generation representatives to build capacity for international relations might also be necessary for the sustainability of international collaboration. Through the KMA's advancements in international affairs, incorporating harmonious perspectives on local, regional, and global agendas, the KMA is fully expected to contribute to addressing health challenges by demonstrating its leadership.

Future perspective on international affairs for Korean doctors

The Korean Medical Association (KMA) has been requested to respond proactively and effectively to local agendas reflecting global perspectives in order to lead our society through the dynamic and fast-changing health care environment, which faces issues such as big data, artificial intelligence, and the increasing health-related impacts of climate change and fine particulate matter. Since the KMA joined the World Medical Association (WMA) in 1949 and the Confederation of Medical Associations in Asia and Oceania (CMAAO) in 1956, the KMA has made continuous progress in international affairs. Based on these achievements, the KMA has recently played important roles, such as the chair of the WMA Finance and Planning Committee, a council member in the WMA, and a council chair in the CMAAO. For the next several decades, the WMA and CMAAO are still expected to be the basic channels for sharing trends and visions, discussing health challenges across borders, and developing powerful initiatives that improve people's health. Maintaining current partnerships with the WMA and CMAAO and strengthening strategic collaboration with promising national medical associations are required to extend the KMA's influence. Training next-generation representatives to build capacity for international relations might also be necessary for the sustainability of international collaboration. Through the KMA's advancements in international affairs, incorporating harmonious perspectives on local, regional, and global agendas, the KMA is fully expected to contribute to addressing health challenges by demonstrating its leadership.

The study to estimate the floating population in Seoul, Korea

Traffic-related pollutants have been reported to increase the morbidity of respiratory diseases. In order to apply management policies related to motor vehicles, studies of the floating population living in cities are important. The rate of metro rail transit system use by passengers residing in Seoul is about 54% of total public transportation use. Through the rate of metro use, the people-flow ratios in each administrative area were calculated. By applying a people-flow ratio based on the official census count, the floating population in 25 regions was calculated. The reduced level of deaths among the floating population in 14 regions having the roadside monitoring station was calculated as assuming a 20% reduction of mobile emission based on the policy. The hourly floating population size was calculated by applying the hourly population ratio to the regional population size as specified in the official census count. The number of people moving from 5 a.m. to next day 1 a.m. could not be precisely calculated when the population size was applied, but no issue was observed that would trigger a sizable shift in the rate of population change. The three patterns of increase, decrease, and no change of population in work hours were analyzed. When the concentration of particulate matter less than 10 μm in aerodynamic diameter was reduced by 20%, the number of excess deaths varied according to the difference of the floating population. The effective establishment of directions to manage the pollutants in cities should be carried out by considering the floating population. Although the number of people using the metro system is only an estimate, this disadvantage was supplemented by calculating inflow and outflow ratio of metro users per time in the total floating population in each region. Especially, 54% of metro usage in public transport causes high reliability in application.

Near-Road Exposure and Impact of Air Pollution on Allergic Diseases in Elementary School Children: A Cross-Sectional Study

PURPOSE: The study aims to classify schools based on traffic pollutants and their complex sources, to assess the environment, to determine the state of allergic diseases among students using the International Study of Asthma and Allergies in children (ISAAC) questionnaire, and to assess their connection to air pollutants. MATERIALS AND METHODS: A total of seven schools were divided into three categories according to the characteristics of their surrounding environments: three schools in traffic-related zones, two schools in complex source zones I (urban), and two schools in complex source zones II (industrial complex). ISAAC questionnaires were administered and the 4404 completed questionnaires were analyzed. RESULTS: The frequency of asthma treatment during the past 12 months showed a significant increase (p<0.05) with exposure to NO2 [1.67, 95% confidence intervals (CIs) 1.03-2.71] in the complex source zones. The frequency of allergic rhinitis treatment during the past 12 months increased significantly with exposure to Black Carbon (1.60, 95% CIs 1.36-1.90) (p<0.001), SO2 (1.09, 95% CIs 1.01-1.17) (p<0.05), NO2 (1.18, 95% CIs 1.07-1.30) (p<0.01) for all subjects. CONCLUSION: In terms of supporting children's health, care, and prevention related to major spaces for children, such as school zones, spaces used in coming to and leaving school, playgrounds, and classrooms are essential to ensuring not only the safety of children from traffic accidents but also their protection from local traffic pollutants and various hazardous environmental factors.

