Collaboration for Lead Poisoning Prevention in Puerto Rico.

In 2010, Puerto Rico experienced a cluster of childhood lead poisoning cases stemming from parental occupational exposure to lead. Following the immediate response to this crisis, a dedicated coalition of pediatricians and public health practitioners sustained a collaborative effort to advance pediatric environmental health initiatives across Puerto Rico. Their commitment laid the groundwork for the establishment and evolution of Puerto Rico's comprehensive Childhood Lead Poisoning Prevention and Blood Lead Level Surveillance Program. This compelling case study showcases the potential for concerted, multidisciplinary action to leverage an acute event to influence public policy and clinical practice to promote children's health. By drawing on the lessons learned and strategies used in Puerto Rico, other jurisdictions can overcome challenges in pursuit of enhanced secondary lead poisoning prevention measures, with the goal of achieving primary prevention in the near future.

Power Outages: An Underappreciated Risk Factor for Children's Carbon Monoxide Poisoning.

Children's risk of exposure to carbon monoxide (CO) increases after disasters, likely due to improper generator use during power outages. Here, we evaluate the impact of outages on children's CO-related emergency department (ED) visits in New York State (NYS). We leveraged power outage data spanning 2017-2020 from the NYS Department of Public Service for 1,865 power operating localities (i.e., communities) and defined all-size and large-scale power outage hours. All-size outage hours affected ≥1% of customers, and large-scale outage hours affected ≥20%. We identified CO poisoning using diagnostic codes among those aged <18 between 2017 and 2020 using the Statewide Planning and Research Cooperative System (SPARCS), an all-payer reporting system in NYS. We linked community power outage exposure to patients using the population-weighted centroid of their block group of residence. We estimated the impact of power outages on CO poisoning using a time-stratified case-crossover study design with conditional logistic regression, controlling for daily relative humidity, mean temperature, and total precipitation. Analyses were stratified by urban and rural communities. From 2017-2020, there were 917 pediatric CO poisoning ED visits in NYS. Most cases (83%) occurred in urban region of the state. We observed an association statewide between all-size and large-scale outages and CO ED visits on the index day and the following two days before a return to baseline on lag day 3. Four hours without power increased the odds of a pediatric CO poisoning ED visit by ≥50% for small-scale and ≥150% for large-scale outages, and associations were stronger in urban versus rural areas. While CO poisoning is a relatively rare cause of pediatric ED visits in NYS, it can be deadly and is also preventable. Expanded analyses of the health impacts of outages and advocacy for reliable energy access are needed to support children's health in a changing climate.

Community violence and asthma: A review.

Over the past 2 decades, epidemiologic studies have identified significant associations between exposure to violence, as a psychosocial stressor, and the incidence or exacerbation of asthma. Across diverse populations, study designs, and measures of community violence, researchers have consistently identified adverse associations. In this review, the published epidemiologic evidence is summarized with special attention to research published in the last 5 years and seminal papers. Hypothesized mechanisms for the direct effects of violence exposure and for how such exposure affects susceptibility to physical agents (eg, air pollution and extreme temperature) are discussed. These include stress-related pathways, behavioral mechanisms, and epigenetic mechanisms. Finally, clinical implications and recommendations are discussed.

Power outages and pediatric unintentional injury hospitalizations in New York State.

Background: In the past decade, electrical power disruptions (outages) have increased in the United States, especially those attributable to weather events. These outages have a range of health impacts but are largely unstudied in children. Here, we investigated the association between outages and unintentional injury hospitalizations, a leading cause of childhood morbidity. Methods: The study setting was New York State (NYS) from 2017 to 2020. Outage exposure was defined as ≥10%, ≥20%, and ≥50% of customers from a power operating locality without power, ascertained from NYS Department of Public Service records and stratified by rural, urban non-New York City (NYC), and NYC regions. Outcome daily block group-level pediatric injury hospitalization data was from the Statewide Planning and Research Cooperative System (SPARCS). We leveraged a case-crossover study design with logistic conditional regression. Results: We identified 23,093 unintentional injury hospitalizations in children <18 years with complete block group and exposure data. Most hospitalizations occurred in urban regions (90%), whereas outages were more likely in rural than urban areas. In urban non-NYC regions, outages ≥4 hours were associated with 30% increased odds of all-cause unintentional injury hospitalizations when ≥50% of customers were without power. Analyses by injury subtype revealed increasing point estimates as the proportion of customers exposed increased. These results, however, had wide confidence intervals. Conclusions: Outage exposure differed significantly across rural, urban non-NYC, and NYC regions across New York. Especially at the highest outage threshold, we observed an increased risk of pediatric unintentional injury hospitalizations.

