Attributable Disease Burden Research Articles

P-3. Assessing the Public Health Impact of Transitioning from a 4-valent to a 9-valent HPV Vaccination Program in Panama

Abstract Background In 2008, a human papillomavirus (HPV) vaccine was introduced for 10-year-old girls in the National Immunization Program in Panama, switching to a quadrivalent HPV gender-neutral vaccination (4vHPV GNV). This analysis aimed to estimate the expected public health and economic impact of switching from a 4vHPV GNV to 9vHPV GNV in Panama.Table 1.Main parameters used in the model Methods A previously published dynamic model of HPV disease transmission was calibrated to simulate the natural history of HPV and attributable disease burden in Panama. The model assumed a two-dose schedule over a 100-year time horizon, lifetime immunity after vaccination, continuous cytology screening, and herd immunity. The outcomes measured were incremental averted cases and deaths of cervical, vaginal, vulvar, anal, penile, head/neck HPV-attributable cancers, recurrent respiratory papillomatosis, genital warts, and cervical intraepithelial neoplasia (CIN) 1 and 2/3. Panama specific data were used for calibration (Table 1).Table 2.Additional avoided cases/cumulative percent reduction and deaths/mortality percnt reduction of HPV-attributable diseases and cancers with 9v-HPV relative to 4v-HPV strategy over 100 years in Panama Results After 100 years, the 9vHPV GNV scenario is estimated to provide faster and greater reductions in the incidence and mortality of HPV 6/11/16/18/31/33/45/52/58-attributable diseases and cancers compared to the 4vHPV GNV. The fastest and greatest cumulative reduction compared to 4vHPV GNV were observed in cervical cancer, CIN 1, and CIN 2/3, totaling 46,760 averted cases and 1,760 deaths (Table 2 and Fig.1). The other cancers also exhibited a reduction in cumulative incidence compared to 4VHPV GNV at year 100, albeit at a later stage than cervical cancer (Fig. 2).Figure 1.Estimated reductions in incidence and mortality of cervical cancer and cervical intraepthelial neoplasia attributable to HPV 6/11/16/18/31/33/45/52/58 over 100 years in Panama Conclusion In Panama, switching from 4vHPV GNV to 9vHPV GNV is projected to provide a substantial public health impact in terms of reduction of HPV-attributable disease and cancers due to HPV 6/11/16/18/31/33/45/52/58 in both genders compared to the current strategy. Faster and greater reductions in the incidence and mortality of cervical cancer and its precursors were seen compared to anal, penile, and head/neck cancers, which typically peak in the sixth decade of life versus fourth decade in cervical cancer, reflecting the natural history of HPV infection in different anatomical sites.Figure 2.Estimated reductions in incidence and mortality of anal cancer attributable to HPV6/11/16/18/31/33/45/52/58 over 100 years in Paranama Disclosures Juan Carlos Orengo, MD, MPH, PhD, Merck & Co., Inc: Employee|Merck & Co., Inc: Stocks/Bonds (Private Company) Ana Marisol Rendon, MD, MS, Merck & Co., Inc: Employee|Merck & Co., Inc: Stocks/Bonds (Private Company) Bruna Cristina Lima, n/a, Merck & Co., Inc: Employee Vincent Daniels, PhD, Merck & Co., Inc: Employee|Merck & Co., Inc: Stocks/Bonds (Private Company) Kunal Saxena, PhD, Merck & Co., Inc: Stocks/Bonds (Private Company) Andrew Pavelyev, n/a, HCL America, Inc.: emplo Cintia I. Parellada, MD, PhD, Merck & Co., Inc: Employee|Merck & Co., Inc: Stocks/Bonds (Private Company)

P-2. Public Health and Economic Impact of Implementing Gender-Neutral Vaccination with the 4-Valent Human Papillomavirus Vaccine in Costa Rica

