The homeless period: a qualitative evidence synthesis.

Women experiencing homelessness are marginalized not only through their housing status but also through their access and ability to manage their menstrual health. Currently, there are no existing published reviews exploring this topic. This study aimed to begin closing that gap, by systematically reviewing the literature examining women's experiences of menstruation whilst being homeless. In June 2020 (and updated in December 2022), we conducted comprehensive and systematic searches of four electronic databases: Medline, Web of Science, CINAHL, and PsychINFO, from which nine studies were found. The findings were thematically analyzed, using the enhancing transparency in reporting the synthesis of qualitative research tools (ENTREQ) guidelines. Three themes related to menstrual experiences were found: (1) challenges in the logistics of managing menstruation while homeless, (2) feelings of embarrassment, shame, and dignity linked to maintaining menstrual health, and (3) making do: how people experiencing homelessness manage challenges related to menstruation. We discuss barriers women face in getting necessary products and in accessing private, safe, and clean facilities to manage menstrual health. The study found that women living with homelessness often abandon other basic needs in favor of managing menstruation (i.e. using unsuitable materials, stealing, etc.), which furthers their risk. The findings highlight the need for future research to investigate the experiences of women who are menstruating while being homeless and what support they would find helpful. Results show that it is high time for commissioners and policy-makers to address the provision of menstrual resources as a basic human right.

Exploring the Experiences of Compassion Fatigue Amongst Peer Support Workers in Homelessness Services.

Peer support workers have lived experiences of the challenges their clients face. While research has shown peer work can benefit recovery, the negative consequences have not been clearly addressed. This study aimed to explore the experiences of compassion fatigue amongst peer support workers in homelessness services, and the coping strategies used. An explorative qualitative design was adopted. Six peer support workers, in homelessness services, were recruited via snowball sampling. Data was collected using semi-structured interviews and analysed using thematic analysis. Five themes were identified: relentless nature of working in homelessness services, change, making meaning of past experiences, organisational support, and personal coping strategies. There were two novel findings: (1) multiple clients recounting traumatic experiences, and (2) being unfairly blamed for lack of progress, exacerbating compassion fatigue. The findings of this study furthers limited research on compassion fatigue and can be used to develop protocols and practices for organisations that utilise peer support.

A robust regression analysis method to determine the significance of trends in concentrations of heavy metals in UK ambient air and improve network design and emission inventories.

A novel application of the Theil-Sen robust regression method for determining the temporal trends in the concentration of heavy metals in UK ambient air over the period 2005-2020 is presented and compared to other regression methods. We have demonstrated improvements over non-robust methods of regression, proving the ability to tease out trends that are small with respect to the variability of the concentration measurement. The method is used to identify, in general, large and significant trends in the concentrations of Ni, As, Pb and V over the period 2005-2020, either across the UK as a whole or at groupings of site classifications in the UK. These trends have been compared to trends in emission data determined in the same manner. Although the results for most metals provide confidence that the UK metal network of monitoring sites is successful in appropriately capturing changes in emissions, a key finding of this work is the disagreement between trends in measured concentrations and emissions for Cu, Mn and Ni, for which we suggest improvements in future network design. The results also indicate that UK emission data for V should be reviewed, as we propose that the rate of reduction of V emissions is likely to have been overestimated.

Are the adverse health effects of air pollution modified among active children and adolescents? A review of the literature.

Air pollution exposure is associated with negative health consequences among children and adolescents. Physical activity is recommended for all children/adolescents due to benefits to health and development. However, it is unclear if physically active children have additional protective benefits when exposed to higher levels of air pollution, compared to less active children. This systematic review evaluates all available literature since 2000 and examines if effect measure modification (EMM) exists between air pollution exposure and health outcomes among children/adolescents partaking in regular physical activity. PubMed, Science Direct, Scopus, Web of Science, and ProQuest Agricultural & Environmental Science databases were queried, identifying 2686 articles. Title/abstract screening and full-text review eliminated 2620 articles, and 56 articles were removed for evaluating individuals >21, leaving 10 articles for review. Of the included articles, half were conducted in China, three in the United States, and one each in Indonesia and Germany. Seven articles identified EMM between active children and air-pollution related health outcomes. Five of these indicated that children/adolescents do not experience any additional benefits from being physically active in higher levels of air pollution, with some studies implying active children may experience additional detriments, compared to less active children. However, the remaining two EMM studies highlighted modest benefits of having a higher activity level, even in polluted air. Overall, active children/adolescents may be at greater risk from air pollution exposure, but results were not consistent across all studies. Future studies assessing the intersection between air pollution and regular physical activity among children would be useful.

