The major respiratory diseases of American Indians

Racial Differences in Respiratory Impairment, Pneumoconiosis, and Federal Compensation for Western U.S. Indigenous Coal Miners

Rationale: Indigenous populations in the United States face numerous health disparities, but the health of Indigenous workers is less well understood. In a recent surveillance study of active Indigenous coal miners, 3% had coal workers' pneumoconiosis/black lung, and 9% had respiratory impairment. However, occupational lung disease prevalence among Indigenous coal miners has not been directly compared with that among other race/ethnicity groups. Coal miners who are totally disabled from black lung may qualify for U.S. Department of Labor (DOL) compensation benefits, but it is unclear how current federal spirometry criteria affect qualification for Indigenous coal miners.Objectives: To compare findings of pneumoconiosis and respiratory impairment in Indigenous and non-Indigenous coal miners in the western United States and assess federal compensation qualification for Indigenous miners using different spirometry standards.Methods: We used voluntary medical surveillance data from 2002 to 2023 to compare the adjusted odds of pneumoconiosis and respiratory impairment between Indigenous/non-Indigenous coal miners. We examined the proportion of Indigenous miners meeting DOL criteria for federal compensation using different spirometry standards.Results: We identified 691 western U.S. coal miners with at least one year of coal mining employment, 289 Indigenous and 402 non-Indigenous (96% White/Hispanic). Indigenous miners had a greater odds ratio for pneumoconiosis for each additional decade of life (2.47 [95% confidence interval (CI), 1.66-3.68]) compared with non-Indigenous coal miners (1.48 [95% CI, 1.19-1.85]). For each decade, Indigenous coal miners also had a greater adjusted odds ratio for respiratory impairment (1.67 [95% CI, 1.25-2.24]) than non-Indigenous miners (1.06 [95% CI, 0.90-1.25]). Indigenous miners had an additional decline of 71 ml (95% CI, 6-136 ml) in forced expiratory volume in 1 second for each decade of life compared with non-Indigenous coal miners. Using the DOL-mandated Knudson (1976) spirometry standard rather than an Indigenous-specific standard, 6 of 18 (33%) Indigenous miners would not qualify for federal compensation.Conclusions: Indigenous coal miners experience greater adjusted odds for pneumoconiosis and respiratory impairment per decade of life and greater decline in forced expiratory volume in 1 second despite lower smoking rates. Structural inequities exist in federal spirometry requirements for Indigenous miners seeking DOL black lung benefits. Regulatory reform is needed to address barriers to compensation for these underrepresented workers.

Ethnic disparity in pneumonia-specific mortality among children under 5 years of age in Sichuan Province of Western China from 2010 to 2017

Background

To reveal the ethnic disparity in the pneumonia-specific mortality rates of children under the age of 5 years (PU5MRs) and provide suggestions regarding priority interventions to reduce preventable under-five-years-of-age deaths.

Methods

Data were obtained from the Direct Report System of Maternal and Child Health in Sichuan. The Cochran-Armitage trend test was used to assess the time trend. The Cochran-Mantel-Haenszel test and Chi-square test were used to examine the differences in the PU5MRs among different groups.

Results

The PU5MRs in the minority and nonminority counties decreased by 53.7 and 42.3% from 2010 to 2017, respectively. The PU5MRs of the minority counties were 4.81 times higher than those of the nonminority counties in 2017. The proportion of pneumonia deaths to total deaths in Sichuan Province increased from 11.7% in 2010 to 15.5% in 2017. The pneumonia-specific mortality rates of children in the categories of 0–28 days, 29 days-11 months, and 12–59 months were reduced by 55.1, 38.8, and 65.5%, respectively, in the minority counties and by 35.5, 43.1, and 43.7%, respectively, in the nonminority counties.

Conclusions

PU5MRs declined in Sichuan, especially in the minority counties, while ethnic disparity still exists. Although the PU5MRs decreased more for the minority counties as a fraction of all mortality, the absolute number of such deaths were higher, and therefore more children in these counties continue to die from pneumonia than from the non-minority counties. Priority should be given to strategies for preventing and controlling child pneumonia, especially for postneonates, in the minority counties.

