Time-series Poisson Regression Research Articles

Cohort study of medical cannabis authorisation and healthcare utilisation in 2014–2017 in Ontario, Canada

BackgroundThe impact of medical cannabis on healthcare utilisation between 2014 and 2017 in Ontario, Canada. With cannabis legalisation in Canada and some states in the USA, high-quality longitudinal cohort research...

Time series analysis of total and direct associations between high temperatures and preterm births in Detroit, Michigan

ObjectivesPreterm births (PTBs) represent significant health risks, and several studies have found associations between high outdoor temperatures and PTB. We estimated both the total and natural direct effects (independent of...

Age-specific seasonal associations between acute exposure to PM2.5 sources and cardiorespiratory hospital admissions in California

Abstract Numerous studies have explored the relationships between short-term exposure to fine particulate matter (PM2.5) and morbidity. However, few studies have investigated which PM2.5 sources and constituents contribute to the health associations, and even fewer studies are available which explored age or seasonal effect modification for the associations between PM2.5 sources and health. We explored age-specific associations between short-term exposure to PM2.5 chemical constituents and its sources, and hospital admissions in California. We linked hospital admission data (n = 1,679,094) with PM2.5 chemical constituents and source apportionment data for eight sites in California for the period of 2002–2009. Site-specific source apportionment was conducted using Positive Matrix Factorization, and five PM2.5 sources were commonly identified in most sites (biomass burning, soil, secondary ammonium nitrate, secondary ammonium sulfate, and vehicular emissions). Age-stratified Poisson time-series regression was conducted for each site, and the health risk estimates were combined to generate overall age-specific associations with cardiovascular- and respiratory-related hospital admissions. We further conducted seasonal interaction models to assess seasonal effect modification. An interquartile range increase in PM2.5 vehicular emissions was associated with increased risk of cardiovascular-related hospital admission at lag 0 (1.32% [95% confidence interval (CI): 0.16, 2.49]) for elderly people (≥65 years old). Exposure to PM2.5 vehicular emissions increased the risk of respiratory-related hospitalizations at lag 2 (3.58% [95% CI: 0.90, 6.33]) for children (0–18 years old). Risk estimates of PM2.5 total mass, vehicular emissions, and its related constituents (e.g., iron) for respiratory admissions were higher in the warm season among children. Heterogeneous seasonal estimates were not observed for other age groups. Our results suggest that short-term exposures to several PM2.5 sources and their related constituents are more harmful than exposures to other pollutants, particularly for children in summer. Identifying toxic sources is important for developing effective interventions and protecting susceptible populations.

P6146Atmospheric front patterns and acute cardiovascular diseases, a new perspective in the cardiovascular threat of global climate change

Abstract Background There is substantial evidence that the health threat of global climate change is real and it could be a medical emergency. The impact of climate change on health is mediated through atmospheric parameters which are direct environmental stressors on the human body and have a potential cardiovascular (CV) morbidity and mortality effect. Acute cardiovascular diseases (ACVDs) are already major public health issues and in the future unfavourable atmospheric situations, such as increasingly volatile fronts and their negative effects can further increase this problem. Despite evidence about the importance of different atmospheric parameters on health outcomes, there have been few results for atmospheric front patterns' CV effects. Weather fronts are the most complex atmospheric phenomena therefore these atmospheric parameters might have the greatest influence on ACVDs. Purpose We aimed to explore the effects of atmospheric front patterns on ACVDs. Methods A time series Poisson-regression analysis was used to analyse 6499 ACVD hospital admissions, during a five-year period (2009–2013), in light of front patterns. Covariates were three-day (target day and the two previous days) front sequence patterns comprised of the five major front types (no front, warm front, occluded front, cold front, stationary front). Relative risk (RR) estimates for front effects were adjusted for seasonality. The relationship on all ACVDs combined and separately on patient groups by major CV risk factors (hypertension, hyperlipidaemia, diabetes, previous CV diseases) was examined. Results We found that in general, front patterns containing warm front days had a detrimental effect. A warm front, when followed by two days with no fronts present, increased RR by 46% (CI: 4–89%, p=0,015). Cold fronts however were protective. A no front – cold front – occluded front pattern corresponded to a 28% (CI: 8–49%, p=0,037) decrease in RR, with this pattern being present in 1.1% of all days of the study period. Out of the group specific results an occluded front, following days with no fronts present, showed to have the largest effect on hyperlipidaemic patients, increasing RR by 144% (CI: 51–295%, p<0.001). Conclusions This work provides both independent evidence of front patterns' CV effects and a novel tool to investigate and help the understanding of complex associations between atmospheric fronts and ACVDs. The importance of our findings is growing in the context that extreme atmospheric conditions and changes are likely to become more common in the future as a result of climate change. Medical meteorology may open up a new horizon and become an important field of preventive cardiology in the future. In conclusion, a better understanding of atmospheric front effects is of particular importance in order to help identify possible targets for future prevention strategies.

