%0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e67538 %T Environmental Impact of Physical Visits and Telemedicine in Nursing Care at Home: Comparative Life Cycle Assessment %A van Bree,Egid M %A Snijder,Lynn E %A Ossebaard,Hans C %A Brakema,Evelyn A %+ , Department of Public Health and Primary Care, Leiden University Medical Center, Albinusdreef 2, PO Box 9600, Leiden, 2300 RC, The Netherlands, 31 0715268444, egid_van_bree@live.nl %K carbon footprint %K eHealth %K telemedicine %K telehealth %K sustainable health care %K digital health care %K environmental impact %K environment %K physical visits %K telemedicine %K nursing %K life cycle assessment %K life cycle %K ecology %K sustainability %K footprint %K planetary health %D 2025 %7 4.4.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: The health care sector contributes notably to environmental harms, impacting human and ecosystem health. Hence, countries increasingly set ambitions to transition to environmentally sustainable health care, focusing on resource use, energy consumption, and patient travel. Telemedicine is often considered a promising solution to reduce travel-related carbon emissions. However, underlying environmental impact assessments lack important components such as staff travel and fail to adhere to standardized conduct and reporting. Moreover, assessments of telemedicine use in primary care are scarce. Objective: This study aims to quantify and compare the environmental impact of physical visits and telemedicine visits in the context of domiciliary care and home nursing. Methods: We conducted a life cycle assessment following international ISO-14040/44 standards of all resources required per individual patient visit, either in person at the patient’s home or via video calling with a dedicated user-friendly tablet. We collected anonymous user data in collaboration with a telemedicine service company, complemented by consulting staff members of four nursing organizations. Telemedicine visits were elementary in nature, such as supporting patients in taking their medication or structuring their daily agenda. We quantified average environmental impacts from cradle to grave, using the Environmental Footprint method, and verified the robustness of the comparison via uncertainty analysis. The variability of environmental impacts in different settings was explored using scenario analyses for the available minimum to maximum ranges. Results: Compared to a single physical visit in the studied setting, a telemedicine visit contributed less to global warming (0.1 vs 0.3 kg of carbon dioxide equivalents [kgCO2eq]; –60%), particulate matter formation (6.2 * 10–9 vs 1.8 * 10–8 disease incidence; –60%), and fossil resource use (1.8 vs 4.4 megajoules; –60%). Mineral/metal resource use was higher for telemedicine than for physical visits (1.1 * 10–5 vs 4.0 * 10–6 kg antimony equivalent; +180%). Only water use was not consistently different in the uncertainty analysis. Scenario analyses indicated that telemedicine’s environmental impact could become similar to physical visits only in urban settings (1-3 km of travel distance) with 50%-100% car commuting (0.1-0.4 vs 0.2-0.7 kgCO2eq). In rural settings (5-15 km of travel distance, 80%-100% car commute), physical visits’ environmental impact was higher (1.0-3.5 kgCO2eq), mostly even for mineral/metal resource use. Conclusions: Using telemedicine for domiciliary care and home nursing mostly reduces its environmental impact compared to physical visits. Benefits are larger in rural settings, where travel distances between patients are larger, and apply to multiple environmental impacts but not always to mineral/metal resource use. In urban settings, factors that influence the degree to which telemedicine is environmentally beneficial are whether staff are working from home versus at the office, commuting to the office by bicycle versus by car, and reusing video-calling devices. Accordingly, considerate application of telemedicine is important to support care for both human and planetary health. %M 40184167 %R 10.2196/67538 %U https://www.jmir.org/2025/1/e67538 %U https://doi.org/10.2196/67538 %U http://www.ncbi.nlm.nih.gov/pubmed/40184167 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 11 %N %P e55356 %T Data Parameters From Participatory Surveillance Systems in Human, Animal, and Environmental Health From Around the Globe: Descriptive Analysis %A McNeil,Carrie %A Divi,Nomita %A Bargeron IV,Charles Thomas %A Capobianco Dondona,Andrea %A Ernst,Kacey C %A Gupta,Angela S %A Fasominu,Olukayode %A Keatts,Lucy %A Kelly,Terra %A Leal Neto,Onicio B %A Lwin,May O %A Makhasi,Mvuyo %A Mutagahywa,Eric Beda %A Montecino-Latorre,Diego %A Olson,Sarah %A Pandit,Pranav S %A Paolotti,Daniela %A Parker,Matt C %A Samad,Muhammad Haiman %A Sewalk,Kara %A Sheldenkar,Anita %A Srikitjakarn,Lertrak %A Suy Lan,Channé %A Wilkes,Michael %A Yano,Terdsak %A Smolinski,Mark %+ Ending Pandemics, 870 Market Street, Suite 528, San Francisco, CA, 94102, United States, 1 9169522185, carrie.s.mcneil@gmail.com %K participatory surveillance %K One Health %K citizen science %K community-based surveillance %K digital disease detection %K environmental health %K wildlife health %K livestock health %K human health %K data standards %D 2025 %7 26.3.2025 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Emerging pathogens and zoonotic spillover highlight the need for One Health surveillance to detect outbreaks as early as possible. Participatory surveillance empowers communities to collect data at the source on the health of animals, people, and the environment. Technological advances increase the use and scope of these systems. This initiative sought to collate information from active participatory surveillance systems to better understand parameters collected across the One Health spectrum. Objective: This study aims to develop a compendium of One Health data parameters by examining participatory surveillance systems active in 2023. The expected outcomes of the compendium were to pinpoint specific parameters related to human, animal, and environmental health collected globally by participatory surveillance systems and to detail how each parameter is collected. The compendium was designed to help understand which parameters are currently collected and serve as a reference for future systems and for data standardization initiatives. Methods: Contacts associated with the 60 systems identified through the One Health Participatory Surveillance System Map were invited by email to provide specific data parameters, methodologies used for data collection, and parameter-specific considerations. Information was received from 38 (63%) active systems. Data were compiled into a searchable spreadsheet-based compendium organized into 5 sections: general, livestock, wildlife, environmental, and human parameters. An advisory group comprising experts in One Health participatory surveillance reviewed the collected parameters, refined the compendium structure, and contributed to the descriptive analysis. Results: A comprehensive compendium of data parameters from a diverse array of single-sector and multisector participatory surveillance systems was collated and reviewed. The compendium includes parameters from 38 systems used in Africa (n=3, 8%), Asia (n=9, 24%), Europe (n=12, 32%), Australia (n=3, 8%), and the Americas (n=12, 32%). Almost one-third of the systems (n=11, 29%) collect data across multiple sectors. Many (n=17, 45%) focus solely on human health. Variations in data collection techniques were observed for commonly used parameters, such as demographics and clinical signs or symptoms. Most human health systems collected parameters from a cohort of users tracking their own health over time, whereas many wildlife and environmental systems incorporated event-based parameters. Conclusions: Several participatory surveillance systems have already adopted a One Health approach, enhancing traditional surveillance by identifying shared health threats among animals, people, and the environment. The compendium reveals substantial variation in how parameters are collected, underscoring the need for further work in system interoperability and data standards to allow for timely data sharing across systems during outbreaks. Parameters collated from across the One Health spectrum represent a valuable resource for informing the development of future systems and identifying opportunities to expand existing systems for multisector surveillance. %M 40138683 %R 10.2196/55356 %U https://publichealth.jmir.org/2025/1/e55356 %U https://doi.org/10.2196/55356 %U http://www.ncbi.nlm.nih.gov/pubmed/40138683 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 14 %N %P e67128 %T Exploring Climate Change’s Impact on the Cardiopulmonary Health of Adults Living in the Canton of Valais, Switzerland: Protocol for a Development and Usability Pilot Study %A Portela Dos Santos,Omar %A Alves,Paulo Jorge Pereira %A Verloo,Henk %+ Department of Nursing Sciences, School of Health Sciences, HES-SO Valais/Wallis, Chemin de l'Agasse 5, Sion, 1950, Switzerland, 41 786680125, omar.porteladossantos@hevs.ch %K climate change %K global warming %K emergency department %K emergency nursing %K sustainable care %K ecological medicine %K cardiopulmonary %K cardio health %K Valais %K Switzerland %K pilot study %K study protocol %K humanity %K air pollution %K impact %K comorbidities %K adults %K mixed methods design %K feasibility %K health promotion %K disease prevention %K acceptability %D 2025 %7 25.3.2025 %9 Protocol %J JMIR Res Protoc %G English %X Background: Climate change is affecting public health and well-being. In 2016, Swiss emergency departments (EDs) treated 1,722,000 cases, with 4718 daily admissions. In 2023, the ED of Sion Regional Hospital recorded 75,000 consultations. The links between climate change and health are complex, necessitating urgent research on its impact on cardiopulmonary health in Valais, Switzerland. Raising awareness among frontline professionals is crucial for developing health promotion and disease prevention strategies. Objective: This study explores the preliminary effects of climate change on cardiopulmonary health in Valais and assesses adult patients’ knowledge of its health consequences. Findings will inform adaptations in patient care, health promotion, and disease prevention at Sion Hospital’s ED. The feasibility of patient selection and data collection will also be evaluated. Methods: Using a convergent, parallel, mixed methods design, data will be collected from September 21, 2024, to September 20, 2025, with a target sample of 60 patients. The quantitative phase will examine patient recruitment feasibility, consultation reasons, and triage levels, correlating them with climate variables (temperature, nitrogen dioxide, particulate matter, sulfur dioxide, and ozone). It will also analyze sociodemographic profiles. The qualitative phase will explore patients’ knowledge of climate change and its potential links to their ED visits. The feasibility and acceptability of the study process will be assessed. The protocol follows the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) Extension for Pilot and Feasibility Trials. Results: Data collection started on September 21, 2024, following the approval by the ethical commission. Data collection will take place over 1 year, until September 20, 2025. Conclusions: This study will test the feasibility of a larger investigation and examine potential associations between Valais’ changing microclimate and population health. Findings will establish patient profiles and explore their perceptions and knowledge of climate change, informing future health interventions. International Registered Report Identifier (IRRID): DERR1-10.2196/67128 %M 40132196 %R 10.2196/67128 %U https://www.researchprotocols.org/2025/1/e67128 %U https://doi.org/10.2196/67128 %U http://www.ncbi.nlm.nih.gov/pubmed/40132196 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 14 %N %P e65576 %T Estimating the Burden of Common Mental Disorders Attributable to Lifestyle Factors: Protocol for the Global Burden of Disease Lifestyle and Mental Disorder (GLAD) Project %A Ashtree,Deborah N %A Orr,Rebecca %A Lane,Melissa M %A Akbaraly,Tasnime N %A Bonaccio,Marialaura %A Costanzo,Simona %A Gialluisi,Alessandro %A Grosso,Giuseppe %A Lassale,Camille %A Martini,Daniela %A Monasta,Lorenzo %A Santomauro,Damian %A Stanaway,Jeffrey %A Jacka,Felice N %A O'Neil,Adrienne %+ IMPACT (the Institute for Mental and Physical Health and Clinical Translation), Food & Mood Centre, School of Medicine, Barwon Health, Deakin University, Level 2, Health Education & Research Building (HERB), Barwon Health Rear, Kitchener House, 299 Ryrie St, Geelong, 3220, Australia, 61 352278361, debbie.ashtree@deakin.edu.au %K mental health %K depression %K anxiety %K diet %K lifestyle %K mental disorders %K epidemiology %K burden of disease %D 2025 %7 14.3.2025 %9 Protocol %J JMIR Res Protoc %G English %X Background: The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) collects and calculates risk-outcome data for modifiable lifestyle exposures (eg, dietary intake) and physical health outcomes (eg, cancers). These estimates form a critical digital resource tool, the GBD VizHub data visualization tool, for governments and policy makers to guide local, regional, and global health decisions. Despite evidence showing the contributions of lifestyle exposures to common mental disorders (CMDs), such as depression and anxiety, GBD does not currently generate these lifestyle exposure-mental disorder outcome pairings. This gap is due to a lack of uniformly collected and analyzed data about these exposures as they relate to CMDs. Such data are required to quantify whether, and to what degree, the global burden of CMDs could be reduced by targeting lifestyle factors at regional and global levels. We have established the Global burden of disease Lifestyle And mental Disorder (GLAD) Taskforce to address this gap. Objective: This study aims to generate the necessary estimates to afford the inclusion of lifestyle exposures as risk factors for CMDs in the GBD study and the GBD digital visualization tools, initially focusing on the relationship between dietary intake and CMDs. Methods: The GLAD project is a multicenter, collaborative effort to integrate lifestyle exposures as risk factors for CMDs in the GBD study. To achieve this aim, global epidemiological studies will be recruited to conduct harmonized data analyses estimating the risk, odds, or hazards of lifestyle exposures with CMD outcomes. Initially, these models will focus on the relationship between dietary intake, as defined by the GBD, and anxiety and depression. Results: As of August 2024, 18 longitudinal cohort studies from 9 countries (Australia: n=4; Brazil: n=1; France: n=1; Italy: n=3; The Netherlands: n=3; New Zealand: n=1; South Africa: n=1; Spain: n=1; and United Kingdom: n=3) have agreed to participate in the GLAD project. Conclusions: Our comprehensive, collaborative approach allows for the concurrent execution of a harmonized statistical analysis protocol across multiple, internationally renowned epidemiological cohorts. These results will be used to inform the GBD study and incorporate lifestyle risk factors for CMD in the GBD digital platform. Consequently, given the worldwide influence of the GBD study, findings from the GLAD project can offer valuable insights to policy makers worldwide around lifestyle-based mental health care. International Registered Report Identifier (IRRID): DERR1-10.2196/65576 %M 40085831 %R 10.2196/65576 %U https://www.researchprotocols.org/2025/1/e65576 %U https://doi.org/10.2196/65576 %U http://www.ncbi.nlm.nih.gov/pubmed/40085831 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 12 %N %P e64111 %T Screening Workers for Occupational Exposure to Respirable Crystalline Silica: Development and Usability of an Electronic Data Capture Tool %A Hore-Lacy,Fiona %A Dimitriadis,Christina %A Hoy,Ryan F %A Jimenez-Martin,Javier %A Sim,Malcolm R %A Fisher,Jane %A Glass,Deborah C %A Walker-Bone,Karen %K silicosis %K occupational history %K electronic data capture tool (EDCT) %K REDCap %K occupational respiratory screening %K occupational hazard %K exposure %K silica %K fibrotic lung disease %K lung disease %K respirable crystalline silica %K mining %K construction %K workers %K occupational lung disease %K occupational %K Australia %K screening %D 2025 %7 24.2.2025 %9 %J JMIR Hum Factors %G English %X Background: Cases of the occupational lung disease silicosis have been identified in workers processing artificial stone in the stone benchtop industry (SBI). In the Australian state of Victoria, the Regulator commissioned a screening program for all workers in this industry. Objective: To facilitate systematic data collection, including high-quality exposure assessment, an electronic data capture tool (EDCT) was developed. Methods: A multidisciplinary team developed an EDCT using Research Electronic Data Capture (REDCap; Vanderbilt University). The needs of the EDCT were (1) data entry by multiple clinicians and the workers attending for screening and (2) systematic collection of data for clinical and research purposes. The comprehensibility and utility of the tool were investigated with a sample of workers, and the EDCT was subsequently refined. Results: The EDCT was used in clinical practice, with capacity for data extraction for research. Testing of comprehension and utility was undertaken with 15 workers, and the refined version of the Occupational Silica Exposure Assessment Tool (OSEAT) was subsequently developed. Conclusions: The refined OSEAT has been determined to be comprehensible to workers and capable of collecting exposure data suitable for assessment of risk of silicosis. It was developed for workers in the SBI in Australia and is adaptable, including translation into other languages. It can also be modified for SBI workers in other countries and for use by workers from other industries (mining, construction) at risk of silica exposure, including in lower-income settings. %R 10.2196/64111 %U https://humanfactors.jmir.org/2025/1/e64111 %U https://doi.org/10.2196/64111 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 11 %N %P e62861 %T Long-Term Exposure to Fine Particulate Matter (PM2.5) Components and Precocious Puberty Among School-Aged Children: Cross-Sectional Study %A Zhou,Xuelian %A Zhang,Xiaochi %A Bai,Guannan %A Dong,Guanping %A Li,Xinyi %A Chen,Ruimin %A Chen,Shaoke %A Zheng,Rongxiu %A Wang,Chunlin %A Wei,Haiyan %A Cao,Bingyan %A Liang,Yan %A Yao,Hui %A Su,Zhe %A Maimaiti,Mireguli %A Luo,Feihong %A Li,Pin %A Zhu,Min %A Du,Hongwei %A Yang,Yu %A Cui,Lanwei %A Wang,Jinling %A Yuan,Jinna %A Liu,Zhuang %A Wu,Wei %A Zhao,Qi %A Fu,Junfen %K fine particulate matter %K PM2.5 %K PM2.5 components %K air pollution %K precocious puberty %K children %K long-term exposure %D 2025 %7 7.2.2025 %9 %J JMIR Public Health Surveill %G English %X Background: The increasing incidence of precocious puberty is a major health challenge for Chinese children, while related risk factors remain less well explored. Exposure to ambient fine particulate matter (PM2.5) is a leading environmental hazard in China. Although certain components of PM2.5 have been reported to be endocrine disruptors for sex hormones, population-based evidence is still lacking on the association between PM2.5 exposure and precocious puberty in China. Objective: Based on a cross-sectional survey covering 30 cities in 2017 to 2019, this study was designed to explore the association between long-term exposure to PM2.5 and its 5 major components with precocious puberty in China and to check the potential modifying effects of family-related and personal factors. Methods: We included 34,105 children aged 6 to 9 years. We collected the 5-year average concentrations of PM2.5 and its 5 major components (sulfate, nitrate, ammonium, organic matter, and black carbon) in the area (at a spatial resolution of 0.1° × 0.1°) where each school was located. We used mixed effect logistic regression to estimate the effect sizes of the total mass of PM2.5 and each of its components on precocious puberty, and we examined the modifying effects of family-related and personal factors using an additional interactive term. A weighted quantile sum (WQS) regression model was applied to identify the weights of each component in explaining the effect size of the total mass of PM2.5. Results: We found that the odds ratio (OR) for precocious puberty per IQR increase in the concentration of total PM2.5 mass was 1.27 (95% CI 0.92-1.75) for the whole population, 2.12 (95% CI 1.27-3.55) for girls, and 0.90 (95% CI 0.62-1.30) for boys. Similarly, the effect sizes of the 5 major components were all substantial for girls but minimal for boys. Results of the WQS analysis showed that organic matter could explain the highest proportion of the effect of PM2.5, with the weight of its contribution being 0.71. Modification effects of family income and dietary habits were only observed in certain population subgroups. Conclusions: Long-term exposure to total PM2.5 mass was significantly associated with precocious puberty in girls, with organic matter identified as the major effect contributor. The results add evidence on the detrimental effects of PM2.5 on children’s development and growth. %R 10.2196/62861 %U https://publichealth.jmir.org/2025/1/e62861 %U https://doi.org/10.2196/62861 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 11 %N %P e67145 %T Ethical Considerations for Wastewater Surveillance Conducted by the US Department of Defense %A Smith,Hunter Jackson %A Agans,Richard T %A Kowallis,William J %K wastewater %K surveillance %K ethics %K military %K Department of Defense %D 2025 %7 6.2.2025 %9 %J JMIR Public Health Surveill %G English %X The US Department of Defense (DoD) is establishing its wastewater surveillance capacities to support national security objectives and promote the public health and medical readiness of US service members. Wastewater surveillance is an emerging technology that has traditionally been leveraged for detecting infectious diseases. However, its potential future applications could yield a vast and unpredictable amount of information that could be used for a wide variety of both health- and nonhealth-related purposes. The US military also serves an inimitable role for the country and its citizens, and exercises significant levels of control over its service members compared to civilian organizations. Further, its present and potential wastewater surveillance activities may reach far beyond just military installations. These factors raise unique ethical considerations that must be accounted for by leaders and policymakers to ensure the DoD implements a wastewater surveillance network in a manner that is both impactful in supporting public health and appropriate to the scope and population under surveillance. This paper explores important ethical features in conducting wastewater surveillance that are both specific to the DoD experience and applicable to wider public health initiatives. %R 10.2196/67145 %U https://publichealth.jmir.org/2025/1/e67145 %U https://doi.org/10.2196/67145 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e63217 %T Resilience Informatics in Public Health: Qualitative Analysis of Conference Proceedings %A Block Ngaybe,Maiya G %A Azurdia Sierra,Lidia %A McNair,Andrew %A Gonzalez,Myla %A Arora,Mona %A Ernst,Kacey %A Noriega-Atala,Enrique %A Iyengar,M Sriram %+ College of Medicine - Phoenix, University of Arizona, 475 N 5th St, Phoenix, AZ, 85004, United States, 1 281 793 4733, msiyengar@arizona.edu %K resilience %K public health %K informatics %K mobile phone %K artificial intelligence %K AI %D 2025 %7 16.1.2025 %9 Original Paper %J JMIR Form Res %G English %X Background: In recent years, public health has confronted 2 formidable challenges: the devastating COVID-19 pandemic and the enduring threat of climate change. The convergence of these crises underscores the urgent need for resilient solutions. Resilience informatics (RI), an emerging discipline at the intersection of informatics and public health, leverages real-time data integration from health systems, environmental monitoring, and technological tools to develop adaptive responses to multifaceted crises. It offers promising avenues for mitigating and adapting to these challenges by proactively identifying vulnerabilities and fostering adaptive capacity in public health systems. Addressing critical questions regarding target audiences, privacy concerns, and scalability is paramount to fostering resilience in the face of evolving health threats. Objective: The University of Arizona held a workshop, titled Resilience Informatics in Public Health, in November 2023 to serve as a pivotal forum for advancing these discussions and catalyzing collaborative efforts within the field. This paper aims to present a qualitative thematic analysis of the findings from this workshop. Methods: A purposive sampling strategy was used to invite 40 experts by email from diverse fields, including public health, medicine, weather services, informatics, environmental science, and resilience, to participate in the workshop. The event featured presentations from key experts, followed by group discussions facilitated by experts. The attendees engaged in collaborative reflection and discussion on predetermined questions. Discussions were systematically recorded by University of Arizona students, and qualitative analysis was conducted. A detailed thematic analysis was performed using an inductive approach, supported by MAXQDA software to manage and organize data. Two independent researchers coded the transcripts; discrepancies in coding were resolved through consensus, ensuring a rigorous synthesis of the findings. Results: The workshop hosted 27 experts at the University of Arizona, 21 (78%) of whom were from public health–related fields. Of these 27 experts, 8 (30%) were from the field of resilience. In addition, participants from governmental agencies, American Indian groups, weather services, and a mobile health organization attended. Qualitative analysis identified major themes, including the potential of RI tools, threats to resilience (eg, health care access, infrastructure, and climate change), challenges with RI tools (eg, usability, funding, and real-time response), and standards for RI tools (eg, technological, logistical, and sociological). The attendees emphasized the importance of equitable access, community engagement, and iterative development in RI projects. Conclusions: The RI workshop emphasized the necessity for accessible, user-friendly tools bridging technical knowledge and community needs. The workshop’s conclusions provide a road map for future public health resilience, highlighting the need for scalable, culturally sensitive, community-driven interventions. Future directions include focused discussions to yield concrete outputs such as implementation guidelines and tool designs, reshaping public health strategies in the face of emerging threats. %M 39819984 %R 10.2196/63217 %U https://formative.jmir.org/2025/1/e63217 %U https://doi.org/10.2196/63217 %U http://www.ncbi.nlm.nih.gov/pubmed/39819984 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 11 %N %P e58862 %T Wastewater Monitoring During the COVID-19 Pandemic in the Veneto Region, Italy: Longitudinal Observational Study %A Ocagli,Honoria %A Zambito,Marco %A Da Re,Filippo %A Groppi,Vanessa %A Zampini,Marco %A Terrini,Alessia %A Rigoli,Franco %A Amoruso,Irene %A Baldovin,Tatjana %A Baldo,Vincenzo %A Russo,Francesca %A Gregori,Dario %K wastewater-based epidemiology %K SARS-CoV-2 %K COVID-19 %K CUSUM %K WBE %K cumulative sum chart %D 2025 %7 14.1.2025 %9 %J JMIR Public Health Surveill %G English %X Background: As the COVID-19 pandemic has affected populations around the world, there has been substantial interest in wastewater-based epidemiology (WBE) as a tool to monitor the spread of SARS-CoV-2. This study investigates the use of WBE to anticipate COVID-19 trends by analyzing the correlation between viral RNA concentrations in wastewater and reported COVID-19 cases in the Veneto region of Italy. Objective: We aimed to evaluate the effectiveness of the cumulative sum (CUSUM) control chart method in detecting changes in SARS-CoV-2 concentrations in wastewater and its potential as an early warning system for COVID-19 outbreaks. Additionally, we aimed to validate these findings over different time periods to ensure robustness. Methods: This study analyzed the temporal correlation between SARS-CoV-2 RNA concentrations in wastewater and COVID-19 clinical outcomes, including confirmed cases, hospitalizations, and intensive care unit (ICU) admissions, from October 2021 to August 2022 in the Veneto region, Italy. Wastewater samples were collected weekly from 10 wastewater treatment plants and analyzed using a reverse transcription–quantitative polymerase chain reaction. The CUSUM method was used to detect significant shifts in the data, with an initial analysis conducted from October 2021 to February 2022, followed by validation in a second period from February 2022 to August 2022. Results: The study found that peaks in SARS-CoV-2 RNA concentrations in wastewater consistently preceded peaks in reported COVID-19 cases by 5.2 days. Hospitalizations followed with a delay of 4.25 days, while ICU admissions exhibited a lead time of approximately 6 days. Notably, certain health care districts exhibited stronger correlations, with notable values in wastewater anticipating ICU admissions by an average of 13.5 and 9.5 days in 2 specific districts. The CUSUM charts effectively identified early changes in viral load, indicating potential outbreaks before clinical cases increased. Validation during the second period confirmed the consistency of these findings, reinforcing the robustness of the CUSUM method in this context. Conclusions: WBE, combined with the CUSUM method, offers valuable insight into the level of COVID-19 outbreaks in a community, including asymptomatic cases, thus acting as a precious early warning tool for infectious disease outbreaks with pandemic potential. %R 10.2196/58862 %U https://publichealth.jmir.org/2025/1/e58862 %U https://doi.org/10.2196/58862 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 11 %N %P e64564 %T Identifying Community-Built Environment’s Effect on Physical Activity and Depressive Symptoms Trajectories Among Middle-aged and Older Adults: Chinese National Longitudinal Study %A Zhang,Kaili %A Huang,Bowen %A Divigalpitiya,Prasanna %+ , Zigong Academy of Urban Planning and Design, Number 19, Donghuan Road, Bancang Street, High-Tech Zone, Zigong, Sichuan Province, 643031, China, 86 15882073304, jpby5223248@gmail.com %K community-built environment %K physical activity %K depressive symptom trajectories %K middle-aged and older adults %K latent growth curve modeling %K longitudinal study %D 2025 %7 13.1.2025 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: The effects of physical activity (PA) across different domains and intensities on depressive symptoms remain inconclusive. Incorporating the community-built environment (CBE) into longitudinal analyses of PA’s impact on depressive symptoms is crucial. Objective: This study aims to examine the effects of PA at different intensities—low-intensity PA (eg, walking activities) and moderate-to-vigorous-intensity PA (eg, activities requiring substantial effort and causing faster breathing or shortness of breath)—across leisure-time and occupational domains on depressive symptom trajectories among middle-aged and older adults. Additionally, it investigated how CBEs influence depressive symptoms and PA trajectories. Methods: This longitudinal study included 6865 middle-aged and older adults from the China Health and Retirement Longitudinal Survey. A CBE variable system was developed using a community questionnaire to assess attributes of the physical built environment. Depressive symptoms were measured using the Center for Epidemiologic Studies Depression Scale. Latent growth curve modeling was applied to analyze 3 waves of the cohort data (2015, 2018, and 2020) to explore the differential effects of PA on depressive symptoms and the role of the CBE. Results: In the 2015 and 2018 waves, higher low-intensity leisure-time physical activity (LTPA) was associated with lower depressive symptoms (β=–.025, P=.01 and β=–.027, P=.005, respectively). Across all waves, moderate-to-vigorous-intensity LTPA showed no significant predictive effects (P=.21 in 2015, P=.57 in 2018, and P=.85 in 2020, respectively). However, higher occupational physical activity (OPA), particularly at moderate-to-vigorous intensities, was consistently associated with higher depressive symptoms. Parallel process latent growth curve modeling revealed that the initial level of total LTPA negatively predicted the initial level of depressive symptoms (β=–.076, P=.01). OPA exhibited dual effects, positively predicting the initial level of depressive symptoms (β=.108, P<.001) but negatively predicting their upward trajectory (β=–.136, P=.009). Among CBE variables, better infrastructure conditions (β=–.082, P<.001) and greater accessibility to public facilities (β=–.036, P=.045) negatively predicted the initial level of depressive symptoms. However, greater accessibility to public facilities positively predicted the upward trajectory of depressive symptoms (β=.083, P=.04). Better infrastructure conditions (β=.100, P=.002) and greater accessibility to public transport (β=.060, P=.01) positively predicted the initial level of total LTPA. Meanwhile, better infrastructure conditions (β=–.281, P<.001) and greater accessibility to public facilities (β=–.073, P<.001) negatively predicted the initial level of total OPA. Better infrastructure conditions positively predicted the declining trajectory of total OPA (β=.100, P=.004). Conclusions: This study underscores the importance of considering the differential effects of PA across domains and intensities on depressive symptoms in public policies and guidelines. Given the influence of the environment on PA and depressive symptoms, targeted community measures should be implemented. %M 39804686 %R 10.2196/64564 %U https://publichealth.jmir.org/2025/1/e64564 %U https://doi.org/10.2196/64564 %U http://www.ncbi.nlm.nih.gov/pubmed/39804686 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 10 %N %P e57495 %T Elevated Ambient Temperature Associated With Reduced Infectious Disease Test Positivity Rates: Retrospective Observational Analysis of Statewide COVID-19 Testing and Weather Across California Counties %A Kwok,Nicholas Wing-Ping %A Pevnick,Joshua %A Feldman,Keith %K body temperature %K BT %K fever %K febrile %K feverish %K ambient temperature %K environmental factor %K environmental context %K environmental %K environment %K COVID-19 %K SARS-CoV-2 %K coronavirus %K respiratory %K infectious %K pulmonary %K COVID-19 pandemic %K pandemic %K diagnostics %K diagnostic test %K diagnostic testing %K public health surveillance %D 2024 %7 12.12.2024 %9 %J JMIR Public Health Surveill %G English %X Background: From medication usage to the time of day, a number of external factors are known to alter human body temperature (BT), even in the absence of underlying pathology. In select cases, clinical guidance already suggests the consideration of clinical and demographic factors when interpreting BT, such as a decreased threshold for fever as age increases. Recent work has indicated factors impacting BT extend to environmental conditions including ambient temperature. However, the effect sizes of these relationships are often small, and it remains unclear if such relationships result in a meaningful impact on real-world health care practices. Objective: Temperature remains a common element in public health screening efforts. Leveraging the unique testing and reporting infrastructure developed around the COVID-19 pandemic, this paper uses a unique resource of daily-level statewide testing data to assess the relationship between ambient temperatures and positivity rates. As fever was a primary symptom that triggered diagnostic testing for COVID-19, this work hypothesizes that environmentally mediated BT increases would not reflect pathology, leading to decreased COVID-19 test positivity rates as temperature rises. Methods: Statewide COVID-19 polymerase chain reaction testing data curated by the California Department of Public Health were used to obtain the daily number of total tests and positivity rates for all counties across the state. These data were combined with ambient temperature data provided by the National Centers for Environmental Information for a period of 133 days between widespread testing availability and vaccine approval. A mixed-effects beta-regression model was used to estimate daily COVID-19 test positivity rate as a function of ambient temperature, population, and estimates of COVID prevalence, with nested random effects for a day of the week within unique counties across the state. Results: Considering over 19 million tests performed over 4 months and across 45 distinct counties, adjusted model results highlighted a significant negative association between daily ambient temperature and testing positivity rate (P<.001). Results of the model are strengthened as, using the same testing data, this relationship was not present in a sensitivity analysis using random daily temperatures drawn from the range of observed values (P=.52). Conclusions: These results support the underlying hypothesis and demonstrate the relationship between environmental factors and BT can impact an essential public health activity. As health care continues to operate using thresholds of BT as anchor points (ie, ≥100.4 as fever) it is increasingly important to develop approaches to integrate the array of factors known to influence BT measurement. Moreover, as weather data are not often readily available in the same systems as patient data, these findings present a compelling case for future research into when and how environmental context can best be used to improve the interpretation of patient data. %R 10.2196/57495 %U https://publichealth.jmir.org/2024/1/e57495 %U https://doi.org/10.2196/57495 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e60289 %T Understanding the Occurrence and Fate of Atmospheric Microplastics and Their Potential Risks to Human Health: Protocol for a Cross-Sectional Analysis %A Hasan,Shaikh Sharif %A Salam,Abdus %A Moniruzzaman,Mohammad %A Bari,Md Aynul %A Aich,Nirupam %A Jahan,Farjana %A Rahman,Mahbubur %A Islam,Zubayer %A Kabir,Md Humayun %A Shaikh,Md Aftab Ali %A Raqib,Rubhana %A Parvez,Sarker Masud %+ Children’s Health and Environment Program, Child Health Research Centre, The University of Queensland, St Lucia, Brisbane Queensland 4072, Brisbane, 4072, Australia, 61 480365175, s.parvez@uq.edu.au %K plastic exposure %K microplastic %K bisphenol %K phthalate %K heavy metals %K health consequences %K potential risk %K cross-sectional analysis %K pollution %K nanoplastics %K additives %K plastic additives %K health consequence %K exposure %K human exposure %K plastic recycling %K recycling activities %D 2024 %7 29.11.