Abstract Background In 2019, the quadrivalent human papillomavirus female only-vaccination (4vHPV-FOV) was introduced for 10-year-old girls in the Costa Rican National Immunization Program. This analysis aims to estimate the public health impact and the incremental cost-effectiveness of switching from a 4vHPV-FOV to a 4vHPV-GNV in Costa Rica.Table 1.Main parameters used in the model Methods A validated dynamic model of HPV disease transmission was calibrated to simulate the natural history of HPV infection and attributable disease burden in Costa Rica. The model assumed a two-dose schedule over a 100-year time horizon, lifetime immunity after vaccination, continuous cytology screening, and herd immunity. The outcomes measured were incremental averted cases and deaths of cervical, vaginal, vulvar, anal, penile, head & neck HPV-attributable cancers; recurrent respiratory papillomatosis, genital warts, and cervical intraepithelial neoplasia (CIN); and incremental cost-effectiveness ratio (ICER) expressed in quality-adjusted life years. Outcomes and costs were discounted at 3% annually rate. Costa Rica specific data were used for calibration (Table 1). The WHO definition of cost-effectiveness was used to define the threshold of highly cost-effective (ICER < 1 GDP/per capita or US$13,365.4 for Costa Rica).Table 2.Additional avoided cases/cumulative percent reduction and deaths/mortality percent reduction of HPV-attributable diseases and cancers with 4vHPV-GNV strategy relative to 4-HPV-FOV over 100 years in Costa Rica. Results After 100 years, the 4vHPV-GNV strategy was projected to avert an additional 206,211 cases and 481 deaths compared to 4vHPV-FOV. The greatest reductions in burden and costs were due to HPV-6/11-attributable diseases (Table 2 and Fig. 1). For HPV 16 and 18-attributable cancers, the greatest reductions in burden were observed in cervical cancer, CIN 1 and 2/3 for females, and head & neck and penile cancers for males (Fig 1 and 2). 4vHPV-GNV was highly cost-effective with an ICER of US$ 2,166.Figure 1.Estimated healthcare costs avoided over 100 years by HPV genotype in Costa Rica Conclusion In Costa Rica, switching from a 4vHPV-FOV to a 4vHPV-GNV strategy is projected to be a cost-effective intervention, providing a substantial public health impact in both genders. The 4vHPV-GNV scenario would result in faster and greater reductions in the incidence of HPV 6/11/16/18-attributable diseases and cancers compared to the 4vHPV-FOV.Figure 2.Estimated HPV 6/11/16/18-attributable disease and cancer incidence over 100 years in Costa RicaA.Genital warts among females, B. Genital warts among males, C. Anal cancer among males, D. Head & Neck cancers among males Disclosures Juan Carlos Orengo, MD, MPH, PhD, Merck & Co., Inc: Employee|Merck & Co., Inc: Stocks/Bonds (Private Company) Ana Marisol Rendon, MD, MS, Merck & Co., Inc: Employee|Merck & Co., Inc: Stocks/Bonds (Private Company) Bruna Cristina Lima, n/a, Merck & Co., Inc: Employee Andrew Pavelyev, n/a, HCL America, Inc.: emplo Vincent Daniels, PhD, Merck & Co., Inc: Employee|Merck & Co., Inc: Stocks/Bonds (Private Company) Kunal Saxena, PhD, Merck & Co., Inc: Stocks/Bonds (Private Company) Wilberth Herrera-Solano, MD, Consultant: Consultant Cintia I. Parellada, MD, PhD, Merck & Co., Inc: Employee|Merck & Co., Inc: Stocks/Bonds (Private Company)

Environmental burden of disease resulting from long-term nitrogen dioxide exposure in Germany

BackgroundExposure to nitrogen dioxide (NO2) is associated with an increased risk of cardiovascular, respiratory, and other diseases and health outcomes. Although NO2 emissions have decreased in Germany, concentrations currently observed still pose a threat to population health. The aim of this study is to estimate the environmental burden of disease (EBD) resulting from long-term NO2 exposure in Germany from 2010 to 2021.MethodsTo estimate the attributable disease burden, World Health Organization’s EBD approach was used. We first conducted a systematic literature review to identify exposure–response functions (ERFs) which mathematically represent the association between NO2 exposure and the health outcomes: asthma, chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus (T2DM), ischemic heart disease, lung cancer, stroke, and cardiovascular and respiratory mortality. Then, we estimated the years of life lost (YLL), years lived with disability (YLD) and, where possible, disability-adjusted life years (DALYs) due to these health outcomes in Germany, using mostly publicly available data. In a third step, using the ERFs and modelled ambient NO2 exposure data, the fraction of the disease burden attributable to NO2 exposure was estimated for each health outcome and year, stratified by sex.ResultsThe systematic review yielded recent ERFs for some exposure-outcome pairs, but not always for both mortality and morbidity outcomes. A full DALY calculation was possible for COPD and T2DM. For the other outcomes, either only YLL or YLD were calculated. Summing up the estimated YLD and YLL of all outcomes, the burden of disease due to NO2 exposure in Germany decreased from 261,503 (95% UI 69,290–489,273) lost healthy years in 2010 to 100,032 (95% UI 24,558–191,715) in 2021.ConclusionsAlthough the burden of disease attributable to NO2 exposure decreased from 2010 to 2021, NO2 still poses a threat to population health in Germany. While the current legal concentration limit was generally not exceeded in Germany in 2021, stricter new values proposed by WHO were frequently surpassed. When comparing the results to a previous assessment, it was obvious how strongly different input data impact the results. Transparent reporting of input data and discussing potential challenges when interpreting EBD results are critical.