CAPTURE of the Human U2 snRNA Genes Expands the Repertoire of Associated Factors.

In order to identify factors involved in transcription of human snRNA genes and 3' end processing of the transcripts, we have carried out CRISPR affinity purification in situ of regulatory elements (CAPTURE), which is deadCas9-mediated pull-down, of the tandemly repeated U2 snRNA genes in human cells. CAPTURE enriched many factors expected to be associated with these human snRNA genes including RNA polymerase II (pol II), Cyclin-Dependent Kinase 7 (CDK7), Negative Elongation Factor (NELF), Suppressor of Ty 5 (SPT5), Mediator 23 (MED23) and several subunits of the Integrator Complex. Suppressor of Ty 6 (SPT6); Cyclin K, the partner of Cyclin-Dependent Kinase 12 (CDK12) and Cyclin-Dependent Kinase 13 (CDK13); and SWI/SNF chromatin remodelling complex-associated SWI/SNF-related, Matrix-associated, Regulator of Chromatin (SMRC) factors were also enriched. Several polyadenylation factors, including Cleavage and Polyadenylation Specificity Factor 1 (CPSF1), Cleavage Stimulation Factors 1 and 2 (CSTF1,and CSTF2) were enriched by U2 gene CAPTURE. We have already shown by chromatin immunoprecipitation (ChIP) that CSTF2-and Pcf11 and Ssu72, which are also polyadenylation factors-are associated with the human U1 and U2 genes. ChIP-seq and ChIP-qPCR confirm the association of SPT6, Cyclin K, and CDK12 with the U2 genes. In addition, knockdown of SPT6 causes loss of subunit 3 of the Integrator Complex (INTS3) from the U2 genes, indicating a functional role in snRNA gene expression. CAPTURE has therefore expanded the repertoire of transcription and RNA processing factors associated with these genes and helped to identify a functional role for SPT6.

Environmental risk factors associated with pulmonary isolation of nontuberculous mycobacteria, a population-based study in the southeastern United States.

The prevalence of pulmonary nontuberculous mycobacteria (NTM) disease is increasing in the United States. Associations were evaluated among residents of central North Carolina between pulmonary isolation of NTM and environmental risk factors including: surface water, drinking water source, urbanicity, and exposures to soils favorable to NTM growth. Reports of pulmonary NTM isolation from patients residing in three counties in central North Carolina during 2006-2010 were collected from clinical laboratories and from the State Laboratory of Public Health. This analysis was restricted to patients residing in single family homes with a valid residential street address and conducted at the census block level (n = 13,495 blocks). Negative binomial regression models with thin-plate spline smoothing function of geographic coordinates were applied to assess effects of census block-level environmental characteristics on pulmonary NTM isolation count. Patients (n = 507) resided in 473 (3.4%) blocks within the study area. Blocks with >20% hydric soils had 26.8% (95% confidence interval (CI): 1.8%, 58.0%), p = 0.03, higher adjusted mean patient counts compared to blocks with ≤20% hydric soil, while blocks with >50% acidic soil had 24.8% (-2.4%, 59.6%), p = 0.08 greater mean patient count compared to blocks with ≤50% acidic soil. Isolation rates varied by county after adjusting for covariates. The effects of using disinfected public water supplies vs. private wells, and of various measures of urbanicity were not significantly associated with NTM. Our results suggest that proximity to certain soil types (hydric and acidic) could be a risk factor for pulmonary NTM isolation in central North Carolina.