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Plastic pollution has reached an alarming magnitude, defining the contemporary era as the “Plastic Age.” Uncontrolled plastic production and inadequate recycling processes have led to widespread contamination of the environment with micro and nanoplastics. Objective: The study aims to assess the environmental and human health consequences of exposure to microplastic particles (MPs) and their additives among plastic recycling workers in Dhaka. Specifically, it focuses on mapping the management pathways of plastic waste from collection to disposal, analyzing the types of MPs in the environment, and assessing the potential health impacts on plastic recycling workers. Methods: A cross-sectional exploratory study design was used, consisting of exposed and nonexposed groups in plastic recycling sites in Dhaka, Bangladesh. The study will establish possible associations between different health consequences and microplastic particle exposure with a systematic approach involving plastic recycling hot spot detection, management pathway mapping, and detecting the presence of environmental MP. MPs and heavy metals will be detected from environmental samples using fluorescence microscopy, Fourier-transform infrared spectroscopy, and inductively coupled plasma mass spectrometry. Human exposure will be assessed by detecting the metabolites of bisphenol and phthalates from urine samples using liquid chromatography–tandem mass spectrometry and thoroughly evaluating endocrine, reproductive, respiratory, and renal functions. The sample size was derived from the mean concentrations of urinary bisphenol and phthalates metabolites, requiring the participation of 168 respondents. A 1:1 exposure to nonexposed stratification would be sufficient to meet our study objectives, considering the conventional level of power and confidence interval. This study protocol (PR#22111) has received approval from the Research Review Committee and Ethical Review Committee of the icddr,b. Results: The project was funded in August 2022. We started collecting environmental samples in January 2023 and completed participant enrollment, exposure survey, and biological sample collection by December 2023. We enrolled 84 adult plastic recycling workers with at least 5 years of exposure history and 84 nonexposed participants who were not involved with plastic recycling activities. Data analysis is currently underway, and the first results are expected to be submitted for publication in November 2024. Conclusions: The findings would provide valuable insights into the adverse impacts of microplastic pollution on both the environment and human health, aiding in better understanding the extent of the issue. International Registered Report Identifier (IRRID): DERR1-10.2196/60289 %M 39612491 %R 10.2196/60289 %U https://www.researchprotocols.org/2024/1/e60289 %U https://doi.org/10.2196/60289 %U http://www.ncbi.nlm.nih.gov/pubmed/39612491 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 10 %N %P e53673 %T The Association Between Solid Fuel Use and Lower Urinary Tract Symptoms Suggestive of Benign Prostatic Hyperplasia in Sichuan, China: Cross-Sectional Study %A Yuan,Qiming %A Zhou,Xianghong %A Ma,Li %A Cai,Boyu %A Zhang,Zilong %A Deng,Linghui %A Hu,Dan %A Jiang,Zhongyuan %A Wang,Mingda %A Wei,Qiang %A Qiu,Shi %K benign prostatic hyperplasia %K lower urinary tract symptoms %K solid fuel %K household air pollution %K China %K male %K cohort study %K prostate %K aging %K smoking %K alcohol %D 2024 %7 31.10.2024 %9 %J JMIR Public Health Surveill %G English %X Background: Benign prostatic hyperplasia (BPH) is a global age-related disease. It has been reported that over half of the Chinese male population aged 70 years or older are experiencing BPH. Solid fuel, which is the major source of household air pollution, has been reportedly associated with several adverse events, including sex hormone disorders. Due to the certain relationship between sex hormone levels and prostate disease, the relationship between solid fuel use and lower urinary tract symptoms (LUTSs) suggestive of BPH (LUTS/BPH) deserves further exploration. Objective: This study mainly aimed to investigate the association between solid fuel use and LUTS/BPH. Methods: The data used in this study were obtained from the West China Natural Population Cohort Study. Household energy sources were assessed using questionnaires. LUTS/BPH was evaluated based on participant self-reports. We performed propensity score matching (PSM) to reduce the influence of bias and unmeasured confounders. The odds ratio (OR) and 95% CI of LUTS/BPH for the solid fuel group compared with the clean fuel group were calculated. We also conducted stratified analyses based on BMI, metabolic syndrome, waist to hip ratio, drinking status, smoking status, and age. Results: A total of 5463 participants were included in this study, including 399 solid fuel users and 5064 clean fuel users. After PSM, the solid fuel group included 354 participants, while the clean fuel group included 701 participants. Solid fuel use was positively correlated with LUTS/BPH before and after PSM (OR 1.68, 95% CI 1.31‐2.15 and OR 1.81, 95% CI 1.35‐2.44, respectively). In stratified analyses, the OR of the nonsmoking group was higher than that of the smoking group (OR 2.56, 95% CI 1.56‐4.20 and OR 1.47, 95% CI 0.99‐2.18, respectively). Similarly, the OR of the nondrinking group was higher than that of the drinking group (OR 2.70, 95% CI 1.46‐4.99 and OR 1.48, 95% CI 1.01‐2.17, respectively). Conclusions: A positive correlation between solid fuel use and LUTS/BPH was observed. The results suggest that improving fuel structure for household cooking and other household needs can possibly help reduce the risk of LUTS/BPH. Trial Registration: China Clinical Trial Registration Center ChiCTR1900024623; https://www.chictr.org.cn/showproj.html?proj=40590 %R 10.2196/53673 %U https://publichealth.jmir.org/2024/1/e53673 %U https://doi.org/10.2196/53673 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 10 %N %P e57948 %T Projections of Climate Change Impact on Acute Heat Illnesses in Taiwan: Case-Crossover Study %A Yang,Hsiao-Yu %A Wu,Chang-Fu %A Tsai,Kun-Hsien %K climate change %K global warming %K heat-related illness %K carbon reduction %K heat %K heat illness %K extreme heat %K Taiwan %K real time %K epidemic %K surveillance %K public health %K emergency department %K early warning system %K nonlinear model %K temperature %K socioeconomic %K environmental health %K heat stress %K environmental %K epidemiology %D 2024 %7 16.10.2024 %9 %J JMIR Public Health Surveill %G English %X Background: With global warming, the number of days with extreme heat is expected to increase and may cause more acute heat illnesses. While decreasing emissions may mitigate the climate impacts, its effectiveness in reducing acute heat illnesses remains uncertain. Taiwan has established a real-time epidemic surveillance and early warning system to monitor acute heat illnesses since January 1, 2011. Predicting the number of acute heat illnesses requires forecasting temperature changes that are influenced by adaptation policies. Objective: The aim of this study was to estimate the changes in the number of acute heat illnesses under different adaptation policies. Methods: We obtained the numbers of acute heat illnesses in Taiwan from January 2011 to July 2023 using emergency department visit data from the real-time epidemic surveillance and early warning system. We used segmented linear regression to identify the join point as a nonoptimal temperature threshold. We projected the temperature distribution and excess acute heat illnesses through the end of the century when Taiwan adopts the “Sustainability (shared socioeconomic pathways 1‐2.6 [SSP1-2.6]),” “Middle of the road (SSP2-4.5),” “Regional rivalry (SSP3-7.0),” and “Fossil-fueled development (SSP5-8.5)” scenarios. Distributed lag nonlinear models were used to analyze the attributable number (AN) and attributable fraction (AF) of acute heat illnesses caused by nonoptimal temperature. Results: We enrolled a total of 28,661 patients with a mean age of 44.5 (SD 15.3) years up to July 2023, of whom 21,619 (75.4%) were male patients. The nonoptimal temperature was 27 °C. The relative risk of acute heat illnesses with a 1-degree increase in mean temperature was 1.71 (95% CI 1.63-1.79). In the SSP5-8.5 worst-case scenario, the mean temperature was projected to rise by +5.8 °C (SD 0.26), with the AN and AF of acute heat illnesses above nonoptimal temperature being 19,021 (95% CI 2249‐35,792) and 89.9% (95% CI 89.3%‐90.5%) by 2090‐2099. However, if Taiwan adopts the Sustainability SSP1-2.6 scenario, the AN and AF of acute heat illnesses due to nonoptimal temperature will be reduced to 12,468 (95% CI 3233‐21,704) and 62.1% (95% CI 61.2‐63.1). Conclusions: Adopting sustainable development policies can help mitigate the risk of acute heat illnesses caused by global warming. %R 10.2196/57948 %U https://publichealth.jmir.org/2024/1/e57948 %U https://doi.org/10.2196/57948 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e63176 %T Investigating Exposure and Hazards of Micro- and Nanoplastics During Pregnancy and Early Life (AURORA Project): Protocol for an Interdisciplinary Study %A Durkin,Amanda M %A Zou,Runyu %A Boucher,Justin M %A Boyles,Matthew SP %A van Boxel,Jeske %A Bustamante,Mariona %A Christopher,Emily A %A Dadvand,Payam %A Dusza,Hanna M %A van Duursen,Majorie %A Forsberg,Markus M %A Galea,Karen S %A Legler,Juliette %A Mandemaker,Laurens DB %A Meirer,Florian %A Muncke,Jane %A Nawrot,Tim S %A Přibylová,Petra %A Robuck,Anna R %A Saenen,Nelly D %A Scholz-Böttcher,Barbara M %A Shao,Kuanliang %A Vrijheid,Martine %A Walker,Douglas I %A Zimmermann,Lisa %A Zoutendijk,Laura M %A Lenters,Virissa %A Vermeulen,Roel %+ Division of Environmental Epidemiology, Institute for Risk Assessment Sciences, Utrecht University, Yalelaan 2, Utrecht, 3584 CM, Netherlands, 31 (0)30 253 35 50, r.c.h.vermeulen@uu.nl %K epidemiology %K pregnancy %K toxicology %K microplastics %K placenta %K risk assessment %D 2024 %7 8.10.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Micro- and nanoplastics (MNPs) are emerging pollutants of concern with ubiquitous presence in global ecosystems. MNPs pose potential implications for human health; however, the health impacts of MNP exposures are not yet understood. Recent evidence suggests that MNPs can cross the placental barrier, underlying the urgent need to understand their impact on reproductive health and development. Objective: The Actionable eUropean ROadmap for early-life health Risk Assessment of micro- and nanoplastics (AURORA) project will investigate MNP exposures and their biological and health effects during pregnancy and early life, which are critical periods due to heightened vulnerability to environmental stressors. The AURORA project will enhance exposure assessment capabilities for measuring MNPs, MNP-associated chemicals, and plastic additives in human tissues, including placenta and blood. Methods: In this interdisciplinary project, we will advance methods for in-depth characterization and scalable chemical analytical strategies, enabling high-resolution and large-scale toxicological, exposure assessment, and epidemiological studies. The AURORA project performs observational studies to investigate determinants and health impacts of MNPs by including 800 mother-child pairs from 2 existing birth cohorts and 110 women of reproductive age from a newly established cohort. This will be complemented by toxicological studies using a tiered-testing approach and epidemiological investigations to evaluate associations between maternal and prenatal MNP exposures and health perturbations, such as placental function, immune-inflammatory responses, oxidative stress, accelerated aging, endocrine disruption, and child growth and development. The ultimate goal of the AURORA project is to create an MNP risk assessment framework and identify the remaining knowledge gaps and priorities needed to comprehensively assess the impact of MNPs on early-life health. Results: In the first 3 years of this 5-year project (2021-2026), progress was made toward all objectives. This includes completion of recruitment and data collection for new and existing cohorts, development of analytical methodological protocols, and initiation of the toxicological tiered assessments. As of September 2024, data analysis is ongoing and results are expected to be published starting in 2025. Conclusions: As plastic pollution increases globally, it is imperative to understand the impact of MNPs on human health, particularly during vulnerable developmental stages such as early life. The contributions of the AURORA project will inform future risk assessment. International Registered Report Identifier (IRRID): DERR1-10.2196/63176 %M 39378424 %R 10.2196/63176 %U https://www.researchprotocols.org/2024/1/e63176 %U https://doi.org/10.2196/63176 %U http://www.ncbi.nlm.nih.gov/pubmed/39378424 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 10 %N %P e62863 %T Association Between Climatic Factors and Varicella Incidence in Wuxi, East China, 2010-2019: Surveillance Study %A Zhang,Kehong %A Shen,Ganglei %A Yuan,Yue %A Shi,Chao %+ President Office, Wuxi Hospital Affiliated to Nanjing University of Chinese Medicine, Room 707, Building 5, Number 8 Zhongnan West Road, Wuxi, 214071, China, 86 051088859999 ext 17003, 1358599249@qq.com %K varicella %K meteorological factors %K Generalized Additive Model %K Segmented Linear Regression Model %K China %K meteorology %K regression %K statistics %K surveillance %D 2024 %7 2.10.2024 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Varicella is a common infectious disease and a growing public health concern in China, with increasing outbreaks in Wuxi. Analyzing the correlation between climate factors and varicella incidence in Wuxi is crucial for guiding public health prevention efforts. Objective: This study examines the impact of meteorological variables on varicella incidence in Wuxi, eastern China, from 2010 to 2019, offering insights for public health interventions. Methods: We collected daily meteorological data and varicella case records from January 1, 2010, to December 31, 2019, in Wuxi, China. Generalized cross-validation identified optimal lag days by selecting those with the lowest score. The relationship between meteorological factors and varicella incidence was analyzed using Poisson generalized additive models and segmented linear regression. Subgroup analyses were conducted by gender and age. Results: The study encompassed 64,086 varicella cases. Varicella incidence in Wuxi city displayed a bimodal annual pattern, with peak occurrences from November to January of the following year and lower peaks from May to June. Several meteorological factors influencing varicella risk were identified. A decrease of 1°C when temperatures were ≤20°C corresponded to a 1.99% increase in varicella risk (95% CI 1.57-2.42, P<.001). Additionally, a decrease of 1°C below 22.38°C in ground temperature was associated with a 1.36% increase in varicella risk (95% CI 0.96-1.75, P<.001). Each 1 mm increase in precipitation above 4.88 mm was associated with a 1.62% increase in varicella incidence (95% CI 0.93-2.30, P<.001). A 1% rise in relative humidity above 57.18% increased varicella risk by 2.05% (95% CI 1.26-2.84, P<.001). An increase in air pressure of 1 hPa below 1011.277 hPa was associated with a 1.75% rise in varicella risk (95% CI 0.75-2.77, P<.001). As wind speed and evaporation increased, varicella risk decreased linearly with a 16-day lag. Varicella risk was higher with sunshine durations exceeding 1.825 hours, with a 14-day lag, increasing by 1.30% for each additional hour of sunshine (95% CI 0.62-2.00, P=.006). Subgroup analyses revealed that teenagers and children under 17 years of age faced higher varicella risks associated with temperature, average ground temperature, precipitation, relative humidity, and air pressure. Adults aged 18-64 years experienced increased risk with longer sunshine durations. Additionally, males showed higher varicella risks related to ground temperature and air pressure compared with females. However, no significant gender differences were observed regarding varicella risks associated with temperature (male: P<.001; female P<.001), precipitation (male: P=.001; female: P=.06), and sunshine duration (male: P=.53; female: P=.04). Conclusions: Our preliminary findings highlight the interplay between varicella outbreaks in Wuxi city and meteorological factors. These insights provide valuable support for developing policies aimed at reducing varicella risks through informed public health measures. %M 39228304 %R 10.2196/62863 %U https://publichealth.jmir.org/2024/1/e62863 %U https://doi.org/10.2196/62863 %U http://www.ncbi.nlm.nih.gov/pubmed/39228304 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 10 %N %P e56059 %T The Effect of Long-Term Particulate Matter Exposure on Respiratory Mortality: Cohort Study in China %A Wang,Ying %A Wang,Zhuohao %A Jiang,Jie %A Guo,Tong %A Chen,Shimin %A Li,Zhiqiang %A Yuan,Zhupei %A Lin,Qiaoxuan %A Du,Zhicheng %A Wei,Jing %A Hao,Yuantao %A Zhang,Wangjian %K respiratory disease %K mortality %K particulate matter %K causal inference %K cohort study %D 2024 %7 24.9.2024 %9 %J JMIR Public Health Surveill %G English %X Background: Particulate matter (PM), which affects respiratory health, has been well documented; however, substantial evidence from large cohorts is still limited, particularly in highly polluted countries and for PM1. Objective: Our objective was to examine the potential causal links between long-term exposure to PMs (PM2.5, PM10, and more importantly, PM1) and respiratory mortality. Methods: A total of 580,757 participants from the Guangzhou area, China, were recruited from 2009 to 2015 and followed up through 2020. The annual average concentrations of PMs at a 1-km spatial resolution around the residential addresses were estimated using validated spatiotemporal models. The marginal structural Cox model was used to estimate the associations of PM exposure with respiratory mortality, accounting for time-varying PM exposure. Results were stratified by demographics and lifestyle behaviors factors. Results: Among the participants, the mean age was 48.33 (SD 17.55) years, and 275,676 (47.47%) of them were men. During the follow-up period, 7260 deaths occurred due to respiratory diseases. The annual average concentrations of PM1, PM2.5, and PM10 showed a declining trend during the follow-up period. After adjusting for confounders, a 6.6% (95% CI 5.6%‐7.6%), 4.2% (95% CI 3.6%‐4.7%), and 4.0% (95% CI 3.6%‐4.5%) increase in the risk of respiratory mortality was observed following each 1-μg/m3 increase in concentrations of PM1, PM2.5, and PM10, respectively. In addition, older participants, nonsmokers, participants with higher exercise frequency, and those exposed to a lower normalized difference vegetation index tended to be more susceptible to the effects of PMs. Furthermore, participants in the low-exposure group tended to be at a 7.6% and 2.7% greater risk of respiratory mortality following PM1 and PM10 exposure, respectively, compared to the entire cohort. Conclusions: This cohort study provides causal clues of the respiratory impact of long-term ambient PM exposure, indicating that PM reduction efforts may continuously benefit the population’s respiratory health. %R 10.2196/56059 %U https://publichealth.jmir.org/2024/1/e56059 %U https://doi.org/10.2196/56059 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 10 %N %P e56283 %T Occupational Exposure to Silica Dust and Silicosis Risk in Chinese Noncoal Mines: Qualitative and Quantitative Risk Assessment %A Liu,Kai %A Sun,Xin %A Hu,Wei-Jiang %A Mei,Liang-Ying %A Zhang,Heng-Dong %A Su,Shi-Biao %A Ning,Kang %A Nie,Yun-Feng %A Qiu,Le-Ping %A Xia,Ying %A Han,Lei %A Zhi,Qiang %A Shi,Chun-Bo %A Wang,Geng %A Wen,Wei %A Gao,Jian-Qiong %A Yu,Bing %A Wang,Xin %A Dong,Yi-Wen %A Kang,Ning %A Han,Feng %A Bian,Hong-Ying %A Chen,Yong-Qing %A Ye,Meng %+ National Institute for Occupational Health and Poison Control, Chinese Center for Disease Control and Prevention, 29 Nanwei Road, Xicheng District, Beijing, 100050, China, 86 010 831 325 19, yemeng@niohp.chinacdc.cn %K Chinese noncoal mine %K silica dust %K silicosis %K qualitative risk assessment %K quantitative risk assessment %K qualitative and quantitative risk assessment %D 2024 %7 2.9.2024 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Despite increasing awareness, silica dust–induced silicosis still contributes to the huge disease burden in China. Worryingly, recent silica dust exposure levels and silicosis risk in Chinese noncoal mines remain unclear. Objective: We aimed to determine recent silica dust exposure levels and assess the risk of silicosis in Chinese noncoal mines. Methods: Between May and December 2020, we conducted a retrospective cohort study on 3 noncoal mines and 1 public hospital to establish, using multivariable Cox regression analyses, prediction formulas of the silicosis cumulative hazard ratio (H) and incidence (I) and a cross-sectional study on 155 noncoal mines in 10 Chinese provinces to determine the prevalence of silica dust exposure (PDE), free silica content, and total dust and respirable dust concentrations. The qualitative risk of silicosis was assessed using the International Mining and Metals Commission’s risk-rating table and the occupational hazard risk index; the quantitative risk was assessed using prediction formulas. Results: Kaplan-Meier survival analysis revealed significant differences in the silicosis probability between silica dust–exposed male and female miners (log-rank test χ21=7.52, P=.01). A total of 126 noncoal mines, with 29,835 miners and 4623 dust samples, were included; 13,037 (43.7%) miners were exposed to silica dust, of which 12,952 (99.3%) were male. The median PDE, free silica content, total dust concentration, and respirable dust concentration were 61.6%, 27.6%, 1.30 mg/m3, and 0.58 mg/m3, respectively, indicating that miners in nonmetal, nonferrous metal, small, and open-pit mines suffer high-level exposure to silica dust. Comprehensive qualitative risk assessment showed noncoal miners had a medium risk of silicosis, and the risks caused by total silica dust and respirable silica dust exposure were high and medium, respectively. When predicting H and I over the next 10, 20, and 30 years, we assumed that the miner gender was male. Under exposure to current total silica dust concentrations, median I10, I20, and I30 would be 6.8%, 25.1%, and 49.9%, respectively. Under exposure to current respirable silica dust concentrations, median I10, I20, and I30 would be 6.8%, 27.7%, and 57.4%, respectively. These findings showed that miners in nonmetal, nonferrous metal, small, and open-pit mines have a higher I and higher qualitative silicosis risk. Conclusions: Chinese noncoal miners, especially those in nonmetal, nonferrous metal, small, and open-pit mines, still suffer high-level exposure to silica dust and a medium-level risk of silicosis. Data of both total silica dust and respirable silica dust are vital for occupational health risk assessment in order to devise effective control measures to reduce noncoal mine silica dust levels, improve miners’ working environment, and reduce the risk of silicosis. %M 39222341 %R 10.2196/56283 %U https://publichealth.jmir.org/2024/1/e56283 %U https://doi.org/10.2196/56283 %U http://www.ncbi.nlm.nih.gov/pubmed/39222341 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 10 %N %P e59924 %T Developing the DIGIFOOD Dashboard to Monitor the Digitalization of Local Food Environments: Interdisciplinary Approach %A Jia,Si Si %A Luo,Xinwei %A Gibson,Alice Anne %A Partridge,Stephanie Ruth %+ Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Level 8, Susan Wakil Health Building, Camperdown, Sydney, 2006, Australia, 61 2 8627 1697, sisi.jia@sydney.edu.au %K online food delivery %K food environment %K dashboard %K web scraping %K big data %K surveillance %K monitoring %K prevention %K food %K food delivery %K development study %K development %K accessibility %K Australia %K monitoring tool %K tool %K tools %D 2024 %7 13.8.2024 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Online food delivery services (OFDS) enable individuals to conveniently access foods from any deliverable location. The increased accessibility to foods may have implications on the consumption of healthful or unhealthful foods. Concerningly, previous research suggests that OFDS offer an abundance of energy-dense and nutrient-poor foods, which are heavily promoted through deals or discounts. Objective: In this paper, we describe the development of the DIGIFOOD dashboard to monitor the digitalization of local food environments in New South Wales, Australia, resulting from the proliferation of OFDS. Methods: Together with a team of data scientists, we designed a purpose-built dashboard using Microsoft Power BI. The development process involved three main stages: (1) data acquisition of food outlets via web scraping, (2) data cleaning and processing, and (3) visualization of food outlets on the dashboard. We also describe the categorization process of food outlets to characterize the healthfulness of local, online, and hybrid food environments. These categories included takeaway franchises, independent takeaways, independent restaurants and cafes, supermarkets or groceries, bakeries, alcohol retailers, convenience stores, and sandwich or salad shops. Results: To date, the DIGIFOOD dashboard has mapped 36,967 unique local food outlets (locally accessible and scraped from Google Maps) and 16,158 unique online food outlets (accessible online and scraped from Uber Eats) across New South Wales, Australia. In 2023, the market-leading OFDS operated in 1061 unique suburbs or localities in New South Wales. The Sydney-Parramatta region, a major urban area in New South Wales accounting for 28 postcodes, recorded the highest number of online food outlets (n=4221). In contrast, the Far West and Orana region, a rural area in New South Wales with only 2 postcodes, recorded the lowest number of food outlets accessible online (n=7). Urban areas appeared to have the greatest increase in total food outlets accessible via online food delivery. In both local and online food environments, it was evident that independent restaurants and cafes comprised the largest proportion of food outlets at 47.2% (17,437/36,967) and 51.8% (8369/16,158), respectively. However, compared to local food environments, the online food environment has relatively more takeaway franchises (2734/16,158, 16.9% compared to 3273/36,967, 8.9%) and independent takeaway outlets (2416/16,158, 14.9% compared to 4026/36,967, 10.9%). Conclusions: The DIGIFOOD dashboard leverages the current rich data landscape to display and contrast the availability and healthfulness of food outlets that are locally accessible versus accessible online. The DIGIFOOD dashboard can be a useful monitoring tool for the evolving digital food environment at a regional scale and has the potential to be scaled up at a national level. Future iterations of the dashboard, including data from additional prominent OFDS, can be used by policy makers to identify high-priority areas with limited access to healthful foods both online and locally. %M 39137032 %R 10.2196/59924 %U https://publichealth.jmir.org/2024/1/e59924 %U https://doi.org/10.2196/59924 %U http://www.ncbi.nlm.nih.gov/pubmed/39137032 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 10 %N %P e50244 %T Association of Fine Particulate Matter and Residential Greenness With Risk of Pulmonary Tuberculosis Retreatment: Population-Based Retrospective Study %A Guo,Tonglei %A Shen,Fei %A Xin,Henan %A Du,Jiang %A Cao,Xuefang %A Feng,Boxuan %A He,Yijun %A Shen,Lingyu %A Di,Yuanzhi %A Chen,Yanxiao %A Li,Zihan %A Jin,Qi %A Li,Hongzhi %A Zhang,Chunming %A Gao,Lei %K tuberculosis %K PM2.5 %K particulate matter %K air pollution %K greenness %K retrospective study %K pulmonary %K retreatment %D 2024 %7 12.8.2024 %9 %J JMIR Public Health Surveill %G English %X Background: The evidence on the association of fine particulate matter with an aerodynamic diameter of 2.5 μm or less (PM2.5) with pulmonary tuberculosis (PTB) retreatment is limited. There are no data on whether greenness exposure protects air pollution–related PTB retreatment in patients with prior PTB. Objective: In a population-based retrospective study, we aimed to investigate the influence of PM2.5 and residential greenness on the risk of PTB retreatment. Methods: A total of 26,482 patients with incident PTB, registered in a mandatory web-based reporting system between 2012 and 2019 in Zhengzhou, China, were included in the analysis. The exposure to PM2.5 was assessed based on the China High Air Pollutants dataset, and the level of greenness was estimated using the Normalized Difference Vegetation Index (NDVI) values. The associations of PTB retreatment with exposure to PM2.5 and greenness were evaluated, respectively, considering the local socioeconomic level indicated by the nighttime light index. Results: Among the 26,482 patients (mean age 46.86, SD 19.52 years) with a median follow-up time of 1523 days per patient, 1542 (5.82%) PTB retreatments were observed between 2012 and 2019. Exposure to PM2.5 was observed to be significantly associated with the increased risk of PTB retreatment in fully adjusted models with a hazard ratio of 1.97 (95% CI 1.34‐2.83) per 10 μg/m3 increase in PM2.5. Patients living in the regions with relatively high quartiles of NDVI values had a 45% lower risk of PTB retreatment than those living in the regions with the lowest quartile for the 500 m buffers (hazard ratio 0.55, 95% CI 0.40‐0.77). Such a protective effect of residential greenness was more pronounced among patients living in lower nighttime light areas. The strength of the association between PM2.5 exposure and the risk of PTB retreatment was attenuated by greenness. No significant association was observed between NDVI and the incidence of drug resistance. Conclusions: Long-term exposure to PM2.5 might be a risk factor for PTB retreatment, while an increased level of residential greenness was found to be associated with reduced risks of PTB retreatment. Our results suggest strengthening the control of ambient air pollution and improving residential greenness may contribute to the reduction of PTB retreatment. %R 10.2196/50244 %U https://publichealth.jmir.org/2024/1/e50244 %U https://doi.org/10.2196/50244 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 10 %N %P e53879 %T Association Between Particulate Matter Exposure and Preterm Birth in Women With Abnormal Preconception Thyrotropin Levels: Large Cohort Study %A Xu,Ting %A Ni,Haobo %A Cai,Xiaoyan %A Dai,Tingting %A Wang,Lingxi %A Xiao,Lina %A Zeng,Qinghui %A Yu,Xiaolin %A Han,Lu %A Guo,Pi %K PM2.5 %K particulate matter with an aerodynamic diameter of ≤2.5 μm %K thyroid stimulating hormone %K preterm birth %K cohort study %K preconception %D 2024 %7 2.8.2024 %9 %J JMIR Public Health Surveill %G English %X Background: Prior research has linked exposure to particulate matter with an aerodynamic diameter of ≤2.5 μm (PM2.5) with preterm birth (PTB). However, the modulating effect of preconception thyroid stimulating hormone (TSH) levels on the relationship between PM2.5 exposure and PTB has not been investigated. Objective: This study aimed to assess whether preconception TSH levels modulate the impact of PM2.5 exposure on PTB. Methods: This cohort study was conducted in Guangdong, China, as a part of the National Free Pre-Pregnancy Checkups Project. PM2.5 exposure was estimated by using the inverse distance weighting method. To investigate the moderating effects of TSH levels on trimester-specific PM2.5 exposure and PTB, we used the Cox proportional hazards model. Additionally, to identify the susceptible exposure windows for weekly specific PM2.5 exposure and PTB, we built distributed lag models incorporating Cox proportional hazards models. Results: A total of 633,516 women who delivered between January 1, 2014, to December 31, 2019, were included. In total, 34,081 (5.4%) of them had abnormal preconception TSH levels. During the entire pregnancy, each 10-μg/m3 increase in PM2.5 was linked to elevated risks of PTB (hazard ratio [HR] 1.559, 95% CI 1.390‐1.748), early PTB (HR 1.559, 95% CI 1.227‐1.980), and late PTB (HR 1.571, 95% CI 1.379‐1.791) among women with abnormal TSH levels. For women with normal preconception TSH levels, PM2.5 exposure during the entire pregnancy was positively associated with the risk of PTB (HR 1.345, 95% CI 1.307‐1.385), early PTB (HR 1.203, 95% CI 1.126‐1.285), and late PTB (HR 1.386, 95% CI 1.342‐1432). The critical susceptible exposure windows were the 3rd-13th and 28th-35th gestational weeks for women with abnormal preconception TSH levels, compared to the 1st-13th and 21st-35th gestational weeks for those with normal preconception TSH levels. Conclusions: PM2.5 exposure was linked with a higher PTB risk, particularly in women with abnormal preconception TSH levels. PM2.5 exposure appears to have a greater effect on pregnant women who are in the early or late stages of pregnancy. %R 10.2196/53879 %U https://publichealth.jmir.org/2024/1/e53879 %U https://doi.org/10.2196/53879 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 10 %N %P e46070 %T Factors Associated With the Spatial Distribution of Severe Fever With Thrombocytopenia Syndrome in Zhejiang Province, China: Risk Analysis Based on Maximum Entropy %A Tao,Mingyong %A Liu,Ying %A Ling,Feng %A Ren,Jiangping %A Zhang,Rong %A Shi,Xuguang %A Guo,Song %A Jiang,Jianmin %A Sun,Jimin %K severe fever with thrombocytopenia syndrome %K MaxEnt %K maximum entropy %K tick density %K spatial distribution %K risk factor %K China %D 2024 %7 2.8.2024 %9 %J JMIR Public Health Surveill %G English %X Background: Severe fever with thrombocytopenia syndrome (SFTS) is an emerging infectious disease that was first identified in mainland China in 2009 and has been reported in Zhejiang Province, China, since 2011. However, few studies have focused on the association between ticks, host animals, and SFTS. Objective: In this study, we analyzed the influence of meteorological and environmental factors as well as the influence of ticks and host animals on SFTS. This can serve as a foundational basis for the development of strategic policies aimed at the prevention and control of SFTS. Methods: Data on SFTS incidence, tick density, cattle density, and meteorological and environmental factors were collected and analyzed using a maximum entropy–based model. Results: As of December 2019, 463 laboratory-confirmed SFTS cases were reported in Zhejiang Province. We found that the density of ticks, precipitation in the wettest month, average temperature, elevation, and the normalized difference vegetation index were significantly associated with SFTS spatial distribution. The niche model fitted accurately with good performance in predicting the potential risk areas of SFTS (the average test area under the receiver operating characteristic curve for the replicate runs was 0.803 and the SD was 0.013). The risk of SFTS occurrence increased with an increase in tick density, and the response curve indicated that the risk was greater than 0.5 when tick density exceeded 1.4. The risk of SFTS occurrence decreased with increased precipitation in the wettest month, and the risk was less than 0.5 when precipitation exceeded 224.4 mm. The relationship between elevation and SFTS occurrence showed a reverse V shape, and the risk peaked at approximately 400 m. Conclusions: Tick density, precipitation, and elevation were dominant influencing factors for SFTS, and comprehensive intervention measures should be adjusted according to these factors to reduce SFTS incidence in Zhejiang Province. %R 10.2196/46070 %U https://publichealth.jmir.org/2024/1/e46070 %U https://doi.org/10.2196/46070 %0 Journal Article %@ 2369-2960 %I %V 10 %N %P e51883 %T Impact of Ambient Temperature on Mortality Burden and Spatial Heterogeneity in 16 Prefecture-Level Cities of a Low-Latitude Plateau Area in Yunnan Province: Time-Series Study %A Chen,Yang %A Zhou,Lidan %A Zha,Yuanyi %A Wang,Yujin %A Wang,Kai %A Lu,Lvliang %A Guo,Pi %A Zhang,Qingying %K mortality burden %K nonaccidental deaths %K multivariate meta-analysis %K distributed lagged nonlinear mode %K attributable risk %K climate change %K human health %K association %K temperature %K mortality %K nonaccidental death %K spatial heterogeneity %K meteorological data %K temperature esposure %K heterogeneous %K spatial planning %K environmental temperature %K prefecture-level %K resource allocation %D 2024 %7 23.7.2024 %9 %J JMIR Public Health Surveill %G English %X Background: The relation between climate change and human health has become one of the major worldwide public health issues. However, the evidence for low-latitude plateau regions is limited, where the climate is unique and diverse with a complex geography and topography. Objectives: This study aimed to evaluate the effect of ambient temperature on the mortality burden of nonaccidental deaths in Yunnan Province and to further explore its spatial heterogeneity among different regions. Methods: We collected mortality and meteorological data from all 129 counties in Yunnan Province from 2014 to 2020, and 16 prefecture-level cities were analyzed as units. A distributed lagged nonlinear model was used to estimate the effect of temperature exposure on years of life lost (YLL) for nonaccidental deaths in each prefecture-level city. The attributable fraction of YLL due to ambient temperature was calculated. A multivariate meta-analysis was used to obtain an overall aggregated estimate of effects, and spatial heterogeneity among 16 prefecture-level cities was evaluated by adjusting the city-specific geographical characteristics, demographic characteristics, economic factors, and health resources factors. Results: The temperature-YLL association was nonlinear and followed slide-shaped curves in all regions. The cumulative cold and heat effect estimates along lag 0‐21 days on YLL for nonaccidental deaths were 403.16 (95% empirical confidence interval [eCI] 148.14‐615.18) and 247.83 (95% eCI 45.73‐418.85), respectively. The attributable fraction for nonaccidental mortality due to daily mean temperature was 7.45% (95% eCI 3.73%‐10.38%). Cold temperature was responsible for most of the mortality burden (4.61%, 95% eCI 1.70‐7.04), whereas the burden due to heat was 2.84% (95% eCI 0.58‐4.83). The vulnerable subpopulations include male individuals, people aged <75 years, people with education below junior college level, farmers, nonmarried individuals, and ethnic minorities. In the cause-specific subgroup analysis, the total attributable fraction (%) for mean temperature was 13.97% (95% eCI 6.70‐14.02) for heart disease, 11.12% (95% eCI 2.52‐16.82) for respiratory disease, 10.85% (95% eCI 6.70‐14.02) for cardiovascular disease, and 10.13% (95% eCI 6.03‐13.18) for stroke. The attributable risk of cold effect for cardiovascular disease was higher than that for respiratory disease cause of death (9.71% vs 4.54%). Furthermore, we found 48.2% heterogeneity in the effect of mean temperature on YLL after considering the inherent characteristics of the 16 prefecture-level cities, with urbanization rate accounting for the highest proportion of heterogeneity (15.7%) among urban characteristics. Conclusions: This study suggests that the cold effect dominated the total effect of temperature on mortality burden in Yunnan Province, and its effect was heterogeneous among different regions, which provides a basis for spatial planning and health policy formulation for disease prevention. %R 10.2196/51883 %U https://publichealth.jmir.org/2024/1/e51883 %U https://doi.org/10.2196/51883 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 12 %N %P e54669 %T Assessment of Heat Exposure and Health Outcomes in Rural Populations of Western Kenya by Using Wearable Devices: Observational Case Study %A Matzke,Ina %A Huhn,Sophie %A Koch,Mara %A Maggioni,Martina Anna %A Munga,Stephen %A Muma,Julius Okoth %A Odhiambo,Collins Ochieng %A Kwaro,Daniel %A Obor,David %A Bärnighausen,Till %A Dambach,Peter %A Barteit,Sandra %+ Heidelberg Institute of Global Health, Heidelberg University Hospital, Heidelberg University, Im Neuenheimer Feld 130, Heidelberg, 69120, Germany, 49 62215634030, barteit@uni-heidelberg.de %K wearables %K wearable %K tracker %K trackers %K climate %K Africa %K environment %K environmental %K heat %K weather %K exposure %K temperature %K rural %K fitness trackers %K climate change %K health %K heat %K sub-Saharan Africa %K Kenya %K outcome %K outcomes %D 2024 %7 4.7.2024 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Climate change increasingly impacts health, particularly of rural populations in sub-Saharan Africa due to their limited resources for adaptation. Understanding these impacts remains a challenge, as continuous monitoring of vital signs in such populations is limited. Wearable devices (wearables) present a viable approach to studying these impacts on human health in real time. Objective: The aim of this study was to assess the feasibility and effectiveness of consumer-grade wearables in measuring the health impacts of weather exposure on physiological responses (including activity, heart rate, body shell temperature, and sleep) of rural populations in western Kenya and to identify the health impacts associated with the weather exposures. Methods: We conducted an observational case study in western Kenya by utilizing wearables over a 3-week period to continuously monitor various health metrics such as step count, sleep patterns, heart rate, and body shell temperature. Additionally, a local weather station provided detailed data on environmental conditions such as rainfall and heat, with measurements taken every 15 minutes. Results: Our cohort comprised 83 participants (42 women and 41 men), with an average age of 33 years. We observed a positive correlation between step count and maximum wet bulb globe temperature (estimate 0.06, SE 0.02; P=.008). Although there was a negative correlation between minimum nighttime temperatures and heat index with sleep duration, these were not statistically significant. No significant correlations were found in other applied models. A cautionary heat index level was recorded on 194 (95.1%) of 204 days. Heavy rainfall (>20 mm/day) occurred on 16 (7.8%) out of 204 days. Despite 10 (21%) out of 47 devices failing, data completeness was high for sleep and step count (mean 82.6%, SD 21.3% and mean 86.1%, SD 18.9%, respectively), but low for heart rate (mean 7%, SD 14%), with adult women showing significantly higher data completeness for heart rate than men (2-sided t test: P=.003; Mann-Whitney U