Use of Emergency Departments by Frail Elderly Patients: Temporal Patterns and Case Complexity.

Emergency department (ED) care for frail elderly patients is associated with an increased use of resources due to their complex medical needs and frequently difficult psycho-social situation. To better target their needs with specially trained staff, it is vital to determine the times during which these particular patients present to the ED. Recent research was inconclusive regarding this question and the applied methods were limited to coarse time windows. Moreover, there is little research on time variation of frail ED patients' case complexity. This study examines differences in arrival rates for frail vs. non-frail patients in detail and compares case complexity in frail patients within vs. outside of regular GP working hours. Arrival times and case variables (admission rate, ED length of stay [LOS], triage level and comorbidities) were extracted from the EHR of an ED in an urban German teaching hospital. We employed Poisson time series regression to determine patterns in hourly arrival rates over the week. Frail elderly patients presented more likely to the ED during already high frequented hours, especially at midday and in the afternoon. Case complexity for frail patients was significantly higher compared to non-frail patients, but varied marginally in time only with respect to triage level and ED LOS. The results suggest that frailty-attuned emergency care should be available in EDs during the busiest hours. Based on EHR data, hospitals thus can tailor their staff needs.

Real-time forecasting of emergency department arrivals using prehospital data

BackgroundCrowding in emergency departments (EDs) is a challenge globally. To counteract crowding in day-to-day operations, better tools to improve monitoring of the patient flow in the ED is needed. The objective of this study was the development of a continuously updated monitoring system to forecast emergency department (ED) arrivals on a short time-horizon incorporating data from prehospital services.MethodsTime of notification and ED arrival was obtained for all 191,939 arrivals at the ED of a Norwegian university hospital from 2010 to 2018. An arrival notification was an automatically captured time stamp which indicated the first time the ED was notified of an arriving patient, typically by a call from an ambulance to the emergency service communication center. A Poisson time-series regression model for forecasting the number of arrivals on a 1-, 2- and 3-h horizon with continuous weekly and yearly cyclic effects was implemented. We incorporated time of arrival notification by modelling time to arrival as a time varying hazard function. We validated the model on the last full year of data.ResultsIn our data, 20% of the arrivals had been notified more than 1 hour prior to arrival. By incorporating time of notification into the forecasting model, we saw a substantial improvement in forecasting accuracy, especially on a one-hour horizon. In terms of mean absolute prediction error, we observed around a six percentage-point decrease compared to a simplified prediction model. The increase in accuracy was particularly large for periods with large inflow.ConclusionsThe proposed model shows increased predictability in ED patient inflow when incorporating data on patient notifications. This approach to forecasting arrivals can be a valuable tool for logistic, decision making and ED resource management.

Association between Weather Types based on the Spatial Synoptic Classification and All-Cause Mortality in Sweden, 1991⁻2014.

Much is known about the adverse health impact of high and low temperatures. The Spatial Synoptic Classification is a useful tool for assessing weather effects on health because it considers the combined effect of meteorological factors rather than temperature only. The aim of this study was to assess the association between oppressive weather types and daily total mortality in Sweden. Time-series Poisson regression with distributed lags was used to assess the relationship between oppressive weather (Dry Polar, Dry Tropical, Moist Polar, and Moist Tropical) and daily deaths over 14 days in the extended summer (May to September), and 28 days during the extended winter (November to March), from 1991 to 2014. Days not classified as oppressive weather served as the reference category. We computed relative risks with 95% confidence intervals, adjusting for trends and seasonality. Results of the southern (Skåne and Stockholm) and northern (Jämtland and Västerbotten) locations were pooled using meta-analysis for regional-level estimates. Analyses were performed using the dlnm and mvmeta packages in R. During summer, in the South, the Moist Tropical and Dry Tropical weather types increased the mortality at lag 0 through lag 3 and lag 6, respectively. Moist Polar weather was associated with mortality at longer lags. In the North, Dry Tropical weather increased the mortality at shorter lags. During winter, in the South, Dry Polar and Moist Polar weather increased mortality from lag 6 to lag 10 and from lag 19 to lag 26, respectively. No effect of oppressive weather was found in the North. The effect of oppressive weather types in Sweden varies across seasons and regions. In the North, a small study sample reduces precision of estimates, while in the South, the effect of oppressive weather types is more evident in both seasons.