Acute effects of short-term exposure to air pollution while being physically active, the potential for modification: A review of the literature.

The science behind the combined effect of (and possible interaction between) physical activity and air pollution exposure on health endpoints is not well established, despite the fact that independent effects of physical activity and air pollution on health are well known. The objective of this review is to systematically assess the available literature pertaining to exposure to air pollution while being physically active, in order to assess statistical interaction. Articles published during 2000-2020 were identified by searching PubMed, Science Direct, and ProQuest Agricultural & Environmental Science Database for terms encompassing air pollution and exercise/physical activity. Articles were included if they examined the following four scenarios: at rest in clean air, physical activity in clean air, at rest in polluted air, and physical activity in polluted air. Risk of bias assessment was performed on all included articles. We identified 25 articles for inclusion and determined risk of bias was low to moderate. Nine articles identified evidence of statistical interaction between air pollution exposure and physical activity, while 16 identified no such interaction. However, pollutant levels, exercise intensity, and the population studied appeared to influence statistical interaction. Even in low levels of air pollution, low-intensity activities (i.e., walking), may intensify the negative impacts of air pollution, particularly among those with pre-existing conditions. However, among healthy adults, the review suggests that exercise is generally beneficial even in high air pollution environments. Particularly, the review indicates that moderate to high-intensity exercise may neutralize any short-term negative effects of air pollution.

Incidence and public health burden of sunburn among beachgoers in the United States.

The beach environment creates many barriers to effective sun protection, putting beachgoers at risk for sunburn, a well-established risk factor for skin cancer. Our objective was to estimate incidence of sunburn among beachgoers and evaluate the relationship between sunburn incidence and sun-protective behaviors. A secondary analysis, of prospective cohorts at 12 locations within the U.S. from 2003 to 2009 (n = 75,614), were pooled to evaluate sunburn incidence 10-12 days after the beach visit. Behavioral and environmental conditions were cross-tabulated with sunburn incidence. Multivariable logistic regression was used to estimate the association between new sunburn and sun-protective behaviors. Overall, 13.1% of beachgoers reported sunburn. Those aged 13-18 years (16.5%), whites (16.0%), and those at beach locations along the Eastern Seaboard (16.1%), had the highest incidence of sunburn. For those spending ≥5 h in the sun, the use of multiple types of sun protection reduced odds of sunburn by 55% relative to those who used no sun protection (Odds Ratio = 0.45 (95% Confidence Interval:0.27-0.77)) after adjusting for skin type, age, and race. Acute health effects of sunburn tend to be mild and self-limiting, but potential long-term health consequences are more serious and costly. Efforts to encourage and support proper sun-protective behaviors, and increase access to shade, protective clothing, and sunscreen, can help prevent sunburn and reduce skin cancer risk among beachgoers.

Values-Based Interventions in Patient Engagement for Those with Complex Needs.

The objective was to evaluate a novel intervention that integrates a psychological, values-based approach with coordinated care management. This paper describes an integrated comprehensive health record system to enhance engagement with a subset of those with complex needs; those who are high-needs, high-cost (HNHC). Patients are selected after conducting data analysis on the most costly and complex patients of a payer system that works with HNHC patients. Specifically, the Patient Care Intervention Center in Houston TX, applies the values-based intervention to HNHC patients. This pilot study reports data from 18 HNHC patients over 6 months; specifically, outcomes related to daily functioning, depression, working alliance, stages of change, and overall well-being. Additionally, this paper reports preliminary findings from qualitative monitoring of provider experiences implementing the values-based approach and integrated evaluation. HNHC patients improved their daily functioning over 4 months but no other significant changes were found over time. Patients self-reported mild depression, strong working alliances with their provider, being in the contemplation phase of change, and moderate well-being. There also was variation when patients completed the assessments and data points were collected. Although this is a small sample and short time frame, preliminary results suggest that the intervention has a positive impact on HNHC patient daily functioning. Provider accounts of the implementation describe using the evaluation items to inform their interactions with patients, and also suggest that patient literacy level impacts when data can be collected. Other changes to the approach are suggested.