Pleural infection in a New Zealand centre: high incidence in Pacific people and RAPID score as a prognostic tool

BACKGROUND

Whilst there is an increase in incidence of pleural infection worldwide, there is a paucity of New Zealand data.

AIMS

This study looked at the epidemiology of pleural infection in a single New Zealand institution and evaluated the RAPID score as a prognostic tool.

METHODS

A retrospective review was performed on patients with pleural infection over a 3-year period. Pleural infection was defined as having clinical evidence of infection and fulfilling one of the following: (i) positive pleural fluid Gram stain or culture, (ii) frank pus, (iii) pH <7.2 or (iv) radiological evidence of complex effusion.

RESULTS

There were 108 patients; 76% were male, and mean age was 54 years. Two thirds of patients came from the most deprived areas. The dominant ethnic group was Pacific people (42%), which was twice as high as the Pacific population in the area (19%), P < 0.0001. After adjusting for deprivation, Pacific people were still over-represented, P = 0.0002. There were 14 deaths (13%), and these were associated with increasing age (P = 0.001) and urea (P = 0.007) but not ethnicity or socioeconomic deprivation. The RAPID score found that those in the high-risk (P = 0.026) and moderate-risk (P = 0.036) groups had significantly higher mortality compared with the low-risk group.

CONCLUSION

The over-representation of Pacific people with pleural infection is not fully explained by socioeconomic deprivation, highlighting other factors at play, such as genetic susceptibility. The RAPID score was of clinical utility in predicting mortality in our population.

Increased influenza-related healthcare utilization by residents of an urban aboriginal community

Most studies describing high rates of acute respiratory illness in aboriginals have focused on rural or remote communities. Hypothesized causes include socioeconomic deprivation, limited access to healthcare, and a high prevalence of chronic disease. To assess influenza rates in an aboriginal community while accounting for healthcare access, deprivation and chronic disease prevalence, we compared rates of influenza-related outpatient and emergency-department visits in an urban Mohawk reserve (Kahnawá:ke) to rates in neighbouring regions with comparable living conditions and then restricted the analysis to a sub-population with a low chronic disease prevalence, i.e. those aged <20 years. Using medical billing claims from 1996 to 2006 we estimated age-sex standardized rate ratios. The rate in Kahnawá:ke was 58% greater than neighbouring regions and 98% greater in the analysis of those aged <20 years. Despite relatively favourable socioeconomic conditions and healthcare access, rates of influenza-related visits in Kahnawá:ke were elevated, particularly in the younger age groups.

Advantages of video questionnaire in estimating asthma prevalence and risk factors for school children: findings from an asthma survey in American Indian youth

OBJECTIVES

The aims of the present study were to estimate the prevalence and risk factors of asthma among a sample of American Indian youth and to evaluate survey instruments used in determining asthma prevalence and risk factors.

METHODS

Three hundred and fifty-two adolescents aged 9 to 21 years enrolled in an Indian boarding school completed an asthma screening. The survey instruments were a written questionnaire and a video-illustrated questionnaire prepared from the International Study of Asthma and Allergies in Childhood (ISAAC), school health records, and a health questionnaire. Participants also underwent spirometry testing.

RESULTS

The prevalence of self-reported asthma varied from 12.7% to 13.4% depending upon the instrument used and the questions asked. A history of hay fever, respiratory infections, and family history of asthma were found to be risk factors for asthma by all instruments. Female gender and living on a reservation were significantly associated with asthma by some, but not all, instruments. Airway obstruction was highly associated with one asthma symptom (wheeze) shown in the video questionnaire. Associations for most risk factors with asthma were strongest for the video questionnaire.

CONCLUSIONS

The prevalence of self-reported asthma among these American Indian youth was similar to rates reported for other ethnic groups. The video-based questionnaire may be the most sensitive tool for identifying individuals at risk for asthma.