Temporal trends in disability adjusted life year and mortality for colorectal cancer attributable to a high red meat diet in China from 1990 to 2021: an analysis of the global burden of disease study 2021

BackgroundHigh red meat consumption is a main modifiable risk factor for colorectal cancer mortality (CRC), but its attributable disease burden remains unclear in China. We aimed to analyze the temporal trends in CRC deaths and disability-adjusted life years (DALYs) attributable to high red meat consumption in China from 1990 to 2021 and to predict the disease burden in the next 15 years.MethodsData was obtained from the Global Burden of Disease (GBD) 2021 study. The Joinpoint regression model was used to calculate the annual percentage change (APC) and the average annual percentage change (AAPC). In addition, the age-period-cohort (APC) model was employed to explore the effects of age, period, and cohort on CRC mortality. The autoregressive integrated moving average (ARIMA) model was utilized to predict the disease burden in 2022–2036. We also compared the CRC burden attributed to high red meat in China with 204 countries worldwide.ResultsThe results showed that the number of CRC deaths in China due to high red meat consumption increased nearly 2.5 times, from 17,608 (95% UI: -3 to 36,613) in 1990 to 43,580 (95% UI: -16 to 92,083) in 2021. Male CRC deaths exhibited a more pronounced increase, rising from 9,800 in 1990 to 27,600 in 2021. Additionally, the number of DALYs increased from 518,213 (95% UI: -105,107 to 1,074,174) in 1990 to 1,091,788 (95% UI: -509 to 2,295,779) in 2021. Joinpoint regression analysis confirmed that the AAPC in ASDR and ASMR was − 0.20 (95% CI: -0.40 ∼ 0.00) and − 0.30 (95% CI: -0.40 ~ -0.10). When age, period, and cohort effects were examined as the reference group, the risk of CRC was found to increase with age. However, women experienced a marked decline in both period and cohort effects compared to men.ConclusionsCompared to global levels, the burden in China is heavier. In terms of mortality or DALY standardized rates, Chinese women show a similar downward trend to the overall trend, while Chinese men show a striking upward trend. This study provides valuable insights into enhancing CRC prevention and improving dietary patterns in China.

Global burden of disease attributable to metabolic risk factors in adolescents and young adults aged 15–39, 1990–2021

Metabolic risk factors are a significant cause of global burden among adolescents and young adults, but there is a lack of attention to the burden attributable to these metabolic risk factors globally. This study aims to provide comprehensive estimates of five important metabolic risk factors and the attributable disease burden in people aged 15-39 years from 1990 to 2021, based on the Global Burden of Disease Study (GBD) database. Global total deaths and disability-adjusted life years (DALYs) were used to describe the burden attributable to five common metabolic risk factors, including high fasting plasma glucose (FPG), high low-density lipoprotein cholesterol (LDL-C), high systolic blood pressure (SBP), high body mass index (BMI), and kidney dysfunction, in adolescents and young adults. The estimated annual percentage changes (EAPC) of DALYs were utilized to depict the trends from 1990 to 2021. From 1990 to 2021, the DALY rates attributable to all metabolic risk factors showed a globally significant upward trend, with EAPC reaching 33.0% (27.4-38.7). Compared to females, males had a heavier burden and a more significant increase in deaths and DALYs attributable to metabolic risk factors. High BMI and high FPG have become the top two metabolic risk factors in 2021, with summary exposure variables (SEV) rising by 84.2% and 53.6%, respectively. Low-middle socio-demographic index (SDI), middle SDI, and high SDI regions experienced upward regional trends in DALY rates, while low SDI regions remained stable. Among 204 countries and territories, 101 (49.5%) showed a significant increase in DALY rates, as indicated by the EAPC. There is a substantial global burden attributable to metabolic risk factors in adolescents and young adults in 2021, especially high BMI and high FPG. This calls for further investigation and intervention to address this emerging trend.