Application of diagnostic criteria for non-tuberculous mycobacterial disease to a case series of mycobacterial-positive isolates.

The American Thoracic Society (ATS) and Infectious Diseases Society of America (IDSA) have provided guidelines to assist in the accurate diagnosis of lung disease caused by nontuberculous mycobacteria (NTM). These microbiologic, radiographic, and clinical criteria are considered equally important and all must be met to make the diagnosis of NTM lung disease. To assess the significance of the three criteria, each was evaluated for its contribution to the diagnosis of NTM lung disease in a case series. Laboratory reports of any specimen positive for NTM isolation were collected between January 1, 2006 and December 31, 2010 at a university medical center. Medical records were reviewed in detail using a standardized form. The total number of patients with a culture from any site positive for NTM was 297 while the number from respiratory specimens during the same period was 232 (78%). Samples from two of these patients also yielded M. tuberculosis complex and were excluded. While 128 of the remaining 230 patients (55.7%) in the cohort met the microbiologic criterion for diagnosis of NTM lung disease, 151 (65.6%) and 189 (78.3%) met the radiologic and clinical criteria respectively. Only 78 patients (33.9%) met all three criteria provided by the ATS/IDSA for diagnosis of NTM lung disease. This evaluation reaffirms that defining NTM lung disease using either one or two of the criteria provided by the 2007 ATS/IDSA guidelines may significantly overestimate the number of cases of NTM lung disease. Based on the experience of defining NTM lung disease in this case series, recommendations for modification of the ATS/IDSA guidelines are provided which include expansion of both radiologic patterns and the list of symptoms associated with NTM lung disease.

INTEGRATING PUBLIC HEALTH IN LAND REUSE AND REDEVELOPMENT: Part 2: Assessing Local Health Agency Capacity to Integrate Environmental Health and Land Reuse Work.

Many local health departments (LHDs) across the country coordinate with their service areas on environmental health or land reuse. The Brownfields & Reuse Opportunity Working Group (BROWN) is a multipartner land reuse stakeholder network that includes member representatives from state and local health agencies, federal agencies, environmental consultants, environmental health professionals, and academia. In 2015, BROWN provided input on five Environmental Health Resources Self Learning Modules (Epidemiology, Risk Assessment, Risk Communications, Land Reuse Sites, and Toxicology) that the Agency for Toxic Substances and Disease Registry (ATSDR) was developing. ATSDR created the educational modules as resources and self-study guides to increase LHD capacity to respond to environmental issues. Following input from BROWN members on the modules, the National Environmental Health Association independently developed a short survey to identify baseline capacity of environmental professionals, primarily LHD professionals, to address environmental health and land reuse issues. The survey results of 93 LHD personnel indicated variation in the level of education among LHD employees and how often specific environmental health and land reuse services were requested. A subset of three LHD respondents also provided input into the learning modules.

Application of a multiplex salivary immunoassay to detect sporadic incident norovirus infections.

Norovirus is one of the most common causes of gastroenteritis. Following infection, anti-norovirus salivary immunoglobulin G (IgG) rises steeply within 2 weeks and remains elevated for several months; this immunoconversion can serve as an indicator of infection. We used a multiplex salivary immunoassay to study norovirus infections among 483 visitors to a Lake Michigan beach in 2015. Saliva was collected on the day of the beach visit (S1); after 10-14 days (S2); and after 30-40 days (S3). Luminex microspheres were coupled to recombinant antigens of genogroup I (GI) and II (GII) noroviruses and incubated with saliva. Immunoconversion was defined as at least 4-fold increase in anti-norovirus IgG antibody response from S1 to S2 and a 3-fold increase from S1 to S3. Ten (2.1%) immunoconverted to either GI (2) or GII (8) norovirus. Among those who immunoconverted, 40% reported at least one gastrointestinal symptom and 33% reported diarrhea, compared to 15% (p = 0.06) and 8% (p = 0.04) among those who did not immunoconvert, respectively. The two participants who immunoconverted to GI norovirus both swallowed water during swimming (p = 0.08). This study demonstrated the utility of a non-invasive salivary immunoassay to detect norovirus infections and an efficient approach to study infectious agents in large cohorts.