test: P=.001). Body shell temperature data achieved 36.2% (SD 24.5%) completeness. Conclusions: Our study provides a nuanced understanding of the health impacts of weather exposures in rural Kenya. Our study’s application of wearables reveals a significant correlation between physical activity levels and high temperature stress, contrasting with other studies suggesting decreased activity in hotter conditions. This discrepancy invites further investigation into the unique socioenvironmental dynamics at play, particularly in sub-Saharan African contexts. Moreover, the nonsignificant trends observed in sleep disruption due to heat expose the need for localized climate change mitigation strategies, considering the vital role of sleep in health. These findings emphasize the need for context-specific research to inform policy and practice in regions susceptible to the adverse health effects of climate change. %M 38963698 %R 10.2196/54669 %U https://mhealth.jmir.org/2024/1/e54669 %U https://doi.org/10.2196/54669 %U http://www.ncbi.nlm.nih.gov/pubmed/38963698 %0 Journal Article %@ 2369-2960 %I %V 10 %N %P e58761 %T Moderation Effects of Streetscape Perceptions on the Associations Between Accessibility, Land Use Mix, and Bike-Sharing Use: Cross-Sectional Study %A Guo,Huagui %A Zhang,Shuyu %A Xie,Xinwei %A Liu,Jiang %A Ho,Hung Chak %K built environment %K streetscape perceptions %K bike-sharing use %K cycling %K moderation effect %K China %D 2024 %7 3.7.2024 %9 %J JMIR Public Health Surveill %G English %X Background: Cycling is known to be beneficial for human health. Studies have suggested significant associations of physical activity with macroscale built environments and streetscapes. However, whether good streetscapes can amplify the benefits of a favorable built environment on physical activity remains unknown. Objective: This study examines whether streetscape perceptions can modify the associations between accessibility, land use mix, and bike-sharing use. Methods: This cross-sectional study used data from 18,019,266 bike-sharing orders during weekends in Shanghai, China. A 500 × 500 m grid was selected as the analysis unit to allocate data. Bike-sharing use was defined as the number of bike-sharing origins. Street view images and a human-machine adversarial scoring framework were combined to evaluate lively, safety, and wealthy perceptions. Negative binomial regression was developed to examine the independent effects of the three perceptual factors in both the univariate model and fully adjusted model, controlling for population density, average building height, distance to nearest transit, number of bus stations, number of points of interest, distance to the nearest park, and distance to the central business district. The moderation effect was then investigated through the interaction term between streetscape perception and accessibility and land use mix, based on the fully adjusted model. We also tested whether the findings of streetscape moderation effects are robust when examinations are performed at different geographic scales, using a small-sample statistics approach and different operationalizations of land use mix and accessibility. Results: High levels of lively, safety, and wealthy perceptions were correlated with more bike-sharing activities. There were negative effects for the interactions between the land use Herfindahl-Hirschman index with the lively perception (β=–0.63; P=.01) and safety perception (β=–0.52; P=.001). The interaction between the lively perception and road intersection density was positively associated with the number of bike-sharing uses (β=0.43; P=.08). Among these, the lively perception showed the greatest independent effect (β=1.29; P<.001), followed by the safety perception (β=1.22; P=.001) and wealthy perception (β=0.72; P=.001). The findings were robust in the three sensitivity analyses. Conclusions: A safer and livelier streetscape can enhance the benefits of land use mix in promoting bike-sharing use, with a safer streetscape also intensifying the effect of accessibility. Interventions focused on streetscape perceptions can encourage cycling behavior and enhance the benefits of accessibility and land use mix. This study also contributes to the literature on potential moderators of built environment healthy behavior associations from the perspective of microscale environmental perceptions. %R 10.2196/58761 %U https://publichealth.jmir.org/2024/1/e58761 %U https://doi.org/10.2196/58761 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 10 %N %P e52221 %T Epidemic Characteristics and Meteorological Risk Factors of Hemorrhagic Fever With Renal Syndrome in 151 Cities in China From 2015 to 2021: Retrospective Analysis %A Luo,Yizhe %A Zhang,Longyao %A Xu,Yameng %A Kuai,Qiyuan %A Li,Wenhao %A Wu,Yifan %A Liu,Licheng %A Ren,Jiarong %A Zhang,Lingling %A Shi,Qiufang %A Liu,Xiaobo %A Tan,Weilong %+ Department of Epidemiology, School of Public Health, Nanjing Medical University, Meiyuan Xincun Street, Nanjing, 210002, China, 86 17384408593, njcdc@163.com %K China %K hemorrhagic fever with renal syndrome %K HFRS %K climate change %K meteorological factors %K distributed lag nonlinear model %D 2024 %7 5.6.2024 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Hemorrhagic fever with renal syndrome (HFRS) continues to pose a significant public health threat to the population in China. Previous epidemiological evidence indicates that HFRS is climate sensitive and influenced by meteorological factors. However, past studies either focused on too-narrow geographical regions or investigated time periods that were too early. There is an urgent need for a comprehensive analysis to interpret the epidemiological patterns of meteorological factors affecting the incidence of HFRS across diverse climate zones. Objective: In this study, we aimed to describe the overall epidemic characteristics of HFRS and explore the linkage between monthly HFRS cases and meteorological factors at different climate levels in China. Methods: The reported HFRS cases and meteorological data were collected from 151 cities in China during the period from 2015 to 2021. We conducted a 3-stage analysis, adopting a distributed lag nonlinear model and a generalized additive model to estimate the interactions and marginal effects of meteorological factors on HFRS. Results: This study included a total of 63,180 cases of HFRS; the epidemic trends showed seasonal fluctuations, with patterns varying across different climate zones. Temperature had the greatest impact on the incidence of HFRS, with the maximum hysteresis effects being at 1 month (–19 ºC; relative risk [RR] 1.64, 95% CI 1.24-2.15) in the midtemperate zone, 0 months (28 ºC; RR 3.15, 95% CI 2.13-4.65) in the warm-temperate zone, and 0 months (4 ºC; RR 1.72, 95% CI 1.31-2.25) in the subtropical zone. Interactions were discovered between the average temperature, relative humidity, and precipitation in different temperature zones. Moreover, the influence of precipitation and relative humidity on the incidence of HFRS had different characteristics under different temperature layers. The hysteresis effect of meteorological factors did not end after an epidemic season, but gradually weakened in the following 1 or 2 seasons. Conclusions: Weather variability, especially low temperature, plays an important role in epidemics of HFRS in China. A long hysteresis effect indicates the necessity of continuous intervention following an HFRS epidemic. This finding can help public health departments guide the prevention and control of HFRS and develop strategies to cope with the impacts of climate change in specific regions. %M 38837197 %R 10.2196/52221 %U https://publichealth.jmir.org/2024/1/e52221 %U https://doi.org/10.2196/52221 %U http://www.ncbi.nlm.nih.gov/pubmed/38837197 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e53437 %T Travel Distance Between Participants in US Telemedicine Sessions With Estimates of Emissions Savings: Observational Study %A Cummins,Mollie R %A Shishupal,Sukrut %A Wong,Bob %A Wan,Neng %A Han,Jiuying %A Johnny,Jace D %A Mhatre-Owens,Amy %A Gouripeddi,Ramkiran %A Ivanova,Julia %A Ong,Triton %A Soni,Hiral %A Barrera,Janelle %A Wilczewski,Hattie %A Welch,Brandon M %A Bunnell,Brian E %+ College of Nursing, University of Utah, 10 South 2000 East, Salt Lake City, UT, 84112-5880, United States, 1 8015859740, mollie.cummins@utah.edu %K air pollution %K environmental health %K telemedicine %K greenhouse gases %K clinical research informatics %K informatics %K data science %K telehealth %K eHealth %K travel %K air quality %K pollutant %K pollution %K polluted %K environment %K environmental %K greenhouse gas %K emissions %K retrospective %K observational %K United States %K USA %K North America %K North American %K cost %K costs %K economic %K economics %K saving %K savings %K finance %K financial %K finances %K CO2 %K carbon dioxide %K carbon footprint %D 2024 %7 15.5.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Digital health and telemedicine are potentially important strategies to decrease health care’s environmental impact and contribution to climate change by reducing transportation-related air pollution and greenhouse gas emissions. However, we currently lack robust national estimates of emissions savings attributable to telemedicine. Objective: This study aimed to (1) determine the travel distance between participants in US telemedicine sessions and (2) estimate the net reduction in carbon dioxide (CO2) emissions attributable to telemedicine in the United States, based on national observational data describing the geographical characteristics of telemedicine session participants. Methods: We conducted a retrospective observational study of telemedicine sessions in the United States between January 1, 2022, and February 21, 2023, on the doxy.me platform. Using Google Distance Matrix, we determined the median travel distance between participating providers and patients for a proportional sample of sessions. Further, based on the best available public data, we estimated the total annual emissions costs and savings attributable to telemedicine in the United States. Results: The median round trip travel distance between patients and providers was 49 (IQR 21-145) miles. The median CO2 emissions savings per telemedicine session was 20 (IQR 8-59) kg CO2). Accounting for the energy costs of telemedicine and US transportation patterns, among other factors, we estimate that the use of telemedicine in the United States during the years 2021-2022 resulted in approximate annual CO2 emissions savings of 1,443,800 metric tons. Conclusions: These estimates of travel distance and telemedicine-associated CO2 emissions costs and savings, based on national data, indicate that telemedicine may be an important strategy in reducing the health care sector’s carbon footprint. %M 38536065 %R 10.2196/53437 %U https://www.jmir.org/2024/1/e53437 %U https://doi.org/10.2196/53437 %U http://www.ncbi.nlm.nih.gov/pubmed/38536065 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e56138 %T An e-Learning Course to Train General Practitioners in Planetary Health: Pilot Intervention Study %A Tourrette,Cédric %A Tostain,Jean-Baptiste %A Kozub,Eva %A Badreddine,Maha %A James,Julia %A Noraz,Aurore %A De Choudens,Charlotte %A Moulis,Lionel %A Duflos,Claire %A Carbonnel,Francois %+ Desbrest Institute of Epidemiology and Public Health, Montpellier University, INSERM, Campus Sante, IURC, 641 Avenue du Doyen Gaston Giraud, Montpellier, 34093, France, 33 684014834, francois.carbonnel@umontpellier.fr %K planetary health %K One Health %K medical education %K environmental health %K education %K e-learning %K general practitioner %K pilot study %K climate change %K training %K environmental %K e-learning module %K behavior change %K ecosystem %K questionnaire %K behavior %K self-assessment %K e-learning intervention %K environment %D 2024 %7 14.5.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: According to the World Health Organization, climate and ecological emergencies are already major threats to human health. Unabated climate change will cause 3.4 million deaths per year by the end of the century, and health-related deaths in the population aged ≥65 years will increase by 1540%. Planetary health (PH) is based on the understanding that human health and human civilization depend on flourishing natural systems and the wise stewardship of those natural systems. Health care systems collectively produce global emissions equivalent to those of the fifth largest country on earth, and they should take steps to reduce their environmental impact. Primary care in France accounts for 23% of greenhouse gas emissions in the health care sector. General practitioners (GPs) have an important role in PH. The course offers first-year GP residents of the Montpellier-Nîmes Faculty of Medicine a blended-learning course on environmental health. An e-learning module on PH, lasting 30 to 45 minutes, has been introduced in this course. Objective: The objective of this study was to assess the impact of the e-learning module on participants’ knowledge and behavior change. Methods: This was a before-and-after study. The module consisted of 3 parts: introduction, degradation of ecosystems and health (based on the Intergovernmental Panel on Climate Change report and planetary limits), and ecoresponsibility (based on the Shift Project report on the impact of the health care system on the environment). The questionnaire used Likert scales to self-assess 10 points of knowledge and 5 points of PH-related behavior. Results: A total of 95 participants completed the pre- and posttest questionnaires (response rate 55%). The mean scores for participants’ pretest knowledge and behaviors were 3.88/5 (SD 0.362) and 3.45/5 (SD 0.705), respectively. There was no statistically significant variation in the results according to age or gender. The pretest mean score of participants who had already taken PH training was statistically better than those who had not taken the PH training before this course (mean 4.05, SD 0.16 vs mean 3.71, SD 0.374; P<.001). Conclusions: The PH module of the Primary Care Environment and Health course significantly improved self-assessment knowledge scores and positively modified PH behaviors among GP residents. Further work is needed to study whether these self-declared behaviors are translated into practice. %M 38743463 %R 10.2196/56138 %U https://formative.jmir.org/2024/1/e56138 %U https://doi.org/10.2196/56138 %U http://www.ncbi.nlm.nih.gov/pubmed/38743463 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 10 %N %P e52456 %T Mutual Associations of Exposure to Ambient Air Pollutants in the First 1000 Days of Life With Asthma/Wheezing in Children: Prospective Cohort Study in Guangzhou, China %A Tian,Fenglin %A Zhong,Xinqi %A Ye,Yufeng %A Liu,Xiaohan %A He,Guanhao %A Wu,Cuiling %A Chen,Zhiqing %A Zhu,Qijiong %A Yu,Siwen %A Fan,Jingjie %A Yao,Huan %A Ma,Wenjun %A Dong,Xiaomei %A Liu,Tao %+ Department of Public Health and Preventive Medicine, School of Medicine, Jinan University, Number 601, West Huangpu Avenue, Guangzhou, 510632, Guangdong, China, 86 18927588462, gztt_2002@163.com %K pregnancy %K air pollution %K asthma %K wheezing %K birth cohort %K children %D 2024 %7 17.4.2024 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: The first 1000 days of life, encompassing pregnancy and the first 2 years after birth, represent a critical period for human health development. Despite this significance, there has been limited research into the associations between mixed exposure to air pollutants during this period and the development of asthma/wheezing in children. Furthermore, the finer sensitivity window of exposure during this crucial developmental phase remains unclear. Objective: This study aims to assess the relationships between prenatal and postnatal exposures to various ambient air pollutants (particulate matter 2.5 [PM2.5], carbon monoxide [CO], sulfur dioxide [SO2], nitrogen dioxide [NO2], and ozone [O3]) and the incidence of childhood asthma/wheezing. In addition, we aimed to pinpoint the potential sensitivity window during which air pollution exerts its effects. Methods: We conducted a prospective birth cohort study wherein pregnant women were recruited during early pregnancy and followed up along with their children. Information regarding maternal and child characteristics was collected through questionnaires during each round of investigation. Diagnosis of asthma/wheezing was obtained from children’s medical records. In addition, maternal and child exposures to air pollutants (PM2.5 CO, SO2, NO2, and O3) were evaluated using a spatiotemporal land use regression model. To estimate the mutual associations of exposure to mixed air pollutants with the risk of asthma/wheezing in children, we used the quantile g-computation model. Results: In our study cohort of 3725 children, 392 (10.52%) were diagnosed with asthma/wheezing. After the follow-up period, the mean age of the children was 3.2 (SD 0.8) years, and a total of 14,982 person-years were successfully followed up for all study participants. We found that each quartile increase in exposure to mixed air pollutants (PM2.5, CO, SO2, NO2, and O3) during the second trimester of pregnancy was associated with an adjusted hazard ratio (HR) of 1.24 (95% CI 1.04-1.47). Notably, CO made the largest positive contribution (64.28%) to the mutual effect. After categorizing the exposure according to the embryonic respiratory development stages, we observed that each additional quartile of mixed exposure to air pollutants during the pseudoglandular and canalicular stages was associated with HRs of 1.24 (95% CI 1.03-1.51) and 1.23 (95% CI 1.01-1.51), respectively. Moreover, for the first year and first 2 years after birth, each quartile increment of exposure to mixed air pollutants was associated with HRs of 1.65 (95% CI 1.30-2.10) and 2.53 (95% CI 2.16-2.97), respectively. Notably, SO2 made the largest positive contribution in both phases, accounting for 50.30% and 74.70% of the association, respectively. Conclusions: Exposure to elevated levels of mixed air pollutants during the first 1000 days of life appears to elevate the risk of childhood asthma/wheezing. Specifically, the second trimester, especially during the pseudoglandular and canalicular stages, and the initial 2 years after birth emerge as crucial susceptibility windows. Trial Registration: Chinese Clinical Trial Registry ChiCTR-ROC-17013496; https://tinyurl.com/2ctufw8n %M 38631029 %R 10.2196/52456 %U https://publichealth.jmir.org/2024/1/e52456 %U https://doi.org/10.2196/52456 %U http://www.ncbi.nlm.nih.gov/pubmed/38631029 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 10 %N %P e48682 %T Correlation of Socioeconomic and Environmental Factors With Incidence of Crohn Disease in Children and Adolescents: Systematic Review and Meta-Regression %A Weidner,Jens %A Glauche,Ingmar %A Manuwald,Ulf %A Kern,Ivana %A Reinecke,Ines %A Bathelt,Franziska %A Amin,Makan %A Dong,Fan %A Rothe,Ulrike %A Kugler,Joachim %+ Institute for Medical Informatics and Biometry, Medical Faculty Carl Gustav Carus, TU Dresden, Fetscherstrasse 74, Dresden, 01307, Germany, 49 351458 ext 89910, jens.weidner@tu-dresden.de %K Crohn’s disease %K inflammatory bowel disease %K pediatric %K children %K adolescents %K environmental factors %K Crohn disease %K gastroenteritis %K inflammatory bowel diseases %K bowel disease %K digestive system %K gastrointestinal disease %D 2024 %7 25.3.2024 %9 Review %J JMIR Public Health Surveill %G English %X Background: The worldwide incidence of Crohn disease (CD) in childhood and adolescence has an increasing trend, with significant differences between different geographic regions and individual countries. This includes an increase in the incidence of CD in countries and geographic regions where CD was not previously prevalent. In response to the increasing incidence, the pediatric care landscape is facing growing challenges. Objective: This systematic review and meta-analysis were undertaken to comprehensively delineate the incidence rates of CD in pediatric populations across different countries and to explore potential influencing factors. Methods: We performed a systematic review of PubMed and Embase (via Ovid) for studies from January 1, 1970, to December 31, 2019. In addition, a manual search was performed in relevant and previously published reviews. The results were evaluated quantitatively. For this purpose, random effects meta-analyses and meta-regressions were performed to investigate the overall incidence rate and possible factors influencing the incidence. Results: A qualitative synthesis of 74 studies was performed, with 72 studies included in the meta-analyses and 52 in the meta-regressions. The results of our meta-analysis showed significant heterogeneity between the individual studies, which cannot be explained by a sample effect alone. Our findings showed geographical differences in incidence rates, which increased with increasing distance from the equator, although no global temporal trend was apparent. The meta-regression analysis also identified geographic location, UV index, and Human Development Index as significant moderators associated with CD incidence. Conclusions: Our results suggest that pediatric CD incidence has increased in many countries since 1970 but varies widely with geographic location, which may pose challenges to the respective health care systems. We identified geographic, environmental, and socioeconomic factors that contribute to the observed heterogeneity in incidence rates. These results can serve as a basis for future research. To this end, implementations of internationally standardized and interoperable registries combined with the dissemination of health data through federated networks based on a common data model, such as the Observational Medical Outcomes Partnership, would be beneficial. This would deepen the understanding of CD and promote evidence-based approaches to preventive and interventional strategies as well as inform public health policies aimed at addressing the increasing burden of CD in children and adolescents. Trial Registration: PROSPERO International prospective register of systematic reviews CRD42020168644; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=168644 International Registered Report Identifier (IRRID): RR2-10.1136/bmjopen-2020-037669 %M 38526534 %R 10.2196/48682 %U https://publichealth.jmir.org/2024/1/e48682 %U https://doi.org/10.2196/48682 %U http://www.ncbi.nlm.nih.gov/pubmed/38526534 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 10 %N %P e46591 %T Association Between Long‑Term Exposure to Air Pollution and the Rate of Mortality After Hip Fracture Surgery in Patients Older Than 60 Years: Nationwide Cohort Study in Taiwan %A Chuang,Shu-Han %A Kuo,Yi-Jie %A Huang,Shu-Wei %A Zhang,Han-Wei %A Peng,Hsiao-Ching %A Chen,Yu-Pin %+ Department of Orthopedics, Wan Fang Hospital, Taipei Medical University, No. 111, Sec. 3, Xinglong Rd, Wenshan District, Taipei City, 116079, Taiwan, 886 933296411, 99231@w.tmu.edu.tw %K air pollution %K hip fracture %K mortality %K exposure %K older adult %K environmental hazard %K hazard %K morbidity %D 2024 %7 18.3.2024 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: To enhance postoperative patient survival, particularly in older adults, understanding the predictors of mortality following hip fracture becomes paramount. Air pollution, a prominent global environmental issue, has been linked to heightened morbidity and mortality across a spectrum of diseases. Nevertheless, the precise impact of air pollution on hip fracture outcomes remains elusive. Objective: This retrospective study aims to comprehensively investigate the profound influence of a decade-long exposure to 12 diverse air pollutants on the risk of post–hip fracture mortality among older Taiwanese patients (older than 60 years). We hypothesized that enduring long-term exposure to air pollution would significantly elevate the 1-year mortality rate following hip fracture surgery. Methods: From Taiwan’s National Health Insurance Research Database, we obtained the data of patients who underwent hip fracture surgery between July 1, 2003, and December 31, 2013. Using patients’ insurance registration data, we estimated their cumulative exposure levels to sulfur dioxide (SO2), carbon dioxide (CO2), carbon monoxide (CO), ozone (O3), particulate matter having a size of <10 μm (PM10), particulate matter having a size of <2.5 μm (PM2.5), nitrogen oxides (NOX), nitrogen monoxide (NO), nitrogen dioxide (NO2), total hydrocarbons (THC), nonmethane hydrocarbons (NMHC), and methane (CH4). We quantified the dose-response relationship between these air pollutants and the risk of mortality by calculating hazard ratios associated with a 1 SD increase in exposure levels over a decade. Results: Long-term exposure to SO2, CO, PM10, PM2.5, NOX, NO, NO2, THC, NMHC, and CH4 demonstrated significant associations with heightened all-cause mortality risk within 1 year post hip fracture surgery among older adults. For older adults, each 1 SD increment in the average exposure levels of SO2, CO, PM10, PM2.5, NOX, NO, NO2, THC, NMHC, and CH4 corresponded to a substantial escalation in mortality risk, with increments of 14%, 49%, 18%, 12%, 41%, 33%, 38%, 20%, 9%, and 26%, respectively. We further noted a 35% reduction in the hazard ratio for O3 exposure suggesting a potential protective effect, along with a trend of potentially protective effects of CO2. Conclusions: This comprehensive nationwide retrospective study, grounded in a population-based approach, demonstrated that long-term exposure to specific air pollutants significantly increased the risk of all-cause mortality within 1 year after hip fracture surgery in older Taiwanese adults. A reduction in the levels of SO2, CO, PM10, PM2.5, NOX, NO, NO2, THC, NMHC, and CH4 may reduce the risk of mortality after hip fracture surgery. This study provides robust evidence and highlights the substantial impact of air pollution on the outcomes of hip fractures. %M 38342504 %R 10.2196/46591 %U https://publichealth.jmir.org/2024/1/e46591 %U https://doi.org/10.2196/46591 %U http://www.ncbi.nlm.nih.gov/pubmed/38342504 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 10 %N %P e53170 %T Mediating Effect of Tobacco Dependence on the Association Between Maternal Smoking During Pregnancy and Chronic Obstructive Pulmonary Disease: Case-Control Study %A Li,Jinxuan %A Xu,Jianying %A Yang,Lan %A Xu,Yongjian %A Zhang,Xiangyan %A Bai,Chunxue %A Kang,Jian %A Ran,Pixin %A Shen,Huahao %A Wen,Fuqiang %A Huang,Kewu %A Yao,Wanzhen %A Sun,Tieying %A Shan,Guangliang %A Yang,Ting %A Lin,Yingxiang %A Zhu,Jianguo %A Wang,Ruiying %A Shi,Zhihong %A Zhao,Jianping %A Ye,Xianwei %A Song,Yuanlin %A Wang,Qiuyue %A Hou,Gang %A Zhou,Yumin %A Li,Wen %A Ding,Liren %A Wang,Hao %A Chen,Yahong %A Guo,Yanfei %A Xiao,Fei %A Lu,Yong %A Peng,Xiaoxia %A Zhang,Biao %A Wang,Zuomin %A Zhang,Hong %A Bu,Xiaoning %A Zhang,Xiaolei %A An,Li %A Zhang,Shu %A Cao,Zhixin %A Zhan,Qingyuan %A Yang,Yuanhua %A Liang,Lirong %A Cao,Bin %A Dai,Huaping %A Chung,Kian Fan %A Chen,Zhengming %A He,Jiang %A Wu,Sinan %A Xiao,Dan %A Wang,Chen %A , %+ Department of Tobacco Control and Prevention of Respiratory Diseases, Center of Respiratory Medicine, China-Japan Friendship Hospital, Yinghua Street, Beijing, 100029, China, 86 010 8420 5425, danxiao@263.net %K chronic obstructive pulmonary disease %K tobacco dependence %K smoking %K mediating effects %K lung function %D 2024 %7 22.2.2024 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Maternal smoking during pregnancy (MSDP) is a known risk factor for offspring developing chronic obstructive pulmonary disease (COPD), but the underlying mechanism remains unclear. Objective: This study aimed to explore whether the increased COPD risk associated with MSDP could be attributed to tobacco dependence (TD). Methods: This case-control study used data from the nationwide cross-sectional China Pulmonary Health study, with controls matched for age, sex, and smoking status. TD was defined as smoking within 30 minutes of waking, and the severity of TD was assessed using the Fagerstrom Test for Nicotine Dependence. COPD was diagnosed when the ratio of forced expiratory volume in 1 second to forced vital capacity was <0.7 in a postbronchodilator pulmonary function test according to the 2017 Global Initiative for Chronic Obstructive Lung Disease criteria. Logistic regression was used to examine the correlation between MSDP and COPD, adjusting for age, sex, BMI, educational attainment, place of residence, ethnic background, occupation, childhood passive smoking, residential fine particulate matter, history of childhood pneumonia or bronchitis, average annual household income, and medical history (coronary heart disease, hypertension, and diabetes). Mediation analysis examined TD as a potential mediator in the link between MSDP and COPD risk. The significance of the indirect effect was assessed through 1000 iterations of the “bootstrap” method. Results: The study included 5943 participants (2991 with COPD and 2952 controls). Mothers of the COPD group had higher pregnancy smoking rates (COPD: n=305, 10.20%; controls: n=211, 7.10%; P<.001). TD was more prevalent in the COPD group (COPD: n=582, 40.40%; controls: n=478, 33.90%; P<.001). After adjusting for covariates, MSDP had a significant effect on COPD (β=.097; P<.001). There was an association between MSDP and TD (β=.074; P<.001) as well as between TD and COPD (β=.048; P=.007). Mediation analysis of TD in the MSDP-COPD association showed significant direct and indirect effects (direct: β=.094; P<.001 and indirect: β=.004; P=.03). The indirect effect remains present in the smoking population (direct: β=.120; P<.001 and indirect: β=.002; P=.03). Conclusions: This study highlighted the potential association between MSDP and the risk of COPD in offspring, revealing the mediating role of TD in this association. These findings contribute to a deeper understanding of the impact of prenatal tobacco exposure on lung health, laying the groundwork for the development of relevant prevention and treatment strategies. %M 38386387 %R 10.2196/53170 %U https://publichealth.jmir.org/2024/1/e53170 %U https://doi.org/10.2196/53170 %U http://www.ncbi.nlm.nih.gov/pubmed/38386387 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 10 %N %P e46638 %T Untapped Potential of Unobtrusive Observation for Studying Health Behaviors %A Benton,Jack S %A French,David P %+ Manchester Centre for Health Psychology, Division of Psychology and Mental Health, The University of Manchester, Oxford Road, Manchester, M13 9PL, United Kingdom, 44 0161 306 6000, jack.benton@manchester.ac.uk %K health behavior %K environments %K context %K unobtrusive observation %K video technology %K computer vision %D 2024 %7 21.2.2024 %9 Viewpoint %J JMIR Public Health Surveill %G English %X Improving the environment is an important upstream intervention to promote population health by influencing health behaviors such as physical activity, smoking, and social distancing. Examples of promising environmental interventions include creating high-quality green spaces, building active transport infrastructure, and implementing urban planning regulations. However, there is little robust evidence to inform policy and decision makers about what kinds of environmental interventions are effective and for which populations. In this viewpoint, we make the case that this evidence gap exists partly because health behavior research is dominated by obtrusive methods that focus on studying individual behavior and that are less suitable for understanding environmental influences. In contrast, unobtrusive observation can assess how behavior varies in different environmental contexts. It thereby provides valuable data relating to how environments affect the behavior of populations, which is often useful knowledge for effectively and equitably tackling population health challenges such as obesity and noncommunicable diseases. Yet despite a long history, unobtrusive observation methods are currently underused in health behavior research. We discuss how developing the use of video technology and automated computer vision techniques can offer a scalable solution for assessing health behaviors, facilitating a more thorough investigation of how environments influence health behaviors. We also reflect on the important ethical challenges associated with unobtrusive observation and the use of these emerging video technologies. By increasing the use of unobtrusive observation alongside other methods, we strongly believe this will improve our understanding of the influences of the environment on health behaviors. %M 38381483 %R 10.2196/46638 %U https://publichealth.jmir.org/2024/1/e46638 %U https://doi.org/10.2196/46638 %U http://www.ncbi.nlm.nih.gov/pubmed/38381483 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 10 %N %P e44648 %T Association Between Nitrogen Dioxide Pollution and Cause-Specific Mortality in China: Cross-Sectional Time Series Study %A Zeng,Jie %A Lin,Guozhen %A Dong,Hang %A Li,Mengmeng %A Ruan,Honglian %A Yang,Jun %+ School of Public Health, Guangzhou Medical University, No. 1 Xinzao Road, Xinzao Town, Panyu District, Guangzhou, 511436, China, 86 020 37103532, yangjun_eci@jnu.edu.cn %K nitrogen dioxide %K cause-specific mortality %K stratification effect %K vulnerable subpopulations %K China %D 2024 %7 5.2.2024 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Nitrogen dioxide (NO2) has been frequently linked to a range of diseases and associated with high rates of mortality and morbidity worldwide. However, there is limited evidence regarding the risk of NO2 on a spectrum of causes of mortality. Moreover, adjustment for potential confounders in NO2 analysis has been insufficient, and the spatial resolution of exposure assessment has been limited. Objective: This study aimed to quantitatively assess the relationship between short-term NO2 exposure and death from a range of causes by adjusting for potential confounders in Guangzhou, China, and determine the modifying effect of gender and age. Methods: A time series study was conducted on 413,703 deaths that occurred in Guangzhou during the period of 2010 to 2018. The causes of death were classified into 10 categories and 26 subcategories. We utilized a generalized additive model with quasi-Poisson regression analysis using a natural cubic splines function with lag structure of 0 to 4 days to estimate the potential lag effect of NO2 on cause-specific mortality. We estimated the percentage change in cause-specific mortality rates per 10 μg/m3 increase in NO2 levels. We stratified meteorological factors such as temperature, humidity, wind speed, and air pressure into high and low levels with the median as the critical value and analyzed the effects of NO2 on various death-causing diseases at those high and low levels. To further identify potentially vulnerable subpopulations, we analyzed groups stratified by gender and age. Results: A significant association existed between NO2 exposure and deaths from multiple causes. Each 10 μg/m3 increment in NO2 density at a lag of 0 to 4 days increased the risks of all-cause mortality by 1.73% (95% CI 1.36%-2.09%) and mortality due to nonaccidental causes, cardiovascular disease, respiratory disease, endocrine disease, and neoplasms by 1.75% (95% CI 1.38%-2.12%), 2.06% (95% CI 1.54%-2.59%), 2.32% (95% CI 1.51%-3.13%), 2.40% (95% CI 0.84%-3.98%), and 1.18% (95% CI 0.59%-1.78%), respectively. Among the 26 subcategories, mortality risk was associated with 16, including intentional self-harm, hypertensive disease, and ischemic stroke disease. Relatively higher effect estimates of NO2 on mortality existed for low levels of temperature, relative humidity, wind speed, and air pressure than with high levels, except a relatively higher effect estimate was present for endocrine disease at a high air pressure level. Most of the differences between subgroups were not statistically significant. The effect estimates for NO2 were similar by gender. There were significant differences between the age groups for mortality due to all causes, nonaccidental causes, and cardiovascular disease. Conclusions: Short-term NO2 exposure may increase the risk of mortality due to a spectrum of causes, especially in potentially vulnerable populations. These findings may be important for predicting and modifying guidelines for NO2 exposure in China. %M 38315528 %R 10.2196/44648 %U https://publichealth.jmir.org/2024/1/e44648 %U https://doi.org/10.2196/44648 %U http://www.ncbi.nlm.nih.gov/pubmed/38315528 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e51851 %T The Impact of the Ecosystem on Health Literacy Among Rural Communities in Protected Areas: Protocol for a Mixed Methods Study %A Abd Kadir,Nor Aziah %A Azzeri,Amirah %A Jaafar,Hafiz %A Mohd Noor,Mohd Iqbal %A Kefeli,Zurina %+ Faculty of Medicine and Health Sciences, Universiti Sains Islam Malaysia, Bandar Baru Nilai, Negeri Sembilan, 71800, Malaysia, 60 132088543, amirah.azzeri@usim.edu.my %K ecosystem %K health literacy %K protected areas %K Net-Map %K quality of life %K rural communities %K protocol %D 2024 %7 29.1.