Pregnancy and newborn health - heat impacts and emerging solutions.

Evidence is accumulating, both in the US and abroad, of the apparent serious health impacts of various environmental exposures tied to climate change. High ambient temperature, or heat, is a worsening global health risk. Heat risk is affected by many factors such as the magnitude, duration, and timing of exposure - such as specific, critical windows during pregnancy. This article focuses on the association of heat with both adverse pregnancy and newborn health outcomes. Regarding pregnancy, studies link heat and preterm birth, low birth weight and stillbirth. Multiple potential mechanisms support the biological plausibility of these associations. Emerging evidence suggests that heat, via epigenetics, may affect maternal health far beyond pregnancy. For newborn health impacts, heat is associated with increased hospitalization, neurologic and gastrointestinal dysfunction, and infant death. Research gaps include the need to study neonates separately from children and determining the mechanisms linking heat to adverse outcomes. We also highlight disparate adverse reproductive health outcomes for communities of color and low income tied to disproportionate exposures to environmental stressors like heat. Finally, we summarize educational and clinical tool resources for clinicians, information for patients, and opportunities for near-term action using the precautionary principle framework.

Pubertal timing, neighborhood income, and mental health in boys and girls: Findings from the adolescent brain cognitive development study.

Early pubertal timing is associated with youth mental health problems, with association amplified or mitigated by characteristics of the residential neighborhood. Yet, limited research simultaneously examines the roles of neighborhood context and biological sex in this association. This study fills this research gap by examining sex-specific associations between pubertal timing and neighborhood income with youth mental health problems (internalizing and externalizing symptoms) in a longitudinal cohort of early adolescents in the United States (US). Participants were 9201 youth aged 9 or 10 years from the Adolescent Brain Cognitive Development Study. Pubertal timing was the average of parent- and youth-reported pubertal status standardized within sex and age. Outcome variables were youths' internalizing and externalizing symptoms assessed at 1-year follow-up via parent survey. We evaluated interaction effects between pubertal timing and neighborhood income in a series of sex-stratified linear mixed effect models, adjusted for family and personal sociodemographic characteristics. In girls, earlier pubertal timing was associated with more internalizing (ß = 0.06, p < 0.001) and externalizing problems (ß = 0.07, p < 0.001) at 1-year follow-up, not moderated by neighborhood income. In boys, earlier pubertal timing was associated with more externalizing problems among youth living in high-income neighborhoods, but not among those in low-income neighborhoods (interaction-p = 0.006). Results suggest that pubertal timing may affect youth mental health differentially in boys and girls, depending on the neighborhood contexts. These findings highlight the importance of both biological and social forces in shaping adolescent mental health and, thus, have public health and clinical implications for health promotion.

The Creation of a Multidomain Neighborhood Environmental Vulnerability Index Across New York City.

Compared to previous studies commonly using a single summary score, we aimed to construct a multidomain neighborhood environmental vulnerability index (NEVI) to characterize the magnitude and variability of area-level factors with the potential to modify the association between environmental pollutants and health effects. Using the Toxicological Prioritization Index framework and data from the 2015-2019 U.S. Census American Community Survey and the 2020 CDC PLACES Project, we quantified census tract-level vulnerability overall and in 4 primary domains (demographic, economic, residential, and health status), 24 subdomains, and 54 distinct area-level features for New York City (NYC). Overall and domain-specific indices were calculated by summing standardized feature values within the subdomains and then aggregating and weighting based on the number of features within each subdomain within equally-weighted primary domains. In citywide comparisons, NEVI was correlated with multiple existing indices, including the Neighborhood Deprivation Index (r = 0.91) and Social Vulnerability Index (r = 0.87) but provided additional information on features contributing to vulnerability. Vulnerability varied spatially across NYC, and hierarchical cluster analysis using subdomain scores revealed six patterns of vulnerability across domains: 1) low in all, 2) primarily low except residential, 3) medium in all, 4) high demographic, economic, and residential 5) high economic, residential, and health status, and 6) high demographic, economic and health status. Created using methods that offer flexibility for theory-based construction, NEVI provided detailed vulnerability metrics across domains that can inform targeted research and public health interventions aimed at reducing the health impacts from environmental exposures across urban centers.