Cardiopulmonary Effects of Fine Particulate Matter Exposure among Older Adults, during Wildfire and Non-Wildfire Periods, in the United States 2008-2010.

BACKGROUND: The effects of exposure to fine particulate matter ([Formula: see text]) during wildland fires are not well understood in comparison with [Formula: see text] exposures from other sources. OBJECTIVES: We examined the cardiopulmonary effects of short-term exposure to [Formula: see text] on smoke days in the United States to evaluate whether health effects are consistent with those during non-smoke days. METHODS: We examined cardiopulmonary hospitalizations among adults [Formula: see text] y of age, in U.S. counties ([Formula: see text]) within [Formula: see text] of 123 large wildfires during 2008-2010. We evaluated associations during smoke and non-smoke days and examined variability with respect to modeled and observed exposure metrics. Poisson regression was used to estimate county-specific effects at lag days 0-6 (L0-6), adjusted for day of week, temperature, humidity, and seasonal trend. We used meta-analyses to combine county-specific effects and estimate overall percentage differences in hospitalizations expressed per [Formula: see text] increase in [Formula: see text]. RESULTS: Exposure to [Formula: see text], on all days and locations, was associated with increased hospitalizations on smoke and non-smoke days using modeled exposure metrics. The estimated effects persisted across multiple lags, with a percentage increase of 1.08% [95% confidence interval (CI): 0.28, 1.89] on smoke days and 0.67% (95% CI: [Formula: see text], 1.44) on non-smoke days for respiratory and 0.61% (95% CI: 0.09, 1.14) on smoke days and 0.69% (95% CI: 0.19, 1.2) on non-smoke days for cardiovascular outcomes on L1. For asthma-related hospitalizations, the percentage increase was greater on smoke days [6.9% (95% CI: 3.71, 10.11)] than non-smoke days [1.34% (95% CI: [Formula: see text], 3.77)] on L1. CONCLUSIONS: The increased risk of [Formula: see text]-related cardiopulmonary hospitalizations was similar on smoke and non-smoke days across multiple lags and exposure metrics, whereas risk for asthma-related hospitalizations was higher during smoke days. https://doi.org/10.1289/EHP3860.

Expert viewpoints of peer support for people experiencing homelessness: A Q sort study.

Peers have shared experiences of phenomena such as mental illness, addiction, and homelessness. Homelessness services are increasingly utilizing peers in their models to support people experiencing homelessness. While there is extensive literature on peer support in general, few studies focus on the potential change mechanisms that might underpin this intervention, particularly regarding homelessness. This study aims to utilize expert opinions to identify common viewpoints on components involved in effective peer support. Forty-three statements were developed from previous literature that broadly describes elements involved in peer support. Forty experts (20 peers and 20 professionals) ranked the statements into a hierarchy. Q methodology is a rigorous method to objectively research participants' subjective viewpoints, using a by-person rather than by-variable approach to factor analysis. The study was done in three stages: first-order analysis to identify shared viewpoints within (a) the peer participant group, (b) the professional participant group, and (c) a second-order analysis of Stage 1 and 2 results to identify common viewpoints held across participant groups. Stage 3 analysis resulted in three differing viewpoints; the dominant viewpoint asserts that effective peer support is rooted in experiential knowledge, where peers build unique, trusting relationships to provide clients with a different level of support. The results highlighted different types of peer support and defined a new one: a unidirectional, mentorship type of intentional peer support. Strengths and limitations are discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Associations between environmental quality and infant mortality in the United States, 2000-2005.