Effects of PM2.5 and PM10 on congenital hypothyroidism in Qingdao, China, 2014-2017: a quantitative analysis.

Background:We aimed to quantify the impact of PM2.5 and PM10 pollution on congenital hypothyroidism (CH) in Qingdao in the period 2014–2017.Methods:A generalized additive mixed model (GAMM) with time-series Poisson regression was conducted to quantify the association between PM2.5 and PM10 variables in the month when cases of CH were born or in the two preceding the months (lag0, lag1 and lag2) and monthly morbidity of people with CH across different populations.Results:A total of 480,633 newborns were screened for CH during 2014–2017 in Qingdao, and there were 268 cases of CH diagnosed. The count of days per month for which average concentrations of PM2.5 and PM10 exceed legal limits were positively associated with monthly CH morbidity at lag1 month among all the populations, and the adjusted relative risks (RRs) with exposure per 10 μg/m3 were close among different populations. However, the number of days per month of PM2.5 and PM10 concentrations exceeding limits were negatively associated with CH morbidity. Additionally, the RRs of CH increase with worsening air pollution.Conclusions:Concentrations of PM2.5 and PM10 exceeding the legal limits are significantly associated with CH in Qingdao. Moreover, it suggests that sudden and short-term particulate matter pollution events with high levels of particulates exceeding the legal limits may be related to risk of CH.

Spatiotemporal or temporal index to assess the association between temperature variability and mortality in China?

Epidemiological studies increasingly provide evidence about the adverse health effects of temperature variability (TV), which reflects short-term intra- and inter-day temperature change. However, calculation of TV only considers the temporal variability and lacks spatial variability. This study intends to investigate whether the lack of spatial variability in TV calculations has biased the health effect estimates. We collected daily data from the fine-gridded hourly temperatures and more than 2 million all-cause mortality counts in Zhejiang province in China from 2009 to 2015. A spatiotemporal TV index was developed by calculating the standard deviation of the hourly temperatures based on records from multiple sites. This new index could be compared to the two typical temporal TV indices that are calculated based on the hourly temperatures from one-site and area-average records. The three types of TV are compared using a three-stage analytical approach: district-specific time series Poisson regression, meta-analysis, and calculation of attributable mortality fraction. We observe that both spatiotemporal and temporal TVs produce very similar TV-mortality associations, attributable mortality fractions, and model fits at the district level. For example, the mortality increase associated for every increase of 1 °C during 0-7 exposure days is 1.53% (95% CI: 1.31, 1.73) in spatiotemporal TV, whereas it is 1.48% (95% CI: 1.27, 1.68) and 1.45% (95% CI: 1.24, 1.67) in the one-site and area-average temporal TV, respectively. Thus, time series models using temporal TV index are equally good at estimating the associations between TV and mortality as spatiotemporal TV at the district level in population-based epidemiological studies in China. Epidemiological studies using temperature from one site or the averages of multiple sites in TV calculation will not bias the effect estimates of TV. Our study could provide an important guidance method for future TV-related research in China and even in other countries.

