Asthma Hospitalization Rates Research Articles

Trends in hospital admissions and mortality rates for asthma in Ecuador: a joinpoint regression analysis of data from 2000 to 2018

BackgroundAlthough asthma has emerged as an important public health problem over recent decades in Latin America, there are limited published data on national hospital admission and mortality rates for asthma...

Regional differences in pediatric asthma hospital admissions: National data from Israel 1996-2017.

Asthma is a common chronic childhood illness and frequent cause of hospitalization. A decline in hospital admission rates was noted up to the 1990s, however, trends are not as clear since the turn of the century. This study aimed to assess the rates and regional differences of asthma admissions over more than two decades using the national Ministry of Health database, which registers data from all the hospitals. A retrospective cohort study, analysis of all pediatric asthma admissions, for Patients 1-14 years old, between 1996 and 2017 as recorded by the National Hospital Discharge Registry, was performed. Asthma admission rates were calculated per 1000 age adjusted residents, using the number of admission cases as the numerator, and age specific population size as the denominator. The annual asthma hospitalization rate decreased in the entire pediatric population from 2.14 in 1996-0.89 in 2017. Children in the 1-4 year age group comprised most of the hospital admissions, and most of the decline was attributable to this age group. Significant differences in hospitalizations were found between different regions as well as differences in the rate of decline in asthma hospitalizations with the lowest admission rate in the Jerusalem district, highest in Haifa, northern and southern Israeli regions and the greatest rate of decline in the Tel-Aviv district. This nationwide study, over more than two decades, shows clear regional differences in the rates of asthma admissions as well as regional differences in the rates of decline.

Effect of Nebulized Magnesium vs Placebo Added to Albuterol on Hospitalization Among Children With Refractory Acute Asthma Treated in the Emergency Department

While intravenous magnesium decreases hospitalizations in refractory pediatric acute asthma, it is variably used because of invasiveness and safety concerns. The benefit of nebulized magnesium to prevent hospitalization is unknown. To evaluate the effectiveness of nebulized magnesium in children with acute asthma remaining in moderate or severe respiratory distress after initial therapy. A randomized double-blind parallel-group clinical trial from September 26, 2011, to November 19, 2019, in 7 tertiary-care pediatric emergency departments in Canada. The participants were otherwise healthy children aged 2 to 17 years with moderate to severe asthma defined by a Pediatric Respiratory Assessment Measure (PRAM) score of 5 or greater (on a 12-point scale) after a 1-hour treatment with an oral corticosteroid and 3 inhaled albuterol and ipratropium treatments. Of 5846 screened patients, 4332 were excluded for criteria, 273 declined participation, 423 otherwise excluded, 818 randomized, and 816 analyzed. Participants were randomized to 3 nebulized albuterol treatments with either magnesium sulfate (n = 410) or 5.5% saline placebo (n = 408). The primary outcome was hospitalization for asthma within 24 hours. Secondary outcomes included PRAM score; respiratory rate; oxygen saturation at 60, 120, 180, and 240 minutes; blood pressure at 20, 40, 60, 120, 180, and 240 minutes; and albuterol treatments within 240 minutes. Among 818 randomized patients (median age, 5 years; 63% males), 816 completed the trial (409 received magnesium; 407, placebo). A total of 178 of the 409 children who received magnesium (43.5%) were hospitalized vs 194 of the 407 who received placebo (47.7%) (difference, -4.2%; absolute risk difference 95% [exact] CI, -11% to 2.8%]; P = .26). There were no significant between-group differences in changes from baseline to 240 minutes in PRAM score (difference of changes, 0.14 points [95% CI, -0.23 to 0.50]; P = .46); respiratory rate (0.17 breaths/min [95% CI, -1.32 to 1.67]; P = .82); oxygen saturation (-0.04% [95% CI, -0.53% to 0.46%]; P = .88); systolic blood pressure (0.78 mm Hg [95% CI, -1.48 to 3.03]; P = .50); or mean number of additional albuterol treatments (magnesium: 1.49, placebo: 1.59; risk ratio, 0.94 [95% CI, 0.79 to 1.11]; P = .47). Nausea/vomiting or sore throat/nose occurred in 17 of the 409 children who received magnesium (4%) and 5 of the 407 who received placebo (1%). Among children with refractory acute asthma in the emergency department, nebulized magnesium with albuterol, compared with placebo with albuterol, did not significantly decrease the hospitalization rate for asthma within 24 hours. The findings do not support use of nebulized magnesium with albuterol among children with refractory acute asthma. ClinicalTrials.gov Identifier: NCT01429415.