BACKGROUND: The United States (U.S.) suffers from high infant mortality (IM) rates and there are significant racial/ethnic differences in these rates. Prior studies on the environment and infant mortality are generally limited to singular exposures. We utilize the Environmental Quality Index (EQI), a measure of cumulative environmental exposure (across air, water, land, sociodemographic, and land domains) for U.S. counties from 2000 to 2005, to investigate associations between ambient environment and IM across maternal race/ethnicity. METHODS: We linked 2000-2005 infant data from the U.S. Centers for Disease Control and Prevention to the EQI (n = 22,702,529; 144,741 deaths). We utilized multi-level regression to estimate associations between quartiles of county-level EQI and IM. We also considered associations between quartiles of county level domain specific indices with IM. We controlled for rural-urban status (RUCC1: urban, metropolitan; RUCC2: urban, non-metropolitan; RUCC3: less urbanized; RUCC4: thinly populated), maternal age, maternal education, marital status, infant sex, and stratified on race/ethnicity. Additionally, we estimated associations for linear combinations of environmental quality and rural-urban status. RESULTS: We found a mix of positive, negative, and null associations and our findings varied across domain and race/ethnicity. Poorer overall environmental quality was associated with decreased odds among Non-Hispanic whites (OR and 95% CI: EQIQ4 (ref. EQIQ1): 0.84[0.80,0.89]). For Non-Hispanic blacks and Hispanics, some increased odds were observed. Poorer air quality was monotonically associated with increased odds among Non-Hispanic whites (airQ4 (ref. airQ1): 1.05[0.99,1.11]) and blacks (airQ4 (ref. airQ1): 1.09 [0.9,1.31]). Rural status was associated with increased IM odds among Hispanics (RUCC4-Q4:1.36[1.04,1.78]; RUCC1-Q4: 1.04[0.92,1.16], ref. for both RUCC1-Q1). CONCLUSIONS: This study is the first to report on associations between ambient environmental quality and IM across the United States. It corroborates prior research suggesting an association between air pollution and IM and identifies residence in thinly populated (rural) areas as a potential risk factor towards IM amongst Hispanics. Some of the counterintuitive findings highlight the need for additional research into potentially differential drivers of environmental quality across the rural-urban continuum, especially with regards to the sociodemographic environment.

Associations between environmental quality and adult asthma prevalence in medical claims data.

As of 2014, approximately 7.4% of U.S. adults had current asthma. The etiology of asthma is complex, involving genetics, behavior, and environmental factors. To explore the association between cumulative environmental quality and asthma prevalence in U.S. adults, we linked the U.S. Environmental Protection Agency's Environmental Quality Index (EQI) to the MarketScan® Commercial Claims and Encounters Database. The EQI is a summary measure of five environmental domains (air, water, land, built, sociodemographic). We defined asthma as having at least 2 claims during the study period, 2003-2013. We used a Bayesian approach with non-informative priors, implementing mixed-effects regression modeling with a Poisson link function. Fixed effects variables were EQI, sex, race, and age. Random effects were counties. We modeled quintiles of the EQI comparing higher quintiles (worse quality) to lowest quintile (best quality) to estimate prevalence ratios (PR) and credible intervals (CIs). We estimated associations using the cumulative EQI and domain-specific EQIs; we assessed U.S. overall (non-stratified) as well as stratified by rural-urban continuum codes (RUCC) to assess rural/urban heterogeneity. Among the 71,577,118 U.S. adults with medical claims who could be geocoded to county of residence, 1,147,564 (1.6%) met the asthma definition. Worse environmental quality was associated with increased asthma prevalence using the non-RUCC-stratified cumulative EQI, comparing the worst to best EQI quintile (PR:1.27; 95% CI: 1.21, 1.34). Patterns varied among different EQI domains, as well as by rural/urban status. Poor environmental quality may increase asthma prevalence, but domain-specific drivers may operate differently depending on rural/urban status.

Estimate of incidence and cost of recreational waterborne illness on United States surface waters.