7.P. Skills building seminar: Using health impact assessment for assessing tobacco control policies

Abstract Tobacco use is the largest contributor to premature death and preventable disease in Europe. Despite decreasing tobacco use in recent years, the European Commission estimates that the number of smokers in Europe is 26% in the population, and 29% among 15-24 year olds. This persistent public health risk is amenable to policy, but targeted and effective strategies are needed. Health impact assessment (HIA) methods can aid decision-makers in exploring the consequences of policy actions on select outcomes, providing a platform for informed, evidence-based policy design. Routine data collection on risk factors including smoking and tobacco use behaviour is common and available in Europe. Analysing and valorising these data can provide a better picture of vulnerable and target groups for which tobacco use is a persistent problem, or where the attributable disease burden is particularly high. These data can form the basis for robust projections and the application of HIA methods. In addition, a number of policy strategies exist for tobacco control including changes in packaging, taxation, labelling, ingredients, creation of smoke-free environments, and restrictions on advertising. These policies have a common goal in improving tobacco control, but may lead to differential effects across age groups, populations, and different measures of tobacco use. It is thus necessary to use robust tools to understand these effects and better coordinate and plan policy. HIA methods, each with their own strengths and limitations, have been applied successfully to estimate the impact of different tobacco control measures. Novel methodologies that make use of available data, computational power, and provide a low-cost way to explore policy interventions can be an essential tool to policy planning and in particular to tackle the intractable areas of tobacco control. This skills building workshop will present two key approaches, each with their own strengths and weaknesses, that have been applied in HIA studies on tobacco control - i.e., a static approach based on the calculation of potential impact fraction, and a dynamic approach based on microsimulation models. Furthermore, the workshop will demonstrate, using two real-life examples, how policy measures can be translated into effect size estimates - which is one of the most crucial steps in any HIA. By providing a step-by-step presentation of how HIA has been applied in practice, attendees will gain unique insights in the different ways by which HIA can be used to gain insights into the relative impact of policy strategies for tobacco control. Key messages • Tobacco use remains the largest contributor to preventable disease burden in Europe; a key area for analysing policies using health impact assessment. • Attendees will gain unique insights in the different ways by which HIA can be used to gain insights into the relative impact of policy strategies for tobacco control.

Burden and economic impact of PM2.5 exposure on Acute Myocardial Infarction in Portugal, 2011-2021

Abstract Background Air pollution, specifically particulate matter with a diameter of 2.5 micrometers (PM2.5), is the primary environmental health risk in Europe. Exposure to PM2.5 increases the risk of cardiovascular diseases, including AMI, resulting in high direct costs associated with in-patient treatment. This study aims to estimate the avoidable and attributable disease and economic burden of AMI due to ambient PM2.5 exposure in Portugal between 2011 and 2021. Methods National databases were used to assess the annual number of hospitalisations and deaths due to AMI between 2011 and 2021. The annual mean costs were calculated using a direct cost analysis (bottom-up micro-costing) to assess the direct economic burden of AMI. In turn, these cases and associated costs were multiplied by the respective morbidity and mortality population attributable fraction (PAF) to estimate the number of hospital admissions and deaths, and their associated costs attributable to ambient PM2.5 exposure. For 2019 and 2021, an alternative scenario of exposure was considered (2021 WHO Air Quality Guidelines), and the avoidable morbidity and mortality costs were determined using the potential impact fraction (PIF). Results Between 2011 and 2021, there were 130,447 hospitalisations and 47,968 deaths due to AMI, with 4.79% and 28.90%, respectively, attributable to ambient PM2.5 exposure. This translates to a direct economic burden of morbidity of more than 44 million euros and mortality of almost 195 million euros. If the proposed scenario guidelines were met, 279 cases and 448 deaths would have been avoided in 2019, resulting in a savings of almost 9.7 million euros. In 2021, 93 cases and 355 deaths would have been avoided, with approximately 4 million euros saved. Conclusions Exposure to ambient PM2.5 significantly contributes to AMI cases and deaths in Portugal, imposing a significant economic burden. These findings highlight the urgent need for measures to improve air quality. Key messages • PM2.5 pollution in Portugal drives AMI cases and fatalities, entailing significant economic costs. • Adhering to WHO air quality guidelines promises substantial reductions in AMI incidence and save millions annually in healthcare expenditure.