High ambient temperatures associations with children and young adult injury emergency department visits in NYC.

Injury is a significant health burden for children and young adult and may be an increasing concern in a warming climate. Research reveals many impacts to children's health associated with hot weather and heatwave events, including a growing literature on the association between high ambient temperature and injury, which may vary by intent such as injury resulting from violence. However, little is known about how this association varies across different types of injury and subgroups of young people. We examined relationships between warm season ambient temperature and intentional and unintentional injury among children and young adults in New York City (NYC). Within a case-crossover design, our study observed injury-related emergency department (ED) visits from the New York Statewide Planning and Research Cooperative System administrative dataset. Injuries were categorized as unintentional or intentional injuries during the warm season (May through September) in NYC from 2005 to 2011 among patients (0, 1-4, 5-9, 10-14, 15-19, 20-25 years old (y.o.)). Conditional logistic regression models with distributed lag non-linear functions were used to model the cumulative odds ratio (OR) injury-related ED visit over 0-5 lag days. Analyses were stratified by age group and sex to understand how associations vary across young people of different age and sex. There were a total of 572 535 injury-related ED visits. The largest effect of elevated temperature (daily minimum 77°F vs 48°F) was for unintentional injury among 5-9 y.o. (OR 1.32, 95% CI 1.23, 1.42) and for intentional injury among 20-25 y.o. (OR 1.54, 95% CI 1.28, 1.85). Further stratified analyses revealed that the highest risk of unintentional injury was among 5-9 y.o. males and 20-25 y.o. males for intentional injury. Our results suggest that high ambient temperatures are associated with higher odds of unintentional and intentional injuries among children. This work adds to a growing body of literature demonstrating the adverse impacts of heat on children, and suggests the need for messaging to parents and children about adopting adaptive strategies to prevent injuries when it is hot outside.

The Climate Change Conversation: Understanding Nationwide Medical Education Efforts.

Despite increasing awareness of the public and global health ramifications of climate change, there is a lack of curricula discussing climate change within medical education. Where greater societal awareness and improved scientific understanding have begun to grab the attention of members of the medical education community, there is the precedent, the desire, and the need to incorporate climate-health topics into medical education. We hosted semi-structured interviews (n=9) with faculty members at different institutions across the country who have been involved with climate change education. We pursued a qualitative approach to begin an inter-institutional conversation and better understand what support our colleagues and peers need to expand climate-health education, and we identified a set of key barriers to implementation: Obtaining Institutional Resources, Formalizing Initiative Leadership, and Empowering Faculty Involvement. We also began to appreciate the creative strategies that programs across the country have employed to tackle these challenges. Working with interested students to manage workload, advocating for funded faculty positions, and integrating curricular materials in multiple formats are just a few of the approaches that have helped climate-health initiatives to achieve longevity and penetration in the curriculum. A better identification of the challenges and drivers for success in curricular efforts can provide a roadmap to more efficient implementation of climate-health topics within medical education.

Neighborhood violence and socioeconomic deprivation influence associations between acute air pollution and temperature on childhood asthma in New York city.