Asthma in American Indian adults: the Strong Heart Study

BACKGROUND

Despite growing recognition that asthma is an important cause of morbidity among American Indians, there has been no systematic study of this disease in older adults who are likely to be at high risk of complications related to asthma. Characterization of the impact of asthma among American Indian adults is necessary in order to design appropriate clinical and preventive measures.

METHODS

A sample of participants in the third examination of the Strong Heart Study, a multicenter, population-based, prospective study of cardiovascular disease in American Indians, completed a standardized respiratory questionnaire, performed spirometry, and underwent allergen skin testing. Participants were > or = 50 years old.

RESULTS

Of 3,197 participants in the third examination, 6.3% had physician-diagnosed asthma and 4.3% had probable asthma. Women had a higher prevalence of physician-diagnosed asthma than men (8.2% vs 3.2%). Of the 435 participants reported in the asthma substudy, morbidity related to asthma was high: among those with physician-diagnosed asthma: 97% reported trouble breathing and 52% had severe persistent disease. The mean FEV(1) in those with physician-diagnosed asthma was 61.3% of predicted, and 67.2% reported a history of emergency department visits and/or hospitalizations in the last year, yet only 3% were receiving regular inhaled corticosteroids.

CONCLUSIONS

The prevalence of asthma among older American Indians residing in three separate geographic areas of the United States was similar to rates in other ethnic groups. Asthma was associated with low lung function, significant morbidity and health-care utilization, yet medications for pulmonary disease were underutilized by this population.

Hospitalization due to pneumonia among Innu, Inuit and non-Aboriginal communities, Newfoundland and Labrador, Canada

OBJECTIVES

The objective of this study was to compare hospitalization rates due to pneumonia between Innu/Inuit communities in Labrador and non-Aboriginal communities on the Northern Peninsula of Newfoundland, Canada.

METHODS

This is a comparative study using data on hospitalization due to pneumonia for the period from April 1, 1995 to March 31, 2001, for the Innu/Inuit communities in Labrador and a sample of non-Aboriginal communities on the Northern Peninsula of Newfoundland. Data were obtained from the provincial hospital database. Hospitalization rates among the study groups were compared by age, gender, and type of pneumonia.

RESULTS

The hospitalization rate due to pneumonia for the Innu/Inuit communities was 11.6 compared to 3.0 per 1000 population for non-Aboriginal communities (p<0.01x10(-4)). Among the Innu/Inuit communities, infants had the highest rate of hospitalization due to pneumonia (93.4 per 1000 population), while the elderly (10.2 per 1000 population) were found to have the highest rate among the non-Aboriginal sample. Overall hospitalization rate for the Innu communities (16.9 per 1000 population) was higher than that for Inuit communities (8.4 per 1000 population) (p<0.01x10(-4)).

CONCLUSIONS

Aboriginal communities, particularly the Innu communities, had higher rates of hospitalization due to pneumonia compared to the non-Aboriginal sample. Findings of this study will be used as a foundation for more specific studies in an effort to increase our understanding of pneumonia and associated risk factors.

Morbidity and mortality rates in a NOVA SCOTIA First Nations Community, 1996-1999

BACKGROUND

Despite an abundance of data and analysis of First Nations morbidity and mortality rates, accurate data have not been available to serve the First Nations community in Eastern Canada.

METHODS

Data for Eskasoni, the largest Mi'kmaq community, were obtained for 1996 through 1999 and Cape Breton and Nova Scotia were used as regional and provincial reference populations respectively. Age-adjusted relative risks (AARR) were calculated for overall mortality and disease-specific hospital admissions.

RESULTS

Eskasoni's mortality AARR was greater than 1.0 in 3 of the 4 years studied, although the data may understate Eskasoni's mortality rates. Eskasoni's total admission AARRs were significantly greater than the two reference populations. Neoplasm admission rates were generally lower, while circulatory disease admission AARRs were significantly higher. A rise in diabetic admission rates was noted with the AARR reaching statistical significance in the final years of the study. Respiratory disease was the leading cause of hospitalization with significantly greater rates of admission than regional or provincial rates. Pneumonia and influenza accounted for more than one half of respiratory admissions. Infectious disease admissions were more prevalent in Eskasoni while rates of liver disease were generally low.

