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Requia WJ, Papatheodorou S. Maternal exposure to ambient temperature and birth defects in Brazil: a nationwide case-control study of over 11 million newborns. INTERNATIONAL JOURNAL OF BIOMETEOROLOGY 2024:10.1007/s00484-024-02746-x. [PMID: 39105774 DOI: 10.1007/s00484-024-02746-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 06/21/2024] [Accepted: 07/22/2024] [Indexed: 08/07/2024]
Abstract
Maternal exposure to extreme ambient temperature during pregnancy has been proposed as a potential risk factor for birth defects. Comprehensive investigations on this association remain limited, particularly in low- and middle-income countries. This study aims to examine the association between ambient temperature exposure during pregnancy and the risk of birth defects in Brazil, contributing to the broader understanding of environmental influences on birth outcomes. Using a large dataset of over 11 million live birth records, we analyzed 12 categories of birth defects, encompassing a time frame from 2001 to 2018. Ambient temperature data were assigned at the municipality level. For the exposure assessment, we considered two biologically driven pregnancy stages by dividing the gestational period into two specific windows: the first trimester (from week 1 to week 12) and the second trimester (from week 13 to week 28). We employed a two-stage case-control design. In the first stage, we applied a conditional logistic regression model to estimate the odds ratio (OR) for specific birth defects and each of the five Brazilian regions (North, Northeast, Midwest, Southeast, and South). The model was adjusted for potential confounding variables, including PM2.5, relative humidity, and socioeconomic status. Temporal trends were addressed using time-stratified sampling. In the second stage, we used mixed-effects meta-analysis to pool region-specific estimates. Our analysis revealed a significant association between maternal exposure to higher ambient temperatures during the first trimester and an increased risk of specific birth defect categories, including those affecting the genital organs (OR = 1.08, 95% CI: 1.02; 1.14), digestive system (OR = 1.12, 95% CI: 1.06; 1.19); circulatory system (OR = 1.08, 95% CI: 1.01; 1.17); eyes, ears, face, and neck (OR = 1.08, 95% CI: 1.02; 1.15); benign neoplasms tumors (OR = 1.17, 95% CI: 1.03; 1.32), musculoskeletal system (OR = 1.03, 95% CI: 1.01; 1.05); and other congenital anomalies (OR = 1.22, 95% CI: 1.15; 1.29). The associations with respiratory system, nervous system, and chromosomal anomalies were null. These findings have significant implications for public health policies aimed at mitigating the impact of environmental factors on birth outcomes, both in Brazil and globally.
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Affiliation(s)
- Weeberb J Requia
- Center for Environment and Public Health Studies, School of Public Policy and Government, Fundação Getúlio Vargas , Brasília, Distrito Federal, Brasília, Brazil.
| | - Stefania Papatheodorou
- Department of Epidemiology, Harvard TH Chan School of Public Health Boston, Boston, MA, USA
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Jia Y, Wang J, Liu C, Zhao P, Ren Y, Xiong Y, Li G, Chen M, Sun X, Tan J. The Methodological Quality of Observational Studies Examining the Risk of Pregnancy Drug Use on Congenital Malformations Needs Substantial Improvement: A Cross-Sectional Survey. Drug Saf 2024:10.1007/s40264-024-01465-x. [PMID: 39093543 DOI: 10.1007/s40264-024-01465-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND AND OBJECTIVE An increasing number of observational studies have investigated the risk of using drugs during pregnancy on congenital malformations. However, the credibility of the causal relationships drawn from these studies remains uncertain. This study aims to evaluate the potential methodological issues in existing observational studies. METHODS We used a stepwise approach to investigate this issue. First, we identified observational studies published in 2020 that examined the risk of congenital malformations associated with medication use during pregnancy. We assessed the methodological characteristics for establishing causality, including study design, confounding control, and sensitivity analysis, and compared them between "core clinical journals" and "general journals." For studies reporting an increased risk of congenital malformations in core clinical journals, we searched for subsequent studies addressing the same research question published between January 2021 and May 2023 to assess the consistency of the literature. RESULTS A total of 40 eligible studies were published in 2020, primarily focused on the safety of vitamin B12 and folic acid (n = 4), antidepressants (n = 4), and others (n = 32). Our findings suggest that only two (5.00%) studies used causal models to guide the identification of confounding, and only eight (20.00%) studies assessed the potential dose-response relationship. In all, 15 (37.50%) studies used propensity score analysis strategy to achieve "mimic-randomization." In addition, 22 studies (55.00%) performed sensitivity analyses, while 10 (45.45%) showed inconsistency with the primary outcome. Furthermore, 5 studies reported positive outcomes, whereas only 1 out of 11 studies demonstrated a positive correlation between drug usage during pregnancy and major malformations in subsequent studies. CONCLUSION A significant portion of the studies has failed to sufficiently consider the essential methodological characteristics required to improve the credibility of causal inferences. The increased risk of congenital malformations documented in core clinical journal was not adequately replicated in subsequent studies.