Ambient air pollution, temperature, and social stressor exposures are linked with asthma risk, with potential synergistic effects. We examined associations for acute pollution and temperature exposures, with modification by neighborhood violent crime and socioeconomic deprivation, on asthma morbidity among children aged 5-17 years year-round in New York City. Using conditional logistic regression in a time-stratified, case-crossover design, we quantified percent excess risk of asthma event per 10-unit increase in daily, residence-specific exposures to PM2.5, NO2, SO2, O3, and minimum daily temperature (Tmin). Data on 145,834 asthma cases presenting to NYC emergency departments from 2005 to 2011 were obtained from the New York Statewide Planning and Research Cooperative System (SPARCS). Residence- and day-specific spatiotemporal exposures were assigned using the NYC Community Air Survey (NYCCAS) spatial data and daily EPA pollution and NOAA weather data. Point-level NYPD violent crime data for 2009 (study midpoint) was aggregated, and Socioeconomic Deprivation Index (SDI) scores assigned, by census tract. Separate models were fit for each pollutant or temperature exposure for lag days 0-6, controlling for co-exposures and humidity, and mutually-adjusted interactions (modification) by quintile of violent crime and SDI were assessed. We observed stronger main effects for PM2.5 and SO2 in the cold season on lag day 1 [4.90% (95% CI: 3.77-6.04) and 8.57% (5.99-11.21), respectively]; Tmin in the cold season on lag day 0 [2.26% (1.25-3.28)]; and NO2 and O3 in the warm season on lag days 1 [7.86% (6.66-9.07)] and 2 [4.75% (3.53-5.97)], respectively. Violence and SDI modified the main effects in a non-linear manner; contrary to hypotheses, we found stronger associations in lower-violence and -deprivation quintiles. At very high stressor exposures, although asthma exacerbations were highly prevalent, pollution effects were less apparent-suggesting potential saturation effects in socio-environmental synergism.

Socioeconomic and racial disparities in source-apportioned PM2.5 levels across urban areas in the contiguous US, 2010.

Fine particulate matter (PM2.5) air pollution exposure is associated with short and long-term health effects. Several studies found differences in PM2.5 exposure associated with neighborhood racial and socioeconomic composition. However, most focused on total PM2.5 mass rather than its chemical components and their sources. In this study, we describe the ZIP code characteristics that drive the disparities in exposure to PM2.5 chemical components attributed to source categories both nationally and regionally. We obtained annual mean predictions of PM2.5 and fourteen of its chemical components from spatiotemporal models and socioeconomic and racial predictor variables from the 2010 US Census, and the American Community Survey 5-year estimates. We used non-negative matrix factorization to attribute the chemical components to five source categories. We fit generalized nonlinear models to assess the associations between the neighborhood predictors and each PM2.5 source category in urban areas in the United States in 2010 (n=25,790 zip codes). We observed higher PM2.5 levels in ZIP codes with higher proportions of Black individuals and lower socioeconomic status. Racial exposure disparities were mainly attributed to Heavy Fuel, Oil and Industrial, Metal Processing Industry and Agricultural, and Motor Vehicle sources. Economic disparities were mainly attributed to Soil and Crustal Dust, Heavy Fuel Oil and Industrial, Metal Processing Industry and Agricultural, and Motor Vehicle sources. Upon further analysis through stratifying by regions within the United States, we found that the associations between ZIP code characteristics and source-attributed PM2.5 levels were generally greater in Western states. In conclusion, racial, socioeconomic, and geographic inequalities in exposure to PM2.5 and its components are driven by systematic differences in component sources that can inform air quality improvement strategies.

Child-focused climate change and health content in medical schools and pediatric residencies.

Anthropogenic climate change-driven primarily by the combustion of fossil fuels that form greenhouse gases-has numerous consequences that impact health, including extreme weather events of accelerating frequency and intensity (e.g., wildfires, thunderstorms, droughts, and heat waves), mental health sequelae of displacement from these events, and the increase in aeroallergens and other pollutants. Children are especially vulnerable to climate-related exposures given that they are still developing, encounter higher exposures compared to adults, and are at risk of losing many healthy future years of life. In order to better meet the needs of generations of children born into a world affected by climate change, medical trainees must develop their knowledge of the relationships between climate change and children's health-with a focus on applying that information in clinical practice. This review provides an overview of salient climate change and children's health topics that medical school and pediatric residency training curricula should cover. In addition, it highlights the strengths and limitations of existing medical school and residency climate change and pediatric health curricula. IMPACT: Provides insight into the current climate change and pediatric health curricular opportunities for medical trainees in North America at both the medical school and residency levels. Condenses climate change and pediatric health material relevant to trainees to help readers optimize curricula at their institutions.