CONCLUSION

Results suggest that members of the largest Mi'kmaq band are at greater risk for a number of disease categories and health promotion should be targeted toward respiratory ailments, circulatory disease and diabetic management. Further analysis, however, remains an important priority.

Prevalence of asthma and chronic respiratory symptoms among Alaska Native children

STUDY OBJECTIVES

To quantify the prevalence and impact of chronic respiratory symptoms among predominantly Alaska Native (AN)/American Indian (AI) middle school students.

DESIGN

School-based prevalence assessment using the International Study of Asthma and Allergy in Children survey, with supplemental video material and added questions about productive cough, exposure to tobacco smoke, and the functional impact of symptoms.

SETTING

The Yukon-Kuskokwim delta region of western Alaska.

PARTICIPANTS

A total of 466 children in the sixth to ninth grades, 81% of whom are AN/AI (377 children).

INTERVENTIONS

No study intervention.

RESULTS

Among the 377 AN/AI children, 40% reported one of the following three categories of chronic respiratory disease: physician-diagnosed asthma, 7.4%; asthma-like symptoms (ALS) without an asthma diagnosis, 11.4%; and chronic productive cough (CPC) without asthma diagnosis or symptoms, 21.5%. Symptom prevalence differed substantially between the largest town in the region and rural villages. After an adjustment for demographic factors, exposure to environmental tobacco smoke, active tobacco smoking, and self-report of atopy, village residents were 63% less likely to have ALS (p = 0.009), and had a twofold greater risk of CPC (p < 0.001) compared to children living in the town. Children with respiratory symptoms experienced sleep disturbances and accessed clinic visits for respiratory problems more often than did asymptomatic children.

CONCLUSIONS

Chronic respiratory symptoms are very common among AN children. CPC is an important nonasthmatic respiratory condition in this population. The differing patterns of respiratory illness within this region may help to elucidate the specific risk factors for asthma and chronic bronchitis in children.

Respiratory symptoms and exposure to wood smoke in an isolated northern community

BACKGROUND

Wood smoke has been associated with respiratory symptoms. This study examined the prevalence of respiratory symptoms and health effects of wood smoke exposures (from home heating, curing meat, and tanning hides) among residents of Deline, Northwest Territories (NWT).

METHODS

A survey was conducted of all residents. Relationships between wood smoke and respiratory symptoms were examined.

RESULTS

The response rate was 70.2% (n=402). 71% of people at least 18 years old were current smokers. Prevalence of symptoms was higher for women (odds ratios (ORs) 1.3-3.1). Women who smoked were more likely to be exposed to indoor smoke from curing and tanning. ORs for respiratory symptoms were higher for females, increased with age, and were strongly affected by smoking. Among those at least 18 years old, phlegm on winter mornings (6.5 (95% CI: 2.3-18.1)), dyspnoea (5.1 (95% CI: 1.9-13.2)), and watery or itchy eyes (3.6 (95% CI: 1.4-9.0)) were significantly related to self-reported outdoor wood smoke and smoke curing. Home heating was marginally associated with wheeze. No significant associations were found for males.

CONCLUSIONS

Women engaged in curing/tanning demonstrated increased prevalence of respiratory symptoms. The cultural importance of these activities precludes abandoning them. Smoking cessation, limiting wood smoke exposure times, and process modifications in curing and tanning could reduce risk of adverse health effects.

The increase in allergic respiratory diseases: survival of the fittest?