BACKGROUND: Activities such as swimming, paddling, motor-boating, and fishing are relatively common on US surface waters. Water recreators have a higher rate of acute gastrointestinal illness, along with other illnesses including respiratory, ear, eye, and skin symptoms, compared to non-water recreators. The quantity and costs of such illnesses are unknown on a national scale. METHODS: Recreational waterborne illness incidence and severity were estimated using data from prospective cohort studies of water recreation, reports of recreational waterborne disease outbreaks, and national water recreation statistics. Costs associated with medication use, healthcare provider visits, emergency department (ED) visits, hospitalizations, lost productivity, long-term sequelae, and mortality were aggregated. RESULTS: An estimated 4 billion surface water recreation events occur annually, resulting in an estimated 90 million illnesses nationwide and costs of $2.2- $3.7 billion annually (central 90% of values). Illnesses of moderate severity (visit to a health care provider or ED) were responsible for over 65% of the economic burden (central 90% of values: $1.4- $2.4 billion); severe illnesses (result in hospitalization or death) were responsible for approximately 8% of the total economic burden (central 90% of values: $108- $614 million). CONCLUSION: Recreational waterborne illnesses are associated with a substantial economic burden. These findings may be useful in cost-benefit analysis for water quality improvement and other risk reduction initiatives.

Child environmental exposures to water and sand at the beach: Findings from studies of over 68,000 subjects at 12 beaches.

Swimming and recreating in lakes, oceans, and rivers is common, yet the literature suggests children may be at greater risk of illness following such exposures. These effects might be due to differences in immunity or differing behavioral factors such as poorer hygiene, longer exposures to, and greater ingestion of potentially contaminated water and sand. We pooled data from 12 prospective cohorts (n=68,685) to examine exposures to potentially contaminated media such as beach water and sand among children compared with adults, and conducted a simulation using self-reported time spent in the water and volume of water swallowed per minute by age to estimate the total volume of water swallowed per swimming event by age category. Children aged 4-7 and 8-12 years had the highest exposures to water, sand, and algae compared with other age groups. Based on our simulation, we found that children (6-12 years) swallow a median of 36 ml (90th percentile=150 ml), whereas adults aged ≥35 years swallow 9 ml (90th percentile=64 ml) per swimming event, with male children swallowing a greater amount of water compared with females. These estimates may help to reduce uncertainty surrounding routes and durations of recreational exposures and can support the development of chemical and microbial risk assessments.

Sanitary Sewer Overflows and Emergency Room Visits for Gastrointestinal Illness: Analysis of Massachusetts Data, 2006-2007.

BACKGROUND: Sanitary sewer overflows (SSOs) occur when untreated sewage is discharged into water sources before reaching the treatment facility, potentially contaminating the water source with gastrointestinal pathogens. OBJECTIVES: The objective of this paper is to assess associations between SSO events and rates of gastrointestinal (GI) illness in Massachusetts. METHODS: A case-crossover study design was used to investigate association between SSO events and emergency room (ER) visits with a primary diagnosis of gastrointestinal (GI) illness in Massachusetts for 2006-2007. ER visits for GI were considered exposed if an SSO event occurred in the county of residence within three hazard periods, 0-4 d, 5-9 d, or 10-14 d, before the visit. A time-stratified bidirectional design was used to select control days for each ER visit on the same day of the week during the same month. Fixed effect logistic regression models were used to estimate the risk of ER visits following the SSO event. RESULTS: During the study period, there were 270 SSO events for northeastern Massachusetts and 66,460 ER admissions with GI illness listed as the primary diagnostic code. The overall odds ratio (OR) for ER visits for GI illness was 1.09 [95% confidence interval (CI): 1.03, 1.16] in the 10-14 d period following an SSO event, with positive ORs for all age groups and for three of the four counties. The 0-4 d and 5-9 d periods following an SSO event were not associated with ER visits for GI illness overall, and associations by county or age were inconsistent. CONCLUSIONS: We demonstrated an association between SSO events and ER visits for GI illness using a case-crossover study design. In light of the aging water infrastructure in the United States and the expected increase in heavy rainfall events, our findings suggest a potential health impact associated with sewage overflows. https://doi.org/10.1289/EHP2048.