The Effects of Publicized Suicide Deaths on Subsequent Suicide Counts in Israel

This study investigated associations between indiscriminate media reporting of suicides and later inflated suicide counts among Israel's general population between the years 2008 and 2012. Self-inflicted deaths that received post-suicide media exposure (referred to as “publicized suicides”) were selected via Google news search-hit appraisals. Distributions of suicides were inspected and risk ratios (RRs) estimated by comparing population suicide rates 4 weeks before and 4 weeks after each publicized suicide (“reference” vs. “affected” periods, respectively). Poisson time series regression was employed to account also for secular trends and seasonality. A total of 2,119 people died by suicide, 13 of whom received noticeable media attention throughout the study. No meaningful impact following the 13 deaths on subsequent suicide counts during the observation window (affected vs. reference phase) was found. Poisson regression confirmed that suicide counts following publicized suicides were independent of media coverage. Given the pronounced search hits following the publicized suicides developing regulation practices that constrain indiscreet media reporting should officially be included as part of suicide prevention practices. Future research should focus on imitation suicide effects as a function of post-suicide media exposure, while including both risk and protective factors.

Association between ambient air pollution and daily hospital admissions for ischemic stroke: A nationwide time-series analysis.

BackgroundEvidence of the short-term effects of ambient air pollution on the risk of ischemic stroke in low- and middle-income countries is limited and inconsistent. We aimed to examine the associations between air pollution and daily hospital admissions for ischemic stroke in China.Methods and findingsWe identified hospital admissions for ischemic stroke in 2014–2016 from the national database covering up to 0.28 billion people who received Urban Employee Basic Medical Insurance (UEBMI) in China. We examined the associations between air pollution and daily ischemic stroke admission using a two-stage method. Poisson time-series regression models were firstly fitted to estimate the effects of air pollution in each city. Random-effects meta-analyses were then conducted to combine the estimates. Meta-regression models were applied to explore potential effect modifiers. More than 2 million hospital admissions for ischemic stroke were identified in 172 cities in China. In single-pollutant models, increases of 10 μg/m3 in particulate matter with aerodynamic diameter <2.5 μm (PM2.5), sulfur dioxide (SO2), nitrogen dioxide (NO2), and ozone (O3) and 1 mg/m3 in carbon monoxide (CO) concentrations were associated with 0.34% (95% confidence interval [CI], 0.20%–0.48%), 1.37% (1.05%–1.70%), 1.82% (1.45%–2.19%), 0.01% (−0.14%–0.16%), and 3.24% (2.05%–4.43%) increases in hospital admissions for ischemic stroke on the same day, respectively. SO2 and NO2 associations remained significant in two-pollutant models, but not PM2.5 and CO associations. The effect estimates were greater in cities with lower air pollutant levels and higher air temperatures, as well as in elderly subgroups. The main limitation of the present study was the unavailability of data on individual exposure to ambient air pollution.ConclusionsAs the first national study in China to systematically examine the associations between short-term exposure to ambient air pollution and ischemic stroke, our findings indicate that transient increase in air pollution levels may increase the risk of ischemic stroke, which may have significant public health implications for the reduction of ischemic stroke burden in China.

The association between short-term ambient air pollution and daily outpatient visits for schizophrenia: A hospital-based study

Schizophrenia is a devastating neuropsychiatric disorder with increasing concern. Limited studies have been conducted to assess the relationship between short-term exposure to ambient air pollution and schizophrenia attacks. This study aimed to investigate the associations between short-term air pollution exposure and schizophrenia outpatient visits based on a time-series study performed in China. Daily data of schizophrenia outpatient admissions and air pollution from 1 October 2010 to 31 December 2013 were collected in Xi'an, a heavily-polluted city in China. We utilized a time-series Poisson regression model to examine the associations between short-term air pollution and schizophrenia outpatient visits with different lag days. A total of 34,865 outpatient-visits for schizophrenia were identified. A 10 μg/m3 increase of PM10, SO2, and NO2 concentrations corresponded to 0.289% (95% Cl: 0.118%, 0.460%), 1.374% (95% Cl: 0.723%, 2.025%), and 1.881% (95% Cl: 0.957%, 2.805%) elevation in outpatient-visits for schizophrenia at lag 0, and the associations appeared to be stronger, although not statistically significantly, in females and in middle and older age adults (40 and over). The most significant associations were observed on the concurrent day in different lag models. In conclusion, short-term exposure to ambient air pollution (PM10, SO2, and NO2) can be associated with increased risk of daily outpatient visits for schizophrenia, which may contribute to the further understanding of the potential adverse effects of air pollution in schizophrenia and other neuropsychiatric disorders.