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Protected areas are crucial for the maintenance of human health and well-being. They aim to preserve biodiversity and natural resources to secure various ecosystem services that are beneficial to human health. Their ecological characteristics can influence local health literacy. Typically, communities surrounding protected areas have limited economic opportunities due to restriction policies to protect the ecosystem, resulting in socioeconomic disparities. The local community faces obstacles in gaining access to health care facilities and health information due to these limitations. It is difficult for them to locate, comprehend, and apply information and services to make better health-related decisions for themselves and others. Objective: This study protocol examines the impact of the ecosystem on health literacy among rural communities in protected areas. Methods: This study comprises 5 phases. In phase 1, we conduct a systematic review to identify the issue of health literacy in protected areas. In phase 2, we will collect data from stakeholders in a protected area of Pahang National Park and analyze the results using Net-Map analysis. In phase 3, we will conduct a survey among the adult community in Pahang National Park related to health literacy, socioeconomic status, health expenditure, and quality of life. In phase 4, informed by the results of the survey, we will determine suitable intervention programs to improve health literacy through a focus group discussion. Finally, in phase 5, we will conduct a costing analysis to analyze which intervention program is the most cost-effective. Results: This study was funded by Universiti Sains Islam Malaysia (USIM) and strategic research partnership grants, and enrollment is ongoing. The first results are expected to be submitted for publication in 2024. Conclusions: This is one of the first studies to explore health literacy among rural communities in protected areas and will provide the first insights into the overall level of health literacy in the protected community, potential determinants, and a suitable intervention program with expected cost analysis. The results can be used to promote health literacy in other protected areas and populations. Trial Registration: International Standard Randomized Controlled Trial Number Registry ISRCTN40626062; http://tinyurl.com/4kjxuwk5 International Registered Report Identifier (IRRID): PRR1-10.2196/51851 %M 38285500 %R 10.2196/51851 %U https://www.researchprotocols.org/2024/1/e51851 %U https://doi.org/10.2196/51851 %U http://www.ncbi.nlm.nih.gov/pubmed/38285500 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 9 %N %P e45870 %T Epidemic Characteristics, Spatiotemporal Pattern, and Risk Factors of Other Infectious Diarrhea in Fujian Province From 2005 to 2021: Retrospective Analysis %A Lu,Yixiao %A Zhu,Hansong %A Hu,Zhijian %A He,Fei %A Chen,Guangmin %+ Fujian Provincial Center for Disease Control and Prevention, The Practice Base on the School of Public Health, Fujian Medical University, No.386 Chong'an Road, Fuzhou, 350001, China, 86 591 87552041, cgmyf34567@163.com %K other infectious diarrhea %K spatiotemporal pattern %K disease cluster %K epidemiological trends %K spatial autocorrelation %K meteorological factors %K environmental factors %D 2023 %7 30.11.2023 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Other infectious diarrhea (OID) continues to pose a significant public health threat to all age groups in Fujian Province. There is a need for an in-depth analysis to understand the epidemiological pattern of OID and its associated risk factors in the region. Objective: In this study, we aimed to describe the overall epidemic characteristics and spatiotemporal pattern of OID in Fujian Province from 2005 to 2021 and explore the linkage between sociodemographic and environmental factors and the occurrence of OID within the study area. Methods: Notification data for OID in Fujian were extracted from the China Information System for Disease Control and Prevention. The spatiotemporal pattern of OID was analyzed using Moran index and Kulldorff scan statistics. The seasonality of and short-term impact of meteorological factors on OID were examined using an additive decomposition model and a generalized additive model. Geographical weighted regression and generalized linear mixed model were used to identify potential risk factors. Results: A total of 388,636 OID cases were recorded in Fujian Province from January 2005 to December 2021, with an average annual incidence of 60.3 (SD 16.7) per 100,000 population. Children aged <2 years accounted for 50.7% (196,905/388,636) of all cases. There was a steady increase in OID from 2005 to 2017 and a clear seasonal shift in OID cases from autumn to winter and spring between 2005 and 2020. Higher maximum temperature, atmospheric pressure, humidity, and precipitation were linked to a higher number of deseasonalized OID cases. The spatial and temporal aggregations were concentrated in Zhangzhou City and Xiamen City for 17 study years. Furthermore, the clustered areas exhibited a dynamic spreading trend, expanding from the southernmost Fujian to the southeast and then southward over time. Factors such as densely populated areas with a large <1-year-old population, less economically developed areas, and higher pollution levels contributed to OID cases in Fujian Province. Conclusions: This study revealed a distinct distribution of OID incidence across different population groups, seasons, and regions in Fujian Province. Zhangzhou City and Xiamen City were identified as the major hot spots for OID. Therefore, prevention and control efforts should prioritize these specific hot spots and highly susceptible groups. %M 38032713 %R 10.2196/45870 %U https://publichealth.jmir.org/2023/1/e45870 %U https://doi.org/10.2196/45870 %U http://www.ncbi.nlm.nih.gov/pubmed/38032713 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 9 %N %P e41207 %T Association Among Household Water, Sanitation, and Hygiene (WASH) Status and Typhoid Risk in Urban Slums: Prospective Cohort Study in Bangladesh %A Tadesse,Birkneh Tilahun %A Khanam,Farhana %A Ahmmed,Faisal %A Liu,Xinxue %A Islam,Md Taufiqul %A Kim,Deok Ryun %A Kang,Sophie SY %A Im,Justin %A Chowdhury,Fahima %A Ahmed,Tasnuva %A Aziz,Asma Binte %A Hoque,Masuma %A Park,Juyeon %A Pak,Gideok %A Jeon,Hyon Jin %A Zaman,Khalequ %A Khan,Ashraful Islam %A Kim,Jerome H %A Marks,Florian %A Qadri,Firdausi %A Clemens,John D %+ Epidemiology, Public Health, Impact Unit, International Vaccine Institute, SNU Research Park, 1 Gwanak-ro, Gwanak-gu, Seoul, 08826, Republic of Korea, 82 1098041348, birkneh.tadesse@ivi.int %K water %K sanitation %K sanitary %K contaminated %K contamination %K hygiene %K hygienic %K WASH %K water, sanitation and hygiene %K typhoid fever %K enteric fever %K typhus %K typhoid %K enteric %K salmonella %K protection %K recursive partitioning %K Bangladesh %K low- and middle-income countries %K LMIC %K bacteria %K bacterial %K bacterial infection %K machine learning %K algorithm %K algorithms %K model %K low income %K slum %K slums %K risk %K infection control %K incidence %K prevalence %K epidemiology %K epidemiological %K poverty %D 2023 %7 20.11.2023 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Typhoid fever, or enteric fever, is a highly fatal infectious disease that affects over 9 million people worldwide each year, resulting in more than 110,000 deaths. Reduction in the burden of typhoid in low-income countries is crucial for public health and requires the implementation of feasible water, sanitation, and hygiene (WASH) interventions, especially in densely populated urban slums. Objective: In this study, conducted in Mirpur, Bangladesh, we aimed to assess the association between household WASH status and typhoid risk in a training subpopulation of a large prospective cohort (n=98,087), and to evaluate the performance of a machine learning algorithm in creating a composite WASH variable. Further, we investigated the protection associated with living in households with improved WASH facilities and in clusters with increasing prevalence of such facilities during a 2-year follow-up period. Methods: We used a machine learning algorithm to create a dichotomous composite variable (“Better” and “Not Better”) based on 3 WASH variables: private toilet facility, safe drinking water source, and presence of water filter. The algorithm was trained using data from the training subpopulation and then validated in a distinct subpopulation (n=65,286) to assess its sensitivity and specificity. Cox regression models were used to evaluate the protective effect of living in “Better” WASH households and in clusters with increasing levels of “Better” WASH prevalence. Results: We found that residence in households with improved WASH facilities was associated with a 38% reduction in typhoid risk (adjusted hazard ratio=0.62, 95% CI 0.49-0.78; P<.001). This reduction was particularly pronounced in individuals younger than 10 years at the first census participation, with an adjusted hazard ratio of 0.49 (95% CI 0.36-0.66; P<.001). Furthermore, we observed an inverse relationship between the prevalence of “Better” WASH facilities in clusters and the incidence of typhoid, although this association was not statistically significant in the multivariable model. Specifically, the adjusted hazard of typhoid decreased by 0.996 (95% CI 0.986-1.006) for each percent increase in the prevalence of “Better” WASH in the cluster (P=.39). Conclusions: Our findings demonstrate that existing variations in household WASH are associated with differences in the risk of typhoid in densely populated urban slums. This suggests that attainable improvements in WASH facilities can contribute to enhanced typhoid control, especially in settings where major infrastructural improvements are challenging. These findings underscore the importance of implementing and promoting comprehensive WASH interventions in low-income countries as a means to reduce the burden of typhoid and improve public health outcomes in vulnerable populations. %M 37983081 %R 10.2196/41207 %U https://publichealth.jmir.org/2023/1/e41207 %U https://doi.org/10.2196/41207 %U http://www.ncbi.nlm.nih.gov/pubmed/37983081 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 9 %N %P e41568 %T The Relationship Between Soil-Transmitted Helminth Infections and Environmental Factors in Puerto Iguazú, Argentina: Cross-Sectional Study %A Candela,Ernesto %A Goizueta,Carolina %A Sandon,Leonardo %A Muñoz-Antoli,Carla %A Periago,Maria Victoria %+ Department of Pharmacy Pharmaceutical Technology and Parasitology, Universitat de València, C/ Vicent Andres Estelles s/n, Burjassot, 46100, Spain, 34 653313156, ercansen@alumni.uv.es %K soil-transmitted helminths %K hookworm %K prevalence %K intensity: distribution: Iguazú %K Argentina %D 2023 %7 7.11.2023 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Soil-transmitted helminths (STHs) are widely distributed throughout the world. Various factors, including the environment, socioeconomic characteristics, and access to water and sanitation, play an important role in the spread and persistence of these parasites within communities. They, in turn, affect the growth and development of members of the community, especially children. Studies in the northern provinces of Argentina have shown variable prevalence of STHs, but the factors associated with their presence have not been completely elucidated. Objective: This cross-sectional study aimed to identify the socioeconomic and environmental factors related to STH infection in indigenous villages located in Puerto Iguazú (Misiones), Argentina. Methods: Between 2018 and 2019, stool samples were collected from individuals ≥1 year residing in 3 villages: Mini-Marangatú, Yriapú, and Fortín Mbororé. Standard parasitological methods were used to determine STH prevalence. Standardized questionnaires were used to assess participants’ habits, customs, and household characteristics, and environmental data were obtained through satellite imagery. Multilinear regression with Akaike information criterion stepwise variables was used to explore relevant associations. Results: A total of 342 individuals from the 3 villages participated in this study. The prevalence of STHs varied across villages: 89.6% (43/48), in Mini-Marangatú, 80.8% (101/125) in Yriapú, and 68.5% (115/169) in Fortín Mbororé. Notably, there was a significant difference in hookworm infection among the villages (P=.02). The analysis highlighted the significant influence of specific environmental factors on STH presence and spatial distribution, particularly in relation to hookworm infection. Vegetation patterns represented by the Vegetation Heterogeneity Index, created ad hoc for this study, emerged as a critical factor, with 2 significant predictors related to it (P=.002 and P=.004) alongside impervious surface density with a significant predictor (P<.001). The multilinear regression model yielded a high F test score (F108=4.75, P<.001), indicating a strong fit (R2=0.5465). Furthermore, socioeconomic factors, including walking barefoot in houses with dirt floors and overcrowding, were significantly correlated with hookworm infection intensity (P<.001 and P=.001, respectively). We also used the multilinear regression model to calculate hookworm infection intensity (F110=21.15, P<.001; R2=0.4971). Conclusions: Our study underscores the complexity of STH transmission, as villages with similar living conditions and environmental characteristics displayed varied STH prevalence and spatial distribution. Specific environmental factors, such as vegetation pattern and impervious surface density, played major roles in STH presence, demonstrating the crucial relationship between environmental factors and hookworm infection distribution. Moreover, our findings emphasize the significant influence of socioeconomic factors on hookworm infection intensity. By gaining insights into this complex interplay, our research contributes to a better understanding of STH transmission characteristics, thereby informing targeted public health interventions for effective control. %M 37934580 %R 10.2196/41568 %U https://publichealth.jmir.org/2023/1/e41568 %U https://doi.org/10.2196/41568 %U http://www.ncbi.nlm.nih.gov/pubmed/37934580 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e45353 %T Analysis of Wastewater Samples to Explore Community Substance Use in the United States: Pilot Correlative and Machine Learning Study %A Severson,Marie A %A Onanong,Sathaporn %A Dolezal,Alexandra %A Bartelt-Hunt,Shannon L %A Snow,Daniel D %A McFadden,Lisa M %+ Division of Basic Biomedical Sciences, University of South Dakota, 414 E. Clark St., Vermillion, SD, 57069, United States, 1 605 658 6436, lisa.mcfadden@usd.edu %K methamphetamine %K opioids %K substance use disorder %K wastewater-based surveillance %K drug detection %K pilot study %K substance use %K detecting %K monitoring %K drugs %K surveillance %K community %D 2023 %7 26.10.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Substance use disorder and associated deaths have increased in the United States, but methods for detecting and monitoring substance use using rapid and unbiased techniques are lacking. Wastewater-based surveillance is a cost-effective method for monitoring community drug use. However, the examination of the results often focuses on descriptive analysis. Objective: The objective of this study was to explore community substance use in the United States by analyzing wastewater samples. Geographic differences and commonalities of substance use were explored. Methods: Wastewater was sampled across the United States (n=12). Selected drugs with misuse potential, prescriptions, and over-the-counter drugs and their metabolites were tested across geographic locations for 7 days. Methods used included wastewater assessment of substances and metabolites paired with machine learning, specifically discriminant analysis and cluster analysis, to explore similarities and differences in wastewater measures. Results: Geographic variations in the wastewater drug or metabolite levels were found. Results revealed a higher use of methamphetamine (z=–2.27, P=.02) and opioids-to-methadone ratios (oxycodone-to-methadone: z=–1.95, P=.05; hydrocodone-to-methadone: z=–1.95, P=.05) in states west of the Mississippi River compared to the east. Discriminant analysis suggested temazepam and methadone were significant predictors of geographical locations. Precision, sensitivity, specificity, and F1-scores were 0.88, 1, 0.80, and 0.93, respectively. Finally, cluster analysis revealed similarities in substance use among communities. Conclusions: These findings suggest that wastewater-based surveillance has the potential to become an effective form of surveillance for substance use. Further, advanced analytical techniques may help uncover geographical patterns and detect communities with similar needs for resources to address substance use disorders. Using automated analytics, these advanced surveillance techniques may help communities develop timely, tailored treatment and prevention efforts. %M 37883150 %R 10.2196/45353 %U https://formative.jmir.org/2023/1/e45353 %U https://doi.org/10.2196/45353 %U http://www.ncbi.nlm.nih.gov/pubmed/37883150 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 9 %N %P e41862 %T Mortality Risk and Burden From a Spectrum of Causes in Relation to Size-Fractionated Particulate Matters: Time Series Analysis %A Yang,Jun %A Dong,Hang %A Yu,Chao %A Li,Bixia %A Lin,Guozhen %A Chen,Sujuan %A Cai,Dongjie %A Huang,Lin %A Wang,Boguang %A Li,Mengmeng %+ State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, No 651 Dongfeng East Road, Guangzhou 510060, Guangzhou, 510060, China, 86 020 87345679, limm@sysucc.org.cn %K size-fractionated particulate matter %K cause-specific mortality %K cardiovascular disease %K respiratory disease %K neoplasm %K attributable burden %D 2023 %7 9.10.2023 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: There is limited evidence regarding the adverse impact of particulate matters (PMs) on multiple body systems from both epidemiological and mechanistic studies. The association between size-fractionated PMs and mortality risk, as well as the burden of a whole spectrum of causes of death, remains poorly characterized. Objective: We aimed to examine the wide range of susceptible diseases affected by different sizes of PMs. We also assessed the association between PMs with an aerodynamic diameter less than 1 µm (PM1), 2.5 µm (PM2.5), and 10 µm (PM10) and deaths from 36 causes in Guangzhou, China. Methods: Daily data were obtained on cause-specific mortality, PMs, and meteorology from 2014 to 2016. A time-stratified case-crossover approach was applied to estimate the risk and burden of cause-specific mortality attributable to PMs after adjusting for potential confounding variables, such as long-term trend and seasonality, relative humidity, temperature, air pressure, and public holidays. Stratification analyses were further conducted to explore the potential modification effects of season and demographic characteristics (eg, gender and age). We also assessed the reduction in mortality achieved by meeting the new air quality guidelines set by the World Health Organization (WHO). Results: Positive and monotonic associations were generally observed between PMs and mortality. For every 10 μg/m3 increase in 4-day moving average concentrations of PM1, PM2.5, and PM10, the risk of all-cause mortality increased by 2.00% (95% CI 1.08%-2.92%), 1.54% (95% CI 0.93%-2.16%), and 1.38% (95% CI 0.95%-1.82%), respectively. Significant effects of size-fractionated PMs were observed for deaths attributed to nonaccidental causes, cardiovascular disease, respiratory disease, neoplasms, chronic rheumatic heart diseases, hypertensive diseases, cerebrovascular diseases, stroke, influenza, and pneumonia. If daily concentrations of PM1, PM2.5, and PM10 reached the WHO target levels of 10, 15, and 45 μg/m3, 7921 (95% empirical CI [eCI] 4454-11,206), 8303 (95% eCI 5063-11,248), and 8326 (95% eCI 5980-10690) deaths could be prevented, respectively. The effect estimates of PMs were relatively higher during hot months, among female individuals, and among those aged 85 years and older, although the differences between subgroups were not statistically significant. Conclusions: We observed positive and monotonical exposure-response curves between PMs and deaths from several diseases. The effect of PM1 was stronger on mortality than that of PM2.5 and PM10. A substantial number of premature deaths could be preventable by adhering to the WHO’s new guidelines for PMs. Our findings highlight the importance of a size-based strategy in controlling PMs and managing their health impact. %M 37812487 %R 10.2196/41862 %U https://publichealth.jmir.org/2023/1/e41862 %U https://doi.org/10.2196/41862 %U http://www.ncbi.nlm.nih.gov/pubmed/37812487 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 9 %N %P e49652 %T Association Between Urinary Bisphenols and Body Composition Among American Adults: Cross-Sectional National Health and Nutrition Examination Survey Study %A Li,Jiakun %A Zhang,Zilong %A Zhang,Chichen %A Zhu,Qiyu %A Zhao,Jing %A Zong,Hui %A Deng,Qi %A Zheng,Jiaming %A Wu,Erman %A Wu,Rongrong %A Tang,Tong %A Zhang,Yihang %A Dong,Qiaosen %A Li,Yifan %A Wang,Jiao %A Yang,Lu %A Qiu,Shi %A Shen,Bairong %A Wei,Qiang %+ Department of Urology, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, Sichuan, P.R., Chengdu, China, 86 18980601425, weiqiang933@126.com %K bisphenols %K body composition %K environmental pollutants %K public health %K medical informatics %D 2023 %7 19.9.2023 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Bisphenol A (BPA), bisphenol S (BPS), and bisphenol F (BPF) are widely used in various consumer products. They are environmental contaminants with estrogenic properties that have been linked to various health outcomes. Understanding their impact on body composition is crucial for identifying potential health risks and developing preventive strategies. However, most current studies have only focused on their relationship with BMI. Objective: This study aimed to investigate the association between urinary levels of BPA, BPS, and BPF and body composition, including BMI, lean mass, and fat mass, in a large population-based sample. Methods: We conducted a cross-sectional analysis using data from the National Health and Nutrition Examination Survey 2003-2016. Body composition data were assessed using dual-energy X-ray absorptiometry, which provided precise measurements of lean mass, fat mass, and other indicators. We used multivariate linear regression models to estimate the associations, adjusting for potential confounders such as age, gender, race, socioeconomic factors, and lifestyle variables. Results: The results revealed significant associations between bisphenol exposure and body composition. After adjusting for covariates, BPS showed a positive association with BMI, with quartiles 3 and 4 having 0.91 (95% CI 0.34-1.48) and 1.15 (95% CI 0.55-1.74) higher BMI, respectively, compared with quartile 1 (P<.001). BPA was negatively associated with total lean mass (TLM) and appendicular lean mass, with quartiles 2, 3, and 4 having –7.85 (95% CI –11.44 to –4.25), –12.33 (95% CI –16.12 to –8.54), and –11.08 (95% CI –15.16 to –7.01) lower TLM, respectively, compared with quartile 1 (P<.001). BPS was negatively associated with TLM, with quartiles 3 (β=–10.53, 95% CI –16.98 to –4.08) and 4 (β=–11.14, 95% CI –17.83 to –4.45) having significantly lower TLM (P=.005). Both BPA and BPS showed a positive dose-response relationship with trunk fat (BPA: P=.002; BPS: P<.001) and total fat (BPA: P<.001; BPS: P=.01). No significant association was found between BPF and any body composition parameter. Conclusions: This large-sample study highlights the associations between urinary levels of BPA and BPS and alterations in body composition, including changes in lean mass, fat mass, and regional fat distribution. These findings underscore the importance of understanding the potential health risks associated with bisphenol exposure and emphasize the need for targeted interventions to mitigate adverse effects on body composition. %M 37615638 %R 10.2196/49652 %U https://publichealth.jmir.org/2023/1/e49652 %U https://doi.org/10.2196/49652 %U http://www.ncbi.nlm.nih.gov/pubmed/37615638 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 9 %N %P e47403 %T Joint Effects of Long-Term Exposure to Ambient Fine Particulate Matter and Ozone on Asthmatic Symptoms: Prospective Cohort Study %A Xu,Jiahong %A Shi,Yan %A Chen,Gongbo %A Guo,Yanfei %A Tang,Weiling %A Wu,Cuiling %A Liang,Shuru %A Huang,Zhongguo %A He,Guanhao %A Dong,Xiaomei %A Cao,Ganxiang %A Yang,Pan %A Lin,Ziqiang %A Zhu,Sui %A Wu,Fan %A Liu,Tao %A Ma,Wenjun %+ Department of Public Health and Preventive Medicine, School of Medicine, Jinan University, No.601 West, Huangpu Road, Tianhe District, Guangzhou, 510632, China, 86 13826026605, gztt_2002@163.com %K asthma %K joint association %K ozone %K PM2.5 %K population attributable fraction %K air pollution %K long-term exposure %D 2023 %7 3.8.2023 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: The associations of long-term exposure to air pollutants in the presence of asthmatic symptoms remain inconclusive and the joint effects of air pollutants as a mixture are unclear. Objective: We aimed to investigate the individual and joint associations of long-term exposure to ambient fine particulate matter (PM2.5) and daily 8-hour maximum ozone concentrations (MDA8 O3) in the presence of asthmatic symptoms in Chinese adults. Methods: Data were derived from the World Health Organization Study on Global Ageing and Adult Health (WHO SAGE) cohort study among adults aged 50 years or older, which was implemented in 1 municipality and 7 provinces across China during 2007-2018. Annual average MDA8 O3 and PM2.5 at individual residential addresses were estimated by an iterative random forest model and a satellite-based spatiotemporal model, respectively. Participants who were diagnosed with asthma by a doctor or taking asthma-related therapies or experiencing related conditions within the past 12 months were recorded as having asthmatic symptoms. The individual associations of PM2.5 and MDA8 O3 with asthmatic symptoms were estimated by a Cox proportional hazards regression model, and the joint association was estimated by a quantile g-computation model. A series of subgroup analyses was applied to examine the potential modifications of some characteristics. We also calculated the population-attributable fraction (PAF) of asthmatic symptoms attributed to PM2.5 and MDA8 O3. Results: A total of 8490 adults older than 50 years were included, and the average follow-up duration was 6.9 years. During the follow-up periods, 586 (6.9%) participants reported asthmatic symptoms. Individual effect analyses showed that the risk of asthmatic symptoms was positively associated with MDA8 O3 (hazard ratio [HR] 1.12, 95% CI 1.01-1.24, for per quantile) and PM2.5 (HR 1.18, 95% CI 1.05-1.31, for per quantile). Joint effect analyses showed that per equal quantile increment of MDA8 O3 and PM2.5 was associated with an 18% (HR 1.18, 95% CI 1.05-1.33) increase in the risk of asthmatic symptoms, and PM2.5 contributed more (68%) in the joint effects. The individual PAFs of asthmatic symptoms attributable to PM2.5 and MDA8 O3 were 2.86% (95% CI 0.17%-5.50%) and 4.83% (95% CI 1.42%-7.25%), respectively, while the joint PAF of asthmatic symptoms attributable to exposure mixture was 4.32% (95% CI 1.10%-7.46%). The joint associations were greater in participants with obesity, in urban areas, with lower family income, and who used unclean household cooking fuel. Conclusions: Long-term exposure to PM2.5 and MDA8 O3 may individually and jointly increase the risk of asthmatic symptoms, and the joint effects were smaller than the sum of individual effects. These findings informed the importance of joint associations of long-term exposure to air pollutants with asthma. %M 37535415 %R 10.2196/47403 %U https://publichealth.jmir.org/2023/1/e47403 %U https://doi.org/10.2196/47403 %U http://www.ncbi.nlm.nih.gov/pubmed/37535415 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 9 %N %P e43914 %T The Association Between Solid Fuel Use and Visual Impairment Among Middle-Aged and Older Chinese Adults: Nationwide Population-Based Cohort Study %A Jiang,Qingqing %A Wang,Shiqi %A Zhang,Hao %A Guo,Yan %A Lou,Yiling %A Huang,Shen %A You,Qiqi %A Cao,Shiyi %+ School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, No 13 Hangkong Road, Wuhan, 430030, China, 86 027 83657984, caoshiyi@hust.edu.cn %K indoor air pollution %K solid fuel %K visual impairment %K cohort study %K Chinese %D 2023 %7 26.7.2023 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Indoor air pollution has been reported to have adverse effects on the eye; however, the health effects of exposure to cooking with solid fuels on visual impairment remain unclear in China. Objective: We aimed to examine the association between cooking with solid fuels and visual impairment, including distance visual impairment (DVI) and near visual impairment (NVI). Methods: Data were obtained from the China Health and Retirement Longitudinal Study, a nationwide survey of adults aged over 45 years who were enrolled in 2011 (Wave 1) and followed up in Wave 2 (2013), Wave 3 (2015), and Wave 4 (2018). We used Cox proportional hazards models to determine the association between solid fuels use and visual impairment. Additionally, the impact of switching cooking fuel types on vision function were examined through wave-specific data analysis (Wave 1 and Wave 4). Interaction and subgroup analyses were performed to explore the potential effect modifiers. Data were collected using the stratified multistage random sampling method and further analyzed using SPSS 27.0 and R 4.2.1 statistical software packages. Results: A total of 9559 middle-aged and older Chinese adults without visual impairment at baseline were included in the study, with 51.2% (n=4914) of the participants reporting that they cooked with solid fuels. During the follow-up period, 2644 (27.5%) and 3130 (32.6%) participants developed DVI and NVI, respectively. Compared with the clean fuel users, participants who cooked with solid fuels had a higher risk of DVI (hazards ratio [HR] 1.38, 95% CI 1.28-1.50) and NVI (HR 1.18, 95% CI 1.10-1.27). In addition, switching the cooking fuel type from clean to solid fuels was associated with an elevated risk of DVI (HR 1.51, 95% CI 1.15-1.98) and NVI (HR 1.39, 95% CI 1.06-1.82) compared to persistently using clean fuels during the follow-up period, although no protective effect of switching from solid to clean fuels on NVI was found (P=.52). In subgroup analysis, we found that cooking with solid fuels increased the risk of DVI in participants younger than 65 years (HR 1.41, 95% CI 1.28-1.55), men (HR 1.45, 95% CI 1.28-1.65), urban residents (HR 1.41, 95% CI 1.08-1.75), and smokers (HR 1.43, 95% CI 1.25-1.64). By contrast, negative effects of cooking with solid fuels on NVI were found in nonsmokers (HR 1.21, 95% CI 1.11-1.33) and urban residents (HR 1.20, 95% CI 1.10-1.37). Conclusions: Cooking with solid fuels was associated with an increased risk of visual impairment among middle-aged and older Chinese adults. These findings indicate that promoting the utilization of clean fuels is conducive to reducing the burden of visual impairment for the public. %M 37494091 %R 10.2196/43914 %U https://publichealth.jmir.org/2023/1/e43914 %U https://doi.org/10.2196/43914 %U http://www.ncbi.nlm.nih.gov/pubmed/37494091 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 9 %N %P e46792 %T The Combined Effects of Short-Term Exposure to Multiple Meteorological Factors on Unintentional Drowning Mortality: Large Case-Crossover Study %A Liu,Yingyin %A Dong,Xiaomei %A Li,Zhixing %A Zhu,Sui %A Lin,Ziqiang %A He,Guanhao %A Gong,Weiwei %A Hu,Jianxiong %A Hou,Zhulin %A Meng,Ruilin %A Zhou,Chunliang %A Yu,Min %A Huang,Biao %A Lin,Lifeng %A Xiao,Jianpeng %A Zhong,Jieming %A Jin,Donghui %A Xu,Yiqing %A Lv,Lingshuang %A Huang,Cunrui %A Liu,Tao %A Ma,Wenjun %+ Department of Public Health and Preventive Medicine, School of Medicine, Jinan University, 601 West Huangpu Avenue, Tianhe District, Guangzhou, 510632, China, 86 13622280436, mawj@gdiph.org.cn %K drowning %K exposure mixture %K quantile g-computation %K environmental epidemiology %K meteorological factor %D 2023 %7 20.7.2023 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Drowning is a serious public health problem worldwide. Previous epidemiological studies on the association between meteorological factors and drowning mainly focused on individual weather factors, and the combined effect of mixed exposure to multiple meteorological factors on drowning is unclear. Objective: We aimed to investigate the combined effects of multiple meteorological factors on unintentional drowning mortality in China and to identify the important meteorological factors contributing to drowning mortality. Methods: Unintentional drowning death data (based on International Classification of Diseases, 10th Edition, codes W65-74) from January 1, 2013, to December 31, 2018, were collected from the Disease Surveillance Points System for Guangdong, Hunan, Zhejiang, Yunnan, and Jilin Provinces, China. Daily meteorological data, including daily mean temperature, relative humidity, sunlight duration, and rainfall in the same period were obtained from the Chinese Academy of Meteorological Science Data Center. We constructed a time-stratified case-crossover design and applied a generalized additive model to examine the effect of individual weather factors on drowning mortality, and then used quantile g-computation to estimate the joint effect of the mixed exposure to meteorological factors. Results: A total of 46,179 drowning deaths were reported in the 5 provinces in China from 2013 to 2018. In an effect analysis of individual exposure, we observed a positive effect for sunlight duration, a negative effect for relative humidity, and U-shaped associations for temperature and rainfall with drowning mortality. In a joint effect analysis of the above 4 meteorological factors, a 2.99% (95% CI 0.26%-5.80%) increase in drowning mortality was observed per quartile rise in exposure mixture. For the total population, sunlight duration was the most important weather factor for drowning mortality, with a 93.1% positive contribution to the overall effects, while rainfall was mainly a negative factor for drowning deaths (90.5%) and temperature and relative humidity contributed 6.9% and –9.5% to the overall effects, respectively. Conclusions: This study found that mixed exposure to temperature, relative humidity, sunlight duration, and rainfall was positively associated with drowning mortality and that sunlight duration, rather than temperature, may be the most important meteorological factor for drowning mortality. These findings imply that it is necessary to incorporate sunshine hours and temperature into early warning systems for drowning prevention in the future. %M 37471118 %R 10.2196/46792 %U https://publichealth.jmir.org/2023/1/e46792 %U https://doi.org/10.2196/46792 %U http://www.ncbi.nlm.nih.gov/pubmed/37471118 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 9 %N %P e47022 %T Associations Between Hourly Ambient Particulate Matter Air Pollution and Ambulance Emergency Calls: Time-Stratified Case-Crossover Study %A Zhou,Qiang %A Shi,Hanxu %A Wu,Rengyu %A Zhu,Hong %A Qin,Chongzhen %A Liang,Zhisheng %A Sun,Shengzhi %A Zhao,Junfeng %A Wang,Yasha %A Huang,Jie %A Jin,Yinzi %A Zheng,Zhijie %A Li,Jingyan %A Zhang,Zhenyu %+ Department of Global Health, Peking University School of Public Health, Southern University of Science and Technology, Beijing, 100191, China, 86 13681165303, zzy@pku.edu.cn %K particulate matter air pollution %K ambulance emergency calls %K AECs %K environmental epidemiology %K public health %K air pollution %K environmental data %K patient data %D 2023 %7 20.6.2023 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Associations between short-term exposure to ambient particulate matter (PM) air pollutants and mortality or hospital admissions have been well-documented in previous studies. Less is known about the associations of hourly exposure to PM air pollutants with ambulance emergency calls (AECs) for all causes and specific causes by conducting a case-crossover study. In addition, different patterns of AECs may be attributed to different seasons and daytime or nighttime periods. Objective: In this study, we quantified the risk of all-cause and cause-specific AECs associated with hourly PM air pollutants between January 1, 2013, and December 31, 2019, in Shenzhen, China. We also examined whether the observed associations of PM air pollutants with AECs for all causes differed across strata defined by sex, age, season, and the time of day. Methods: We used ambulance emergency dispatch data and environmental data between January 1, 2013, and December 31, 2019, from the Shenzhen Ambulance Emergency Centre and the National Environmental Monitor Station to conduct a time-stratified case-crossover study to estimate the associations of air pollutants (ie, PM with an aerodynamic diameter less than 2.5 µm [PM2.5] or 10 µm [PM10]) with all-cause and cause-specific AECs. We generated a well-established, distributed lag nonlinear model for nonlinear concentration response and nonlinear lag-response functions. We used conditional logistic regression to estimate odds ratios with 95% CIs, adjusted for public holidays, season, the time of day, the day of the week, hourly temperature, and hourly humidity, to examine the association of all-cause and cause-specific AECs with hourly air pollutant concentrations. Results: A total of 3,022,164 patients were identified during the study period in Shenzhen. Each IQR increase in PM2.5 (24.0 µg/m3) and PM10 (34.0 µg/m3) concentrations over 24 hours was associated with an increased risk of AECs (PM2.5: all-cause, 1.8%, 95% CI 0.8%-2.4%; PM10: all-cause, 2.0%, 95% CI 1.1%-2.9%). We observed a stronger association of all-cause AECs with PM2.5 and PM10 in the daytime than in the nighttime (PM2.5: daytime, 1.7%, 95% CI 0.5%-3.0%; nighttime, 1.4%, 95% CI 0.3%-2.6%; PM10: daytime, 2.1%, 95% CI 0.9%-3.4%; nighttime, 1.7%, 95% CI 0.6%-2.8%) and in the older group than in the younger group (PM2.5: 18-64 years, 1.4%, 95% CI 0.6%-2.1%; ≥65 years, 1.6%, 95% CI 0.6%-2.6%; PM10: 18-64 years, 1.8%, 95% CI 0.9%-2.6%; ≥65 years, 2.0%, 95% CI 1.1%-3.0%). Conclusions: The risk of all-cause AECs increased consistently with increasing concentrations of PM air pollutants, showing a nearly linear relationship with no apparent thresholds. PM air pollution increase was associated with a higher risk of all-cause AECs and cardiovascular diseases–, respiratory diseases–, and reproductive illnesses–related AECs. The results of this study may be valuable to air pollution attributable to the distribution of emergency resources and consistent air pollution control. %M 37243735 %R 10.2196/47022 %U https://publichealth.jmir.org/2023/1/e47022 %U https://doi.org/10.2196/47022 %U http://www.ncbi.nlm.nih.gov/pubmed/37243735 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 9 %N %P e45199 %T Periodic Characteristics of Hepatitis Virus Infections From 2013 to 2020 and Their Association With Meteorological Factors in Guangdong, China: Surveillance Study %A Zhao,Xixi %A Li,Meijia %A Haihambo,Naem %A Wang,Xinni %A Wang,Bin %A Sun,Meirong %A Guo,Mingrou %A Han,Chuanliang %+ The Brain Cognition and Brain Disease Institute, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, 1068 Xueyuan Avenue Shenzhen University Town, Nanshan District, Shenzhen, 518055, China, 86 18800129802, hanchuanliang2014@163.com %K hepatitis virus %K meteorological factors %K epidemics %K recrudescence %K public health %D 2023 %7 15.6.2023 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: In the past few decades, liver disease has gradually become one of the major causes of death and illness worldwide. Hepatitis is one of the most common liver diseases in China. There have been intermittent and epidemic outbreaks of hepatitis worldwide, with a tendency toward cyclical recurrences. This periodicity poses challenges to epidemic prevention and control. Objective: In this study, we aimed to investigate the relationship between the periodic characteristics of the hepatitis epidemic and local meteorological elements in Guangdong, China, which is a representative province with the largest population and gross domestic product in China. Methods: Time series data sets from January 2013 to December 2020 for 4 notifiable infectious diseases caused by hepatitis viruses (ie, hepatitis A, B, C, and E viruses) and monthly data of meteorological elements (ie, temperature, precipitation, and humidity) were used in this study. Power spectrum analysis was conducted on time series data, and correlation and regression analyses were performed to assess the relationship between the epidemics and meteorological elements. Results: The 4 hepatitis epidemics showed clear periodic phenomena in the 8-year data set in connection with meteorological elements. Based on the correlation analysis, temperature demonstrated the strongest correlation with hepatitis A, B, and C epidemics, while humidity was most significantly associated with the hepatitis E epidemic. Regression analysis revealed a positive and significant coefficient between temperature and hepatitis A, B, and C epidemics in Guangdong, while humidity had a strong and significant association with the hepatitis E epidemic, and its relationship with temperature was relatively weak. Conclusions: These findings provide a better understanding of the mechanisms underlying different hepatitis epidemics and their connection to meteorological factors. This understanding can help guide local governments in predicting and preparing for future epidemics based on weather patterns and potentially aid in the development of effective prevention measures and policies. %M 37318858 %R 10.2196/45199 %U https://publichealth.jmir.org/2023/1/e45199 %U https://doi.org/10.2196/45199 %U http://www.ncbi.nlm.nih.gov/pubmed/37318858 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e41627 %T Indigenous Food Systems Changes and Resiliency: Protocol for a Scoping Review %A Monteith,Hiliary %A Hiscock,Elizabeth Claire %A Sadeghi,Yasamin %A Smith,Emily V %A Mashford-Pringle,Angela %+ Department of Nutritional Sciences, University of Toronto, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada, 1 4168869242, hiliary.monteith@gmail.com %K Indigenous %K food systems %K Indigenous health %K scoping review %K traditional foods %K colonization %K climate change %K pollution %K environment %D 2023 %7 21.4.