Novel R package to quantify and monetize burden of disease attributable to air pollution and noise

Abstract Background Ambient air pollution and noise substantially impact public health and the economy. Different methods to quantify these impacts are described in the literature. Objectives Within the European project BEST-COST (Burden of disease-based methods for estimating the socio-economic cost of environmental stressors), we aim to develop an open-source R package to quantify and monetise the disease burden attributable to air pollution and noise, including the impact of social inequalities. Methods The developed code will allow for different calculation pathways including: single baseline health data vs. age-specific estimates from life tables; relative and absolute risk; scenario comparison based on the population attributable fraction vs. population impact fraction; single-pollutant vs. correlated exposures; and outdoor vs. indoor air pollution. Moreover, the package can digest a variety of input data formats for the exposure-response function (e.g. relative risk with fixed shape vs. user-defined function) and exposure data (e.g. population-weighted mean vs. categorical distribution, spatial data). Eligible impact metrics will include morbidity incidence and prevalence, number of deaths, years of life lost, and years lived with disability. Finally, the R package will enable quantifying social inequities (using a novel multiple deprivation index) and monetising the attributable disease burden (using a state-of-the-art approach). Results During development, the R package will be tested in BEST-COST case studies in 5 European countries (BE, EE, FR, NO, PT), compared with existing tools, and discussed with key users in a workshop. The final R package will be available on GitHub in 2026. Conclusions This tool will allow the quantification and monetisation of the health impact of air pollution and noise. The R package will be a flexible programming resource that can be used as a standalone or combined with existing tools to build a more solid basis for evidence-based policy making. Key messages • This open-source tool will allow the quantification and monetisation of the health impact of air pollution and noise, including the impact of social inequalities. • The R package will be a flexible programming resource that can be used as a standalone or combined with existing tools to build a more solid basis for evidence-based policy making.

Assessing drinking water quality based on water quality indices, human health risk, and burden of disease attributable to heavy metals in rural communities of Yazd County, Iran, 2015–2021

The water quality indices, health risk, and burden of disease attributable to heavy metals in rural communities of Yazd County, Iran during 2015–2021 were studied. The drinking water quality index (DWQI) based on 27 parameters (including heavy metals) and heavy metal pollution index (HPI) were used for assessing drinking water quality. The health risk and burden of disease from heavy metals in drinking water were estimated in terms of hazard quotient (HQ), hazard index (HI), incremental lifetime cancer risk (ILCR), and disability-adjusted life year (DALY). Based on the DWQI scores by community, the drinking water quality in rural communities of Yazd County was characterized as good for 61 %, fair for 25 %, marginal for 2 %, and poor for 12 %. The distribution of the rural communities into the HPI categories was as follows: 43 % for excellent, 36 % for good, 14 % for poor, and 7 % for unsuitable. In about 20 % of the rural communities, the average HI level of heavy metals was higher than the boundary limit of one. The highest average HQ level at the county level was related to arsenic (As) to be 0.44. In all the communities, the total ILCR values of the heavy metals were in the category of significant increased cancer risk (10−6 to 10−4). At the county level, As and cadmium (Cd) exhibited the two highest cancer risk levels to be 1.96 × 10−4 and 1.87 × 10−4 for ILCR, respectively. The DALY rate (per 100,000 people) induced by exposure to the heavy metals via drinking water was 13.9, which was considered relatively high as compared to that of other drinking water pollutants obtained in the previous studies. The drinking water quality improvement through decreasing Cd and As levels below the standard values can drastically reduce the attributable burden of disease and promote the public health in the rural communities.

Trends in smokeless tobacco use and attributable mortality and morbidity in the South-East Asia Region: implications for policy

ObjectivesTo describe the prevalence of smokeless tobacco (SLT) use and number of users by year, in addition to trends in mortality and attributable disease burden in countries of the WHO...

Letter to the Editor From Landrigan et al: “Chemicals Used in Plastic Materials: An Estimate of the Attributable Disease Burden and Costs in the United States”

Letter to the Editor From Landrigan et al: “Chemicals Used in Plastic Materials: An Estimate of the Attributable Disease Burden and Costs in the United States”

Response to Letter to the Editor From Landrigan et al: "Chemicals Used in Plastic Materials: An Estimate of the Attributable Disease Burden and Costs in the United States".

Response to Letter to the Editor From Landrigan et al: "Chemicals Used in Plastic Materials: An Estimate of the Attributable Disease Burden and Costs in the United States".