Ambient Air Pollution and Cardiopulmonary Morbidity Outcomes in Columbia, South Carolina, 1999 to 2015

Background: Much is still to be learned about the health effects of multiple air pollutants. Methods: We estimate acute health effects for single and multiple pollutants on multiple cardiopulmonary-related morbidity outcomes using time-series Poisson regression in Columbia, South Carolina between 1999 and 2015. Health outcomes included emergency department (ED) visits for asthma and upper respiratory infection (URI) and hospital admissions (HA) for congestive heart failure (CHF) and ischemic heart disease (IHD). Pollutants included daily measures of 1-hr max nitrogen dioxide (NO2) in ppb, 1-hr max sulfur dioxide (SO2) in ppb, 8-hr max ozone (O3) in ppb, and 24-hr particulate matter &amp;#8804; 2.5 microns (PM2.5) in µg/m3. Multipollutant exposures were characterized using exposure categories defined by self-organizing maps based multipollutant day types (MDTs). Results: Single pollutant models found positive associations for 10-unit increases in PM2.5 (asthma, IHD), O3 (asthma, URI, CHF), SO2 (asthma), and NO2 (CHF, IHD), with the highest effects for asthma (RR: 1.014; 95%CI: 1.005-1.024). Multipollutant models found that, when compared to &amp;#8216;clean&amp;#8217; air days, there were associations between the occurrence of four different MDTs exhibiting increasing pollution and increasing risk for two outcomes - asthma and IHD. The joint effects largest in magnitude were between asthma ED visits and days (MDT [2, 2]) experiencing elevated levels for all pollutants (RR: 1.023; 95%CI: 1.005-1.041). Conclusion: Using our framework, we found significant joint effects between multipollutant day types and cardiopulmonary morbidity.

Projected Temperature-Related Years of Life Lost from Stroke Caused by Climate Change

Global warming has attracted worldwide attention. Numerous studies have indicated that stroke is associated with temperature; however, few studies are available on the projections of the burden of stroke attributable to future climate change. We aimed to investigate the future trends of stroke years of life lost (YLL) associated with global warming.We collected death records to examine YLL in Tianjin, China, from 2006 to 2011. We fitted a standard time-series Poisson regression model after controlling for trends, day of the week, relative humidity, and air pollution. We estimated temperature&amp;#8211;YLL associations with a distributed lag nonlinear model. These models were then applied to the local climate projections to estimate temperature-related YLL in the 2050s and 2070s. We projected temperature-related YLL from stroke in Tianjin under 19 global-scale climate models and 3 different greenhouse gas emission scenarios.The results showed a slight decrease in YLL with percent decreases of 0.85%, 0.97%, and 1.02% in the 2050s and 0.94%, 1.02%, and 0.91% in the 2070s for the 3 scenarios, respectively. The increases in heat-related annual YLL and the decreases in cold-related YLL under the high emission scenario were the strongest. The monthly analysis showed that the most significant increase occurred in the summer months.Future changes in climate are likely to lead to an increase in heat-related YLL, and this increase will not be offset by adaptation under both medium emission and high emission scenarios. Health protections from hot weather will become increasingly necessary, and measures to reduce cold effects will also remain important.

The potential impact of the demographic shift on the incidence of salmonellosis in seniors in Canada

Background: Salmonella infections remain an important public health issue in Canada and worldwide. Although the majority of Salmonella cases are self-limiting, some will lead to severe symptoms and occasionally invasive infections, especially in vulnerable populations. Among this group, seniors (those 60 years and over) are one sub-population that is expected to change significantly in the next decade, especially considering the Canadian population is experiencing a demographic shift toward an increase in seniors. This study was performed to predict temporal trends of Salmonella cases in seniors by 2028 and assess the possible impacts of a demographic shift on the national incidence. Methods & Materials: The number of reported Salmonella cases in seniors in eight provinces and territories (90% of the Canadian population) for a period of 15 years were analysed using a time-series Poisson regression model taking into account annual seasonal oscillation. Results: Between January 1999 and December 2013, an annual average of 842 Salmonella reported cases were recorded in seniors, resulting in a mean annual incidence rate of 15.45 cases per 100,000 persons. With the demographic changes predicted in the age-structure of the population and in the absence of any targeted interventions, our analysis showed the incidence of Salmonella cases in seniors could increase by 16% by 2028, representing an increase of almost 700 cases per year. As a result, the age distribution of salmonellosis in Canada is expected to increase in seniors from 15% of all reported cases (1999 to 2013) to 26% by 2028. Conclusion: Over the following decades, cases of infection, hospitalizations and deaths associated with Salmonella in seniors could represent a challenge to public health due to an increasing aging population. As higher hospitalization and death rates have been reported for seniors, this would have an enormous impact on the health care system in terms of capacity and expenditures. The economic burden of Salmonella is substantial and hospitalizations and deaths associated with severe infections account for much of this cost. As life expectancy increases in Canada, identification of unique risk factors and targeted prevention in seniors should be pursued to reduce the impact of the demographic shift on disease incidence.