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Indigenous food systems (IFS) consider the complex relationships and connections between land, animals, plants, water, and people. These food systems may differ between regions, Indigenous cultures, and history; however, given the similar colonial histories and policies influencing Indigenous groups in Canada, the United States, Australia, and Aotearoa (New Zealand), the IFS changes and responses in these regions may follow similar trends. Climate change and pollution continue to impact the environment in catastrophic ways, and this, in turn, impacts IFS. However, to date, there has been no review of the literature on IFS, how they are changing, and how communities are responding to these changes. Objective: In this scoping review, we will summarize primary research in Canada, the United States, Australia, and Aotearoa related to IFS addressing the following questions: (1) What changes are IFS experiencing in the context of climate change and pollution? (2) What actions have been taken in response to IFS changes? (3) What are the characteristics of IFS research in peer-reviewed academic literature? Methods: We will use the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for scoping reviews and the Joanna Briggs Institute reviewer’s manual to inform the review process. MEDLINE, SCOPUS, International Bibliography of the Social Sciences, Sociological Abstracts, and the Bibliography of Native North Americans are the databases included in this review search. All screening and extraction have been supported by Covidence software (Veritas Health Innovation) with 2 independent reviewers conducting the abstract and full-text screening. We will map concepts and themes related to the research questions to contribute to the understanding of IFS within the academic literature and provide a narrative review of the outcomes. Results: The electronic database searches for this review were conducted in May 2021. Screening and full-text review were initially completed in the winter of 2022. We are currently in the process of compiling results and aim to share findings in 2023. Conclusions: This review will provide valuable insight into current IFS needs by summarizing the peer-reviewed literature on how IFS are changing because of climate change and pollution and how communities are responding to these changes. The results of this review will be shared with Indigenous communities, through academic publications, community conversations, and conference presentations. Trial Registration: OSF Registries osf.io/xrj87; https://osf.io/xrj87 International Registered Report Identifier (IRRID): RR1-10.2196/41627 %M 37083598 %R 10.2196/41627 %U https://www.researchprotocols.org/2023/1/e41627 %U https://doi.org/10.2196/41627 %U http://www.ncbi.nlm.nih.gov/pubmed/37083598 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 9 %N %P e44070 %T The Association Between Social Determinants of Health and Population Health Outcomes: Ecological Analysis %A Vo,Ace %A Tao,Youyou %A Li,Yan %A Albarrak,Abdulaziz %+ Information Systems and Business Analytics Department, Loyola Marymount University, 1 Loyola Marymount University Dr, Los Angeles, CA, 90045, United States, 1 3103384522, ace.vo@lmu.edu %K social determinants of health %K public policy %K health outcomes %K policy recommendation %K cities %D 2023 %7 29.3.2023 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: With the increased availability of data, a growing number of studies have been conducted to address the impact of social determinants of health (SDOH) factors on population health outcomes. However, such an impact is either examined at the county level or the state level in the United States. The results of analysis at lower administrative levels would be useful for local policy makers to make informed health policy decisions. Objective: This study aimed to investigate the ecological association between SDOH factors and population health outcomes at the census tract level and the city level. The findings of this study can be applied to support local policy makers in efforts to improve population health, enhance the quality of care, and reduce health inequity. Methods: This ecological analysis was conducted based on 29,126 census tracts in 499 cities across all 50 states in the United States. These cities were grouped into 5 categories based on their population density and political affiliation. Feature selection was applied to reduce the number of SDOH variables from 148 to 9. A linear mixed-effects model was then applied to account for the fixed effect and random effects of SDOH variables at both the census tract level and the city level. Results: The finding reveals that all 9 selected SDOH variables had a statistically significant impact on population health outcomes for ≥2 city groups classified by population density and political affiliation; however, the magnitude of the impact varied among the different groups. The results also show that 4 SDOH risk factors, namely, asthma, kidney disease, smoking, and food stamps, significantly affect population health outcomes in all groups (P<.01 or P<.001). The group differences in health outcomes for the 4 factors were further assessed using a predictive margin analysis. Conclusions: The analysis reveals that population density and political affiliation are effective delineations for separating how the SDOH affects health outcomes. In addition, different SDOH risk factors have varied effects on health outcomes among different city groups but similar effects within city groups. Our study has 2 policy implications. First, cities in different groups should prioritize different resources for SDOH risk mitigation to maximize health outcomes. Second, cities in the same group can share knowledge and enable more effective SDOH-enabled policy transfers for population health. %M 36989028 %R 10.2196/44070 %U https://publichealth.jmir.org/2023/1/e44070 %U https://doi.org/10.2196/44070 %U http://www.ncbi.nlm.nih.gov/pubmed/36989028 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 9 %N %P e40782 %T Trends in Exposure to Secondhand Smoke Among Adolescents in China From 2013-2014 to 2019: Two Repeated National Cross-sectional Surveys %A Ma,Chuanwei %A Huang,Yayang %A Li,Sixuan %A Zhao,Min %A Zeng,Xinying %A Di,Xinbo %A Magnussen,Costan G %A Xi,Bo %A Liu,Shiwei %+ Tobacco Control Office, Chinese Center for Disease Control and Prevention, 27 Nanwei Road, Beijing, 100050, China, 86 1063185150, shiwei_liu@aliyun.com %K secondhand smoke exposure %K trends %K adolescents %K China %K secondhand smoke %K youth %D 2023 %7 24.3.2023 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: It is well-known that secondhand smoke exposure in childhood or adolescence is positively associated with morbidity and mortality. However, less is known about the current status of and most recent trends in secondhand smoke exposure among adolescents in China. Objective: We aimed to assess recent changes in the prevalence of secondhand smoke exposure among adolescents in China using nationally representative data. Methods: We used data from 2 repeated national cross-sectional surveys conducted in 2013-2014 and 2019. A total of 155,117 students (median age 13.5 years) in 2013-2014 and 147,270 students (median age 13.1 years) in 2019 were included in this study. Sociodemographic factors and secondhand smoke exposure information were collected via a standardized questionnaire. Exposure was defined as secondhand smoke exposure ≥1 day during the past 7 days at home or in public places. Other frequencies of secondhand smoke exposure (ie, ≥3 days, ≥5 days, and every day) during the past 7 days were also assessed. The weighted prevalence of secondhand smoke exposure was calculated according to the complex sample design for surveys. Results: The prevalence of secondhand smoke exposure in any place (home or public places ≥1 day during the past 7 days) decreased from 2013-2014 (72.9%, 95% CI 71.5%-74.3%) to 2019 (63.2%, 95% CI 62%-64.5%), as did exposure at home (2013-2014: 44.4%, 95% CI 43.1%-45.7%; 2019: 34.1%, 95% CI 33.1%-35.2%) and in public places (2013-2014: 68.3%, 95% CI 66.9%-69.6%; 2019: 57.3%, 95% CI 56%-58.6%). The prevalence of secondhand smoke exposure decreased with increased gross domestic product per capita in each of the 2 survey years irrespective of exposure frequency or location. The prevalence of exposure at other frequencies (ie, ≥3 days, ≥5 days, or every day during the past 7 days) also decreased in any place, at home, and in public places. Secondhand smoke exposure was associated with higher school grade level (ninth vs seventh grade: odds ratio [OR] 1.76, 95% CI 1.68-1.84), gender (boys vs girls: OR 1.18, 95% CI 1.15-1.22), urban status (urban vs rural: OR 1.10, 95% CI 1.01-1.19), and cigarette smoking (yes vs no: OR 6.67, 95% CI 5.83-7.62). Conclusions: Although the prevalence of secondhand smoke exposure among Chinese adolescents declined from 2013-2014 to 2019, it remains unacceptably high. More effective strategies and stronger action are needed in China to further, and dramatically, curb secondhand smoke exposure among adolescents. %M 36961497 %R 10.2196/40782 %U https://publichealth.jmir.org/2023/1/e40782 %U https://doi.org/10.2196/40782 %U http://www.ncbi.nlm.nih.gov/pubmed/36961497 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 9 %N %P e41442 %T Risk of De Novo Hypertensive Disorders of Pregnancy After Exposure to PM1 and PM2.5 During the Period From Preconception to Delivery: Birth Cohort Study %A Yuan,Zhichao %A Wang,Hai-Jun %A Li,Qin %A Su,Tao %A Yang,Jie %A Chen,Junjun %A Peng,Yuanzhou %A Zhou,Shuang %A Bao,Heling %A Luo,Shusheng %A Wang,Hui %A Liu,Jue %A Han,Na %A Guo,Yuming %A Ji,Yuelong %+ Department of Maternal and Child Health, School of Public Health, Peking University, 38 Huayuan Road, Haidian District, Beijing, 100089, China, 86 13161989008, yuelong.ji@pku.edu.cn %K air pollution %K PM2.5 %K PM1 %K hypertensive disorders of pregnancy %K preconceptional period %K lag effect %K pregnancy %K hypertension %K hypertensive disorders %K risk %K pollutants %K exposure %K maternal health %K perinatal health %K pollution %D 2023 %7 23.1.2023 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Particulate matter (PM) is detrimental to the respiratory and circulatory systems. However, no study has evaluated the lag effects of weekly exposure to fine PM during the period from preconception to delivery on the risk of hypertensive disorders of pregnancy (HDPs). Objective: We set out to investigate the lag effect windows of PM on the risk of HDPs on a weekly scale. Methods: Data from women with de novo HDPs and normotensive pregnant women who were part of the Peking University Retrospective Birth Cohort, based on the hospital information system of Tongzhou district, were obtained for this study. Meteorological data and data on exposure to fine PM were predicted by satellite remote sensing data based on maternal residential address. The de novo HDP group consisted of pregnant women who were diagnosed with gestational hypertension or preeclampsia. Fine PM was defined as PM2.5 and PM1. The gestational stage of participants was from preconception (starting 12 weeks before gestation) to delivery (before the 42nd gestational week). A distributed-lag nonlinear model (DLNM) was nested in a Cox regression model to evaluate the lag effects of weekly PM exposure on de novo HDP hazard by controlling the nonlinear relationship of exposure–reaction. Stratified analyses by employment status (employed or unemployed), education level (higher or lower), and parity (primiparity or multiparity) were performed. Results: A total of 22,570 pregnant women (mean age 29.1 years) for whom data were available between 2013 and 2017 were included in this study. The prevalence of de novo HDPs was 6.7% (1520/22,570). Our findings showed that PM1 and PM2.5 were significantly associated with an elevated hazard of HDPs. Exposure to PM1 during the 5th week before gestation to the 6th gestational week increased the hazard of HDPs. A significant lag effect of PM2.5 was observed from the 1st week before gestation to the 6th gestational week. The strongest lag effects of PM1 and PM2.5 on de novo HDPs were observed at week 2 and week 6 (hazard ratio [HR] 1.024, 95% CI 1.007-1.042; HR 1.007, 95% CI 1.000-1.015, respectively, per 10 μg/m3 increase). The stratified analyses indicated that pregnant women who were employed, had low education, and were primiparous were more vulnerable to PM exposure for de novo HDPs. Conclusions: Exposure to PM1 and PM2.5 was associated with the risk of de novo HDPs. There were significant lag windows between the preconception period and the first trimester. Women who were employed, had low education, and were primiparous were more vulnerable to the effects of PM exposure; more attention should be paid to these groups for early prevention of de novo HDPs. %M 36689262 %R 10.2196/41442 %U https://publichealth.jmir.org/2023/1/e41442 %U https://doi.org/10.2196/41442 %U http://www.ncbi.nlm.nih.gov/pubmed/36689262 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 9 %N %P e40659 %T The Environmental and Socioeconomic Effects and Prediction of Patients With Tuberculosis in Different Age Groups in Southwest China: A Population-Based Study %A Wei,Wen %A Xia,Lan %A Wu,Jianlin %A Zhou,Zonglei %A Zhang,Wenqiang %A Luan,Rongsheng %+ Department of Epidemiology and Biostatistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, 16#, Section 3, Renmin Nan Lu, Chengdu, 610041, China, 86 028 85501604, luan_rs@scu.edu.cn %K tuberculosis %K risk factors %K age %K sex %K prediction %K TB control %K tuberculosis control %D 2023 %7 13.1.2023 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: While the End Tuberculosis (TB) Strategy has been implemented worldwide, the cause of the TB epidemic is multifactorial and not fully understood. Objective: This study aims to investigate the risk factors of TB and incorporate these factors to forecast the incidence of TB infection across different age groups in Sichuan, China. Methods: Correlation and linear regression analyses were conducted to assess the relationships between TB cases and ecological factors, including environmental, economic, and social factors, in Sichuan Province from 2006 to 2017. The transfer function-noise model was used to forecast trends, considering both time and multifactor effects. Results: From 2006 to 2017, Sichuan Province had a reported cumulative incidence rate of 1321.08 cases per 100,000 individuals in male patients and 583.04 cases per 100,000 individuals in female patients. There were significant sex differences in the distribution of cases among age groups (trend χ225=12,544.4; P<.001). Ganzi Tibetan Autonomous Prefecture had the highest incidence rates of TB in both male and female patients in Sichuan. Correlation and regression analyses showed that the total illiteracy rate and average pressure at each measuring station (for individuals aged 15-24 years) were risk factors for TB. The protective factors were as follows: the number of families with the minimum living standard guarantee in urban areas, the average wind speed, the number of discharged patients with invasive TB, the number of people with the minimum living standard guarantee in rural areas, the total health expenditure as a percentage of regional gross domestic product, and being a single male individual (for those aged 0-14 years); the number of hospitals and number of health workers in infectious disease hospitals (for individuals aged 25-64 years); and the amount of daily morning and evening exercise, the number of people with the urban minimum living standard guarantee, and being married (for female individuals aged ≥65 years). The transfer function-noise model indicated that the incidence of TB in male patients aged 0-14 and 15-24 years will continue to increase, and the incidence of TB in female patients aged 0-14 and ≥65 years will continue to increase rapidly in Sichuan by 2035. Conclusions: The End TB Strategy in Sichuan should consider environmental, educational, medical, social, personal, and other conditions, and further substantial efforts are needed especially for male patients aged 0-24 years, female patients aged 0-14 years, and female patients older than 64 years. %M 36456535 %R 10.2196/40659 %U https://publichealth.jmir.org/2023/1/e40659 %U https://doi.org/10.2196/40659 %U http://www.ncbi.nlm.nih.gov/pubmed/36456535 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 9 %N %P e42694 %T Effects of Greenness on Myopia Risk and School-Level Myopia Prevalence Among High School–Aged Adolescents: Cross-sectional Study %A Zhang,Chang %A Wang,Cheng %A Guo,Xin %A Xu,Huiyu %A Qin,Zihao %A Tao,Liyuan %+ Research Center of Clinical Epidemiology, Peking University Third Hospital, 49 North Garden Rd, Haidian District Beijing, Beijing, 100191, China, 86 1082265732, tendytly@163.com %K high school–aged adolescent %K personal myopia risk %K school-level myopia prevalence %K green space %K adjusted effects %D 2023 %7 9.1.2023 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Myopia is a serious public health issue. High school–aged adolescents in Beijing have an alarming prevalence of myopia. Therefore, determining myopia protective factors is essential. Green space has a certain association with myopia protective factors that can protect against myopia. Objective: This study aims to examine the effects of green space around schools on individual myopia risk in high school–aged adolescents and the school-level myopia prevalence. Methods: Green space was measured using the normalized difference vegetation index (NDVI). A total of 13,380 samples of 51 high schools were selected from a 2021 Beijing Municipal Health Commission survey. Adolescent myopia was defined as a spherical equivalent of ≤–1.00 diopters in the worse eye. Generalized linear mixed models with a binomial error structure were used to analyze the effects of the NDVI on personal myopia risk and adjust them by other factors, such as demographics, exposure time, and outdoor exercise. The effects of the NDVI on school-level myopia prevalence with adjusted demographics and the relative position factors of trees were analyzed through quasibinomial regression. Results: The overall prevalence of myopia was 80.61% (10,785/13,380, 95% CI 79.93%-81.27%). Although with a 0.1 increase in the 500 and 1000 m buffer NDVIs adjusted by demographic and other factors, the high school–aged personal myopia risk significantly dropped by 16% (odds ratio [OR] 0.84, 95% CI 0.73-0.97) and 12% (OR 0.88, 95% CI 0.79-0.99), respectively. However, only the adjusted 500 m buffer NDVI (by demographics and the position of trees) with a 0.1 increase significantly reduced the school-level myopia prevalence by 15% (OR 0.85, 95% CI 0.74-0.98). Subgroup analysis showed that the adjusted effects of the 500 m buffer NDVI are significant in schoolgirls (OR 0.82, 95% CI 0.72-0.93), juniors (OR 0.82, 95% CI 0.72-0.94), the Han nationality (OR 0.84, 95% CI 0.72-0.97), 1-year exposure (OR 0.84, 95% CI 0.71-0.99) and 3-year exposure (OR 0.78, 95% CI 0.65-0.94). Conclusions: The greenness of a 500 m buffer around schools is associated with a lower personal myopia risk among adolescents and a lower prevalence of myopia in schools. With regard to prevention and control activities, green space within a 500 m buffer around schools is suggested as an independent protective factor for adolescent myopia. %M 36622746 %R 10.2196/42694 %U https://publichealth.jmir.org/2023/1/e42694 %U https://doi.org/10.2196/42694 %U http://www.ncbi.nlm.nih.gov/pubmed/36622746 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 12 %P e38471 %T Evaluating User Preferences, Comprehension, and Trust in Apps for Environmental Health Hazards: Qualitative Case Study %A Workman,Annabelle %A Johnston,Fay H %A Campbell,Sharon L %A Williamson,Grant J %A Lucani,Chris %A Bowman,David M J S %A Cooling,Nick %A Jones,Penelope J %+ Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool Street, Hobart, 7000, Australia, 61 362267726, penelope.jones@utas.edu.au %K health app %K evaluation %K air pollution %K pollen %K temperature %K mobile phone %D 2022 %7 22.12.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Climate change is projected to increase environmental health hazard risks through fire-related air pollution and increased airborne pollen levels. To protect vulnerable populations, it is imperative that evidence-based and accessible interventions are available. The environmental health app, AirRater, was developed in 2015 in Australia to provide information on multiple atmospheric health hazards in near real time. The app allows users to view local environmental conditions, and input and track their personal symptoms to enable behaviors that protect health in response to environmental hazards. Objective: This study aimed to develop insights into users’ perceptions of engagement, comprehension, and trust in AirRater to inform the future development of environmental health apps. Specifically, this study explored which AirRater features users engaged with, what additional features or functionality needs users felt they required, users’ self-perception of understanding app information, and their level of trust in the information provided. Methods: A total of 42 adult AirRater users were recruited from 3 locations in Australia to participate in semistructured interviews to capture location- or context-specific experiences. Participants were notified of the recruitment opportunity through multiple avenues including newsletter articles and social media. Informed consent was obtained before participation, and the participants were remunerated for their time and perspectives. A preinterview questionnaire collected data including age range, any preexisting conditions, and location (postcode). All participant data were deidentified. Interviews were recorded, transcribed, and analyzed using thematic analysis in NVivo 12 (QSR International). Results: Participants discussed app features and functionality, as well as their understanding of, and trust in, the information provided by the app. Most (26/42, 62%) participants used and valued visual environmental hazard features, especially maps, location settings, and hazard alerts. Most (33/42, 78%) found information in the app easy to understand and support their needs, irrespective of their self-reported literacy levels. Many (21/42, 50%) users reported that they did not question the accuracy of the data presented in the app. Suggested enhancements include the provision of meteorological information (eg, wind speed or direction, air pressure, UV rating, and humidity), functionality enhancements (eg, forecasting, additional alerts, and the inclusion of health advice), and clarification of existing information (eg, symptom triggers), including the capacity to download personal summary data for a specified period. Conclusions: Participants’ perspectives can inform the future development of environmental health apps. Specifically, participants’ insights support the identification of key elements for the optimal development of environmental health app design, including streamlining, capacity for users to customize, use of real time data, visual cues, credibility, and accuracy of data. The results also suggest that, in the future, iterative collaboration between developers, environmental agencies, and users will likely promote better functional design, user trust in the data, and ultimately better population health outcomes. %M 36548030 %R 10.2196/38471 %U https://formative.jmir.org/2022/12/e38471 %U https://doi.org/10.2196/38471 %U http://www.ncbi.nlm.nih.gov/pubmed/36548030 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 12 %P e23422 %T Detecting Elevated Air Pollution Levels by Monitoring Web Search Queries: Algorithm Development and Validation %A Lin,Chen %A Yousefi,Safoora %A Kahoro,Elvis %A Karisani,Payam %A Liang,Donghai %A Sarnat,Jeremy %A Agichtein,Eugene %+ Department of Computer Science, Emory University, 201 Dowman Drive, W302, Atlanta, GA, 30322, United States, 1 404 395 0266, chen.lin@emory.edu %K nowcasting of air pollution %K web-based public health surveillance %K neural network sequence modeling %K search engine log analysis %K air pollution exposure assessment %K mobile phone %D 2022 %7 19.12.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Real-time air pollution monitoring is a valuable tool for public health and environmental surveillance. In recent years, there has been a dramatic increase in air pollution forecasting and monitoring research using artificial neural networks. Most prior work relied on modeling pollutant concentrations collected from ground-based monitors and meteorological data for long-term forecasting of outdoor ozone (O3), oxides of nitrogen, and fine particulate matter (PM2.5). Given that traditional, highly sophisticated air quality monitors are expensive and not universally available, these models cannot adequately serve those not living near pollutant monitoring sites. Furthermore, because prior models were built based on physical measurement data collected from sensors, they may not be suitable for predicting the public health effects of pollution exposure. Objective: This study aimed to develop and validate models to nowcast the observed pollution levels using web search data, which are publicly available in near real time from major search engines. Methods: We developed novel machine learning–based models using both traditional supervised classification methods and state-of-the-art deep learning methods to detect elevated air pollution levels at the US city level by using generally available meteorological data and aggregate web-based search volume data derived from Google Trends. We validated the performance of these methods by predicting 3 critical air pollutants (O3, nitrogen dioxide, and PM2.5) across 10 major US metropolitan statistical areas in 2017 and 2018. We also explore different variations of the long short-term memory model and propose a novel search term dictionary learner-long short-term memory model to learn sequential patterns across multiple search terms for prediction. Results: The top-performing model was a deep neural sequence model long short-term memory, using meteorological and web search data, and reached an accuracy of 0.82 (F1-score 0.51) for O3, 0.74 (F1-score 0.41) for nitrogen dioxide, and 0.85 (F1-score 0.27) for PM2.5, when used for detecting elevated pollution levels. Compared with using only meteorological data, the proposed method achieved superior accuracy by incorporating web search data. Conclusions: The results show that incorporating web search data with meteorological data improves the nowcasting performance for all 3 pollutants and suggest promising novel applications for tracking global physical phenomena using web search data. %M 36534457 %R 10.2196/23422 %U https://formative.jmir.org/2022/12/e23422 %U https://doi.org/10.2196/23422 %U http://www.ncbi.nlm.nih.gov/pubmed/36534457 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 11 %P e37663 %T Prevalence of Antibiotic-Resistant Bacteria and Antibiotic-Resistant Genes and the Quantification of Antibiotics in Drinking Water Treatment Plants of Malaysia: Protocol for a Cross-sectional Study %A Mohamad,Zuraifah Asrah %A Bakon,Sophia Karen %A Jamilan,Mohd Azerulazree Jamilan %A Daud,Norhafizan %A Ciric,Lena %A Ahmad,Norazah %A Muhamad,Nor Asiah %+ Health Risk Assessment Unit, Environmental Health Research Centre, Institute For Medical Research, National Institutes of Health, Ministry of Health of Malaysia, 2nd Floor, Block C, Shah Alam, 40170, Malaysia, 60 3362 7772, asrahz@moh.gov.my %K drinking water %K river %K safe %K antibiotic %K resistant %K antimicrobial %K sanitation %K Malaysia %K Asia %K bacteria %D 2022 %7 21.11.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Antimicrobial resistance is a known global public health threat. In addition, it brings serious economic consequences to agriculture. Antibiotic resistance in humans, animals, and environment is interconnected, as proposed in the tricycle surveillance by the World Health Organization. In Malaysia, research and surveillance of antimicrobial resistance are mainly performed in clinical samples, agricultural settings, and surface waters, but no surveillance of the drinking water systems has been performed yet. Hence, this policy-driven study is a combined effort of microbiologists and engineers to provide baseline data on the magnitude of antimicrobial resistance in the drinking water systems of Malaysia. Objective: The aim of this study was to study the baseline level of antibiotic-resistant bacteria in the drinking water distribution systems of Malaysia by collecting samples from the pretreatment and posttreatment outlets of water treatment plants in a selected state of Malaysia. We aimed to determine the prevalence of antibiotic-resistant bacteria, the occurrence of antibiotic-resistant genes, and the level of antibiotics present in the drinking water systems. Methods: This is a laboratory-based, cross-sectional study in a selected state of Malaysia. Water samples from 6 drinking water treatment plants were collected. Samples were collected at 3 sampling points, that is, the intake sampling station, service reservoir outlet station, and the distribution system sampling station. These were tested against 7 types of antibiotics in triplicates. Samples were screened for antibiotic-resistant bacteria and antibiotic-resistant genes and quantified for the level of antibiotics present in the drinking water treatment plants. Results: We will show the descriptive statistics of the number of bacterial colonies harvested from water samples grown on Reasoner’s 2A agar with or without antibiotics, the occurrence of antibiotic-resistant genes, and the level of antibiotics detected in the water samples. The sampling frame was scheduled to start from November 2021 and continue until December 2022. Data analysis is expected to be completed by early 2023, and the results are expected to be published in mid-2023. Conclusions: This study provides baseline information on the status of the antimicrobial-resistant bacteria, the presence of resistance genes as contaminants, and the level of antibiotics present in the drinking water systems of Malaysia, with the aim of demonstrating to policymakers the need to consider antimicrobial resistance as a parameter in drinking water surveillance. International Registered Report Identifier (IRRID): DERR1-10.2196/37663 %M 36409546 %R 10.2196/37663 %U https://www.researchprotocols.org/2022/11/e37663 %U https://doi.org/10.2196/37663 %U http://www.ncbi.nlm.nih.gov/pubmed/36409546 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 8 %N 8 %P e37379 %T Estimating the Health Effects of Adding Bicycle and Pedestrian Paths at the Census Tract Level: Multiple Model Comparison %A Gore,Ross %A Lynch,Christopher J %A Jordan,Craig A %A Collins,Andrew %A Robinson,R Michael %A Fuller,Gabrielle %A Ames,Pearson %A Keerthi,Prateek %A Kandukuri,Yash %+ Virginia Modeling Analysis and Simulation Center, Old Dominion University, 1030 University Dr, Suffolk, VA, 23435, United States, 1 757 686 6200, ross.gore@gmail.com %K bicycle paths %K pedestrian paths %K bicycling %K walking %K diabetes %K high blood pressure %K physical health %K factor analysis %K digital neighborhoods %K data analysis %D 2022 %7 24.8.2022 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Adding additional bicycle and pedestrian paths to an area can lead to improved health outcomes for residents over time. However, quantitatively determining which areas benefit more from bicycle and pedestrian paths, how many miles of bicycle and pedestrian paths are needed, and the health outcomes that may be most improved remain open questions. Objective: Our work provides and evaluates a methodology that offers actionable insight for city-level planners, public health officials, and decision makers tasked with the question “To what extent will adding specified bicycle and pedestrian path mileage to a census tract improve residents’ health outcomes over time?” Methods: We conducted a factor analysis of data from the American Community Survey, Center for Disease Control 500 Cities project, Strava, and bicycle and pedestrian path location and use data from two different cities (Norfolk, Virginia, and San Francisco, California). We constructed 2 city-specific factor models and used an algorithm to predict the expected mean improvement that a specified number of bicycle and pedestrian path miles contributes to the identified health outcomes. Results: We show that given a factor model constructed from data from 2011 to 2015, the number of additional bicycle and pedestrian path miles in 2016, and a specific census tract, our models forecast health outcome improvements in 2020 more accurately than 2 alternative approaches for both Norfolk, Virginia, and San Francisco, California. Furthermore, for each city, we show that the additional accuracy is a statistically significant improvement (P<.001 in every case) when compared with the alternate approaches. For Norfolk, Virginia (n=31 census tracts), our approach estimated, on average, the percentage of individuals with high blood pressure in the census tract within 1.49% (SD 0.85%), the percentage of individuals with diabetes in the census tract within 1.63% (SD 0.59%), and the percentage of individuals who had >2 weeks of poor physical health days in the census tract within 1.83% (SD 0.57%). For San Francisco (n=49 census tracts), our approach estimates, on average, that the percentage of individuals who had a stroke in the census tract is within 1.81% (SD 0.52%), and the percentage of individuals with diabetes in the census tract is within 1.26% (SD 0.91%). Conclusions: We propose and evaluate a methodology to enable decision makers to weigh the extent to which 2 bicycle and pedestrian paths of equal cost, which were proposed in different census tracts, improve residents’ health outcomes; identify areas where bicycle and pedestrian paths are unlikely to be effective interventions and other strategies should be used; and quantify the minimum amount of additional bicycle path miles needed to maximize health outcome improvements. Our methodology shows statistically significant improvements, compared with alternative approaches, in historical accuracy for 2 large cities (for 2016) within different geographic areas and with different demographics. %M 36001362 %R 10.2196/37379 %U https://publichealth.jmir.org/2022/8/e37379 %U https://doi.org/10.2196/37379 %U http://www.ncbi.nlm.nih.gov/pubmed/36001362 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 8 %P e39887 %T Utilizing Real-time Technology to Assess the Impact of Home Environmental Exposures on Asthma Symptoms: Protocol for an Observational Pilot Study %A Nyenhuis,Sharmilee %A Cramer,Emily %A Grande,Matthew %A Huntington-Moskos,Luz %A Krueger,Kathryn %A Bimbi,Olivia %A Polivka,Barbara %A Eldeirawi,Kamal %+ Section of Allergy and Immunology, Department of Pediatrics, University of Chicago, 5841 S. Maryland Ave., MC 5042, Chicago, IL, 60637, United States, 1 773 834 7121, snyenhuis@bsd.uchicago.edu %K asthma %K home environment %K ecologic momentary assessment %K air quality %K spirometry %D 2022 %7 2.8.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: It is estimated that over 60% of adults with asthma have uncontrolled symptoms, representing a substantial health and economic impact. The effects of the home environment and exposure to volatile organic compounds (VOCs) and fine particulate matter (PM2.5) on adults with asthma remain unknown. In addition, methods currently used to assess the home environment do not capture real-time data on potentially modifiable environmental exposures or their effect on asthma symptoms. Objective: The aims of this study are to (1) determine the feasibility and usability of ecological momentary assessment (EMA) to assess self-report residential environmental exposures and asthma symptoms, home monitoring of objective environmental exposures (total VOCs and PM2.5), and lung function in terms of forced expiratory volume in 1 second (FEV1%); (2) assess the frequency and level of residential environmental exposures (eg, disinfectants/cleaners, secondhand smoke) via self-reported data and home monitoring objective measures; (3) assess the level of asthma control as indicated by self-reported asthma symptoms and lung function; and (4) explore associations of self-reported and objective measures of residential environmental exposures with self-reported and objective measures of asthma control. Methods: We will recruit 50 adults with asthma who have completed our online Global COVID-19 Asthma Study, indicated willingness to be contacted for future studies, reported high use of disinfectant/cleaning products, and have asthma that is not well controlled. Participants will receive an indoor air quality monitor and a home spirometer to measure VOCs, PM2.5, and FEV1%, respectively. EMA data will be collected using a personal smartphone and EMA software platform. Participants will be sent scheduled and random EMA notifications to assess asthma symptoms, environmental exposures, lung function, and mitigation strategies. After the 14-day data collection period, participants will respond to survey items related to acceptability, appropriateness, and feasibility. Results: This study was funded in March 2021. We pilot tested our procedures and began recruitment in April 2022. The anticipated completion of the study is 2023. Conclusions: Findings from this feasibility study will support a powered study to address the impact of home environmental exposures on asthma symptoms and develop tailored, home-based asthma interventions that are responsive to the changing home environment and home routines. Trial Registration: ClinicalTrials.gov NCT05224076; https://clinicaltrials.gov/ct2/show/NCT05224076 International Registered Report Identifier (IRRID): DERR1-10.2196/39887 %M 35916686 %R 10.2196/39887 %U https://www.researchprotocols.org/2022/8/e39887 %U https://doi.org/10.2196/39887 %U http://www.ncbi.nlm.nih.gov/pubmed/35916686 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 8 %N 7 %P e34782 %T Age- and Sex-Specific Association Between Vegetation Cover and Mental Health Disorders: Bayesian Spatial Study %A Abdullah,Abu Yousuf Md %A Law,Jane %A Perlman,Christopher M %A Butt,Zahid A %+ School of Planning, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada, 1 226 978 2838, aymabdul@uwaterloo.ca %K mental health disorders %K vegetation cover %K age- and sex- specific association %K Enhanced Vegetation Index %K Bayesian %K spatial %K hierarchical modeling %K marginalization %K latent covariates %D 2022 %7 28.7.2022 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Despite growing evidence that reduced vegetation cover could be a putative risk factor for mental health disorders, the age- and the sex-specific association between vegetation and mental health disorder cases in urban areas is poorly understood. However, with rapid urbanization across the globe, there is an urgent need to study this association and understand the potential impact of vegetation loss on the mental well-being of urban residents. Objective: This study aims to analyze the spatial association between vegetation cover and the age- and sex-stratified mental health disorder cases in the neighborhoods of Toronto, Canada. Methods: We used remote sensing to detect urban vegetation and Bayesian spatial hierarchical modeling to analyze the relationship between vegetation cover and mental health disorder cases. Specifically, an Enhanced Vegetation Index was used to detect urban vegetation, and Bayesian Poisson lognormal models were implemented to study the association between vegetation and mental health disorder cases of males and females in the 0-19, 20-44, 45-64, and ≥65 years age groups, after controlling for marginalization and unmeasured (latent) spatial and nonspatial covariates at the neighborhood level. Results: The results suggest that even after adjusting for marginalization, there were significant age- and sex-specific effects of vegetation on the prevalence of mental health disorders in Toronto. Mental health disorders were negatively associated with the vegetation cover for males aged 0-19 years (−7.009; 95% CI −13.130 to −0.980) and for both males (−4.544; 95% CI −8.224 to −0.895) and females (−3.513; 95% CI −6.289 to −0.681) aged 20-44 years. However, for older adults in the 45-64 and ≥65 years age groups, only the marginalization covariates were significantly associated with mental health disorder cases. In addition, a substantial influence of the unmeasured (latent) and spatially structured covariates was detected in each model (relative contributions>0.7), suggesting that the variations in area-specific relative risk were mainly spatial in nature. Conclusions: As significant and negative associations between vegetation and mental health disorder cases were found for young males and females, investments in urban greenery can help reduce the future burden of mental health disorders in Canada. The findings highlight the urgent need to understand the age-sex dynamics of the interaction between surrounding vegetation and urban dwellers and its subsequent impact on mental well-being. %M 35900816 %R 10.2196/34782 %U https://publichealth.jmir.org/2022/7/e34782 %U https://doi.org/10.2196/34782 %U http://www.ncbi.nlm.nih.gov/pubmed/35900816 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 3 %P e25614 %T Understanding Public Perceptions of Per- and Polyfluoroalkyl Substances: Infodemiology Study of Social Media %A Tian,Hao %A Gaines,Christy %A Launi,Lori %A Pomales,Ana %A Vazquez,Germaine %A Goharian,Amanda %A Goodnight,Bradley %A Haney,Erica %A Reh,Christopher M %A Rogers,Rachel D %+ Office of Director, National Center for Environmental Health, Centers for Disease Control and Prevention, 4770 Buford Highway NE, MS S106-7, Atlanta, GA, 30341, United States, 1 404 718 5708, ejq7@cdc.gov %K PFAS %K per- and polyfluoroalkyl substances %K social media %K public perceptions %D 2022 %7 11.3.