Short-term Effects of Ambient Air Pollution on Emergency Department Visits for Asthma: An Assessment of Effect Modification by Prior Allergic Disease History / 예방의학회지

OBJECTIVES: The goal of this study was to investigate the short-term effect of ambient air pollution on emergency department (ED) visits in Seoul for asthma according to patients’ prior history of allergic diseases. METHODS: Data on ED visits from 2005 to 2009 were obtained from the Health Insurance Review and Assessment Service. To evaluate the risk of ED visits for asthma related to ambient air pollutants (carbon monoxide [CO], nitrogen dioxide [NO₂], ozone [O₃], sulfur dioxide [SO₂], and particulate matter with an aerodynamic diameter <10 μm [PM₁₀]), a generalized additive model with a Poisson distribution was used; a single-lag model and a cumulative-effect model (average concentration over the previous 1-7 days) were also explored. The percent increase and 95% confidence interval (CI) were calculated for each interquartile range (IQR) increment in the concentration of each air pollutant. Subgroup analyses were done by age, gender, the presence of allergic disease, and season. RESULTS: A total of 33 751 asthma attack cases were observed during the study period. The strongest association was a 9.6% increase (95% CI, 6.9% to 12.3%) in the risk of ED visits for asthma per IQR increase in O₃ concentration. IQR changes in NO₂ and PM₁₀ concentrations were also significantly associated with ED visits in the cumulative lag 7 model. Among patients with a prior history of allergic rhinitis or atopic dermatitis, the risk of ED visits for asthma per IQR increase in PM₁₀ concentration was higher (3.9%; 95% CI, 1.2% to 6.7%) than in patients with no such history. CONCLUSIONS: Ambient air pollutants were positively associated with ED visits for asthma, especially among subjects with a prior history of allergic rhinitis or atopic dermatitis.

Residential radon and environmental burden of disease among Non-smokers

BACKGROUND: Lung cancer was the second highest absolute cancer incidence globally and the first cause of cancer mortality in 2014. Indoor radon is the second leading risk factor of lung cancer after cigarette smoking among ever smokers and the first among non-smokers. Environmental burden of disease (EBD) attributable to residential radon among non-smokers is critical for identifying threats to population health and planning health policy. METHODS: To identify and retrieve literatures describing environmental burden of lung cancer attributable to residential radon, we searched databases including Ovid-MEDLINE, -EMBASE from 1980 to 2016. Search terms included patient keywords using ‘lung’, ‘neoplasm’, exposure keywords using ‘residential’, ‘radon’, and outcomes keywords using ‘years of life lost’, ‘years of life lost due to disability’, ‘burden’. Searching through literatures identified 261 documents; further 9 documents were identified using manual searching. Two researchers independently assessed 271 abstracts eligible for inclusion at the abstract level. Full text reviews were conducted for selected publications after the first assessment. Ten studies were included in the final evaluation. REVIEW: Global disability‐adjusted life years (DALYs)(95 % uncertainty interval) for lung cancer were increased by 35.9 % from 23,850,000(18,835,000-29,845,000) in 1900 to 32,405,000(24,400,000-38,334,000) in 2000. DALYs attributable to residential radon were 2,114,000(273,000-4,660,000) DALYs in 2010. Lung cancer caused 34,732,900(33,042,600 ~ 36,328,100) DALYs in 2013. DALYs attributable to residential radon were 1,979,000(1,331,000-2,768,000) DALYs for in 2013. The number of attributable lung cancer cases was 70-900 and EBD for radon was 1,000-14,000 DALYs in Netherland. The years of life lost were 0.066 years among never-smokers and 0.198 years among ever-smoker population in Canada. CONCLUSION: In summary, estimated global EBD attributable to residential radon was 1,979,000 DALYs for both sexes in 2013. In Netherlands, EBD for radon was 1,000–14,000 DALYs. Smoking population lost three times more years than never-smokers in Canada. There was no study estimating EBD of residential radon among never smokers in Korea and Asian country. In addition, there were a few studies reflecting the age of building, though residential radon exposure level depends on the age of building. Further EBD study reflecting Korean disability weight and the age of building is required to estimate EBD precisely. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1186/s40557-016-0092-5) contains supplementary material, which is available to authorized users.

World Medical Association Guidelines on Promotional Mass Media Appearances by Physicians: Starting Campaigns for Ethics

No abstract available.