Household air pollution and attributable burden of disease in rural China: A literature review and a modelling study

Household air pollution prevails in rural residences across China, yet a comprehensive nationwide comprehending of pollution levels and the attributable disease burdens remains lacking. This study conducted a systematic review focusing on elucidating the indoor concentrations of prevalent household air pollutants—specifically, PM2.5, PAHs, CO, SO2, and formaldehyde—in rural Chinese households. Subsequently, the premature deaths and economic losses attributable to household air pollution among the rural population of China were quantified through dose-response relationships and the value of statistical life. The findings reveal that rural indoor air pollution levels frequently exceed China's national standards, exhibiting notable spatial disparities. The estimated annual premature mortality attributable to household air pollution in rural China amounts to 966 thousand (95% CI: 714–1226) deaths between 2000 and 2022, representing approximately 22.2% (95% CI: 16.4%−28.1%) of total mortality among rural Chinese residents. Furthermore, the economic toll associated with these premature deaths is estimated at 486 billion CNY (95% CI: 358–616) per annum, constituting 0.92% (95% CI: 0.68%−1.16%) of China's GDP. The findings quantitatively demonstrate the substantial disease burden attributable to household air pollution in rural China, which highlights the pressing imperative for targeted, region-specific interventions to ameliorate this pressing public health concern.

Trihalomethanes in global drinking water: Distributions, risk assessments, and attributable disease burden of bladder cancer

This study aimed to assess the global spatiotemporal variations of trihalomethanes (THMs) in drinking water, evaluate their cancer and non-cancer risks, and THM-attributable bladder cancer burden. THM concentrations in drinking water around fifty years on a global scale were integrated. Health risks were assessed using Monte Carlo simulations and attributable bladder cancer burden was estimated by comparative risk assessment methodology. The results showed that global mean THM concentrations in drinking water significantly decreased from 78.37 μg/L (1973–1983) to 51.99 μg/L (1984–2004) and to 21.90 μg/L (after 2004). The lifestage-integrative cancer risk and hazard index of THMs through all exposure pathways were acceptable with the average level of 6.45 × 10−5 and 7.63 × 10−2, respectively. The global attributable disability adjusted of life years (DALYs) and the age-standardized DALYs rate (ASDR) dropped by 16% and 56% from 1990–1994 to 2015–2019, respectively. A big decline in the attributable ASDR was observed in the United Kingdom (62%) and the United States (27%), while China experienced a nearly 3-fold increase due to the expanded water supply coverage and increased life expectancy. However, China also benefited from the spread of chlorination, which helped reduce nearly 90% of unsafe-water-caused mortality from 1998 to 2018.

Chemicals Used in Plastic Materials: An Estimate of the Attributable Disease Burden and Costs in the United States.

Chemicals used in plastics have been described to contribute to disease and disability, but attributable fractions have not been quantified to assess specific contributions. Without this information, interventions proposed as part of the Global Plastics Treaty cannot be evaluated for potential benefits. To accurately inform the tradeoffs involved in the ongoing reliance on plastic production as a source of economic productivity in the United States, we calculated the attributable disease burden and cost due to chemicals used in plastic materials in 2018. We first analyzed the existing literature to identify plastic-related fractions (PRF) of disease and disability for specific polybrominated diphenylethers (PBDE), phthalates, bisphenols, and polyfluoroalkyl substances and perfluoroalkyl substances (PFAS). We then updated previously published disease burden and cost estimates for these chemicals in the United States to 2018. By uniting these data, we computed estimates of attributable disease burden and costs due to plastics in the United States. We identified PRFs of 97.5% for bisphenol A (96.25-98.75% for sensitivity analysis), 98% (96%-99%) for di-2-ethylhexylphthalate, 100% (71%-100%) for butyl phthalates and benzyl phthalates, 98% (97%-99%) for PBDE-47, and 93% (16%-96%) for PFAS. In total, we estimate $249 billion (sensitivity analysis: $226 billion-$289 billion) in plastic-attributable disease burden in 2018. The majority of these costs arose as a result of PBDE exposure, though $66.7 billion ($64.7 billion-67.3 billion) was due to phthalate exposure and $22.4 billion was due to PFAS exposure (sensitivity analysis: $3.85-$60.1 billion). Plastics contribute substantially to disease and associated social costs in the United States, accounting for 1.22% of the gross domestic product. The costs of plastic pollution will continue to accumulate as long as exposures continue at current levels. Actions through the Global Plastics Treaty and other policy initiatives will reduce these costs in proportion to the actual reductions in chemical exposures achieved.