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: Per- and polyfluoroalkyl substances (PFAS) are environmental contaminants that have received significant public attention. PFAS are a large group of human-made chemicals that have been used in industry and consumer products worldwide since the 1950s. Human exposure to PFAS is a growing public health concern. Studies suggest that exposure to PFAS may increase the risk of some cancers and have negative health impacts on the endocrine, metabolic, and immune systems. Federal and state health partners are investigating the exposure to and possible health effects associated with PFAS. Government agencies can observe social media discourse on PFAS to better understand public concerns and develop targeted communication and outreach efforts. Objective: The primary objective of this study is to understand how social media is used to share, disseminate, and engage in public discussions of PFAS-related information in the United States. Methods: We investigated PFAS-related content across 2 social media platforms between May 1, 2017, and April 30, 2019, to identify how social media is used in the United States to seek and disseminate PFAS-related information. Our key variable of interest was posts that mentioned “PFAS,” “PFOA,” “PFOS,” and their hashtag variations across social media platforms. Additional variables included post type, time, PFAS event, and geographic location. We examined term use and post type differences across platforms. We used descriptive statistics and regression analysis to assess the incidence of PFAS discussions and to identify the date, event, and geographic patterns. We qualitatively analyzed social media content to determine the most prevalent themes discussed on social media platforms. Results: Our analysis revealed that Twitter had a significantly greater volume of PFAS-related posts compared with Reddit (98,264 vs 3126 posts). PFAS-related social media posts increased by 670% over 2 years, indicating a marked increase in social media users’ interest in and awareness of PFAS. Active engagement varied across platforms, with Reddit posts demonstrating more in-depth discussions compared with passive likes and reposts among Twitter users. Spikes in PFAS discussions were evident and connected to the discovery of contamination events, media coverage, and scientific publications. Thematic analysis revealed that social media users see PFAS as a significant public health concern and seek a trusted source of information about PFAS-related public health efforts. Conclusions: The analysis identified a prevalent theme—on social media, PFAS are perceived as an immediate public health concern, which demonstrates a growing sense of urgency to understand this emerging contaminant and its potential health impacts. Government agencies can continue using social media research to better understand the changing community sentiment on PFAS and disseminate targeted information and then use social media as a forum for dispelling misinformation, communicating scientific findings, and providing resources for relevant public health services. %M 35275066 %R 10.2196/25614 %U https://www.jmir.org/2022/3/e25614 %U https://doi.org/10.2196/25614 %U http://www.ncbi.nlm.nih.gov/pubmed/35275066 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 1 %P e25690 %T Assessment of Personal Exposure to Particulate Air Pollution in Different Microenvironments and Traveling by Several Modes of Transportation in Bogotá, Colombia: Protocol for a Mixed Methods Study (ITHACA) %A Malagon-Rojas,Jeadran N %A Pinzón-Silva,Diana Carolina %A Parra,Eliana L %A Lagos M,Luisa F %A Toloza-Perez,Yesith Guillermo %A Hernández Florez,Luis Jorge %A Morales Betancourt,Ricardo %A Romero,Sol Angie %A Ríos Cabra,Ana Paola %A Sarmiento,Olga L %+ Grupo de Salud Ambiental y Laboral, Instituto Nacional de Salud, Ac. 26 #5120, Bogotá, 111311, Colombia, 57 2207700 ext 1476, jmalagon@ins.gov.co %K air pollution %K particulate matter %K black carbon %K mixed methods %K toxic %K air quality %K respiratory %K pollution %K pollutants %K microenvironments %K Bogota %K respiratory disease %K exposure to air pollutants %K air contamination %D 2022 %7 31.1.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Air pollution in most countries exceeds the levels recommended by the World Health Organization, causing up to one-third of deaths due to noncommunicable diseases. Fine particulate matter (PM2.5) and black carbon (BC) from mobile sources are the main contaminants. Objective: The aim of this study is to assess the relationship of exposure to air pollutants (PM2.5 and BC) in microenvironments according to respiratory health and physical activity in users traveling by different types of transportation in Bogotá, Colombia. Methods: A mixed methods study based on a convergent parallel design will be performed with workers and students. The sample will include 350 healthy transport users traveling by different urban transportation modes in three main routes in Bogotá. The study is broken down into two components: (1) a descriptive qualitative component focused on assessing the individual perception of air pollution using semistructured interviews; and (2) a cross-sectional study measuring the individual exposure to PM2.5 and BC using portable instruments (DustTrak and microAeth, respectively), pulmonary function by spirometry, and physical activity with accelerometry. The analysis will include concurrent triangulation and logistic regression. Results: The findings will be useful for the conception, design, and decision-making process in the sectors of health and mobility from public, academy, and private perspectives. This study includes personal measurements of PM2.5 and BC during typical trips in the city to assess the exposure to these contaminants in the major roadways in real time. The study further compares the performance of two different lung tests to identify possible short-term respiratory effects. As a limitation, the protocol will include participants from different institutions in the city, which are not necessarily representative of all healthy populations in Bogotá. In this sense, it is not possible to draw causation conclusions. Moreover, a convergent parallel design could be especially problematic concerning integration because such a design often lacks a clear plan for making a connection between the two sets of results, which may not be well connected. Nevertheless, this study adopts a procedure for how to integrate qualitative and quantitative data in the interpretation of the results and a multilevel regression. The time that participants must live in the city will be considered; this will be controlled in the stratified analysis. Another limitation is the wide age range and working status of the participants. Regional pollution levels and episodes (PM2.5) will be handled as confounding variables. The study is currently in the enrollment phase of the participants. Measurements have been made on 300 participants. Pandemic conditions affected the study schedule; however, the results are likely to be obtained by late 2022. Conclusions: This study investigates the exposure to air pollutants in microenvironments in Bogotá, Colombia. To our knowledge, this is the first mixed methods study focusing on PM2.5, BC, and respiratory health effects in a city over 2 meters above sea level. This study will provide an integration of air pollution exposure variables and respiratory health effects in different microenvironments. International Registered Report Identifier (IRRID): PRR1-10.2196/25690 %M 35099404 %R 10.2196/25690 %U https://www.researchprotocols.org/2022/1/e25690 %U https://doi.org/10.2196/25690 %U http://www.ncbi.nlm.nih.gov/pubmed/35099404 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 11 %P e33365 %T Effective Treatment Strategies for the Removal of Antibiotic-Resistant Bacteria, Antibiotic-Resistance Genes, and Antibiotic Residues in the Effluent From Wastewater Treatment Plants Receiving Municipal, Hospital, and Domestic Wastewater: Protocol for a Systematic Review %A Alam,Mahbub-Ul %A Ferdous,Sharika %A Ercumen,Ayse %A Lin,Audrie %A Kamal,Abul %A Luies,Sharmin Khan %A Sharior,Fazle %A Khan,Rizwana %A Rahman,Md Ziaur %A Parvez,Sarker Masud %A Amin,Nuhu %A Tadesse,Birkneh Tilahun %A Moushomi,Niharu Akter %A Hasan,Rezaul %A Taneja,Neelam %A Islam,Mohammad Aminul %A Rahman,Mahbubur %+ Environmental Interventions Unit, Infectious Disease Division, icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh), 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh, 880 1818585465, mahbubalam@icddrb.org %K antimicrobial resistance %K antimicrobial-resistant bacteria %K antibiotic-resistant bacteria %K antimicrobial-resistance genes %K antibiotic-resistance genes %K antibiotics %K antibiotic residues %K wastewater treatment plant %K effluent %K systematic review %D 2021 %7 26.11.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: The widespread and unrestricted use of antibiotics has led to the emergence and spread of antibiotic-resistant bacteria (ARB), antibiotic-resistance genes (ARGs), and antibiotic residues in the environment. Conventional wastewater treatment plants (WWTPs) are not designed for effective and adequate removal of ARB, ARGs, and antibiotic residues, and therefore, they play an important role in the dissemination of antimicrobial resistance (AMR) in the natural environment. Objective: We will conduct a systematic review to determine the most effective treatment strategies for the removal of ARB, ARGs, and antibiotic residues from the treated effluent disposed into the environment from WWTPs that receive municipal, hospital, and domestic discharge. Methods: We will search the MEDLINE, EMBASE, Web of Science, World Health Organization Global Index Medicus, and ProQuest Environmental Science Collection databases for full-text peer-reviewed journal articles published between January 2001 and December 2020. We will select only articles published in the English language. We will include studies that measured (1) the presence, concentration, and removal rate of ARB/ARGs going from WWTP influent to effluent, (2) the presence, concentration, and types of antibiotics in the effluent, and (3) the possible selection of ARB in the effluent after undergoing treatment processes in WWTPs. At least two independent reviewers will extract data and perform risk of bias assessment. An acceptable or narrative synthesis method will be followed to synthesize the data and present descriptive characteristics of the included studies in a tabular form. The study has been approved by the Ethics Review Board at the International Centre for Diarrhoeal Disease Research, Bangladesh (protocol number: PR-20113). Results: This protocol outlines our proposed methodology for conducting a systematic review. Our results will provide an update to the existing literature by searching additional databases. Conclusions: Findings from our systematic review will inform the planning of proper treatment methods that can effectively reduce the levels of ARB, ARGs, and residual antibiotics in effluent, thus lowering the risk of the environmental spread of AMR and its further transmission to humans and animals. International Registered Report Identifier (IRRID): PRR1-10.2196/33365 %M 34842550 %R 10.2196/33365 %U https://www.researchprotocols.org/2021/11/e33365 %U https://doi.org/10.2196/33365 %U http://www.ncbi.nlm.nih.gov/pubmed/34842550 %0 Journal Article %@ 2561-3278 %I JMIR Publications %V 6 %N 4 %P e28920 %T Understanding “Atmosome”, the Personal Atmospheric Exposome: Comprehensive Approach %A Bhimaraju,Hari %A Nag,Nitish %A Pandey,Vaibhav %A Jain,Ramesh %+ Donald Bren School of Information and Computer Sciences, University of California, Donald Bren Hall, 6210, Irvine, CA, 92697, United States, 1 949 824 7427, hari.bhimaraju@columbia.edu %K exposome %K exposomics %K personal health %K indoor air quality %K health state estimation %K health informatics %K public health policy %K epidemiology %K embedded systems %K internet of things %D 2021 %7 23.11.2021 %9 Original Paper %J JMIR Biomed Eng %G English %X Background: Modern environmental health research extensively focuses on outdoor air pollutants and their effects on public health. However, research on monitoring and enhancing individual indoor air quality is lacking. The field of exposomics encompasses the totality of human environmental exposures and its effects on health. A subset of this exposome deals with atmospheric exposure, termed the “atmosome.” The atmosome plays a pivotal role in health and has significant effects on DNA, metabolism, skin integrity, and lung health. Objective: The aim of this work is to develop a low-cost, comprehensive measurement system for collecting and analyzing atmosomic factors. The research explores the significance of the atmosome in personalized and preventive care for public health. Methods: An internet of things microcontroller-based system is introduced and demonstrated. The system collects real-time indoor air quality data and posts it to the cloud for immediate access. Results: The experimental results yield air quality measurements with an accuracy of 90% when compared with precalibrated commercial devices and demonstrate a direct correlation between lifestyle and air quality. Conclusions: Quantifying the individual atmosome is a monumental step in advancing personalized health, medical research, and epidemiological research. The 2 main goals in this work are to present the atmosome as a measurable concept and to demonstrate how to implement it using low-cost electronics. By enabling atmosome measurements at a communal scale, this work also opens up potential new directions for public health research. Researchers will now have the data to model the impact of indoor air pollutants on the health of individuals, communities, and specific demographics, leading to novel approaches for predicting and preventing diseases. %M 38907376 %R 10.2196/28920 %U https://biomedeng.jmir.org/2021/4/e28920 %U https://doi.org/10.2196/28920 %U http://www.ncbi.nlm.nih.gov/pubmed/38907376 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 11 %P e27875 %T Prediction of Smoking Risk From Repeated Sampling of Environmental Images: Model Validation %A Engelhard,Matthew M %A D'Arcy,Joshua %A Oliver,Jason A %A Kozink,Rachel %A McClernon,F Joseph %+ Department of Biostatistics & Bioinformatics, Duke University School of Medicine, 2608 Erwin Rd, Durham, NC, 27705, United States, 1 919 613 3665, m.engelhard@duke.edu %K smoking %K smoking cessation %K machine learning %K computer vision %K digital health %K eHealth %K behavior %K CNN %K neural network %K artificial intelligence %K AI %K images %K environment %K ecological momentary assessment %K mobile health %K mHealth %K mobile phone %D 2021 %7 1.11.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Viewing their habitual smoking environments increases smokers’ craving and smoking behaviors in laboratory settings. A deep learning approach can differentiate between habitual smoking versus nonsmoking environments, suggesting that it may be possible to predict environment-associated smoking risk from continuously acquired images of smokers’ daily environments. Objective: In this study, we aim to predict environment-associated risk from continuously acquired images of smokers’ daily environments. We also aim to understand how model performance varies by location type, as reported by participants. Methods: Smokers from Durham, North Carolina and surrounding areas completed ecological momentary assessments both immediately after smoking and at randomly selected times throughout the day for 2 weeks. At each assessment, participants took a picture of their current environment and completed a questionnaire on smoking, craving, and the environmental setting. A convolutional neural network–based model was trained to predict smoking, craving, whether smoking was permitted in the current environment and whether the participant was outside based on images of participants’ daily environments, the time since their last cigarette, and baseline data on daily smoking habits. Prediction performance, quantified using the area under the receiver operating characteristic curve (AUC) and average precision (AP), was assessed for out-of-sample prediction as well as personalized models trained on images from days 1 to 10. The models were optimized for mobile devices and implemented as a smartphone app. Results: A total of 48 participants completed the study, and 8008 images were acquired. The personalized models were highly effective in predicting smoking risk (AUC=0.827; AP=0.882), craving (AUC=0.837; AP=0.798), whether smoking was permitted in the current environment (AUC=0.932; AP=0.981), and whether the participant was outside (AUC=0.977; AP=0.956). The out-of-sample models were also effective in predicting smoking risk (AUC=0.723; AP=0.785), whether smoking was permitted in the current environment (AUC=0.815; AP=0.937), and whether the participant was outside (AUC=0.949; AP=0.922); however, they were not effective in predicting craving (AUC=0.522; AP=0.427). Omitting image features reduced AUC by over 0.1 when predicting all outcomes except craving. Prediction of smoking was more effective for participants whose self-reported location type was more variable (Spearman ρ=0.48; P=.001). Conclusions: Images of daily environments can be used to effectively predict smoking risk. Model personalization, achieved by incorporating information about daily smoking habits and training on participant-specific images, further improves prediction performance. Environment-associated smoking risk can be assessed in real time on a mobile device and can be incorporated into device-based smoking cessation interventions. %M 34723819 %R 10.2196/27875 %U https://www.jmir.org/2021/11/e27875 %U https://doi.org/10.2196/27875 %U http://www.ncbi.nlm.nih.gov/pubmed/34723819 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 9 %P e24671 %T Attitudes Toward the Environment and Use of Information and Communication Technologies to Address Environmental Health Risks in Marginalized Communities: Prospective Cohort Study %A Perez-Ramos,Jose G %A McIntosh,Scott %A Barrett,Emily S %A Velez Vega,Carmen M %A Dye,Timothy D %+ Department of Obstetrics and Gynecology, School of Medicine and Dentistry, University of Rochester, 601 Elmwood Ave, Box 668, Rochester, NY, 14622, United States, 1 5852768755, j.perezramos@rochester.edu %K community engagement %K environmental health risk %K epidemiology %K ICT %K mHealth %K mobile phone %K Puerto Rico %D 2021 %7 23.9.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Information and communication technologies, including mobile health (mHealth), can help isolated communities address environmental health challenges. The Puerto Rican island of Culebra has faced multiple sociopolitical and economic factors that have distressed the island’s environment and health. Culebrenses are technologically engaged and have demonstrated a use of technology that transcends socioeconomic barriers. As a result, technological interventions could potentially help manage environmental risks on the island. Objective: This study aims to test and evaluate the potential benefits of an mHealth tool, termed ¡mZAP! (Zonas, Acción y Protección), for engaging communities with environmental risks through technology. Methods: Participants using ¡mZAP! (N=111) were surveyed. Bivariate analyses were used to examine associations of mHealth use with sociodemographics, technology use, an adapted environmental attitudes inventory, and the multidimensional health locus of control. Logistic regression was used to examine associations between attitudes toward environmental health risks and mHealth use. Results: Higher positive attitudes toward the environment were significantly associated with the use of ¡mZAP! (odds ratio 5.3, 95% CI 1.6-17.0). Environmental attitudes were also associated with the multidimensional health locus of control powerful others subscale (P=.02), indicating that attitudes toward the environment become more negative as feelings controlled by others increase. Participants felt that the authorities would resolve the challenges (63/111, 56.7%). Conclusions: Perceived lack of control could present barriers to collective actions to address salient environmental health challenges in communities. The ongoing dependency on government-based solutions to community problems is worrisome, especially after the hurricane experiences of 2017 (which may potentially continue to be an issue subsequent to the more recent 2020 earthquakes). %M 34554103 %R 10.2196/24671 %U https://www.jmir.org/2021/9/e24671 %U https://doi.org/10.2196/24671 %U http://www.ncbi.nlm.nih.gov/pubmed/34554103 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 9 %P e31389 %T The Food Equity and Environmental Data Sovereignty (FEEDS) Project: Protocol for a Quasi-Experimental Study Evaluating a Digital Platform for Climate Change Preparedness %A Bhawra,Jasmin %A Skinner,Kelly %A Favel,Duane %A Green,Brenda %A Coates,Ken %A Katapally,Tarun Reddy %+ Johnson Shoyama Graduate School of Public Policy, University of Saskatchewan, 101 Diefenbaker Place, Saskatoon, SK, S7N 5B8, Canada, 1 3065854544, jasmin.bhawra@usask.ca %K food security %K food sovereignty %K food equity %K mental health %K solastalgia %K climate change impacts %K climate change preparedness %K digital health %K digital dashboards %K Indigenous health %K mobile phone %D 2021 %7 15.9.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Despite having the tools at our disposal to enable an adequate food supply for all people, inequities in food acquisition, distribution, and most importantly, food sovereignty, worsen food insecurity. The detrimental impact of climate change on food systems and mental health is further exacerbated by a lack of food sovereignty. We urgently require innovative solutions to enable food sovereignty, minimize food insecurity, and address climate change–related mental distress (ie, solastalgia). Indigenous communities have a wealth of Traditional Knowledge for climate change adaptation and preparedness to strengthen food systems. Traditional Knowledge combined with Western methods can revolutionize ethical data collection, engagement, and knowledge mobilization. Objective: The Food Equity and Environmental Data Sovereignty (FEEDS) Project takes a participatory action, citizen science approach for early detection and warning of climate change impacts on food sovereignty, food security, and solastalgia. The aim of this project is to develop and implement a sustainable digital platform that enables real-time decision-making to mitigate climate change–related impacts on food systems and mental well-being. Methods: Citizen science enables citizens to actively contribute to all aspects of the research process. The FEEDS Project is being implemented in five phases: participatory project planning, digital climate change platform customization, community-led evaluation, digital platform and project refinement, and integrated knowledge translation. The project is governed by a Citizen Scientist Advisory Council comprising Elders, Traditional Knowledge Keepers, key community decision makers, youth, and FEEDS Project researchers. The Council governs all phases of the project, including coconceptualizing a climate change platform, which consists of a smartphone app and a digital decision-making dashboard. Apart from capturing environmental and health-related big data (eg, weather, permafrost degradation, fire hazards, and human movement), the custom-built app uses artificial intelligence to engage and enable citizens to report on environmental hazards, changes in biodiversity or wildlife, and related food and mental health issues in their communities. The app provides citizens with valuable information to mitigate health-related risks and relays big data in real time to a digital dashboard. Results: This project is currently in phase 1, with the subarctic Métis jurisdiction of Île-à-la-Crosse, Saskatchewan, Canada. Conclusions: The FEEDS Project facilitates Indigenous Peoples’ self-determination, governance, and data sovereignty. All citizen data are anonymous and encrypted, and communities have ownership, access, control, and possession of their data. The digital dashboard system provides decision makers with real-time data, thereby increasing the capacity to self-govern. The participatory action research approach, combined with digital citizen science, advances the cocreation of knowledge and multidisciplinary collaboration in the digital age. Given the urgency of climate change, leveraging technology provides communities with tools to respond to existing and emerging crises in a timely manner, as well as scientific evidence regarding the urgency of current health and environmental issues. International Registered Report Identifier (IRRID): PRR1-10.2196/31389 %M 34524106 %R 10.2196/31389 %U https://www.researchprotocols.org/2021/9/e31389 %U https://doi.org/10.2196/31389 %U http://www.ncbi.nlm.nih.gov/pubmed/34524106 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 7 %N 9 %P e32958 %T #HealthyClimate: Call for Emergency Action to Limit Global Temperature Increases, Restore Biodiversity, and Protect Health %A Atwoli,Lukoye %A Baqui,Abdullah H %A Benfield,Thomas %A Bosurgi,Raffaella %A Godlee,Fiona %A Hancocks,Stephen %A Horton,Richard %A Laybourn-Langton,Laurie %A Monteiro,Carlos Augusto %A Norman,Ian %A Patrick,Kirsten %A Praities,Nigel %A Olde Rikkert,Marcel GM %A Rubin,Eric J %A Sahni,Peush %A Smith,Richard %A Talley,Nick %A Turale,Sue %A Vazquez,Damian %+ Senior Advisor, UK Health Alliance on Climate Change, c/o BMJ Publishing Group, Tavistock Square, London, WC1H 9JR, United Kingdom, +44 (0) 20 7387 4410, laurie.laybourn@ukhealthalliance.org %K climate change %K global warming %K emergency action %D 2021 %7 5.9.2021 %9 Editorial %J JMIR Public Health Surveill %G English %X The UN General Assembly in September 2021 will bring countries together at a critical time for marshalling collective action to tackle the global environmental crisis. They will meet again at the biodiversity summit in Kunming, China, and the climate conference (COP26) in Glasgow, UK. Ahead of these pivotal meetings, we—the editors of health journals worldwide—call for urgent action to keep average global temperature increases below 1.5°C, halt the destruction of nature, and protect health. %M 34483097 %R 10.2196/32958 %U https://publichealth.jmir.org/2021/9/e32958 %U https://doi.org/10.2196/32958 %U http://www.ncbi.nlm.nih.gov/pubmed/34483097 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 8 %P e25781 %T A Technological-Based Platform for Risk Assessment, Detection, and Prevention of Falls Among Home-Dwelling Older Adults: Protocol for a Quasi-Experimental Study %A Araújo,Fátima %A Nogueira,Maria Nilza %A Silva,Joana %A Rego,Sílvia %+ Escola Superior de Enfermagem do Porto (ESEP), Inovação e Desenvolvimento em Enfermagem, Centro de Investigação em Tecnologias e Serviços de Saúde, Rua Dr. António Bernardino, 830, 844, 856, Porto, 4200-072, Portugal, 351 00351 225 073 5, araujo@esenf.pt %K fall prevention %K technological platform %K elderly %K Otago Exercise Program %D 2021 %7 12.8.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: According to the United Nations, it is estimated that by 2050, the number of people aged 80 years and older will have increased by 3 times. Increased longevity is often accompanied by structural and functional changes that occur throughout an individual’s lifespan. These changes are often aggravated by chronic comorbidities, adopted behaviors or lifestyles, and environmental exposure, among other factors. Some of the related outcomes are loss of muscle strength, decreased balance control, and mobility impairments, which are strongly associated with the occurrence of falls in the elderly. Despite the continued undervaluation of the importance of knowledge on fall prevention among the elderly population by primary care health professionals, several evidence-based (single or multifaceted) fall prevention programs such as the Otago Exercise Program (OEP) have demonstrated a significant reduction in the risk of falls and fall-related injuries in the elderly within community settings. Recent studies have strived to integrate technology into physical exercise programs, which is effective for adherence and overcoming barriers to exercise, as well as improving physical functioning. Objective: This study aims to assess the impact of the OEP on the functionality of home-dwelling elderly using a common technological platform. Particularly, the impact on muscle strength, balance, mobility, risk of falling, the perception of fear of falling, and the perception of the elderly regarding the ease of use of technology are being examined in this study. Methods: A quasi-experimental study (before and after; single group) will be conducted with male and female participants aged 65 years or older living at home in the district of Porto. Participants will be recruited through the network COLABORAR, with a minimum of 30 participants meeting the study inclusion and exclusion criteria. All participants will sign informed consent forms. The data collection instrument consists of sociodemographic and clinical variables (self-reported), functional evaluation variables, and environmental risk variables. The data collection tool integrates primary and secondary outcome variables. The primary outcome is gait (timed-up and go test; normal step). The secondary outcome variables are lower limb strength and muscle resistance (30-second chair stand test), balance (4-stage balance test), frequency of falls, functional capacity (Lawton and Brody - Portuguese version), fear of falling (Falls Efficacy Scale International - Portuguese version), usability of the technology (System Usability Scale - Portuguese version), and environmental risk variables (home fall prevention checklist for older adults). Technological solutions, such as the FallSensing Home application and Kallisto wearable device, will be used, which will allow the detection and prevention of falls. The intervention is characterized by conducting the OEP through a common technological platform 3 times a week for 8 weeks. Throughout these weeks, the participants will be followed up in person or by telephone contact by the rehabilitation nurse. Considering the COVID-19 outbreak, all guidelines from the National Health Service will be followed. The project was funded by InnoStars, in collaboration with the Local EIT Health Regional Innovation Scheme Hub of the University of Porto. Results: This study was approved on October 9, 2020 by the Ethics Committee of Escola Superior de Enfermagem do Porto (ESEP). The recruitment process was meant to start in October, but due to the COVID-19 pandemic, it was suspended. We expect to restart the study by the beginning of the third quarter of 2021. Conclusions: The findings of this study protocol will contribute to the design and development of future robust studies for technological tests in a clinical context. Trial Registration: ISRCTN 15895163; https://www.isrctn.com/ISRCTN15895163 International Registered Report Identifier (IRRID): PRR1-10.2196/25781 %M 34387557 %R 10.2196/25781 %U https://www.researchprotocols.org/2021/8/e25781 %U https://doi.org/10.2196/25781 %U http://www.ncbi.nlm.nih.gov/pubmed/34387557 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 8 %P e15864 %T Health Impacts of Perchlorate and Pesticide Exposure: Protocol for Community-Engaged Research to Evaluate Environmental Toxicants in a US Border Community %A Trotter II,Robert %A Baldwin,Julie %A Buck,Charles Loren %A Remiker,Mark %A Aguirre,Amanda %A Milner,Trudie %A Torres,Emma %A von Hippel,Frank Arthur %+ Department of Anthropology, Northern Arizona University, 1395 Knoles Drive, Flagstaff, AZ, 86011, United States, 1 9283808684, robert.trotter@nau.edu %K community-engaged research %K endocrine disruption %K environmental contaminants %K health disparities %K toxic metal contamination %K perchlorates %K pesticides %K population health %K thyroid disease %D 2021 %7 11.8.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: The Northern Arizona University (NAU) Center for Health Equity Research (CHER) is conducting community-engaged health research involving “environmental scans” in Yuma County in collaboration with community health stakeholders, including the Yuma Regional Medical Center (YRMC), Regional Center for Border Health, Inc. (RCBH), Campesinos Sin Fronteras (CSF), Yuma County Public Health District, and government agencies and nongovernmental organizations (NGOs) working on border health issues. The purpose of these efforts is to address community-generated environmental health hazards identified through ongoing coalitions among NAU, and local health care and research institutions. Objective: We are undertaking joint community/university efforts to examine human exposures to perchlorate and agricultural pesticides. This project also includes the parallel development of a new animal model for investigating the mechanisms of toxicity following a “one health” approach. The ultimate goal of this community-engaged effort is to develop interventions to reduce exposures and health impacts of contaminants in Yuma populations. Methods: All participants completed the informed consent process, which included information on the purpose of the study, a request for access to health histories and medical records, and interviews. The interview included questions related to (1) demographics, (2) social determinants of health, (3) health screening, (4) occupational and environmental exposures to perchlorate and pesticides, and (5) access to health services. Each participant provided a hair sample for quantifying the metals used in pesticides, urine sample for perchlorate quantification, and blood sample for endocrine assays. Modeling will examine the relationships between the concentrations of contaminants and hormones, demographics and social determinants of health, and health status of the study population, including health markers known to be impacted by perchlorate and pesticides. Results: We recruited 323 adults residing in Yuma County during a 1-year pilot/feasibility study. Among these, 147 residents were patients from either YRMC or RCBH with a primary diagnosis of thyroid disease, including hyperthyroidism, hypothyroidism, thyroid cancer, or goiter. The remaining 176 participants were from the general population but with no history of thyroid disorder. The pilot study confirmed the feasibility of using the identified community-engaged protocol to recruit, consent, and collect data from a difficult-to-access, vulnerable population. The demographics of the pilot study population and positive feedback on the success of the community-engaged approach indicate that the project can be scaled up to a broader study with replicable population health findings. Conclusions: Using a community-engaged approach, the research protocol provided substantial evidence regarding the effectiveness of designing and implementing culturally relevant recruitment and dissemination processes that combine laboratory findings and public health information. Future findings will elucidate the mechanisms of toxicity and the population health effects of the contaminants of concern, as well as provide a new animal model to develop precision medicine capabilities for the population. International Registered Report Identifier (IRRID): DERR1-10.2196/15864 %M 34383679 %R 10.2196/15864 %U https://www.researchprotocols.org/2021/8/e15864 %U https://doi.org/10.2196/15864 %U http://www.ncbi.nlm.nih.gov/pubmed/34383679 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 7 %P e28624 %T The Efficacy of the Dyson Air Purifier in Improving Asthma Control: Protocol for a Single-Center, Investigator-Led, Randomized, Double-Blind, Placebo-Controlled Trial %A Fong,Wei Chern Gavin %A Grevatt,Susan %A Potter,Stephen %A Tidbury,Tracey %A Kadalayil,Latha %A Bennett,Kaisha %A Larsson,Maria %A Nicolas,Frédéric %A Kurukulaaratchy,Ramesh %A Arshad,Syed Hasan %+ David Hide Asthma and Allergy Research Centre, Isle Of Wight NHS Trust, Newport, , United Kingdom, 44 (0) 1983 534373, S.H.Arshad@soton.ac.uk %K air purifier %K asthma %K clinical trial %K air pollution %K allergens %K respiratory function tests %K bronchial provocation tests %D 2021 %7 27.7.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Indoor air quality has been shown to influence asthma control and outcomes. Air purifiers and high-efficiency particulate air filtration devices can improve indoor air quality by reducing the indoor levels of air pollution and allergens. However, the influence of this improved indoor air quality on asthma control remains unclear; hence, randomized controlled trials are needed to further elucidate this phenomenon. Objective: This study aims to investigate the effect of reducing the levels of allergens and pollutants in the bedroom and living room through the use of Dyson air purifiers (Dyson Pure Cool) on asthma control. Methods: This is an 18-month long, investigator-led, randomized, double-blinded, placebo-controlled, single-center trial. Subjects will be randomized in a 1:1 ratio to active or placebo Dyson filters. The primary outcome is the change in the scores of Asthma Control Questionnaire 6 and Asthma-specific Quality of Life Questionnaire from baseline. Secondary outcomes include changes in lung function (forced expiratory volume in one second, forced expiratory volume in one second/forced vital capacity ratio, and midexpiratory flows), peak expiratory flow measurements, airway hyperresponsiveness (assessed by methacholine bronchial challenge), fractional exhaled nitric oxide, and indoor air pollutant levels. The sample size will be 50 subjects, and all subjects will have a confirmed diagnosis of mild persistent to moderate persistent asthma along with an Asthma Control Questionnaire 6 score of >1.5. Results: This study was approved by the West Midlands Research Ethics Committee (18/WM/0277). The study results will be published in peer-reviewed scientific journals; presented at relevant scientific conferences; and shared in plain English with participants in our newsletters, in our clinics, and via the David Hide Asthma and Allergy Research Centre website. Our trial began in September 2019 and is expected to end in August 2021. Conclusions: This is a double-blinded, placebo-controlled, randomized, investigator-led study to investigate the efficacy of a novel air purifier in improving asthma control in adults. The trial period of 18 months will facilitate the collection of robust data and will therefore generate clear signals. However, this extended trial duration may lead to patient withdrawal. Furthermore, this trial is conducted at a single center and in a location with a homogenous cohort of people, which may affect translatability. Nonetheless, it is hoped that the findings of this trial may help further inform clinicians regarding the utility of this novel device as an adjunct in asthma care. Trial Registration: ClinicalTrials.gov NCT04729530; https://clinicaltrials.gov/ct2/show/NCT04729530 International Registered Report Identifier (IRRID): DERR1-10.2196/28624 %M 34313599 %R 10.2196/28624 %U https://www.researchprotocols.org/2021/7/e28624 %U https://doi.org/10.2196/28624 %U http://www.ncbi.nlm.nih.gov/pubmed/34313599 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 7 %N 6 %P e26605 %T The Association Between Short-term Exposure to Ambient Air Pollution and Patient-Level Home Blood Pressure Among Patients With Chronic Cardiovascular Diseases in a Web-Based Synchronous Telehealth Care Program: Retrospective Study %A Huang,Ching-Chang %A Chen,Ying-Hsien %A Hung,Chi-Sheng %A Lee,Jen-Kuang %A Hsu,Tse-Pin %A Wu,Hui-Wen %A Chuang,Pao-Yu %A Chen,Ming-Fong %A Ho,Yi-Lwun %+ Telehealth Center, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, 10002, Taiwan, 886 223123456 ext 63737, ylho@ntu.edu.tw %K ambient air pollution %K blood pressure %K cardiovascular disease %K chronic disease %K climate %K home blood pressure %K particulate matter %K pollution %K remote monitoring %K telehealth care %K telemonitoring %K weather %D 2021 %7 8.6.2021 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: The association between short-term exposure to ambient air pollution and blood pressure has been inconsistent, as reported in the literature. Objective: This study aimed to investigate the relationship between short-term ambient air pollution exposure and patient-level home blood pressure (HBP). Methods: Patients with chronic cardiovascular diseases from a telehealth care program at a university-affiliated hospital were enrolled as the study population. HBP was measured by patients or their caregivers. Hourly meteorological data (including temperature, relative humidity, wind speed, and rainfall) and ambient air pollution monitoring data (including CO, NO2, particulate matter with a diameter of <10 µm, particulate matter with a diameter of <2.5 µm, and SO2) during the same time period were obtained from the Central Weather Bureau and the Environmental Protection Administration in Taiwan, respectively. A stepwise multivariate repeated generalized estimating equation model was used to assess the significant factors for predicting systolic and diastolic blood pressure (SBP and DBP). Results: A total of 253 patients and 110,715 HBP measurements were evaluated in this study. On multivariate analysis, demographic, clinical, meteorological factors, and air pollutants significantly affected the HBP (both SBP and DBP). All 5 air pollutants evaluated in this study showed a significant, nonlinear association with both home SBP and DBP. Compared with demographic and clinical factors, environmental factors (meteorological factors and air pollutants) played a minor yet significant role in the regulation of HBP. Conclusions: Short-term exposure to ambient air pollution significantly affects HBP in patients with chronic cardiovascular disease. %M 34100764 %R 10.2196/26605 %U https://publichealth.jmir.org/2021/6/e26605 %U https://doi.org/10.2196/26605 %U http://www.ncbi.nlm.nih.gov/pubmed/34100764 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 5 %P e22973 %T Usability of Rapid Cholera Detection Device (OmniVis) for Water Quality Workers in Bangladesh: Iterative Convergent Mixed Methods Study %A Rager,Theresa L %A Koepfli,Cristian %A Khan,Wasif A %A Ahmed,Sabeena %A Mahmud,Zahid Hayat %A Clayton,Katherine N %+ OmniVis Inc, 280 Utah Ave Ste 200, South San Francisco, CA, , United States, 1 415 938 4300, kclayton@omnivistech.com %K cholera %K environmental surveillance %K mHealth %K usability %D 2021 %7 12.5.