House-plant placement for indoor air purification and health benefits on asthmatics

OBJECTIVES: Some plants were placed in indoor locations frequented by asthmatics in order to evaluate the quality of indoor air and examine the health benefits to asthmatics. METHODS: The present study classified the participants into two groups: households of continuation and households of withdrawal by a quasi-experimental design. The households of continuation spent the two observation terms with indoor plants, whereas the households of withdrawal passed the former observation terms with indoor plants and went through the latter observation term without any indoor plants. RESULTS: The household of continuation showed a continual decrease in the indoor concentrations of volatile organic compounds (VOCs) during the entire observation period, but the household of withdrawal performed an increase in the indoor concentrations of VOCs, except formaldehyde and toluene during the latter observation term after the decrease during the former observation term. Peak expiratory flow rate (PEFR) increased in the households of continuation with the value of 13.9 L/min in the morning and 20.6 L/ min in the evening, but decreased in the households of withdrawal with the value of -24.7 L/min in the morning and -30.2 L/min in the evening in the first experimental season. All of the households exhibited a decrease in the value of PEFR in the second experimental season. CONCLUSIONS: Limitations to the generalizability of findings regarding the presence of plants indoors can be seen as a more general expression of such a benefit of human-environment relations.

Medical Care Expenditure in Suicides From Non-illness-related Causes / 예방의학회지

OBJECTIVES: Several epidemiological studies on medical care utilization prior to suicide have considered the motivation of suicide, but focused on the influence of physical illnesses. Medical care expenditure in suicide completers with non-illness-related causes has not been investigated. METHODS: Suicides motivated by non-illness-related factors were identified using the investigator's note from the National Police Agency, which was then linked to the Health Insurance Review and Assessment data. We investigated the medical care expenditures of cases one year prior to committing suicide and conducted a case-control study using conditional logistic regression analysis after adjusting for age, gender, area of residence, and socioeconomic status. RESULTS: Among the 4515 suicides motivated by non-illness-related causes, medical care expenditures increased in only the last 3 months prior to suicide in the adolescent group. In the younger group, the proportion of total medical expenditure for external injuries was higher than that in the older groups. Conditional logistic regression analysis showed significant associations with being a suicide completer and having a rural residence, low socioeconomic status, and high medical care expenditure. After stratification into the four age groups, a significant positive association with medical care expenditures and being a suicide completer was found in the adolescent and young adult groups, but no significant results were found in the elderly groups for both men and women. CONCLUSIONS: Younger adults who committed suicide motivated by non-illness-related causes had a higher proportion of external injuries and more medical care expenditures than their controls did. This reinforces the notion that suicide prevention strategies for young people with suicidal risk factors are needed.

Medical Care Utilization During 1 Year Prior to Death in Suicides Motivated by Physical Illnesses / 예방의학회지

OBJECTIVES: Many epidemiological studies have suggested that a variety of medical illnesses are associated with suicide. Investigating the time-varying pattern of medical care utilization prior to death in suicides motivated by physical illnesses would be helpful for developing suicide prevention programs for patients with physical illnesses. METHODS: Suicides motivated by physical illnesses were identified by the investigator's note from the National Police Agency, which was linked to the data from the Health Insurance Review and Assessment. We investigated the time-varying patterns of medical care utilization during 1 year prior to suicide using repeated-measures data analysis after adjustment for age, gender, area of residence, and socioeconomic status. RESULTS: Among 1994 suicides for physical illness, 1893 (94.9%) suicides contacted any medical care services and 445 (22.3%) suicides contacted mental health care during 1 year prior to suicide. The number of medical care visits and individual medical expenditures increased as the date of suicide approached (p<0.001). The number of medical care visits for psychiatric disorders prior to suicide significantly increased only in 40- to 64-year-old men (p=0.002), women <40 years old (p=0.011) and women 40 to 64 years old (p=0.021) after adjustment for residence, socioeconomic status, and morbidity. CONCLUSIONS: Most of the suicides motivated by physical illnesses contacted medical care during 1 year prior to suicide, but many of them did not undergo psychiatric evaluation. This underscores the need for programs to provide psychosocial support to patients with physical illnesses.