Estimates of the global burden of non-Hodgkin lymphoma attributable to HIV: a population attributable modeling study

Human immunodeficiency virus (HIV) significantly increases the risk of non-Hodgkin lymphoma (NHL) development, yet the population-level impact on NHL burden is unquantified. We aim to quantify this association and estimate the global burden of HIV-associated NHL. In this meta-analysis, we searched five databases (PubMed, EMBASE, Cochrane Library, Web of Science, Scopus) from database inception up to September 13, 2023, identifying cohort, case-control, or cross-sectional studies with an effective control group to assess NHL risk among individuals with HIV infection, with two authors extracting summary data from reports. Global and regional HIV-associated population attributable fraction (PAF) and NHL disease burden were calculated based on the pooled risk ratio (RR). HIV prevalence and NHL incidence were obtained from the Joint United Nations Programme on HIV/AIDS (UNAIDS) and Global Burden of Diseases, Injuries, and Risk Factors Study 2019. Trends in NHL incidence due to HIV were assessed using age-standardised incidence rate (ASIR) and estimated annual percentage change (EAPC). This study was registered with PROSPERO (CRD42023404150). Out of 14,929 literature sources, 39 articles met our inclusion criteria. The risk of NHL was significantly increased in the population living with HIV (pooled RR 23.51, 95% CI 17.62-31.37; I2=100%, p<0.0001), without publication bias. Globally, 6.92% (95% CI 2.18%-11.57%) of NHL new cases in 2019 were attributable to HIV infection (30,503, 95% CI 9585-52,209), which marked a more than three-fold increase from 1990 (8340, 95% CI 3346-13,799). The UNAIDS region of Eastern and Southern Africa was the highest affected region, with 44.46% (95% CI 19.62%-58.57%) of NHL new cases attributed to HIV infection. The Eastern Europe and Central Asia region experienced the highest increase in ASIR of NHL due to HIV in the past thirty years, wherein the EAPC was 8.74% (95% CI 7.66%-9.84%), from 2010 to2019. People with HIV infection face a significantly increased risk of NHL. Targeted prevention and control policies are especially crucial for countries in Eastern and Southern Africa, Eastern Europe and Central Asia, to achieve the UNAIDS's '90-90-90' Fast-Track targets. Limited studies across diverse regions and heterogeneity between research have hindered precise estimations for specific periods and regions. Sichuan Provincial People's Hospital, Chengdu, China; Health Care for Cadres of Sichuan Province, Chengdu, China; Science and Technology Department of Sichuan Province, Chengdu, China.

Health impact assessment of the chemical exposome in European children

Abstract Background We aimed to assess the impact of the chemical exposome on the health of European children since previous health impact assessments (HIA) were limited to a few chemicals. Methods 74 out of 484 substance-outcome associations had an overall level of evidence at least likely and were therefore considered for HIA. For 51 of the 74 associations, dose-response relationships were identified from systematically searched meta-analyses or epidemiological studies. For 41 of these, exposure levels were compatible for HIA. Exposure levels were based on biomarker concentrations assessed in 1301 pregnant women and children of the HELIX cohorts in 6 European countries. The baseline burden of disease were from national estimates of the World Health Organisation for 8 outcomes. The attributable burden of disease was estimated by combining exposures and dose-response relationships and expressed in terms of population attributable fraction, disability-adjusted life years (DALYs) or variations in mean level for quantitative health outcomes. Associated uncertainty was taken into account using Monte-Carlo simulations. Results Each substance harmful for cognition or birth weight entailed an average estimated decrease in Intellectual Quotient by 1.7 points (95% confidence interval (CI) 0, 4.3) and in birth weight by 57 g (95%CI 0, 138). The chemical exposome entailed 1.65 (95%CI 0.63; 2.90) DALYs for 1,000 children per year. The main contributors to the impact were perfluoroalkyl substances, other persistent organic pollutants and tobacco. The impact was mainly due to neurodevelopment (0.4 DALY), congenital heart defects (0.6 DALY), respiratory health (0.4 DALY) and sudden infant death syndrome (0.3 DALY). Conclusions Our study is one of the largest HIA in terms of number of chemicals considered. The results exclude urban exposures such as air pollution and are probably largely underestimated because of a lack of data on dose-response relationships and baseline burden of disease. Key messages • Chemical exposures (mainly perfluoroalkyl substances, persistent organic pollutants, metals and tobacco) contribute to the burden of disease in European children. • Chemical exposures have an impact on fetal and infant death, neurodevelopment, cardiometabolism, respiratory and reproductive health of children.