Occupants' Health and Their Living Conditions of Remote Indigenous Communities in New Zealand.

The New Zealand Ministry of Health reported that respiratory disease affects 700,000 people, annually costs New Zealand NZ$7.05 billion, and is the third-highest cause of death. The hospitalisation rate for asthma of Māori communities is 2.0 higher than that of other ethnic groups, and hospitalisation rates for deprived homes are 2.3 times higher than those of the least deprived homes. Based on physical data and evidence, which were drawn from a mixed methodology that includes field studies of the indoor microclimate, dust-mite allergens, mould growth, and occupants’ Respiratory Health Survey of a number of sample houses of Māori communities in Minginui, Te Whaiti, Murupara, and Rotorua of New Zealand, the study identifies unhealthy indoor thermal conditions, thresholds or ranges of indoor micro-climate related to different levels of dust-mite allergen and mould growth, the most common type of indoor mould, and correlations between dust-mite and mould and correlations. The study not only identified that the poor health of occupants is closely related to their inadequate living conditions, but also identifies the threshold of indoor micro-climates to maintain indoor allergens at the acceptable level, which can be used as a guideline to maintain or improve indoor health conditions for future housing development or retrofitted old housing.

Disparate air quality impacts from roadway emissions on schools in Santa Clara County (CA)

Vehicle emissions are major sources of air pollution linked to negative health outcomes in children. Consequently, California State Bill 352 stipulates that new schools may not be sited within 500 ft of major roadways. However, the exposure of existing schools to roadway emissions and the uneven distribution of the burden of air pollution have not been systematically explored for most cities. IN response, the objectives of our study were twofold: We used spatial analysis and an evaluation of traffic count data to develop a proximity-based approach to assessing school exposure to roadway air pollution emissions. Second, we applied our method to ask whether the risk of exposure to high concentrations of roadway emissions is equally distributed for schools in Santa Clara County (SCC; USA), and which demographic or spatial patterns emerge. In the process, our proximity-based approach estimated total annual traffic counts throughout SCC, identified major roadways, and assessed cumulative emission burdens and socio-economic indicators for each school in the study area. Results were compared to output from a physically-based model and to county asthma data. Our results suggest that (i) 14% of schools in SCC are potentially exposed to high levels of air pollution from roadways, a rate that is higher than the national average, and (ii) students from economically disadvantaged backgrounds and receiving aid are more likely to be educated in schools with higher risk of exposure to elevated levels of roadway vehicle emissions. Asthma hospitalization rates are highest in socio-economically disadvantaged areas with a higher density of major roadways. Areas of higher vehicle emissions determined by the physically-based model are in general agreement with those of the distance-based approach. We propose a combination of short- and long-term mitigation strategies to reduce the risk of exposure to vehicle emissions for school children.

Assessing satellite-derived spring phenology for public health applications

Background: Timing shifts in spring phenological events, such as leaf-out and flowering, may alter pollen season dynamics, consequently impacting pollen allergic diseases including asthma. Satellite-derived spring phenology, measuring the start of season (SOS) from regional to global, is important to study the risk of pollen allergy at large spatial scales. However, different SOS products are likely to provide inconsistent spring onset dates. Whether SOS products that exhibit such limitations affect outcomes in health studies is rarely discussed. Methods: In the northeastern United States, SOS metrics from MODIS Land Change Dynamic (MLCD) and eMODIS Remote Sensing Phenology (eMODIS) products of 2009 to 2014 were used to characterize differences in SOS under different spatial scales and vegetation coverage. Furthermore, a univariate linear regression model was built between changes in SOS (early: < -7, normal: -7 to 7 and late: > 7) and crude rates of hospitalization for asthma in counties over the Northeast. Results: MLCD and eMODIS products showed significant differences in SOS at both pixel and county levels, which were 16 and 17 days, respectively. Their SOS differences varied by the degree of vegetation coverage, tending to be higher in areas with lower vegetation coverage. Results of regression analysis showed the late SOS, indicating later onset of spring, was significantly associated with a decrease in asthma hospitalization rate. This association was true for both types of SOS, but was stronger when using the eMODIS-SOS. Conclusions: Although MLCD and eMODIS products perform differently in determining spring onset dates, they may lead to similar outcomes in applications by providing changes in SOS. Therefore, the use of relative changes of SOS is a better choice for public health research.