Exposure and Toxicity Assessment of Ultrafine Particles from Nearby Traffic in Urban Air in Seoul, Korea

OBJECTIVES: We investigated the particle mass size distribution and chemical properties of air pollution particulate matter (PM) in the urban area and its capacity to induce cytotoxicity in human bronchial epithelial (BEAS-2B) cells. METHODS: To characterize the mass size distributions and chemical concentrations associated with urban PM, PM samples were collected by a 10-stage Micro-Orifice Uniform Deposit Impactor close to nearby traffic in an urban area from December 2007 to December 2009. PM samples for in vitro cytotoxicity testing were collected by a mini-volume air sampler with PM10 and PM2.5 inlets. RESULTS: The PM size distributions were bi-modal, peaking at 0.18 to 0.32 and 1.8 to 3.2 microm. The mass concentrations of the metals in fine particles (0.1 to 1.8 microm) accounted for 45.6 to 80.4% of the mass concentrations of metals in PM10. The mass proportions of fine particles of the pollutants related to traffic emission, lead (80.4%), cadmium (69.0%), and chromium (63.8%) were higher than those of other metals. Iron was the dominant transition metal in the particles, accounting for 64.3% of the PM10 mass in all the samples. We observed PM concentration-dependent cytotoxic effects on BEAS-2B cells. CONCLUSIONS: We found that exposure to PM2.5 and PM10 from a nearby traffic area induced significant increases in protein expression of inflammatory cytokines (IL-6 and IL-8). The cell death rate and release of cytokines in response to the PM2.5 treatment were higher than those with PM10. The combined results support the hypothesis that ultrafine particles from vehicular sources can induce inflammatory responses related to environmental respiratory injury.

Corrigendum: Health Risks Assessments in Children for Phthalates Exposure Associated with Childcare Facilities and Indoor Playgrounds

In Table 6, the unit concentration of phthalates was not correctly indicated.

Health Risk Assessment of Lead Ingestion Exposure by Particle Sizes in Crumb Rubber on Artificial Turf Considering Bioavailability

OBJECTIVES: The purpose of this study was to assess the risk of ingestion exposure of lead by particle sizes of crumb rubber in artificial turf filling material with consideration of bioavailability. METHODS: This study estimated the ingestion exposure by particle sizes (more than 250 um or less than 250 um) focusing on recyclable ethylene propylene diene monomer crumb rubber being used as artificial turf filling. Analysis on crumb rubber was conducted using body ingestion exposure estimate method in which total content test method, acid extraction method and digestion extraction method are reflected. Bioavailability which is a calibrating factor was reflected in ingestion exposure estimate method and applied in exposure assessment and risk assessment. Two methods using acid extraction and digestion extraction concentration were compared and evaluated. RESULTS: As a result of the ingestion exposure of crumb rubber material, the average lead exposure amount to the digestion extraction result among crumb rubber was calculated to be 1.56x10(-4) mg/kg-day for low grade elementary school students and 4.87x10(-5) mg/kg-day for middle and high school students in 250 um or less particle size, and that to the acid extraction result was higher than the digestion extraction result. Results of digestion extraction and acid extraction showed that the hazard quotient was estimated by about over 2 times more in particle size of lower than 250 um than in higher than 250 um. There was a case of an elementary school student in which the hazard quotient exceeded 0.1. CONCLUSIONS: Results of this study confirm that the exposure of lead ingestion and risk level increases as the particle size of crumb rubber gets smaller.

Association Between Body Mass Index and Asthma Symptoms Among Korean Children: A Nation-Wide Study

The purpose of this study was to investigate the association between body mass index (BMI) and the prevalence of wheeze using nation-wide cross-sectional study in Korean children. Total 50,200 children from 427 elementary schools were randomly selected according to residential areas (metropolitan, provincial, rural, and industrial areas) by the cluster sampling method. The International Study of Asthma and Allergies in Childhood (ISAAC) questionnaires were used to measure the prevalence of wheeze. Among 31,026 respondents, 25,322 were analyzed. BMI was classified into quartiles based on BMI-for-age percentile. In all residential areas, pets at home and visible mold or moisture were associated with an increased prevalence of wheeze in both genders. However, other living environment factors were not consistently associated among residential areas and gender. Among girls, lowest BMI was negatively associated with prevalence of wheeze and highest BMI was positively associated in all residential areas. In multilevel logistic regression analysis, environmental tobacco smoking exposure, pets at home, visible mold or moisture, and being in the lowest and highest BMI quartile were significantly associated with the prevalence of wheeze in both genders. BMI has become an important risk factor for asthma symptoms among Korean children.