Implementation of a multifaceted program to sustainably improve appropriate intraoperative antibiotic redosing

National guidelines recommend intraoperative redosing of prophylactic antibiotics at defined intervals to reduce the risk of surgical site infections. Compliance with these guidelines is poor. A quality improvement project-including education, progress reports, and automated redosing reminders in the anesthesia electronic health record-was implemented at a large university-affiliated hospital to increase rates of intraoperative antibiotic redosing for surgeries lasting more than 4 hours. A retrospective, observational study was then conducted. The primary outcome was the compliance rate with intraoperative antibiotic redosing criteria for all surgeries lasting more than 4 hours in the pre- and post-project period. The effect of the intervention was assessed by an interrupted time-series Poisson regression model. A total of 13,695 surgical procedures were evaluated. Time-series analysis demonstrated that the project was associated with significant improvement of compliance rates (incidence rate ratio [IRR]: 1.16; P = .002) with no significant change in underlying improvement trend (IRR: 1.00; P = .22). Few peer-reviewed manuscripts describe effective methods to ensure appropriate antibiotic redosing during prolonged surgeries. We demonstrated that a multipronged approach was very effective at producing immediate and sustained improvements in guideline compliance. Implementation of a multifaceted intervention improved rates of guideline-concordant redosing of intraoperative prophylactic antibiotics.

Impact of a Multidisciplinary Infection Prevention Initiative on Central Line and Urinary Catheter Utilization in a Long-term Acute Care Hospital.

BackgroundProlonged central line (CL) and urinary catheter (UC) use can increase risk of central line–associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI).MethodsThis interventional study conducted in a 76-bed long-term acute care hospital (LTACH) in Southeast Michigan was divided into 3 periods: pre-intervention (January 2015–June 2015), intervention (July–November 2015), and postintervention (December 2015–March 2017). During the intervention period, a multidisciplinary infection prevention team (MIPT) made weekly recommendations to remove unnecessary CL/UC or switch to alternate urinary/intravenous access. Device utilization ratios (DURs) and infection rates were compared between the study periods. Interrupted time series (ITS) and 0-inflated poisson (ZIP) regression were used to analyze DUR and CLABSI/CAUTI data, respectively.ResultsUC-DUR was 31% in the pre- and postintervention periods and 21% in the intervention period. CL-DUR decreased from 46% (pre-intervention) to 39% (intervention) to 37% (postintervention). The results of ITS analysis indicated nonsignificant decrease and increase in level/trend in DURs coinciding with our intervention. The CAUTI rate per catheter-days did not decrease during intervention (4.36) compared with pre- (2.49) and postintervention (1.93). The CLABSI rate per catheter-days decreased by 73% during intervention (0.39) compared with pre-intervention (1.45). Rates again quadrupled postintervention (1.58). ZIP analysis indicated a beneficial effect of intervention on infection rates without reaching statistical significance.ConclusionsWe demonstrated that a workable MIPT initiative focusing on removal of unnecessary CL and UC can be easily implemented in an LTACH requiring minimal time and resources. A rebound increase in UC-DURs to pre-intervention levels after intervention end indicates that continued vigilance is required to maintain performance.