Alteration in Plant Phenology and Asthma hospitalization in New York State

Background/Aim.Recent trend in warming temperature is changing the timing of spring onset for deciduous trees, that are dominant source of springtime pollen. Such changes can alter springtime pollen exposure dynamics and negatively impact burden of allergic disease including asthma hospitalization.Methods.We used phenology data from the Landsat series to calculate a cardinal date for start of spring (SOS) for each county within the state of New York for the years 1996–2016. We categorized yearly deviations in SOS for each county (N=62) from their respective long-term averages as: early (>7 days early), average (within 7 days), and late (>7 days late). We linked this changes in SOS to springtime asthma hospitalization counts in the respective 62 counties during 1996 to 2016, obtained from Healthcare Cost and Utilization Project (HCUP). We investigated the association between deviations in SOS and springtime asthma hospitalizations using negative binomial Generalized Estimating Equations.Results.We observed that counties in lower latitudes had earlier SOS while counties in higher latitudes had later SOS. There was considerable variability in cardinal date for SOS ranging from 88 to 135 in lower latitudes and 114 to 134 in higher latitudes. During the 20-year period, there was a negative trend in SOS and this change was more pronounced in higher latitudes. During 1996-2016, there were 502,103 asthma inpatient hospitalizations in the New York state. In depth analysis is ongoing to investigate the relationship between changes in timing of spring onset and asthma hospitalization in New York State.Conclusions.Our data shows that changes in timing of spring onset is associated with asthma hospitalization rates.

Spatiotemporal variations of asthma admission rates and their relationship with environmental factors in Guangxi, China

ObjectiveThe study aimed to determine if and how environmental factors correlated with asthma admission rates in geographically different parts of Guangxi province in China.SettingGuangxi, China.ParticipantsThis study was done among 7804...

Hospitalizacja dzieci i młodzieży w województwie śląskim

Introduction. Health condition is one of the basic factors determining the quality of life of children and adolescents. Childhood ill health is especially dangerous as it can interfere with developmental processes and lead to long-term and permanent health problems. Health problems that cause hospitalization are mainly childhood diseases, which, due to the course or accompanying complications, require hospital treatment. The most common reasons for hospitalizing children and adolescents in children are respiratory infections, cardiovascular diseases, cancer, and mental diseases. Aim. The aim of the article is to present the most frequent hospitalizations of children and adolescents from various cities of the Silesian Voivodeship in 2010-2018. Material and methods. The research material is data from the Silesian Voivodeship Office in Katowice – Department of Health. Results. The hospitalization rate for bronchial asthma is increasing in Bielsko-Biała and Sosnowiec. In Bielsko-Biała, Katowice, Sosnowiec and Zabrze, the number of children hospitalized due to mental disorders is increasing. Conclusions. Hospitalization due to neoplastic diseases is variable in all the discussed cities of the Silesian Voivodeship. One of the basic elements of health policy is having knowledge about the health condition of the population of children and adolescents and its wider health needs. Analyzes of the frequency and causes of hospitalization of children and adolescents can be a source of information on factors influencing the health of children and adolescents.

Regional asthma hospitalization rates and global asthma mortality rate in Chilean children.

In recent years, there has been a significant increase in asthma hospitalization rates in children, however, regional and mortality rates are yet unknown. To determine regional asth ma hospitalization rates in children and the global mortality rate in this age group. We determined asthma hospitalization rates in the 15 regions of the country existing at the time of the study, between 2008 and 2014, based on the number of hospital discharges in each region and the population at risk of hospitalization. The mortality rate was obtained using the ratio between deaths due to asthma in children aged 5 to 15 and the exposed population. the 5th region presented the highest hospitalization rate (7.6 per 10,000 inhabitants). Except for 4 regions, the median hospitalization rates of the different regions were similar to those found in the Metro politan Region. The overall mortality rate due to asthma in 5 to 15-year-old children was 0.37 per 100,000 inhabitants in the analyzed period. most regions of the country have similar hospitalization rates to the Metropolitan Region and the 5th region presents the highest hospitali zation rate due to asthma. The global mortality rate in children between 5 and 15 years old is 0.37 per 100,000 inhabitants.