Temperature and mental health-related emergency department and hospital encounters among children, adolescents and young adults.

AIMS: We examine the association between high ambient temperature and acute mental health-related healthcare encounters in New York City for children, adolescents and young adults. METHODS: This case-crossover study included emergency department (ED) visits and hospital encounters with a primary diagnosis of any mental health disorder during warm-season months (June-August) in New York City from 2005 to 2011 from patients of three age groups (6-11, 12-17 and 18-25 years). Using a distributed lag non-linear model over 0-5 lag days, by fitting a conditional logistic regression for each age group, we calculated the cumulative odds ratios of mental health encounters associated with an elevated temperature. Analyses were stratified by race/ethnicity, payment source and mental health categories to elucidate vulnerable subpopulations. RESULTS: In New York City, there were 82,982 mental health-related encounters for young people aged 6 to 25 years during our study period months. Elevated temperature days were associated with higher risk of mental health-related ED and hospital encounters for the 6- to 11-year-olds (odds ratio [OR]: 1.28, 95% confidence interval [CI]: 1.13-1.46), for the 12- to 17-year-olds (OR: 1.17, 95% CI: 1.09-1.25) and for the 18- to 25-year-olds (OR: 1.09, 95% CI: 1.04-1.15). Children with reaction disorders, adolescents with anxiety and bipolar disorders, young adults with psychosis and reaction disorders and Black and non-Hispanic children and adolescents showed vulnerability to elevated temperature. CONCLUSIONS: We found that elevated ambient temperatures were associated with acute mental health ED or hospital encounters across childhood, adolescence and young adulthood.

Neighborhood environmental vulnerability and pediatric asthma morbidity in US metropolitan areas.

BACKGROUND: Research suggests demographic, economic, residential, and health-related factors influence vulnerability to environmental exposures. Greater environmental vulnerability may exacerbate environmentally related health outcomes. We developed a neighborhood environmental vulnerability index (NEVI) to operationalize environmental vulnerability on a neighborhood level. OBJECTIVE: We explored the relationship between NEVI and pediatric asthma emergency department (ED) visits (2014-19) in 3 US metropolitan areas: Los Angeles County, Calif; Fulton County, Ga; and New York City, NY. METHODS: We performed separate linear regression analyses examining the association between overall NEVI score and domain-specific NEVI scores (demographic, economic, residential, health status) with pediatric asthma ED visits (per 10,000) across each area. RESULTS: Linear regression analyses suggest that higher overall and domain-specific NEVI scores were associated with higher annual pediatric asthma ED visits. Adjusted R2 values suggest that overall NEVI scores explained at least 40% of the variance in pediatric asthma ED visits. Overall NEVI scores explained more of the variance in pediatric asthma ED visits in Fulton County. NEVI scores for the demographic, economic, and health status domains explained more of the variance in pediatric asthma ED visits in each area compared to the NEVI score for the residential domain. CONCLUSION: Greater neighborhood environmental vulnerability was associated with greater pediatric asthma ED visits in each area. The relationship differed in effect size and variance explained across the areas. Future studies can use NEVI to identify populations in need of greater resources to mitigate the severity of environmentally related outcomes, such as pediatric asthma.

Particulate Air Pollution Exposure and Stroke among Adults in Israel.

Stroke is the second most common cause of death and disability in the world. Many studies have found fine particulate matter (PM2.5) exposure to be associated with an increased risk of atherosclerotic cardiovascular disease, mostly focusing on ischemic heart disease and acute myocardial infarction. In a national analysis conducted in Israel-an area with unique climate conditions and high air pollution levels, we estimated the association between short-term PM2.5 exposure and ischemic stroke, intracerebral hemorrhage (ICH), or transient ischemic attacks (TIA). Using the Israeli National Stroke Registry, we obtained information on all stroke cases across Israel in 2014-2018. We obtained daily PM2.5 exposures from spatiotemporally resolved exposure models. We restricted the analytical data to days in which PM2.5 levels did not exceed the Israeli 24 h standard (37.5 µg/m3). We repeated the analysis with a stratification by sociodemographic characteristics and comorbidities. For all outcomes, the exposure-response curves were nonlinear. PM2.5 exposure was associated with a higher ischemic stroke risk, with larger effect estimates at higher exposure levels. Although nonsignificant, the exposure-response curve for TIA was similar. The associations with ICH were nonsignificant throughout the PM2.5 exposure distribution. The associations with ischemic stroke/TIA were larger among women, non-Jewish individuals, older adults, and individuals with diabetes, hypertension, and ischemic heart disease. In conclusion, short-term PM2.5 exposure is associated with a higher risk for ischemic stroke and possibly TIA, even when PM2.5 concentrations do not exceed the Israeli air quality guideline threshold. Vulnerability to the air pollution effects differed by age, sex, ethnicity, and comorbidities.