Hot Weather Impacts on New York City Restaurant Food Safety Violations and Operations

Previous studies have shown that higher ambient air temperature is associated with increased incidence of gastrointestinal illnesses, possibly as a result of leaving potentially hazardous food in the temperature danger zone for too long. However, little is known about the effect of hot weather on restaurant practices to maintain safe food temperatures. We examined hot weather impacts on restaurant food safety violations and operations in New York City using quantitative and qualitative methods. We used data from 64,661 inspections conducted among 29,614 restaurants during May to September, 2011 to 2015. We used Poisson time-series regression to estimate the cumulative relative risk (CRR) of temperature-related food safety violations across a range of daily maximum temperature (13 to 40°C [56 to 104°F]) over a lag of 0 to 3 days. We present CRRs for an increase in daily maximum temperature from the median (28°C [82°F]) to the 95th percentile (34°C [93°F]) values. Maximum temperature increased the risk of violations for cold food holding above 5°C (41°F) (CRR, 1.19; 95% CI, 1.14, 1.25) and insufficient refrigerated or hot holding equipment (CRR, 2.37; 95% CI, 2.02, 2.79). We also conducted focus groups among restaurant owners and managers to aid interpretation of findings and identify challenges or knowledge gaps that prevent hot weather preparedness. Focus group participants cited refrigeration issues as a common problem during hot weather. Participants expressed the need for more guidance on hot weather and power outages to be delivered concisely. Our findings suggest that hotter temperatures may compromise cold and hot food holding, possibly by straining refrigeration or other equipment. The findings have public health implications because holding potentially hazardous foods in the temperature danger zone allows foodborne pathogens to proliferate and increases risk for foodborne illness. Distribution of simple guidelines that can be easily accessed during emergencies could help restaurants respond better.

Health Impacts of Citywide and Localized Power Outages in New York City.

Background:Previous studies investigated potential health effects of large-scale power outages, including the massive power failure that affected the northeastern United States and Ontario, Canada, in August 2003, and outages associated with major storms. However, information on localized outages is limited.Objective:The study sought to examine potential health impacts of citywide and localized outages in New York City (NYC).Methods:Along with the citywide 2003 outage, localized outages in July 1999 and July 2006 were identified. We additionally investigated localized, warm- and cold-weather outages that occurred in any of 66 NYC electric-grid networks during 2002–2014 using New York State Public Service Commission data. Mortality and hospitalizations were geocoded and linked to the networks. Associations were estimated using Poisson time-series regression, including examining distributed lags and adjusting for temperature and temporal trends. Network-specific estimates were pooled by season.Results:Respiratory disease hospitalizations were associated with the 2006 localized outage [cumulative relative risk [CRR] over 0–1 lag day, (95% confidence interval [CI]: 1.08, 4.74)] and the 2003 citywide outage, but not with other localized, warm-weather outages. Renal disease hospitalizations were associated with the 2003 citywide outage, and with localized, warm-weather outages, pooled across networks [RR at (95% CI: 1.00, 1.34)], but not the 2006 localized outage. All-cause mortality was positively associated with the 1999, 2003, and 2006 outages (significant for the 2003 outage only), but not with other localized, warm-weather outages. Localized, cold-weather outages were associated with all-cause mortality [ (95% CI: 1.01, 1.12)] and cardiovascular disease hospitalizations [ (95% CI: 1.03, 1.26)], and fewer respiratory disease hospitalizations [ (95% CI: 0.61, 0.97)].Conclusions:Localized outages may affect health. This information can inform preparedness efforts and underscores the public health importance of ensuring electric grid resiliency to climate change. https://doi.org/10.1289/EHP2154

Floods Increase the Risks of Hand-Foot-Mouth Disease in Qingdao, China, 2009-2013: A Quantitative Analysis.

We aimed to quantify the impact of few times floods on hand-foot-mouth disease (HFMD) in Qingdao during 2009-2013. The Spearman correlation test was applied to examine the lagged effects of floods on monthly morbidity of HFMD during study period in Qingdao. We further quantified the effects of 5 flood events on the morbidity of HFMD using the time-series Poisson regression controlling for climatic factors, seasonality, and lagged effects among different populations. A total of 55,920 cases of HFMD were reported in the study region over the study period. The relative risks of floods on the morbidity of HFMD among the total population, males, females, under 1-2 years old, and 3-5 years old were 1.178, 1.165, 1.198, 1.338, and 1.245, respectively. This study has, for the first time, provided the positive evidence of the impact of floods on HFMD. It demonstrates that floods can significantly increase the risk of HFMD during study period. Additionally, among the different populations, the risks were higher among children under 1-5 years old. (Disaster Med Public Health Preparedness. 2018;12:723-729).