Anti-IL-5 treatments in severe eosinophilic asthma: real life datas

Randomized controlled studies have shown that anti-IL-5 treatments reduce the need for oral corticosteroids, annual asthma exacerbation and hospitalization rates, blood eosinophil count and increase FEV1 values, asthma control, and quality of life in patients with eosinophilic severe asthma. Although the number of real-life studies with anti-IL-5 is limited, there are 10 real life studies with mepolizumab, one real life study with benralizumab and one real life study with reslizumab in the current literature. Similar to randomized controlled trials, real-life studies reported that a reduction in the need for oral corticosteroids, annual asthma exacerbation and hospitalization rates, and blood eosinophil counts and increase FEV1 values, asthma control test and quality of life scores, Response criteria were defined in some of the real-life studies and although different response rates were given according to these criteria, most of the patients with severe eosinophilic asthma showed high response rates to anti-IL-5 treatments. In real-life studies evaluating the safety of anti-IL-5 treatments, the most common adverse effect is mild local injection site reaction that does not require treatment, in conclusion, real-life studies suggest that all three anti-IL-5 treatments in clinical practice are effective and well tolerated.

Association Between Changes in Timing of Spring Onset and Asthma Hospitalization in Maryland

Ongoing climate change is affecting the health of communities across the globe. While direct consequences, including morbidity and mortality tied to increases in the frequency of extreme weather events, have received significant attention, indirect health effects, particularly those associated with climate change-driven disruptions in ecosystems, are less understood. To investigate how ongoing changes in the timing of spring onset related to climate change are associated with rates of asthma hospitalization in Maryland. This cross-sectional study of 29 257 patients with asthma used general additive (quasi Poisson) and mixed-effect (negative binomial) models to investigate the association between changes in the timing of spring onset, detected using satellite observations, and the risk of asthma hospitalization in Maryland from 2001 to 2012. Data analysis was conducted from January 2016 to March 2019. Phenology data, derived from the National Aeronautics and Space Administration's Moderate Resolution Imaging Spectroradiometer, were used to calculate location-specific median dates for start of season from 2001 to 2012. How the start of season for a given year and location deviated from the long-term average was calculated and categorized as very early, early, normal, or late. Daily asthma hospitalization in Maryland during the spring season (ie, March to May). There were 108 358 total asthma hospitalizations during the study period, of which 29 257 (27.0%; 14 379 [49.1%] non-Hispanic black patients; 17 877 [61.1%] women) took place during springtime. In the unadjusted model, very early (incident rate ratio [IRR], 1.17; 95% CI, 1.07-1.28) and late (IRR, 1.07; 95% CI, 1.00-1.15) onset of spring were associated with increased risk of asthma hospitalization. When the analysis was adjusted for extreme heat events and concentrations of particulate matter with an aerodynamic diameter less than 2.5 μm, the risk remained significant for very early spring onset (IRR, 1.10; 95% CI, 1.02-1.20) but not for late spring onset (IRR, 1.03; 95% CI, 0.97-1.11). These results suggest that ongoing changes in the timing of spring onset, which are related to climate variability and change, are associated with asthma hospitalization. Given the high burden of allergic diseases and the number of individuals sensitized to tree pollen, these findings serve as a wake-up call to public health and medical communities regarding the need to anticipate and adapt to the ongoing changes in the timing and severity of the spring allergy season.

Analysis of the trend of hospitalizations for asthma in children and adolescents in Brazil

ObjectiveTo analyze the trend of hospitalizations for asthma in children and adolescents by region and age group in Brazil, from 2008 to 2017. MethodThis is a time-series study with secondary data regarding hospitalizations for asthma in children and adolescents, according to age, region, and gender. Descriptive statistics procedures were used with measures of central tendency to calculate the variation between the periods of 2008 and 2017. Rates of hospitalizations were calculated specifically by age group and region. Time trend analysis was performed by simple linear regression, considered as stationary (p>0.05), declining (p<0.05 and negative regression coefficient), or ascending (p<0.05) and positive regression coefficient). ResultsThe present study identified a higher proportion of hospitalizations for asthma in Brazil in children aged 5–9 years. Regarding gender, there were more hospitalizations in boys. The region that presented the highest proportion of hospitalizations, in all age groups investigated, was the Northeast. As for the trend analysis, this article showed that, in Brazil, there was a trend toward a reduction in hospitalization rates for asthma. ConclusionIn Brazil, there was a tendency to reduce hospitalizations for all investigated age groups. The Northeast was the only region that showed a decline in all age groups.