The prevalence of allergic respiratory diseases, asthma and allergic rhinoconjunctivitis, has increased since the advent of industrialization. The inverse relationship between the number of infections early in life and atopy has been interpreted as the "hygiene hypothesis." That is, many infections early in life promote the development of T helper type 1 cytokines, while fewer infections early in life favor the development of T helper type 2 (Th2) cytokines and atopy. An alternate interpretation of the same data, that atopy is protective against infections early in life, is rarely considered. With epidemiologic, historical, and immunologic data, I suggest that human evolution has favored individuals with an atopic predisposition. Th2 immune responses promote parity, and ensure successful pregnancy and term birth; provide the infant protection against infections and the inflammation induced by common pathogens in the first years of life until the immune system matures; and protect young adults exposed to viral respiratory pathogens. These traits are of particular value with the advent of industrialization, especially so in the era prior to the development of antibiotics. This theory contradicts the assumption that there is no biological or evolutionary advantage for allergic disease to exist in humans and has significant implications for our current and future treatments of allergic diseases.

Ethnic comparisons of disease severity in children hospitalized with pneumonia in New Zealand

OBJECTIVE

To determine if there are ethnic differences in disease severity in children hospitalized with pneumonia in New Zealand.

METHODOLOGY

A population based audit of children hospitalized in Auckland with pneumonia over 12 months from 1 November 1994 to 31 October 1995. The study population was children aged from 0 to 14 years with a discharge diagnosis of pneumonia. The sample was stratified by ethnicity and included 151 Pacific, 85 Mäori and 151 European children. Measurements were made of demographics and prehospital care; vital signs and therapy received in the emergency department and inpatient wards and laboratory investigations performed. Comparisons between the three ethnic groups were adjusted for age, weight, gender, socio-economic status and relationship with primary care.

RESULTS

A larger proportion of Pacific (15%) and Mäori (22%) children than European children (8%) had a respiratory rate elevated for > or = 2 days, odds ratio (OR) (95% CI): Pacific versus European 2.7 (1.1, 6.8), Mäori versus European 4.3 (1.7, 11.6). A larger proportion of Pacific (15%) and Mäori (15%) children than European children (< 1%) had a heart rate elevated for > or = 2 days, OR Pacific versus European 17.2 (3.2, 320), Mäori versus European 26.1 (4.4, 508). Compared with European children, a larger proportion of Pacific and Mäori children received intravenous fluids and antibiotics. A larger proportion of Pacific (29%) and Mäori (27%) children than European children (11%) received oxygen for > = 2 days, OR Pacific versus European 3.2 (1.6, 6.6), Mäori versus Europeans 2.6 (1.2, 6.2).

CONCLUSIONS

Based on the comparisons of vital signs and intensity of therapy, Pacific and Mäori children hospitalized with pneumonia have more severe pneumonia than European children.

The curious 2000-year case of asthma

Millions worldwide have asthma, with the numbers succumbing increasing sharply in the past two decades. After 2000 years of scientific study, who succumbs to asthma when is as puzzling as who regains health when and how. The discipline of psychosomatic medicine and science investigates and treats diseases like asthma that typically confound general medicine. Still psychosomatic medicine, like general medicine, only manages but does not remedy asthma, which can currently only be in remission but not cured. This historical review reveals the progress and missteps that have been made in the study and treatment of asthma by comparing the general medicine approach with the major research findings on asthma published over 60 years in Psychosomatic Medicine. Research has identified antecedent, collateral, and subsequent factors to scientifically describe and control this disease in terms of diagnosis, management, and treatment. Paradoxically and regrettably, the prognosis for those with asthma is worse than ever. Curious also that a noninfectious disease should spread so rapidly and mostly for specific groups identified by variables like age, gender, ethnicity, and socioeconomic status. Furthermore, partial, not full, family concordance indicates merely genetic influence, not determination. General medicine now focuses on enumerating the range of environmental and situational triggers, or stimuli, producing asthma and describing the pathophysiology of bronchial inflammation. With a more comprehensive multifactorial approach, psychosomatic medicine seems well suited to investigate further the physiological, psychological, social, and environmental factors implicated in this medical conundrum. A future challenge for psychosomatic medicine is to stem the tide of rising prevalence and cure the disease of asthma.

Preventive health care among rural American Indians in New Mexico

BACKGROUND

Incidence of and mortality from cardiovascular disease, cancer, diabetes, and other chronic diseases are rapidly increasing among American Indians; however, the utilization of preventive services for these conditions is not well characterized in these ethnic groups.