Association of ambient extreme heat with pediatric morbidity: a scoping review.

Global climate change is leading to higher ambient temperatures and more frequent heatwaves. To date, impacts of ambient extreme heat on childhood morbidity have been understudied, although-given children's physiologic susceptibility, with smaller body surface-to-mass ratios, and many years of increasing temperatures ahead-there is an urgent need for better information to inform public health policies and clinical approaches. In this review, we aim to (1) identify pediatric morbidity outcomes previously associated with extreme heat, (2) to identify predisposing co-morbidities which may make children more susceptible to heat-related outcomes, and (3) to map the current body of available literature. A scoping review of the current full-text literature was conducted using the Arksey and O'Malley framework Int J Soc Res Methodol 8:19-32, (2015). Search terms for (1) pediatric population, (2) heat exposures, (3) ambient conditions, and (4) adverse outcomes were combined into a comprehensive PubMed and Medline literature search. Of the 1753 publications identified, a total of 20 relevant studies were ultimately selected based on selection criteria of relevance to US urban populations. Most identified studies supported positive associations between high extreme temperature exposures and heat-related illness, dehydration/electrolyte imbalance, general symptoms, diarrhea and digestion disorders, infectious diseases/infections, asthma/wheeze, and injury. Most studies found no association with renal disease, cardiovascular diseases, or diabetes mellitus. Results were mixed for other respiratory diseases and mental health/psychological disorders. Very few of the identified studies examined susceptibility to pre-existing conditions; Cystic Fibrosis was the only co-morbidity for which we found significant evidence. Further research is needed to understand the nuances of associations between extreme heat and specific outcomes-particularly how associations may vary by child age, sex, race/ ethnicity, community characteristics, and other pre-existing conditions.

Climate change and physical activity: ambient temperature and urban trail use in Texas.

Individuals in the USA are insufficiently active, increasing their chronic disease risk. Extreme temperatures may reduce physical activity due to thermal discomfort. Cooler climate studies have suggested climate change may have a net positive effect on physical activity, yet research gaps remain for warmer climates and within-day physical activity patterns. We determined the association between ambient temperatures (contemporary and projected) and urban trail use in a humid subtropical climate. At a trail in Austin, TX, five electronic counters recorded hourly pedestrian and cyclist counts in 2019. Weather data were acquired from World Weather Online. Generalized additive models estimated the association between temperature and trail counts. We then combined the estimated exposure-response relation with weather projections from climate models for intermediate (RCP4.5) and high (RCP8.5) emissions scenarios by NASA NEX-GDDP. From summer to autumn to spring to winter, hourly trail counts shifted from bimodal (mid-morning and early-evening peaks) to one mid-day peak. Pedestrians were more likely to use the trail between 7 and 27 °C (45-81°F) with peak use at 17 °C (63°F) and cyclists between 15 and 33 °C (59-91°F) with peak use at 27 °C (81°F) than at temperature extremes. A net decrease in trail use was estimated by 2041-2060 (RCP4.5: pedestrians = - 4.5%, cyclists = - 1.1%; RCP8.5: pedestrians = - 6.6%, cyclists = - 1.6%) and 2081-2100 (RCP4.5: pedestrians = - 7.5%, cyclists = - 1.9%; RCP8.5: pedestrians = - 16%, cyclists = - 4.5%). Results suggest climate change may reduce trail use. We recommend interventions for thermal comfort at settings for physical activity.