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Cholera poses a significant global health burden. In Bangladesh, cholera is endemic and causes more than 100,000 cases each year. Established environmental reservoirs leave millions at risk of infection through the consumption of contaminated water. The Global Task Force for Cholera Control has called for increased environmental surveillance to detect contaminated water sources prior to human infection in an effort to reduce cases and deaths. The OmniVis rapid cholera detection device uses loop-mediated isothermal amplification and particle diffusometry detection methods integrated into a handheld hardware device that attaches to an iPhone 6 to identify and map contaminated water sources. Objective: The aim of this study was to evaluate the usability of the OmniVis device with targeted end users to advance the iterative prototyping process and ultimately design a device that easily integrates into users’ workflow. Methods: Water quality workers were trained to use the device and subsequently completed an independent device trial and usability questionnaire. Pretraining and posttraining knowledge assessments were administered to ensure training quality did not confound trial and questionnaire Results: Device trials identified common user errors and device malfunctions including incorrect test kit insertion and device powering issues. We did not observe meaningful differences in user errors or device malfunctions accumulated per participant across demographic groups. Over 25 trials, the mean time to complete a test was 47 minutes, a significant reduction compared with laboratory protocols, which take approximately 3 days. Overall, participants found the device easy to use and expressed confidence and comfort in using the device independently. Conclusions: These results are used to advance the iterative prototyping process of the OmniVis rapid cholera detection device so it can achieve user uptake, workflow integration, and scale to ultimately impact cholera control and elimination strategies. We hope this methodology will promote robust usability evaluations of rapid pathogen detection technologies in device development. %M 33978590 %R 10.2196/22973 %U https://www.jmir.org/2021/5/e22973 %U https://doi.org/10.2196/22973 %U http://www.ncbi.nlm.nih.gov/pubmed/33978590 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 5 %P e22591 %T Acute Exacerbation of a Chronic Obstructive Pulmonary Disease Prediction System Using Wearable Device Data, Machine Learning, and Deep Learning: Development and Cohort Study %A Wu,Chia-Tung %A Li,Guo-Hung %A Huang,Chun-Ta %A Cheng,Yu-Chieh %A Chen,Chi-Hsien %A Chien,Jung-Yien %A Kuo,Ping-Hung %A Kuo,Lu-Cheng %A Lai,Feipei %+ Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, No 7 Chung-Shan S Road, Taipei, 100, Taiwan, 886 972651516, jychien@ntu.edu.tw %K chronic obstructive pulmonary disease %K clinical decision support systems %K health risk assessment %K wearable device %D 2021 %7 6.5.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The World Health Organization has projected that by 2030, chronic obstructive pulmonary disease (COPD) will be the third-leading cause of mortality and the seventh-leading cause of morbidity worldwide. Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are associated with an accelerated decline in lung function, diminished quality of life, and higher mortality. Accurate early detection of acute exacerbations will enable early management and reduce mortality. Objective: The aim of this study was to develop a prediction system using lifestyle data, environmental factors, and patient symptoms for the early detection of AECOPD in the upcoming 7 days. Methods: This prospective study was performed at National Taiwan University Hospital. Patients with COPD that did not have a pacemaker and were not pregnant were invited for enrollment. Data on lifestyle, temperature, humidity, and fine particulate matter were collected using wearable devices (Fitbit Versa), a home air quality–sensing device (EDIMAX Airbox), and a smartphone app. AECOPD episodes were evaluated via standardized questionnaires. With these input features, we evaluated the prediction performance of machine learning models, including random forest, decision trees, k-nearest neighbor, linear discriminant analysis, and adaptive boosting, and a deep neural network model. Results: The continuous real-time monitoring of lifestyle and indoor environment factors was implemented by integrating home air quality–sensing devices, a smartphone app, and wearable devices. All data from 67 COPD patients were collected prospectively during a mean 4-month follow-up period, resulting in the detection of 25 AECOPD episodes. For 7-day AECOPD prediction, the proposed AECOPD predictive model achieved an accuracy of 92.1%, sensitivity of 94%, and specificity of 90.4%. Receiver operating characteristic curve analysis showed that the area under the curve of the model in predicting AECOPD was greater than 0.9. The most important variables in the model were daily steps walked, stairs climbed, and daily distance moved. Conclusions: Using wearable devices, home air quality–sensing devices, a smartphone app, and supervised prediction algorithms, we achieved excellent power to predict whether a patient would experience AECOPD within the upcoming 7 days. The AECOPD prediction system provided an effective way to collect lifestyle and environmental data, and yielded reliable predictions of future AECOPD events. Compared with previous studies, we have comprehensively improved the performance of the AECOPD prediction model by adding objective lifestyle and environmental data. This model could yield more accurate prediction results for COPD patients than using only questionnaire data. %M 33955840 %R 10.2196/22591 %U https://mhealth.jmir.org/2021/5/e22591 %U https://doi.org/10.2196/22591 %U http://www.ncbi.nlm.nih.gov/pubmed/33955840 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 9 %P e15167 %T Chronic Low-Dose Exposure to Xenoestrogen Ambient Air Pollutants and Breast Cancer Risk: XENAIR Protocol for a Case-Control Study Nested Within the French E3N Cohort %A Amadou,Amina %A Coudon,Thomas %A Praud,Delphine %A Salizzoni,Pietro %A Leffondre,Karen %A Lévêque,Emilie %A Boutron-Ruault,Marie-Christine %A Danjou,Aurélie M N %A Morelli,Xavier %A Le Cornet,Charlotte %A Perrier,Lionel %A Couvidat,Florian %A Bessagnet,Bertrand %A Caudeville,Julien %A Faure,Elodie %A Mancini,Francesca Romana %A Gulliver,John %A Severi,Gianluca %A Fervers,Béatrice %+ Department of Prevention Cancer Environment, Centre Léon Bérard, Lyon, France, 33 4 78 78 28 01, beatrice.fervers@lyon.unicancer.fr %K breast cancer %K hormone receptor status %K air pollution %K endocrine disruptors %K multipollutant %K geographic information system %K land use regression %K chemistry-transport model %K epigenetic %K gene-environment interaction %K prospective study %D 2020 %7 15.9.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Breast cancer is the most frequent cancer in women in industrialized countries. Lifestyle and environmental factors, particularly endocrine-disrupting pollutants, have been suggested to play a role in breast cancer risk. Current epidemiological studies, although not fully consistent, suggest a positive association of breast cancer risk with exposure to several International Agency for Research on Cancer Group 1 air-pollutant carcinogens, such as particulate matter, polychlorinated biphenyls (PCB), dioxins, Benzo[a]pyrene (BaP), and cadmium. However, epidemiological studies remain scarce and inconsistent. It has been proposed that the menopausal status could modify the relationship between pollutants and breast cancer and that the association varies with hormone receptor status. Objective: The XENAIR project will investigate the association of breast cancer risk (overall and by hormone receptor status) with chronic exposure to selected air pollutants, including particulate matter, nitrogen dioxide (NO2), ozone (O3), BaP, dioxins, PCB-153, and cadmium. Methods: Our research is based on a case-control study nested within the French national E3N cohort of 5222 invasive breast cancer cases identified during follow-up from 1990 to 2011, and 5222 matched controls. A questionnaire was sent to all participants to collect their lifetime residential addresses and information on indoor pollution. We will assess these exposures using complementary models of land-use regression, atmospheric dispersion, and regional chemistry-transport (CHIMERE) models, via a Geographic Information System. Associations with breast cancer risk will be modeled using conditional logistic regression models. We will also study the impact of exposure on DNA methylation and interactions with genetic polymorphisms. Appropriate statistical methods, including Bayesian modeling, principal component analysis, and cluster analysis, will be used to assess the impact of multipollutant exposure. The fraction of breast cancer cases attributable to air pollution will be estimated. Results: The XENAIR project will contribute to current knowledge on the health effects of air pollution and identify and understand environmental modifiable risk factors related to breast cancer risk. Conclusions: The results will provide relevant evidence to governments and policy-makers to improve effective public health prevention strategies on air pollution. The XENAIR dataset can be used in future efforts to study the effects of exposure to air pollution associated with other chronic conditions. International Registered Report Identifier (IRRID): DERR1-10.2196/15167 %M 32930673 %R 10.2196/15167 %U http://www.researchprotocols.org/2020/9/e15167/ %U https://doi.org/10.2196/15167 %U http://www.ncbi.nlm.nih.gov/pubmed/32930673 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 4 %P e17138 %T Investigating Health Impacts of Natural Resource Extraction Projects in Burkina Faso, Ghana, Mozambique, and Tanzania: Protocol for a Mixed Methods Study %A Farnham,Andrea %A Cossa,Hermínio %A Dietler,Dominik %A Engebretsen,Rebecca %A Leuenberger,Andrea %A Lyatuu,Isaac %A Nimako,Belinda %A Zabre,Hyacinthe R %A Brugger,Fritz %A Winkler,Mirko S %+ Swiss Tropical and Public Health Institute, PO Box, Basel, 4002, Switzerland, 41 612848684, andrea.farnham@swisstph.ch %K health impact assessment %K environmental health %K mixed methods %K extractive industry %K DHIS2 %K time series %K GIS %K cost-benefit %K DHS %D 2020 %7 8.4.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Natural resource extraction projects offer both opportunities and risks for sustainable development and health in host communities. Often, however, the health of the community suffers. Health impact assessment (HIA) can mitigate the risks and promote the benefits of development but is not routinely done in the developing regions that could benefit the most. Objective: Our study aims to investigate health and health determinants in regions affected by extractive industries in Burkina Faso, Ghana, Mozambique, and Tanzania. The evidence generated in our study will inform a policy dialogue on how HIA can be promoted as a regulatory approach as part of the larger research initiative called the HIA4SD (Health impact assessment for sustainable development) project. Methods: The study is a concurrent triangulation, mixed methods, multi-stage, multi-focus project that specifically addresses the topics of governance and policy, social determinants of health, health economics, health systems, maternal and child health, morbidity and mortality, and environmental determinants, as well as the associated health outcomes in natural resource extraction project settings across four countries. To investigate each of these health topics, the project will (1) use existing population-level databases to quantify incidence of disease and other health outcomes and determinants over time using time series analysis; (2) conduct two quantitative surveys on mortality and cost of disease in producer regions; and (3) collect primary qualitative data using focus groups and key informant interviews describing community perceptions of the impacts of extraction projects on health and partnership arrangements between the projects and local and national governance. Differences in health outcomes and health determinants between districts with and without an extraction project will be analyzed using matched geographical analyses in quasi-Poisson regression models and binomial regression models. Costs to the health system and to the households from diseases found to be associated with projects in each country will be estimated retrospectively. Results: Fieldwork for the study began in February 2019 and concluded in February 2020. At the time of submission, qualitative data collection had been completed in all four study countries. In Burkina Faso, 36 focus group discussions and 74 key informant interviews were conducted in three sites. In Ghana, 34 focus group discussions and 64 key informant interviews were conducted in three sites. In Mozambique, 75 focus group discussions and 103 key informant interviews were conducted in four sites. In Tanzania, 36 focus group discussions and 84 key informant interviews were conducted in three sites. Quantitative data extraction and collection is ongoing in all four study countries. Ethical approval for the study was received in all four study countries prior to beginning the fieldwork. Data analyses are underway and results are expected to be published in 2020 and 2021. Conclusions: Disentangling the complex interactions of resource extraction projects with their host communities requires an integrative approach drawing on many methodologies under the HIA umbrella. By using complementary data sources to address the question of population health in project areas from several angles, bias and missing data will be reduced, generating high-quality evidence to aid countries in moving toward sustainable development. International Registered Report Identifier (IRRID): DERR1-10.2196/17138 %M 32266876 %R 10.2196/17138 %U http://www.researchprotocols.org/2020/4/e17138/ %U https://doi.org/10.2196/17138 %U http://www.ncbi.nlm.nih.gov/pubmed/32266876 %0 Journal Article %@ 1947-2579 %I JMIR Publications %V 11 %N 1 %P e9814 %T Roles of Health Literacy in Relation to Social Determinants of Health and Recommendations for Informatics-Based Interventions: Systematic Review %D 2019 %7 ..2019 %9 %J Online J Public Health Inform %G English %X ObjectiveTo inform asthmatic, health plan patients of air quality conditions in their specific geographic location and to assess if the communication is successful in reducing the number of emergency department visits for asthmatic/respiratory flare ups.IntroductionSouthwest states are prone to wildfires, dust storms, and high winds especially during the monsoon season (June – September). Wildfire smoke is a complex mixture of carbon monoxide, carbon dioxide, water vapor, hydrocarbons, nitrogen, oxides, metals, and particulate matter (PM). Dust storms are made up of aerosols and dust particles varying in size; particles bigger than 10 µm are not breathable, but can damage external organs such as causing skin and eye irritations. Particles smaller than 10 µm are inhalable and often are trapped in the nose, mouth, and upper respiratory tracts, and can cause respiratory disorders such as asthma and pneumonia. Numerous studies have characterized the epidemiological and toxicological impact of exposure to PM in dust or smoke form on human health.1All of these environmental conditions can have impacts on cardiovascular conditions such as hypertension and cause respiratory flare ups, especially asthma. Previous studies have shown a relationship between PM exposure and increases in respiratory-related hospital admissions.1-4 In an analysis of the health effects of a large wildfire in California in 2008, Reid, et. al, observed a linear increase in risk for asthma hospitalizations (RR=1.07, 95% CI= (1.05, 1.10) per 5 µg/m3 increase) and asthma emergency department visits (RR=1.06, 95% CI=(1.05, 1.07) per 5 µg/m3 increase) with increasing PM2.5 during wildfires.5 In a study specific to New Mexico, Resnick, et. al, found that smoke from the Wallow fire in Arizona in 2011 impacted the health of New Mexicans, observing increases in emergency department visits for asthma flare-ups in Santa Fe, Espanola, and Albuquerque residents.6This current study will evaluate the effectiveness of outreach to asthmatic members during times of poor air quality; informing them of the air quality, instructing them to limit their outdoor activity, and to remind them to carry or access their inhalers or other medical necessities if/when needed.MethodsA recent 12-month eligible member list was generated including member ID, street address, zip code, and a count of the number of emergency department (ED) visits for the specified time period. The member list was then geocoded using the tool Quest. Any records that did not map to a latitude and longitude within the state boundary of New Mexico were excluded. The geocoded list was then joined to a list of members who had an indicator for asthma (a hospital admission or ED visit with a primary diagnosis for asthma). This list of asthmatic, eligible members was then mapped using QGIS 3.2.The New Mexico Environment Department’s (NMED) air quality bureau operates a network of ambient air monitors across the state. Monitors range in size from neighborhood level to regional and pollutants measured include ozone, PM2.5, PM10, Nitrogen Dioxide, and Sulfur Dioxide. Each individual air monitor was mapped to a point location with individual buffer zones (dependent on the monitor’s collection size).Asthmatic members were mapped to air monitor buffers using a spatial overlap program in QGIS. Each air monitor then had a list of asthmatic members who were tied to the air monitor and would be contacted if the air quality index (AQI) value for that air monitor was less than good (>50).ResultsIn a given 12-month period, there were 38,364 asthmatic members mapped to a geographic point within the state boundary of New Mexico. Of the 14 air monitors across the state, 9,965 (26%) asthmatic members mapped to an air monitor. NMED posts air monitor readings on their website daily. During the upcoming 2019 monsoon season, air monitors with a daily AQI reading of >50 will trigger the emailing of a scripted letter to asthmatic members (connected to that specific monitor) informing them of poor air quality in their area and alerting them to limit their outdoor time and to ensure that their medications are up-to-date and easily available. In order to construct this letter in a non-intrusive, succinct manner, collaboration with business partners (who have experience with working with members on a 1:1 basis) within the organization will assist with ensuring a targeted message.After the 2019 monsoon season, this project will be evaluated to determine if the intervention was beneficial in reducing the number of ED visits for the members who were contacted. ED visit rates specific to asthma (inclusion of asthma specific diagnosis code) will be compared for the pre and post intervention monsoon seasons.ConclusionsCombining external, state-level data with internal member-level data can have powerful results. Due to protected health information (PHI), state level data sometimes is unavailable at a person-level basis, and thus pointed, individual interventions are not possible. By combining internal and external data sources on different health related topics, it is possible to create a more cohesive, person-level, health-impactful view of a person and their environment.References1. Fann N, Alman B, Broome RA, et al. The health impacts and economic value of wildland fire episodes in the U.S.: 2008-2012. Sci Total Environ. 2018;610-611:802-809.2. Delfino RJ, Brummel S, Wu J, et al. The relationship of respiratory and cardiovascular hospital admissions to the southern california wildfires of 2003. Occup Environ Med. 2009;66(3):189-197.3. Gan RW, Ford B, Lassman W, et al. Comparison of wildfire smoke estimation methods and associations with cardiopulmonary-related hospital admissions. Geohealth. 2017;1(3):122-136.4. Kanatani KT, Ito I, Al-Delaimy WK, et al. Desert dust exposure is associated with increased risk of asthma hospitalization in children. Am J Respir Crit Care Med. 2010;182(12):1475-1481.5. Reid CE, Jerrett M, Tager IB, Petersen ML, Mann JK, Balmes JR. Differential respiratory health effects from the 2008 northern california wildfires: A spatiotemporal approach. Environ Res. 2016;150:227-235.6. Resnick A, Woods B, Krapfl H, Toth B. Health outcomes associated with smoke exposure in albuquerque, new mexico, during the 2011 wallow fire. J Public Health Manag Pract. 2015;21 Suppl 2:S55-61. %R 10.5210/ojphi.v11i1.9814 %U %U https://doi.org/10.5210/ojphi.v11i1.9814 %0 Journal Article %@ 1947-2579 %I JMIR Publications %V 11 %N 1 %P e9819 %T Roles of Health Literacy in Relation to Social Determinants of Health and Recommendations for Informatics-Based Interventions: Systematic Review %D 2019 %7 ..2019 %9 %J Online J Public Health Inform %G English %X ObjectiveTo analyze Los Angeles County’s (LAC) extreme heat season in 2018 and evaluate the Council of State and Territorial Epidemiologists’ (CSTE) syndrome query for heat-related-illness (HRI) in Los Angeles County (LAC)IntroductionLAC experienced several days of record-breaking temperatures during the summer of 2018. Downtown Los Angeles temperatures soared to 108°F in July with an average daily maximum of 92°F. Extreme heat events such as these can pose major risks to human health. Syndromic surveillance can be a useful tool in providing near real-time surveillance of HRI. In 2014, a working group was formed within the CSTE Climate Change Subcommittee to define and analyze HRI. The workgroup’s goal was to provide guidance to public health professionals in adapting and implementing an HRI syndrome surveillance query. The Acute Communicable Disease Control Program’s (ACDC) Syndromic Surveillance Unit utilized CSTE’s HRI query to provide surveillance during the extreme heat season in 2018 in LAC. Additional modifications to the CSTE query were evaluated for potential improvements towards characterizing HRI trends.MethodsFrom May 1 to September 30, 2018, Emergency Department (ED) data were queried for cases using the CSTEs definition for HRI. The queries consisted of key word searches within the chief complaint (CC) data field, and, if available, the diagnosis data fields. The query was derived from the CSTE HRI query published in 20161. In addition, ACDC explored the utility of expanding the CSTE syndrome definition to include additional chief complaints commonly associated with HRI such as dehydration and syncope. Both queries were applied on all participating syndromic EDs in LAC alongside daily high temperature data trends. Local temperature data for downtown Los Angeles weather station KCQT were taken from the Weather Underground website. Spearman correlation coefficients were calculated for each query during the heat season. Similarly, both queries were also applied during colder months from October 1, 2017 to April 30, 2018 for comparison. Lastly, results for dehydration and syncope were independently assessed apart from other HRI query terms during both heat seasons and colder months.ResultsThe CSTE HRI query and the query with the added terms yielded 1,258 and 63,332 ED visits, respectively, during the heat season. On July 6, the maximum daily temperature peaked at 108 °F; the HRI and the query with the added terms yielded 136 and 618 ED visits, respectively. The HRI query and the HRI query with the added terms had a correlation coefficient of 0.714 (p <0.0001) and 0.427 (p <0.0001), respectively. During colder months, the CSTE HRI query and the query with the added terms yielded 377 and 86,008, respectively, with correlation coefficients of 0.342 (p < 0.0001) and 0.133 (p < 0.052). The syncope-only query saw no variation in HRI classified encounters throughout the heat season (mean: 328; min: 228; max: 404) or colder months (mean: 328; min: 261; max: 404) with correlation coefficients of 0.238 (p = 0.003) and 0.155 (p = 0.024), respectively. Similarly, the dehydration-only query saw no variation in HRI classified encounters throughout the heat season (mean: 96; min: 58; max: 258) or colder months (mean: 94; min: 60; max: 160) with correlation coefficients of 0.596 (p < 0.0001) and -0.016 (p = 0.822).ConclusionsThe CSTE HRI query proved to be a strong indicator for HRI, and the addition of terms associated with dehydration and syncope to the CSTE HRI query weakened the correlation with temperature. Compared to the original CSTE HRI query, the added terms yielded a 4934% increase in HRI classified encounters during the heat season; however, these were likely due to causes other than HRI -- adding the extra terms resulted in a weaker correlation with temperature. Additionally, the comparative analysis showed that, with the added terms, the volume of HRI encounters was larger during colder months than hotter months suggesting misclassification of non-HRI illnesses. Surveillance of HRI has proven to be difficult because many of the HRI symptoms are too commonly associated with non-HRI conditions which would explain the weaker correlations when adding additional chief complaints associated with HRI. In conclusion, the CSTE syndrome definition for HRI proved to be the most robust query for HRI during the heat season. Case counts of HRI are difficult due to symptom overlap with many other medical conditions. However, syndromic surveillance using the CSTE HRI query is useful for trend analysis in near real-time during heat events.References1. Council of State and Territorial Epidemiologists. Heat-Related Illness Syndrome Query: A Guidance Document for Implementing Heat-Related Illness Syndromic Surveillance in Public Health Practice. Version 1.0. 2016 Sep. 12 p. %R 10.5210/ojphi.v11i1.9819 %U %U https://doi.org/10.5210/ojphi.v11i1.9819 %0 Journal Article %@ 1947-2579 %I JMIR Publications %V 11 %N 1 %P e9905 %T Roles of Health Literacy in Relation to Social Determinants of Health and Recommendations for Informatics-Based Interventions: Systematic Review %D 2019 %7 ..2019 %9 %J Online J Public Health Inform %G English %X ObjectiveThe Louisiana Early Event Detection System (LEEDS), Louisiana’s syndromic surveillance system, was used to monitor uncharacteristically low temperatures during the 2017-2018 winter season and determine the impact of these temperatures on the number of weather related personal injuries in emergency departments throughout Louisiana.IntroductionThe Infectious Disease Epidemiology Section (IDEpi) in the Louisiana Office of Public Health (OPH) has several applications for syndromic surveillance including situational awareness during unusual and/or high profile events, such as the uncharacteristic winter weather Louisiana experienced during the 2017-2018 winter season. December 8th, 2017 saw freezing temperatures with some parts of the state experiencing snow, and January 16 – 18, 2018 saw record breaking freezing temperatures throughout the state. Both weather events led to many state office, school and business closures. The freezing temperatures from January 16th – 18th led to office closures that lasted longer than the freezing temperatures due to the infrastructure damage the freezing temperatures caused. For example, Orleans parish experienced low water pressure throughout its water systems due to broken pipes following the freeze, leading to boil water advisories. Many people throughout Louisiana had broken pipes at their homes, resulting in flooding and further contributing to low water pressure in some areas. IDEpi used syndromic surveillance to monitor the impacts of the severe winter weather and its aftermath on weather related personal injuries throughout the state.MethodsLEEDS was queried to obtain the number of cold weather related emergency department visits. This was done by querying for records that mentioned “cold exposure,” “fell on ice,” “freeze,” “hypothermia,” “ice,” “slipped on ice,” or “snow” in the chief complaint or admit reason. Records were excluded if they mentioned “antifreeze,” “device,” “jaundice,” “lice,” “notice,” “office,” “orifice,” “police,” “practice,” “septicemia,” “twice,” or “voice” in the chief complaint or admit reason. A record review was done to determine if the returned visits were in fact cold weather related, and the number of visits were grouped by triage date. The daily cold weather related ED visit counts were plotted against weather data taken from ESSENCE, the National Syndromic Surveillance Program’s syndromic surveillance application. The data obtained from ESSENCE was used to calculate the daily average minimum temperature throughout Louisiana from December 1, 2017 through February 29, 2018. This was done by selecting all of the fourteen Louisiana weather stations in ESSENCE and calculating the daily average minimum temperature across all stations. The number of cold weather related ED visits were then plotted against the daily minimum temperature in Louisiana. The initial active surveillance took place during the extreme cold weather that occurred from January 15, 2018 – January 20, 2018. Data starting on December 1, 2017 was pulled to provide a baseline. Additional data through February 28, 2018 was pulled retrospectively to analyze the overall trend of cold weather related ED visits throughout winter season.ResultsCold weather related ED visits and daily average minimum temperatures were analyzed for the time period of December 1, 2017 to February 28, 2018. The average number of cold weather ED visits for this time period was 1.8 visits with a standard deviation of +/- 4.4 visits, and the average minimum temperature was 40.9 °F. The number of cold weather related ED visits went above 6.1 visits on the following occasions: December 9th had 7 visits and an average minimum temperature of 25.9 °F and January 17th-18th had 37 and 18 visits, respectively, with respective average minimum temperatures of 12.5 °F and 16.1 °F. The 2017 - 2018 Winter Weather Surveillance in Louisiana graph also reflects these results. Of the cold weather related ED visits that took place on either December 9th or January 17th-18th, 81% indicated an ice or snow related personal injury, 14% indicated hypothermia, and 5% indicated cold exposure.ConclusionsThe three coldest days, January 16th -18th, corresponded with the largest spikes in cold weather related ED visits. The spike in visits on December 9, 2017 did not correspond to very low temperatures, but areas of Louisiana did experience snowfall on December 8th, which led to ice formation. A record review of all visits that fit the inclusion criteria of a cold weather related ED visit showed that many of the visits that took place from January 19th-21st were also personal injuries that had either just taken place from slipping on ice or had occurred several days prior and remained unresolved. Ultimately, syndromic surveillance was instrumental in maintaining situational awareness during the uncharacteristic winter weather experienced in Louisiana. The results of this winter weather surveillance were published in the Louisiana Morbidity Report. IDEpi will continue to use syndromic surveillance during periods of uncharacteristic winter weather to maintain situational awareness, which may be used in public safety messaging to reduce the number of cold weather related personal injuries in the population that is not accustomed to such conditions. %R 10.5210/ojphi.v11i1.9905 %U %U https://doi.org/10.5210/ojphi.v11i1.9905 %0 Journal Article %@ 1947-2579 %I JMIR Publications %V 11 %N 1 %P e9944 %T Roles of Health Literacy in Relation to Social Determinants of Health and Recommendations for Informatics-Based Interventions: Systematic Review %D 2019 %7 ..2019 %9 %J Online J Public Health Inform %G English %X ObjectiveTo evaluate Vaccine Derived Polio Virus 2 isolation rate from Environmental Surveillance and its contribution to Polio Eradication Initiative (PEI)IntroductionNigeria is the only country in Africa yet to be certified free of Wild Polio Virus (WPV). The country consists of 36 States and a Federal Capital Territory. Gombe is one of the 19 Polio high risk States in the North-eastern geo-political zone of the country. The last case of WPV isolated in Gombe State was in 2013.One of the strategies for Polio eradication is a sensitive Acute Flaccid Paralysis (AFP) surveillance system in which any AFP is promptly detected and timely investigated. The focus of the investigation is to analyze two faecal samples of the patient, and/or sometimes those from contacts for any possible isolation of Polio Virus1 (PV). AFP surveillance is meant to be applicable to any human population at any time; however, there are situations in which there are good reasons to suspect that negative results of AFP surveillance are not reliable. Supplementary information is required in such situations and one approach for that is Environmental Surveillance (ES), in which a search for PV is made in environmental specimens contaminated by human feaces2ES in the African region started in Nigeria in July 20113,4. Since the introduction of this strategy, it has achieved its objective of complimenting the AFP surveillance system. There has been a gradual increase in the number of ES sites in Nigeria from 2011 to date4. The increase is largely due to the successes recorded in terms of the PV isolation from the sites, PV epidemiology, the large population size and mobility4,5. The last cases of WPV1 and WPV3 from environmental samples had dates of collection in May 2014 (Kaduna) and July 2012 (Kano) respectively4.ES was initiated in Gombe State in December 2016. Four ES sites were identified and sample collection began soon after training of personnel responsible for collection of the sewage sample. The four identified ES sites are Baba Roba Valley, Unguwauku Railway Bridge, Gadan Bayan Moonshine and Dan Gusau Bridge. Since inception of ES in Gombe State, 2 ambiguous Vaccine Derived Poliovirus type 2 (aVDPV2) were confirmed from sewage samples collected from Baba Roba Valley site on the 30th January 2017 and from Dan Gusau Bridge site on the 6th March 2017. In 2018, a circulating Vaccine Derived Poliovirus type 2 (cVDPV2) was also detected from sewage samples collected on the 9th April 2018 from Baba Roba Valley site. We reviewed the laboratory results from the 2 surveillance methods so as to evaluate the VDPV2 isolation rate.MethodsES involves collection of one litre of environmental sample (sewage water) via grab sampling method in accordance with World Health Organization’s (WHO) Guidelines for Environmental Surveillance for Polioviruses2. All ES sewage samples were transported in a 1 litre container appropriately packaged in a Giostyle with 8 frozen icepacks to maintain reverse cold chain to a Polio Laboratory where the samples are analyzed as per WHO ES testing standard operating procedures. Poliovirus type 2 isolates are sent to the reference laboratory at the US Centre for Disease Control for sequencing for PV isolation.We reviewed all the results of the environmental samples (ES) and stool samples from patients with Acute flaccid paralysis (AFP) from January 2017 to June 2018. The environmental samples were from five pre-selected sites that was based on the perceived risks for polio circulation that included poor sanitation, overcrowding, extend of drainage population, availability of sewage system and absence of discharge into the sites. The stool samples were from patients detected with AFP in Gombe local government area.The results from the two methods of surveillance for PV were evaluated and compared based on yields and isolates (Negative results, VDPV2, Non-polio enterovirus (NPENT).ResultsA total of 309 sewage samples from five (5) sites and 142 AFP stool samples from Gombe LGA were collected from January 2017 to June 2018. Three 3(0.97%) of the sewage samples yielded VDPV2, 102(33.01%) had Non-polio enteroviruses (NPENT) and 41 (13.27%) negative samples. On the other hand, no VDPV was isolated from the AFP stool samples, the NPENT detection rate was 13(9.16%) and 121(85.21%) samples were negative. The Non-polio AFP (NPAFP) and stool adequacy rates for Gombe LGA during the reporting period were calculated to be 17.2 and 100% respectively.ConclusionsThe polio virus (VDPV) isolation from ES in this review is higher than in AFP surveillance. This has demonstrated amongst others benefit of ES its ability to detect polio virus even in the absence of the virus among AFP cases. ES can thus detect virus that are probably missed by AFP surveillance and hence allow for early response so as to curtail further transmission. The high NPAFP and stool adequacy rates are indication of a sensitive surveillance system nonetheless, the virus isolation from the AFP surveillance was very low. It is important to mention here that other laboratory indicators were not factored into this review. We recommend therefore that both ES and AFP surveillance be done together where facility, resources and personnel are available to implement.References[1] WHO. Field guide for supplementary activities aimed at achieving polio eradication, publication no. WHO/EPI/GEN/95.1. Geneva: World Health Organization, 1995.[2] WHO. Guidelines for environmental surveillance of poliovirus circulation. World Health Organization 2003,Department of Vaccines and Biologicals, 2003. (http://www.who.int/vaccines-documents/DoxGen/H5-Surv.htm). Accessed 6 October 2010.[3] Nicksy Gumede et al. Status of environmental surveillance in the African Regional. African health monitor. March 2015 Issue 19: Pg 38-41[4] Ticha Johnson Muluh et al. Contribution of Environmental Surveillance Toward Interruption of Poliovirus Transmission in Nigeria, 2012–2015. The Journal of Infectious Diseases, Volume 213, Issue suppl_3, 1 May 2016, Pages S131–S135, https://doi.org/10.1093/infdis/jiv767[5] Humayun Ashgar et al. Environmental Surveillance for Polioviruses in the Global Polio Eradication Initiative. The Journal of Infectious Diseases, Volume 210, Issue suppl_1, 1 November 2014, Pages S294–S303, https://doi.org/10.1017/S095026881000316X %R 10.5210/ojphi.v11i1.9944 %U %U https://doi.org/10.5210/ojphi.v11i1.9944 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 3 %P e48 %T Effect of Using an Indoor Air Quality Sensor on Perceptions of and Behaviors Toward Air Pollution (Pittsburgh Empowerment Library Study): Online Survey and Interviews %A Wong-Parodi,Gabrielle %A Dias,M Beatrice %A Taylor,Michael %+ Carnegie Mellon University, 5000 Forbes Avenue, Pittsburgh, PA, 15213, United States, 1 412 268 2000, gwongpar@cmu.edu %K indoor air pollution %K particulate matter %K inhalation %K decision aids %D 2018 %7 08.03.