Local approach to attributable disease burden: case study for air pollution and mortality in Belgium

Abstract Comparative risk assessment is commonly applied to derive the share of the burden of disease attributable to specific risk factors, including air pollution. This method is usually conducted at national level, meaning areas and population groups within the country cannot be compared. We propose a novel approach, where the burden attributable to air pollution is derived locally. Mortality in Belgium due to long-term exposure to particulate matter with diameter &amp;lt;2.5 µm (PM2.5) and nitrogen dioxide (NO2) is derived for the year 2019. In the local method, the attributable burden is calculated at the statistical sector, the smallest territorial unit. Results for individual sectors with small populations are potentially biased when using a concentration-response function (CRF) for the general population. Therefore, the local method is validated by comparing the results, summed to the Belgian total, to estimates derived with a ‘global’ national-scale approach. The discrepancy between the two methods is compared with the uncertainty related to exposure (5th and 95th concentration percentiles) and to the CRF (95% confidence interval of the relative risk), where the central global estimate acts as a baseline. The difference due to methods is limited to under 2% for both pollutants: 8665 deaths derived globally vs. 8588 (-77) locally for PM2.5, and 3688 globally vs. 3633 (-55) locally for NO2. For PM2.5, the method discrepancy and exposure uncertainty (-128, +236) are comparable in magnitude, while both are severely outweighed by CRF uncertainty (-2039, +990). For NO2, the exposure uncertainty (-300, +735) is substantially higher, which could be expected given its greater spatial variability, although CRF uncertainty (-1819, +3495) is again greatest. The local attributable burden method shows potential for comparing areas and population groups at subnational level, on the condition that the results are aggregated to a sufficiently large scale to compensate for possible bias. Key messages • A local burden of disease method offers possibilities for comparing areas and population groups at subnational level. • Validation by comparison with global results shows that potential local bias is mitigated after sufficient aggregation.

Quantifying the potential effects of air pollution reduction on population health and health expenditure in Taiwan

Air pollution, particularly ambient fine particulate matter (PM2.5) pollution, poses a significant risk to public health, underscoring the importance of comprehending the long-term impact on health burden and expenditure at national and subnational levels. Therefore, this study aims to quantify the disease burden and healthcare expenditure associated with PM2.5 exposure in Taiwan and assess the potential benefits of reducing pollution levels. Using a comparative risk assessment framework that integrates an auto-aggressive integrated moving average model, we evaluated the avoidable burden of cardiopulmonary diseases (including ischemic heart disease, stroke, chronic obstructive pulmonary disease, lung cancer, and diabetes mellitus) and related healthcare expenditure under different air quality target scenarios, including status quo and target scenarios of 15, 10, and 5 μg/m3 reduction in PM2.5 concentration. Our findings indicate that reducing PM2.5 exposure has the potential to significantly alleviate the burden of multiple diseases. Comparing the estimated attributable disease burden and healthcare expenditure between reference and target scenarios from 2022 to 2050, the avoidable disability-adjusted life years were 0.61, 1.83, and 3.19 million for the 15, 10, and 5 μg/m3 target scenarios, respectively. Correspondingly, avoidable healthcare expenditure ranged from US$ 0.63 to 3.67 billion. We also highlighted the unequal allocation of resources and the need for policy interventions to address health disparities due to air pollution. Notably, in the 5 μg/m3 target scenario, Kaohsiung City stands to benefit the most, with 527,368 disability-adjusted life years avoided and US$ 0.53 billion saved from 2022 to 2050. Our findings suggest that adopting stricter emission targets can effectively reduce the health burden and associated healthcare expenditure in Taiwan. Overall, this study provides policymakers in Taiwan with valuable insights for mitigating the negative effects of air pollution by establishing a comprehensive framework for evaluating the co-benefits of air pollution reduction on healthcare expenditure and disease burden.

Evaluation of Health Pattern and Stress Levels among Patients Undergoing Alcohol Addiction Treatment-A Cross Sectional Study.

Alcohol consumption is linked to over 200 diseases and injuries. It is also classified as a risk factor for several types of neoplasms as well as infectious diseases (i.e., HIV and tuberculosis). In 2019, among people aged 25 to 49, alcohol use was the leading risk factor for attributable burden of disease. There are many factors that affect alcohol drinking patterns such as social and economic status, social norms, cultural customs, availability of alcohol, etc. Stress also plays a significant role in the process of developing alcohol addiction. The aim of our study was to examine health patterns and stress levels among patients undergoing alcohol addiction treatment. The study sample consisted of 104 patients who were treated in a hospital ward due to alcohol dependence. Three standardized questionnaire tools were used to measure the sense of coherence and the level of stress among those patients. The main results suggest that the level of perceived stress correlated negatively with all dimensions of sense of coherence and all indicators of health behaviors, however, age was positively correlated with positive mental attitude, proper eating habits, and health behaviors. In conclusion, it is worth noting that developing patterns for positive health behaviors will make it possible to avoid alcohol dependence or reinforce the treatment results if alcohol dependence syndrome occurs.