Decline in hospitalization for childhood asthma in different air pollution regions in Taiwan, 2001–2012

ABSTRACT This study aimed to investigate the trends in childhood asthma hospitalization in regions with differing levels of air pollution in Taiwan, 2001–2012. Joinpoint regression was used to identify significant trend changes. The hospitalization rate varied according to gender, geographic region, and age. The incidence of childhood asthma hospitalization decreased from 127.99 to 76.67 (/100,000 population), with an average annual percentage change of around −4.1%; in the Yilan region, the average air pollution concentrations were 19.92 μg/m3, 39.47 μg/m3, 25.99 ppb, 2.19 ppb, and 11.23 ppb for PM2.5, PM10, O3, SO2, and NO2, respectively, which were lower than Taiwan’s average values; however, the childhood asthma hospitalization rate was the highest (179.75/100,000 population). The national trend in childhood asthma hospitalization exhibited a significant decrease. The effects of air pollution on childhood asthma were greater in the higher-level air pollution regions, while less association was observed in the lower-level air pollution regions.

Prevalence of asthma at a school-based health clinic in Nicaragua.

Worldwide, it is estimated that 235-334 million people have been diagnosed with asthma. In Nicaragua, the current asthma rate for children 13-14 years of age was 15.2%. The purpose of this study was to determine the prevalence of asthma at this school-based health clinic in Managua, Nicaragua, associated symptoms or diseases, determine asthma classification, medications, and hospitalization rates. A retrospective chart review was performed on all pediatric patient's medical records seen in the clinic during a 5-day period (n = 105). A total of 23 patients (21.9%) had asthma documented in the medical chart and were included in the analysis. Of the 23 patients, 3 (13%) patients were classified with intermittent asthma while the rest of the patients (87%) were not classified. Albuterol was prescribed for 19 (86%) of the patients with two patients who had both albuterol and QVAR® prescribed. Six (26%) patients had a family history of asthma. This study demonstrated the prevalence of asthma in school-aged children in Nicaragua is significant and higher than previously reported. The lack of a classification of asthma prevents patients from potentially being treated appropriately.

Hotspot detection and socio-ecological factor analysis of asthma hospitalization rate in Guangxi, China

BackgroundAsthma is a major public health concern throughout the world. Numerous researches have shown that the spatial-temporal patterns of asthma are inconsistent, leading to the suggestion that these patterns are determined by multiple factors. This study aims to detect spatial-temporal clusters of asthma and analyze socio-ecological factors associated with the asthma hospitalization rate in Guangxi, China. MethodsAsthma hospitalization and socio-ecological data for 88 counties/municipal districts in Guangxi, China in 2015 was collected. Space-time scan statistics were applied to identify the high-risk periods and areas of asthma hospital admissions. We further used GeoDetector and Spearman correlation coefficient to investigate the socio-ecological factors associated with the asthma hospitalization rates. ResultsThere were a total of 7804 asthma admissions in 2015. The high-risk period was from April to June. The age groups of 0–4 and ≥65 years were both at the highest risk, with hospital admission rates of 45.0/105 and 46.5/105, respectively. High-risk areas were found in central and western Guangxi with relative risk (RR) values of asthma hospitalizations greater than 2.0. GDP per capita and altitude were positively associated with asthma hospitalizations, while air pressure and wind speed had a negative association. The explanatory powers of these factors (i.e., GDP per capita, altitude, air pressure, wind speed) were 22%, 20%, 14% and 10%, respectively. ConclusionsThe GDP per capita appears to have the strongest correlation with asthma hospitalization rates. High-risk areas were identified in central and western Guangxi characterized by high GDP per capita. These findings may be helpful for authorities developing targeted asthma prevention policies for high-risk areas and vulnerable populations, especially during high-risk periods.

Regional Variation of Hospitalization Rates for Asthma in Korea: Association with Ambient Carbon Monoxide and Health Care Supply.