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Air quality affects us all and is a rapidly growing concern in the 21st century. We spend the majority of our lives indoors and can be exposed to a number of pollutants smaller than 2.5 microns (particulate matter, PM2.5) resulting in detrimental health effects. Indoor air quality sensors have the potential to provide people with the information they need to understand their risk and take steps to reduce their exposure. One such sensor is the Speck sensor developed at the Community Robotics, Education and Technology Empowerment Lab at Carnegie Mellon University. This sensor provides users with continuous real-time and historical PM2.5 information, a Web-based platform where people can track their PM2.5 levels over time and learn about ways to reduce their exposure, and a venue (blog post) for the user community to exchange information. Little is known about how the use of such monitors affects people’s knowledge, attitudes, and behaviors with respect to indoor air pollution. Objective: The aim of this study was to assess whether using the sensor changes what people know and do about indoor air pollution. Methods: We conducted 2 studies. In the first study, we recruited 276 Pittsburgh residents online and through local branches of the Carnegie Library of Pittsburgh, where the Speck sensor was made available by the researchers in the library catalog. Participants completed a 10- to 15-min survey on air pollution knowledge (its health impact, sources, and mitigation options), perceptions of indoor air quality, confidence in mitigation, current behaviors toward air quality, and personal empowerment and creativity in the spring and summer of 2016. In our second study, we surveyed 26 Pittsburgh residents in summer 2016 who checked out the Speck sensor for 3 weeks on the same measures assessed in the first study, with additional questions about the perception and use of the sensor. Follow-up interviews were conducted with a subset of those who used the Speck sensor. Results: A series of paired t tests found participants were significantly more knowledgeable (t25=−2.61, P=.02), reported having significantly better indoor air quality (t25=−5.20, P<.001), and felt more confident about knowing how to mitigate their risk (t25=−1.87, P=.07) after using the Speck sensor than before. McNemar test showed participants tended to take more action to reduce indoor air pollution after using the sensor (χ225=2.7, P=.10). Qualitative analysis suggested possible ripple effects of use, including encouraging family and friends to learn about indoor air pollution. Conclusions: Providing people with low- or no-cost portable indoor air quality monitors, with a supporting Web-based platform that offers information about how to reduce risk, can help people better express perceptions and adopt behaviors commensurate with the risks they face. Thus, thoughtfully designed and deployed personal sensing devices can help empower people to take steps to reduce their risk. %M 29519779 %R 10.2196/mhealth.8273 %U http://mhealth.jmir.org/2018/3/e48/ %U https://doi.org/10.2196/mhealth.8273 %U http://www.ncbi.nlm.nih.gov/pubmed/29519779 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 3 %N 4 %P e64 %T Effects of the Ambient Fine Particulate Matter on Public Awareness of Lung Cancer Risk in China: Evidence from the Internet-Based Big Data Platform %A Yang,Hongxi %A Li,Shu %A Sun,Li %A Zhang,Xinyu %A Hou,Jie %A Wang,Yaogang %+ School of Public Health, Tianjin Medical University, No 22, Qixiangtai Road, Heping District, Tianjin, 300070, China, 86 13820046130, wyg@tmu.edu.cn %K lung cancer %K risk factors %K particulate matter %K PM2.5 %K Baidu Index %K information seeking behavior %K public awareness %K China %D 2017 %7 03.10.2017 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: In October 2013, the International Agency for Research on Cancer classified the particulate matter from outdoor air pollution as a group 1 carcinogen and declared that particulate matter can cause lung cancer. Fine particular matter (PM2.5) pollution is becoming a serious public health concern in urban areas of China. It is essential to emphasize the importance of the public’s awareness and knowledge of modifiable risk factors of lung cancer for prevention. Objective: The objective of our study was to explore the public’s awareness of the association of PM2.5 with lung cancer risk in China by analyzing the relationship between the daily PM2.5 concentration and searches for the term “lung cancer” on an Internet big data platform, Baidu. Methods: We collected daily PM2.5 concentration data and daily Baidu Index data in 31 Chinese capital cities from January 1, 2014 to December 31, 2016. We used Spearman correlation analysis to explore correlations between the daily Baidu Index for lung cancer searches and the daily average PM2.5 concentration. Granger causality test was used to analyze the causal relationship between the 2 time-series variables. Results: In 23 of the 31 cities, the pairwise correlation coefficients (Spearman rho) between the daily Baidu Index for lung cancer searches and the daily average PM2.5 concentration were positive and statistically significant (P<.05). However, the correlation between the daily Baidu Index for lung cancer searches and the daily average PM2.5 concentration was poor (all r2s<.1). Results of Granger causality testing illustrated that there was no unidirectional causality from the daily PM2.5 concentration to the daily Baidu Index for lung cancer searches, which was statistically significant at the 5% level for each city. Conclusions: The daily average PM2.5 concentration had a weak positive impact on the daily search interest for lung cancer on the Baidu search engine. Well-designed awareness campaigns are needed to enhance the general public’s awareness of the association of PM2.5 with lung cancer risk, to lead the public to seek more information about PM2.5 and its hazards, and to cope with their environment and its risks appropriately. %M 28974484 %R 10.2196/publichealth.8078 %U https://publichealth.jmir.org/2017/4/e64/ %U https://doi.org/10.2196/publichealth.8078 %U http://www.ncbi.nlm.nih.gov/pubmed/28974484 %0 Journal Article %@ 1947-2579 %I JMIR Publications %V 9 %N 1 %P e7725 %T Roles of Health Literacy in Relation to Social Determinants of Health and Recommendations for Informatics-Based Interventions: Systematic Review %D 2017 %7 ..2017 %9 %J Online J Public Health Inform %G English %X ObjectiveTo assess the impact on human health observed in associationwith periods of poor air quality which extended across internationalborders, affecting both London (UK) and Paris (France).In particular to quantify increased levels of emergency department(ED) attendances for asthma and wheeze/ difficulty breathing, andhow different age groups were affected. Here, using ED syndromicsurveillance from England and France, we aimed to identify anddescribe the acute impact of periods of particularly poor air qualityduring 2014 on human health in both London and Paris.IntroductionThe impact of poor air quality (AQ) on human health is a globalissue, with periods of poor AQ known to occur in multiple locations,across different countries at, or around the same time.The Public Health England (PHE) Emergency DepartmentSyndromic Surveillance System (EDSSS) is a public health legacyof the London 2012 Olympic and Paralympic Games, monitoringanonymised daily attendance data in near real-time from a sentinelnetwork of up to 38 EDs across England and Northern Ireland during2014.The Organisation de la Surveillance COordonnée des URgences(OSCOUR®) is a similar ED system coordinated by Santé publiqueFrance and has been running in France since 2004, establishedfollowing a major heatwave in 2003 to improve real-time publichealth surveillance capabilities. This truly national network includedaround 540 EDs in 2014.MethodsPeriods of poor AQ during 2014 in both London and Paris, whichwere likely to have an acute impact on human health were identifiedfrom the daily particulate monitoring data made available by themonitoring authorities in each location.1,2Daily ED syndromic surveillance data for selected health indicators(asthma, difficulty breathing type attendances and myocardialischaemia (MI)) were gathered from EDSSS and OSCOUR®forLondon and Paris respectively.The standard method used for the daily statistical analysis ofEDSSS(RAMMIE method),3was also applied to OSCOUR®and usedto identify days where the numbers of attendances reported in boththe EDSSS and OSCOUR®systems were statistically significantlydifferent to the historical data, based on the previous 2 years.ResultsDistinct differences were identified between the impact observedon different age groups, with increased asthma ED attendances forchildren during/ following some AQ events, though a greater impactwas observed in adults around other AQ events.Increases in ED attendances for asthma were identified at severalpoints where no AQ events were reported, both short lived spikesduring the summer period in particular and a more sustained increasetowards the start of autumn.ConclusionsDespite EDSSS and OSCOUR®having been developed in differentcountries, at different times and resulting from different drivers, bothsystems use very similar syndromic indicators to identify asthma,difficulty breathing and MI attendances. Using these systems theshort term impacts of multiple AQ events which crossed internationalboundaries were successfully identified and investigated by Englishand French public health authorities.Periods of poor AQ are not the only events that can affect asthmatype attendances as identified here, thunderstorm activity and thebeginning of a new academic year also coincided with increasedattendances in both London and Paris.Harmonisation of surveillance methods across differentinternational jurisdictions is possible and there is the potential forfuture cross border surveillance and harmonisation of methodsbetween countries to improve international health surveillance andearly warning of potential public health threats affecting multiplecountries. %R 10.5210/ojphi.v9i1.7725 %U %U https://doi.org/10.5210/ojphi.v9i1.7725 %0 Journal Article %@ 1947-2579 %I JMIR Publications %V 9 %N 1 %P e7727 %T Roles of Health Literacy in Relation to Social Determinants of Health and Recommendations for Informatics-Based Interventions: Systematic Review %D 2017 %7 ..2017 %9 %J Online J Public Health Inform %G English %X ObjectiveTo build capacity to conduct syndromic surveillance at the locallevel by leveraging a health surveillance need.IntroductionWildfires occur annually in Oregon, and the health risks of wildfiresmoke are well documented1. Before implementing syndromicsurveillance through Oregon ESSENCE, assessing the health effectsof wildfires in real time was very challenging. Summer 2015 markedthe first wildfire season with 60 of 60 eligible Oregon emergencydepartments (EDs) reporting to ESSENCE. The Oregon ESSENCEteam developed a wildfire surveillance pilot project with two localpublic health authorities (LPHAs) to determine their surveillanceneeds and practices and developed a training program to increasecapacity to conduct surveillance at the local level. Following thetraining, one of the LPHAs integrated syndromic surveillance intoits routine surveillance practices. Oregon ESSENCE also integratedthe evaluation findings into the summer 2016 statewide wildfiresurveillance plan.MethodsOregon ESSENCE staff recruited two LPHA preparednesscoordinators whose jurisdictions are regularly affected by wildfiresmoke to participate in the pilot project. A state public healthemergency preparedness liaison served as facilitator in order toincrease syndromic surveillance capacity among state preparednessstaff.A pre-season interview assessed data and surveillance needs,risk communication practices, and typical response activities duringwildfires. Initial project calls focused on determining specific queriesthat would meet local needs. Participants wanted total ED visitnumbers and health outcomes including asthma, chest pain or heartproblems. Both LPHAs were interested in using the data to assesshealth effects on vulnerable populations, including elderly, children,and migrant workers. Oregon ESSENCE staff also recommendedqueries that would be used if large numbers of people were displaced(e.g., medication refills, dialysis).Before the onset of wildfire season, Oregon ESSENCEepidemiologists created queries and a MyESSENCE page for eachparticipant. LPHA staff practiced running the queries, modifyingthem, and discussed interpretation and data-sharing best practices.During wildfire season, brief weekly webinars enabled participantsto ask questions and learn additional techniques including displayingtime series as proportions and adjusting geographic parameters tofocus on areas with poor air quality.Results2015 was a severe wildfire season in Oregon, with over 685,000acres burned2. For the first time, local and state public health were ableto monitor and share near real-time health information on interagencysmoke calls. In the post project evaluation, participants reportedincreased knowledge of syndromic surveillance, interpretation,and risk communications. There were no marked increases in totalemergency department visits, or visits for asthma, heart palpitations,or other heart complaints. The public may have adhered to warningsand effectively protected themselves against exposure to wildfiresmoke, or health effects may have been less severe and not reflectedin emergency department data. Over the next several years, OregonESSENCE will integrate select urgent care data, which may bettercapture morbidity due to wildfire smoke.ConclusionsFraming syndromic surveillance training around a healthsurveillance need was effective because participants were engagedaround a high-priority health hazard. In summer 2016, OregonESSENCE integrated wildfire health surveillance into a biweeklyESSENCE seasonal hazard surveillance report and invited wildfireresponse partners to subscribe. Local ESSENCE users can use ormodify the queries. In 2017, Oregon ESSENCE will incorporate airquality data from the Environmental Protection Agency so partnerscan monitor air quality and health effects simultaneously. %R 10.5210/ojphi.v9i1.7727 %U %U https://doi.org/10.5210/ojphi.v9i1.7727 %0 Journal Article %@ 1947-2579 %I JMIR Publications %V 9 %N 1 %P e7754 %T Roles of Health Literacy in Relation to Social Determinants of Health and Recommendations for Informatics-Based Interventions: Systematic Review %D 2017 %7 ..2017 %9 %J Online J Public Health Inform %G English %X ObjectiveThe main focus of this study was to study the spread of botulism inGeorgia and the biological characteristics of the strains ofClostridiumbotulinumisolated from territories in the country.IntroductionAccumulation ofC. botulinumin soil occurs through excretion ofbacterial spores from the intestines of humans, animals, birds andfish. In Georgia, during the winter season, the population consumeshomemade vegetable preserves, which are made of locally produced(as well as imported) vegetables. Historical surveys confirmed that thepresence ofC. botulinumin the soil is widespread. Some researchersconsiderC. botulinuma characteristic component of soil flora.MethodsSoil samples were collected from areas, where from 2001-2002cases of botulism caused by homemade vegetable preserves (producedfrom vegetables cultivated in those areas) were registered. Soilsamples were collected from Kakheti, Shida Kartli, Kvemo Kartli,Samtkhe-Javakheti, and Samegrelo regions. Standard bacteriologyand PCR were used to confirm the presence ofC. botulinumfrom soilsamples. Separation of strains and their examination was conducted inaccordance with the scheme provided by the CDC Atlanta ReferenceLaboratory (USA), which was later tested by NCDC. Toxigenicityand toxin production of strains were tested using a biotest on whitemice.ResultsIn total, 258 soil samples were tested, from which, 40 (15.5%)cultures ofC. botulinumtype B were obtained. Toxigenicity andtoxin production were confirmed through biotests. These resultsconfirm the presence ofC. botulinumin agricultural lands, whichcauses contamination of vegetables cultivated on those lands, whichare used for the preparation of homemade preserves, causing botulismin humans.ConclusionsFor the purpose of finding solutions to botulism, it is essentialto verify the ecology of the pathogen through establishing theprevalence of bacteria in different soil types. It was shown that someareas of Georgia, where vegetable growing is greatly developed, andwhich, are the main sources of crops, are highly contaminated withC. botulinum. In Georgia, land used for agriculture is contaminatedwithC. botulinum.C. botulinumtype B was isolated from 40 culturesobtained from 258 soil samples, which represents contamination in15.5% of sampled areas. These results suggest that vegetables andmelons may be highly contaminated as well. All cases ofC. botulinumin humans that were researched were connected to homemade cannedvegetables. %R 10.5210/ojphi.v9i1.7754 %U %U https://doi.org/10.5210/ojphi.v9i1.7754 %0 Journal Article %@ 1947-2579 %I JMIR Publications %V 9 %N 1 %P e7712 %T Roles of Health Literacy in Relation to Social Determinants of Health and Recommendations for Informatics-Based Interventions: Systematic Review %D 2017 %7 ..2017 %9 %J Online J Public Health Inform %G English %X ObjectiveTo evaluate syndrome definitions capturing storm- and extremeweather-related emergency department visits in Kansas hospitalsparticipating in the National Syndromic Surveillance Program(NSSP).IntroductionKansas storms can occur without warning and have potential tocause a multitude of health issues. Extreme weather preparednessand event monitoring for public health effects is being developedas a function of syndromic surveillance at the Kansas Departmentof Health and Environment (KDHE). The Syndromic SurveillanceProgram at KDHE utilized emergency department (ED) data to detectdirect health effects of the weather events in the first 9 months of2016. Current results show injuries directly related to the storms andalso some unexpected health effects that warrant further exploration.MethodsA basic syndrome definition was defined based on extreme springand summer weather events experienced in Kansas. This broaddefinition pulled records from Kansas EDs that included the followingin the Chief Complaint or Triage Notes fields:●Storm●Rain●Torna(dos)●Wind●FloodThis broad syndrome definition was performed on data submittedto the Kansas’s production server through NSSP between January 1stand August 30th, 2016. After the initial pull, duplicate records for thesame patient and visit were removed.The remaining set was then searched by hand to identify termscaught by the syndrome definition that were not related to stormactivity or extreme weather. Record chief complaints were thenscanned by hand to identify common words containing the searchcriteria and then removed. Keywords not of interest to the syndromedefinition that were caught were: migraine, window, drain, restrain,train, and many other proper nouns that contained one of the keywords.These remaining visits were then sorted by nature of visit andunexpected records were recorded for future direction of syndromedefinition development.ResultsThe initial data pull under these conditions yielded 17,691 uniqueemergency department visits from January 1stto August 30thduringthe 2016 year. From this, records were classified based on key wordsresulting in the pull. The table below shows the initial pull results, theremaining records after errant results were expunged, the percentageof visits that were removed, and the most common reason for removal.Of these records remaining after cleaning, 20 were related tostorms, 62 were related to rain, 7 were related to tornado activity,66 were related to wind, and 14 were related to flooding along withthe mixed variable instances shown in the table. A majority of thewind-related ED visits were injuries and the majority of the tornadoactivity events were related to injuries sustained while taking shelter.Many of the injuries mentioning storms were sustained in preparationfor the storm, and a handful were due to mental stresses regardingstorm activity.ConclusionsSyndrome definition development is an iterative process thatwill vary by region. By manually looking at line-level data details,future searches can better accommodate these errant results and falsepositives. These studies will facilitate more rapid extreme weatherresponse in Kansas and allow better situational awareness. Alongwith general storm-related injuries, knowledge of the unusual recordscaught by a syndrome definition can also help direct public educationin preparation of future storms. With injuries sustained while takingshelter and injuries sustained in preparation for the storm, we can takethese unique ED visits and work on interventions to prevent futureoccurrences. %R 10.5210/ojphi.v9i1.7712 %U %U https://doi.org/10.5210/ojphi.v9i1.7712 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 3 %N 2 %P e16 %T Making Air Pollution Visible: A Tool for Promoting Environmental Health Literacy %A Cleary,Ekaterina Galkina %A Patton,Allison P %A Wu,Hsin-Ching %A Xie,Alan %A Stubblefield,Joseph %A Mass,William %A Grinstein,Georges %A Koch-Weser,Susan %A Brugge,Doug %A Wong,Carolyn %+ Institute for Asian American Studies, University of Massachusetts Boston, 100 Morrissey Blvd, Boston, MA, 02125, United States, 1 650 269 4421, carolyn.wong@umb.edu %K computer visualization %K digital cartography %K environmental health literacy %K health communication %K environmental health %K computer-based education %K air pollution %K ultrafine particles %K immigrant education %D 2017 %7 12.04.2017 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Digital maps are instrumental in conveying information about environmental hazards geographically. For laypersons, computer-based maps can serve as tools to promote environmental health literacy about invisible traffic-related air pollution and ultrafine particles. Concentrations of these pollutants are higher near major roadways and increasingly linked to adverse health effects. Interactive computer maps provide visualizations that can allow users to build mental models of the spatial distribution of ultrafine particles in a community and learn about the risk of exposure in a geographic context. Objective: The objective of this work was to develop a new software tool appropriate for educating members of the Boston Chinatown community (Boston, MA, USA) about the nature and potential health risks of traffic-related air pollution. The tool, the Interactive Map of Chinatown Traffic Pollution (“Air Pollution Map” hereafter), is a prototype that can be adapted for the purpose of educating community members across a range of socioeconomic contexts. Methods: We built the educational visualization tool on the open source Weave software platform. We designed the tool as the centerpiece of a multimodal and intergenerational educational intervention about the health risk of traffic-related air pollution. We used a previously published fine resolution (20 m) hourly land-use regression model of ultrafine particles as the algorithm for predicting pollution levels and applied it to one neighborhood, Boston Chinatown. In designing the map, we consulted community experts to help customize the user interface to communication styles prevalent in the target community. Results: The product is a map that displays ultrafine particulate concentrations averaged across census blocks using a color gradation from white to dark red. The interactive features allow users to explore and learn how changing meteorological conditions and traffic volume influence ultrafine particle concentrations. Users can also select from multiple map layers, such as a street map or satellite view. The map legends and labels are available in both Chinese and English, and are thus accessible to immigrants and residents with proficiency in either language. The map can be either Web or desktop based. Conclusions: The Air Pollution Map incorporates relevant language and landmarks to make complex scientific information about ultrafine particles accessible to members of the Boston Chinatown community. In future work, we will test the map in an educational intervention that features intergenerational colearning and the use of supplementary multimedia presentations. %M 28404541 %R 10.2196/publichealth.7492 %U http://publichealth.jmir.org/2017/2/e16/ %U https://doi.org/10.2196/publichealth.7492 %U http://www.ncbi.nlm.nih.gov/pubmed/28404541 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 6 %N 2 %P e29 %T Epigenetic Alterations and Exposure to Air Pollutants: Protocol for a Birth Cohort Study to Evaluate the Association Between Adverse Birth Outcomes and Global DNA Methylation %A Maghbooli,Zhila %A Hossein-Nezhad,Arash %A Ramezani,Majid %A Moattari,Syamak %+ Osteoporosis Research Center, Endocrinology and Metabolism Research Institute of Tehran University of Medical Sciences, 5th floor, Shariati Hospital, North Karegar St., Tehran,, Islamic Republic Of Iran, 1 00982188220072, arash_hsi@yahoo.com %K epigenomics %K DNA methylation %K air pollutants %K pregnancy %K adverse birth outcomes %K placenta %D 2017 %7 23.02.2017 %9 Protocol %J JMIR Res Protoc %G English %X Background: Prenatal exposure to air pollutants can increase the risk of adverse birth outcomes and susceptibility to a number of complex disorders later in life. Despite this general understanding, the molecular and cellular responses to air pollution exposure during early life are not completely clear. Objective: The aims of this study are to test the association between air pollution and adverse pregnancy outcomes, and to determine whether the levels of maternal and cord blood and of placental DNA methylation during pregnancy predict adverse birth outcomes in polluted areas. Methods: This is a birth cohort study. We will enroll pregnant healthy women attending prenatal care clinics in Tehran, Iran, who are resident in selected polluted and unpolluted regions before the 14th week of pregnancy. We will calculate the regional background levels of fine particulate matter (particles with a diameter between 2.5 and 10 μm) and nitrogen dioxide for all regions of by using data from the Tehran Air Quality Control Company. Then, we will select 2 regions as the polluted and unpolluted areas of interest. Healthy mothers living in the selected polluted and non polluted regions will be enrolled in this study. A maternal health history questionnaire will be completed at each trimester. During the first and second trimester, we will draw mothers’ blood for biochemical and DNA methylation analyses. At the time of delivery time, we will collect maternal and cord blood for biochemical, gene expression, and DNA methylation analyses. We will also record birth outcomes (the newborn’s sex, birth date, birth weight and length, gestational age, Apgar score, and level of neonatal care required). Results: The project was funded in March 2016 and enrollment will be completed in August 2017. Data analysis is under way, and the first results are expected to be submitted for publication in November 2017. Conclusions: We supposed that prenatal exposures to air pollutants can influence fetal reprogramming by epigenetic modifications such as DNA methylation. This could explain the association between air pollution and adverse pregnancy outcomes. %M 28232302 %R 10.2196/resprot.7114 %U http://www.researchprotocols.org/2017/2/e29/ %U https://doi.org/10.2196/resprot.7114 %U http://www.ncbi.nlm.nih.gov/pubmed/28232302 %0 Journal Article %@ 1929-0748 %I JMIR Publications Inc. %V 4 %N 3 %P e98 %T Street Food Environment in Maputo (STOOD Map): a Cross-Sectional Study in Mozambique %A Gelormini,Marcello %A Damasceno,Albertino %A Lopes,Simão António %A Maló,Sérgio %A Chongole,Célia %A Muholove,Paulino %A Casal,Susana %A Pinho,Olívia %A Moreira,Pedro %A Padrão,Patrícia %A Lunet,Nuno %+ Faculty of Medicine – University of Porto (FMUP), Departament of Clinical Epidemiology, Predictive Medicine and Public Health, Al. Prof. Hernâni Monteiro, Porto, 4200-319, Portugal, 351 225513652, nlunet@med.up.pt %K fast foods %K commerce %K marketing %K Mozambique %D 2015 %7 05.08.2015 %9 Original Paper %J JMIR Res Protoc %G English %X Background: Street food represents a cultural, social, and economic phenomenon that is typical of urbanized areas, directly linked with a more sedentary lifestyle and providing a very accessible and inexpensive source of nutrition. Food advertising may contribute to shaping consumers’ preferences and has the potential to drive the supply of specific foods. Objective: The purpose of this study is to characterize the street food offerings available to the urban population of Maputo, the capital city of Mozambique, and the billboard food advertising in the same setting. Methods: People selling ready-to-eat foods, beverages, or snacks from venues such as carts, trucks, stands, and a variety of improvised informal setups (eg, shopping carts, trunks of cars, sides of vans, blankets on the sidewalk, etc) will be identified in the district of KaMpfumu. We will gather information about the actual food being sold through direct observation and interviews to vendors, and from the billboard advertising in the same areas. A second phase of the research entails collecting food samples to be analyzed in a specialized laboratory. The street food environment will be characterized, overall and according to socioeconomic and physical characteristics of the neighborhood, using descriptive statistics and spatial analysis. The study protocol was approved by the National Committee for Bioethics for Health in Mozambique. Results: Data collection, including the identification of street food vending sites and billboard advertising, started on October 20, 2014, and lasted for 1 month. The collection of food samples took place in December 2014, and the bromatological analyses are expected to be concluded in August 2015. Conclusions: The district of KaMpfumu is the wealthiest and most urbanized in Maputo, and it is the area with the highest concentration and variety of street food vendors. The expected results may yield important information to assess the nutritional environment and the characteristics of the foods to which a great majority of the urban population living or working in Maputo are exposed. Furthermore, this study protocol provides a framework for a stepwise standardized characterization of the street food environment, comprising 3 steps with increasing complexity and demand for human and technical resources: Step 1 consists of the evaluation of food advertising in the streets; Step 2 includes the identification of street food vendors and the characterization of the products available; and Step 3 requires the collection of food samples for bromatological analyses. This structured approach to the assessment of the street food environment may enable within-country and international comparisons as well as monitoring of temporal trends. %M 26245231 %R 10.2196/resprot.4096 %U http://www.researchprotocols.org/2015/3/e98/ %U https://doi.org/10.2196/resprot.4096 %U http://www.ncbi.nlm.nih.gov/pubmed/26245231 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 17 %N 3 %P e22 %T Social Media as a Sensor of Air Quality and Public Response in China %A Wang,Shiliang %A Paul,Michael J %A Dredze,Mark %+ Johns Hopkins University, Department of Computer Science, 3400 N Charles St, Baltimore, MD, 21218, United States, 1 410 516 4237, mpaul@cs.jhu.edu %K air pollution %K public health surveillance %K social media %K data mining %K text mining %K natural language processing %D 2015 %7 26.03.2015 %9 Original Paper %J J Med Internet Res %G English %X Background: Recent studies have demonstrated the utility of social media data sources for a wide range of public health goals, including disease surveillance, mental health trends, and health perceptions and sentiment. Most such research has focused on English-language social media for the task of disease surveillance. Objective: We investigated the value of Chinese social media for monitoring air quality trends and related public perceptions and response. The goal was to determine if this data is suitable for learning actionable information about pollution levels and public response. Methods: We mined a collection of 93 million messages from Sina Weibo, China’s largest microblogging service. We experimented with different filters to identify messages relevant to air quality, based on keyword matching and topic modeling. We evaluated the reliability of the data filters by comparing message volume per city to air particle pollution rates obtained from the Chinese government for 74 cities. Additionally, we performed a qualitative study of the content of pollution-related messages by coding a sample of 170 messages for relevance to air quality, and whether the message included details such as a reactive behavior or a health concern. Results: The volume of pollution-related messages is highly correlated with particle pollution levels, with Pearson correlation values up to .718 (n=74, P<.001). Our qualitative results found that 67.1% (114/170) of messages were relevant to air quality and of those, 78.9% (90/114) were a firsthand report. Of firsthand reports, 28% (32/90) indicated a reactive behavior and 19% (17/90) expressed a health concern. Additionally, 3 messages of 170 requested that action be taken to improve quality. Conclusions: We have found quantitatively that message volume in Sina Weibo is indicative of true particle pollution levels, and we have found qualitatively that messages contain rich details including perceptions, behaviors, and self-reported health effects. Social media data can augment existing air pollution surveillance data, especially perception and health-related data that traditionally requires expensive surveys or interviews. %M 25831020 %R 10.2196/jmir.3875 %U http://www.jmir.org/2015/3/e22/ %U https://doi.org/10.2196/jmir.3875 %U http://www.ncbi.nlm.nih.gov/pubmed/25831020 %0 Journal Article %@ 1929-0748 %I JMIR Publications Inc. %V 3 %N 4 %P e77 %T Gestational Age Assessment in the Ghana Randomized Air Pollution and Health Study (GRAPHS): Ultrasound Capacity Building, Fetal Biometry Protocol Development, and Ongoing Quality Control %A Boamah,Ellen A %A Asante,KP %A Ae-Ngibise,KA %A Kinney,Patrick L %A Jack,Darby W %A Manu,Grace %A Azindow,Irene T %A Owusu-Agyei,Seth %A Wylie,Blair J %+ Massachusetts General Hospital, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, United States, 1 617 643 4331, bwylie@partners.org %K ultrasound %K capacity building %K gestational age %K biometry %K household air pollution %D 2014 %7 18.12.2014 %9 Protocol %J JMIR Res Protoc %G English %X Background: Four million premature deaths occur yearly as a result of smoke from cooking fires. The Ghana Randomized Air Pollution and Health Study (GRAPHS) is underway in the Kintampo North municipality and South district of rural Ghana to evaluate the impact of improved cook stoves introduced during pregnancy on birth weight and childhood pneumonia. These hypotheses are being tested in a cluster-randomized intervention trial among 1415 maternal-infant pairs within 35 communities assigned to a control arm (traditional cooking) or one of two intervention arms (cooking with an improved biomass stove; cooking with liquefied petroleum gas stoves). Objective: The trial is designed to ensure delivery of the stove intervention prior to the period of maximal fetal growth. To answer questions about the impact of household air pollution on pregnancy outcome, accurate gestational age assessment is critical. This manuscript describes in detail the development of the gestational dating protocol, intensive ultrasound training involved, ultrasound capacity building, and ultrasound quality control program. Methods: Ultrasound training occurred in several phases over the course of 2 years. Training included a basic obstetric ultrasound course offered to all midwives performing antenatal care at the two study hospitals, followed by a more intense period of hands-on training focused on fetal biometry for a select group of providers demonstrating aptitude in the basic course. A standard operating procedure was developed describing how to obtain all fetal biometric measurements. Consensus was obtained on how biometric images are used in the trial to establish gestational age and estimate the delivery date. An ongoing ultrasound quality control program including the use of an image scorecard was also designed. Results: Publication of trial results is anticipated in late 2016. Conclusions: Use of ultrasound should be strongly considered in field-based trials involving pregnant women to accurately establish gestational age, as menstrual dates may be incorrect or unknown. The inclusion of ultrasound in areas where ultrasound capacity does not previously exist requires a significant investment of time and resources. Such investment ensures appropriate training, high quality images, and accurate dating pregnancies. We outline our ultrasound training, image acquisition, quality control, and dating protocols in detail. Trial Registration: Clinicaltrials.gov NCT01335490; http://clinicaltrials.gov/ct2/show/NCT01335490 (Archived by WebCite at http://www.webcitation.org/6UbERJNO6). %M 25525828 %R 10.2196/resprot.3797 %U http://www.researchprotocols.org/2014/4/e77/ %U https://doi.org/10.2196/resprot.3797 %U http://www.ncbi.nlm.nih.gov/pubmed/25525828 %0 Journal Article %@ 2291-5222 %I JMIR Publications Inc. %V 2 %N 1 %P e16 %T Usage of Social Media and Smartphone Application in Assessment of Physical and Psychological Well-Being of Individuals in Times of a Major Air Pollution Crisis %A Zhang,Melvyn WB %A Ho,Cyrus SH %A Fang,Pan %A Lu,Yanxia %A Ho,Roger CM %+ Southeast Asian Haze Research Consortium, Department of Medical Psychology, School of Medicine, Shandong University, Department of Medical Psychology, School of Medicine, Shandong University, China, 250102, China, 86 053188382039, melvynzhangweibin@gmail.com %K crisis %K haze %K Internet %K Web-based medium %K social networking %K smartphone application %D 2014 %7 25.03.2014 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Crisis situations bring about many challenges to researchers, public institutions, and governments in collecting data and conducting research in affected individuals. Recent developments in Web-based and smartphone technologies have offered government and nongovernment organizations a new system to disseminate and acquire information. However, research into this area is still lacking. The current study focuses largely on how new social networking websites and, in particular, smartphone technologies could have helped in the acquisition of crucial research data from the general population during the recent 2013 Southeast Asian Haze. This crisis lasted only for 1 week, and is unlike other crisis where there are large-scale consequential after-effects. Objective: To determine whether respondents will make use of Internet, social media, and smartphone technologies to provide feedback regarding their physical and psychological wellbeing during a crisis, and if so, will these new mechanisms be as effective as conventional, technological, Internet-based website technologies. Methods: A Web-based database and a smartphone application were developed. Participants were recruited by snowball sampling. The participants were recruited either via a self-sponsored Facebook post featuring a direct link to the questionnaire on physical and psychological wellbeing and also a smartphone Web-based application; or via dissemination of the questionnaire link by emails, directed to the same group of participants. Information pertaining to physical and psychological wellbeing was collated. Results: A total of 298 respondents took part in the survey. Most of them were between the ages of 20 to 29 years and had a university education. More individuals preferred the option of accessing and providing feedback to a survey on physical and psychological wellbeing via direct access to a Web-based questionnaire. Statistical analysis showed that demographic variables like age, gender, and educational levels did not influence the mechanism of access. In addition, the participants reported a mean number of 4.03 physical symptoms (SD 2.6). The total Impact of Event Scale–Revised (IES-R) score was 18.47 (SD 11.69), which indicated that the study population did experience psychological stress but not post-traumatic stress disorder. The perceived dangerous Pollutant Standards Index (PSI) level and the number of physical symptoms were associated with higher IES-R Score (P<.05). Conclusions: This is one of the first few studies demonstrating the use of Internet in data collection during an air-pollution crisis. Our results demonstrated that the newer technological modalities have the potential to acquire data, similar to that of conventional technologies. Demographic variables did not influence the mechanism of usage. In addition, our findings also suggested that there are acute physical and psychological impacts on the population from an air-pollution crisis. %M 25098255 %R 10.2196/mhealth.2827 %U http://mhealth.jmir.org/2014/1/e16/ %U https://doi.org/10.2196/mhealth.2827 %U http://www.ncbi.nlm.nih.gov/pubmed/25098255 %0 Journal Article %@ 1947-2579 %I JMIR Publications %V 6 %N 1 %P e5044 %T Roles of Health Literacy in Relation to Social Determinants of Health and Recommendations for Informatics-Based Interventions: Systematic Review %D 2014 %7 ..2014 %9 %J Online J Public Health Inform %G English %X Uncertainty surrounding microbial fate and transport renders the assessment of climate change effects on waterborne pathogens complex and difficult to forecast. The objective of this study is to use watershed modeling to predict the impacts of future climate change and land management scenarios on microbial water quality. Preliminary findings suggest an increased risk to human health due to direct consequences of climate change. Results of watershed-scale microbial load modeling can inform the adoption of pollution control measures required to protect human health and aid development of new water policy. %R 10.5210/ojphi.v6i1.5044 %U %U https://doi.org/10.5210/ojphi.v6i1.5044