METHODS

We interviewed 1,273 American Indian adults in New Mexico, ages 18 years and older, by telephone regarding routine health checks, including blood pressure, blood cholesterol, mammograms, clinical breast exams, Pap smears, influenza and pneumonia vaccinations, and diabetes using items from the CDC Behavioral Risk Factor Surveillance System.

RESULTS

We found that utilization of preventive service was surprisingly high among rural American Indians. Routine health checks and blood pressure checks within the past year were reported by more than 70% of the population. Blood cholesterol checks (41.1%) and pneumonia vaccinations (30.7%) were less commonly reported. Utilization of cancer screening for the most common women's cancers was also high. Most women reported ever having a Pap smear test (88.3%), a clinical breast examination (79.5%), and a mammogram (75.6%). The prevalence of diagnosed diabetes (8.8% overall and 26.4% for ages 50 years and older) greatly exceeds the nationwide prevalence.

CONCLUSIONS

The utilization of preventive services delivered by a unique governmental partnership is high among American Indians in New Mexico and, except for cholesterol screening, is comparable with rates for the U.S. population. Because cardiovascular disease is on the rise, more attention to preventive services in this arena is warranted. The high and increasing prevalence of diagnosed diabetes suggests that aggressive diabetes screening and interventions are needed.

Increased asthma hospitalizations among registered Indian children and adults in Saskatchewan, 1970-1989

We investigated asthma morbidity in children and adults among Registered Indians in Saskatchewan using hospitalization data for 1970-1989. In Registered Indians, significant increases were observed in the asthma hospitalization rates from 1979 to 1989 in boys and girls under 4 years, boys aged 5-14 years, and female adults aged 15-34 years respectively. In children under 4 years, the asthma hospitalization rates increased from 12.7 per 1000 in 1979 to 21.7 per 1000 in 1989. Asthma hospitalizations were higher among Indian boys than girls in the age group 0-4 years but this was reversed in the age groups 15-34 and 35-64 years. When compared with other Saskatchewan populations, the Indian population in age groups 0-4 and 35-64 years had significantly increased risk for hospitalization for asthma. Even though asthma was reported to be rare among Indians before 1975, we observed increases in asthma morbidity in recent years among Indian children and young adults.

Etiology and risk factors of adult pneumonia

The authors point out the remarkable importance that pneumonia has today among infectious diseases, and survey the main risk factors and etiological agents both of the forms acquired in the community and in the hospital, also considering the data from the international literature. The authors stress the high incidence of gram-positive microorganisms, among which Streptococcus pneumoniae is the most widespread in the forms acquired in the community, and the absolute prevalence of the gram-negatives in the nosocomial forms and, among the gram-positives, the pre-eminence of Staphylococcus aureus; these are "difficult" bacterial species, whose prevalence has been determined mainly by induced selective pressure through the inadequate use of antibiotics. The authors also point out the principal factors that favor the onset of pneumonia; they are connected to the host and to the environment; their combination with the infectious agent causes the infective event.

Comparative analysis of violent deaths in American Indians and Alaska Natives

Accidents, injuries, and outcomes from adverse effects have been identified as the second leading cause of death for American Indians and Alaska Natives (AI/AN). However, no studies have been done which analyze violent deaths (homicides, suicides, and other accidents) for this population with a focus on time trends. For this study, overall and gender-specific mortality rates due to violent deaths were computed for 1973-88. The results indicate that overall and gender-specific mortality rates for violent deaths in AI/AN have been decreasing on average per year: homicide, 4.3%; suicide, 2.7%; other accidents, 5.6%. Similarly, age-adjusted rates have been declining, and at faster rates than those of the U.S. general population: homicide, 4.5% vs. 1.4%; suicide, 2.5% vs. 0.6%; other accidents, 6.2% vs. 2.6%. However, the male-female ratio for homicides and other accidents has remained unchanged, and the ratio for suicide has been increasing. While the gap between age-adjusted rates have been narrowing, the age-adjusted rates for AI/AN have remained consistently above those of the U.S. general population.