This study was performed to investigate the relationship between the hospitalization rate for asthma and the ambient carbon monoxide (CO) by examining regional variation of the hospitalization rates for asthma in Korea and its factors. The hospital inpatient claims for asthma were acquired from the National Health Insurance database in 2015. A multivariate linear regression was performed with the hospitalization rate for asthma as a dependent variable. The annual ambient concentration of CO showed a negative association with the hospitalization rates for asthma while that of sulfur dioxide showed a positive association. The number of primary care physicians showed a negative association with the hospitalization rates for asthma while the number of beds in hospitals with less than 300 beds showed a positive association. The negative association of the ambient concentration of CO with the hospitalization rates for asthma showed results upon further investigation.

Characteristics Relevant To Respiratory Health Among African Americans Attending Church-based Asthma Programs in Atlanta.

Not One More Life (NOML), a health and faith partnership, aims to engage African Americans at risk for asthma morbidity into community-partnered asthma programs. Not One More Life programs consisted of interactive presentations, a questionnaire, and spirometry. 4,522 individuals attended NOML programs at 136 Atlanta churches over nine years. Over 90% of attendees were African American. Attendees with asthma had high rates of obesity (9.4% of children, 47.9% of adults) and airflow obstruction (34.6% of children, 17.2%, of adults). Over 20% of attendees with asthma reported past hospitalization for asthma. Among those with a history of hospitalizations for asthma, just 17.6% reported treatment with inhaled corticosteroids Conclusion. Not One More Life program attendees with asthma report considerable morbidity including exceptionally high rates of asthma hospitalizations. Participants have multiple remediable characteristics associated with poorly controlled asthma, including medication undertreatment and obesity.

Asthma Hospitalizations Among Homeless Children in New York State.

Asthma is widely prevalent among US children, particularly in homeless children, who often lack proper medication storage or the ability to avoid environmental triggers. In this study, we assess asthma-attributed health care use among homeless youth. We hypothesize that asthma hospitalization rates, symptom severity, and admission through the emergency department (ED) will be higher among homeless youth compared with nonhomeless youth. This secondary data analysis identified homeless and nonhomeless pediatric patients (<18 years old) with a primary diagnosis of asthma from New York statewide inpatient databases between 2009 and 2014. Hospitalization rate, readmission rate, admission through the ED, ventilation use, ICU admittance, hospitalization cost, and length of stay were measured. We identified 71 837 asthma hospitalizations, yielding 73.8 and 2.3 hospitalizations per 1000 homeless and nonhomeless children, respectively. Hospitalization rates varied by nonhomeless income quartile, with low-income children experiencing higher rates (5.4) of hospitalization. Readmissions accounted for 16.0% of homeless and 12.5% of nonhomeless hospitalizations. Compared with nonhomeless patients, homeless patients were more likely to be admitted from the ED (odds ratio 1.96; 95% confidence interval: 1.82-2.12; P < .01), and among patients >5 years old, homeless patients were more likely to receive ventilation (odds ratio 1.45; 95% confidence interval: 1.01-2.09; P = .04). No significant differences were observed in ICU admittance, cost, or length of stay. Homeless youth experience an asthma hospitalization rate 31 times higher than nonhomeless youth, with higher rates of readmission. Homeless youth live under uniquely challenging circumstances. Tailored asthma control strategies and educational intervention could greatly reduce hospitalizations.

“Housing First” for Optimal Child Health

* Abbreviation: HUD — : US Department of Housing and Urban Development According to the World Health Organization, health is “a state of physical, mental, and social well-being and not merely the absence of disease or infirmity.”1 Healthy children live in families, environments, and communities that provide them with the opportunity to reach their fullest developmental potential.1 In this issue of Pediatrics , Sakai-Bizmark et al2 share results of a large population-based study on asthma hospitalization rates among homeless youth in the state of New York. The investigators reviewed administrative data from 71 837 pediatric asthma hospitalizations over 5 years using the New York Healthcare Cost and Utilization Project’s Statewide Inpatient Database, compiled by the Agency for Healthcare Research and Quality.2 The authors of this study build on previous work by McLean et al3 in 2004 in which the authors reported a 39.8% increase in the prevalence of asthma among homeless children in New York city. Per the latest Centers for Disease Control and Prevention data, the national rate of childhood asthma is 8.3%.4 In their work, Sakai-Bizmark et al2 found a 31 times higher rate … Address correspondence to Kerry K. Sease, MD, MPH, Department of Pediatrics, University of South Carolina School of Medicine, 255 Enterprise Blvd, Suite 110, Greenville, SC 29615. E-mail: kerry.sease{at}prismahealth.org