Prevalence of Allergic Diseases among Korean School-age Children: A Nationwide Cross-Sectional Questionnaire Study

The purpose of this study was to investigate the nationwide prevalence of childhood asthma, eczema and other allergic diseases in Korean school-age children (8-11 yr old) and to assess the difference between residential areas. Among 6,279 elementary schools, 427 schools were randomly selected according to residential area (metropolitan, provincial, rural, and industrial area) by the cluster sampling method. Parents of students completed a modified Korean version of a questionnaire formulated by the International Study of Asthma and Allergies in Childhood (ISAAC). Among 50,200 subjects, 31,026 (61.8%) responded, and 30,893 (99.6%) were analyzed. The 12-month prevalence of wheeze, flexural rash, and allergic rhinitis symptoms were 4.8%, 15.3%, and 32.9%, respectively. The prevalence of diagnosis of allergic diseases in boys was higher than that in girls, with the exception of eczema. In both boys and girls, the difference of the prevalence of allergic diseases among industrial, metropolitan and provincial areas was not statistically significant, but the differences between rural area and other areas were significant. Our results support the importance of contextual effect associated with residential area as causative agents of allergic diseases among Korean school-age children.

Ambient Particulate Matter and the Risk of Deaths from Cardiovascular and Cerebrovascular Disease

BACKGROUND: To assess the association between ambient particulate matter and cardiovascular death in seven cities in the Republic of Korea during the period of 2002-2008. METHODS: A time-stratified case-crossover design was used to examine association between particulate matter and deaths from cardiovascular or cerebrovascular disease; hypertensive disease 12,821, ischemic heart disease 39,577, cardiac arrhythmia 1,627, cerebrovascular disease 88,047. Mortality data was obtained from National Statistical Office, and hourly mean concentrations of particulate matter < or = 10 microm in aerodynamic diameter and meteorological data were obtained from the Ministry of Environment. The percent increase in the risk of death associated with an interquartile range increase in particulate matter was determined by conditional logistic regression analysis after adjusting for national holidays and meteorological factors. RESULTS: The largest association was a 0.8% increase (95% confidence interval [CI], 0.1-1.6) in death risk related to an interquartile range increase in particulate matter < or = 10 microm (average of 0 to 2 days prior to the day of death). Classified as the cause of death, the association was a 1.2% increase (95% CI, 0.2-2.2) in death from cerebrovascular disease related to an interquartile range increase in particulate matter < or = 10 microm. But others were statistically not significant. After stratification of death cases by year of death, statistically significant associations were a 2.3% increase (95% CI, 0.1-4.4) in death risk from ischemic heart disease in 2002-2004 and 2.0% increase in death from cerebrovascular disease (95% CI, 0.3-3.8) in 2006-2008. CONCLUSIONS: Our results suggest that ambient air pollution increases the risk of deaths from cardiovascular and cerebrovascular disease in the Republic of Korea.

Health Risks Assessment in Children for Phthalate Exposure Associated with Childcare Facilities and Indoor Playgrounds

OBJECTIVES: This study assessed the health risks for children exposed to phthalate through several pathways including house dust, surface wipes and hand wipes in child facilities and indoor playgrounds. METHODS: The indoor samples were collected from various children's facilities (40 playrooms, 42 daycare centers, 44 kindergartens, and 42 indoor-playgrounds) in both summer (Jul-Sep, 2007) and winter (Jan-Feb, 2008). Hazard index (HI) was estimated for the non-carcinogens and the examined phthalates were diethylhexyl phthalate (DEHP), diethyl phthalate (DEP), dibutyl-n-butyl phthalate (DnBP), and butylbenzyl phthalate (BBzP). The present study examined these four kinds of samples, i.e., indoor dust, surface wipes of product and hand wipes. RESULTS: Among the phthalates, the detection rates of DEHP were 98% in dust samples, 100% in surface wipe samples, and 95% in hand wipe samples. In this study, phthalate levels obtained from floor dust, product surface and children's hand wipe samples were similar to or slightly less compared to previous studies. The 50th and 95th percentile value of child-sensitive materials did not exceed 1 (HI) for all subjects in all facilities. CONCLUSIONS: For DEHP, DnBP and BBzP their detection rates through multi-routes were high and their risk based on health risk assessment was also observed to be acceptable. This study suggested that ingestion and dermal exposure could be the most important pathway of phthalates besides digestion through food.