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Affiliation(s)
- Yulong Jia
- Institute of Integrated Traditional Chinese and Western Medicine and Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Wuhou District, Chengdu, 610041, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, Sichuan, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, Sichuan, China
| | - Jing Wang
- Institute of Integrated Traditional Chinese and Western Medicine and Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Wuhou District, Chengdu, 610041, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, Sichuan, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, Sichuan, China
| | - Chunrong Liu
- Institute of Integrated Traditional Chinese and Western Medicine and Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Wuhou District, Chengdu, 610041, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, Sichuan, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, Sichuan, China
| | - Peng Zhao
- Institute of Integrated Traditional Chinese and Western Medicine and Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Wuhou District, Chengdu, 610041, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, Sichuan, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, Sichuan, China
| | - Yan Ren
- Institute of Integrated Traditional Chinese and Western Medicine and Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Wuhou District, Chengdu, 610041, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, Sichuan, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, Sichuan, China
| | - Yiquan Xiong
- Institute of Integrated Traditional Chinese and Western Medicine and Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Wuhou District, Chengdu, 610041, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, Sichuan, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, Sichuan, China
| | - GuoWei Li
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Meng Chen
- Department of Obstetrics and Gynecology, and Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, 610041, Sichuan, China
- West China Second University Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Xin Sun
- Institute of Integrated Traditional Chinese and Western Medicine and Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Wuhou District, Chengdu, 610041, China.
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, Sichuan, China.
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, Sichuan, China.
| | - Jing Tan
- Institute of Integrated Traditional Chinese and Western Medicine and Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Wuhou District, Chengdu, 610041, China.
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, Sichuan, China.
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, Sichuan, China.
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Leung M, Weisskopf MG, Modest AM, Hacker MR, Iyer HS, Hart JE, Wei Y, Schwartz J, Coull BA, Laden F, Papatheodorou S. Using Parametric g-Computation for Time-to-Event Data and Distributed Lag Models to Identify Critical Exposure Windows for Preterm Birth: An Illustrative Example Using PM2.5 in a Retrospective Birth Cohort Based in Eastern Massachusetts (2011-2016). ENVIRONMENTAL HEALTH PERSPECTIVES 2024; 132:77002. [PMID: 38995210 PMCID: PMC11243950 DOI: 10.1289/ehp13891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 04/18/2024] [Accepted: 06/20/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND Parametric g-computation is an attractive analytic framework to study the health effects of air pollution. Yet, the ability to explore biologically relevant exposure windows within this framework is underdeveloped. OBJECTIVES We outline a novel framework for how to incorporate complex lag-responses using distributed lag models (DLMs) into parametric g-computation analyses for survival data. We call this approach "g-survival-DLM" and illustrate its use examining the association between PM 2.5 during pregnancy and the risk of preterm birth (PTB). METHODS We applied the g-survival-DLM approach to estimate the hypothetical static intervention of reducing average PM 2.5 in each gestational week by 20% on the risk of PTB among 9,403 deliveries from Beth Israel Deaconess Medical Center, Boston, Massachusetts, 2011-2016. Daily PM 2.5 was taken from a 1 -km grid model and assigned to address at birth. Models were adjusted for sociodemographics, time trends, nitrogen dioxide, and temperature. To facilitate implementation, we provide a detailed description of the procedure and accompanying R syntax. RESULTS There were 762 (8.1%) PTBs in this cohort. The gestational week-specific median PM 2.5 concentration was relatively stable across pregnancy at ∼ 7 μ g / m 3 . We found that our hypothetical intervention strategy changed the cumulative risk of PTB at week 36 (i.e., the end of the preterm period) by - 0.009 (95% confidence interval: - 0.034 , 0.007) in comparison with the scenario had we not intervened, which translates to about 86 fewer PTBs in this cohort. We also observed that the critical exposure window appeared to be weeks 5-20. DISCUSSION We demonstrate that our g-survival-DLM approach produces easier-to-interpret, policy-relevant estimates (due to the g-computation); prevents immortal time bias (due to treating PTB as a time-to-event outcome); and allows for the exploration of critical exposure windows (due to the DLMs). In our illustrative example, we found that reducing fine particulate matter [particulate matter (PM) with aerodynamic diameter ≤ 2.5 μ m (PM 2.5 )] during gestational weeks 5-20 could potentially lower the risk of PTB. https://doi.org/10.1289/EHP13891.
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Affiliation(s)
- Michael Leung
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Marc G Weisskopf
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Anna M Modest
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts, USA
| | - Michele R Hacker
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts, USA
| | - Hari S Iyer
- Section of Cancer Epidemiology and Health Outcomes, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey, USA
| | - Jaime E Hart
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Yaguang Wei
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Joel Schwartz
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Brent A Coull
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Francine Laden
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Stefania Papatheodorou
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, New Brunswick, New Jersey, USA
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Bommarito PA, Stevens DR, Welch BM, Ospina M, Calafat AM, Meeker JD, Cantonwine DE, McElrath TF, Ferguson KK. Organophosphate Ester Flame Retardants and Plasticizers in Relation to Fetal Growth in the LIFECODES Fetal Growth Study. ENVIRONMENTAL HEALTH PERSPECTIVES 2024; 132:77001. [PMID: 38968089 PMCID: PMC11225970 DOI: 10.1289/ehp14647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 05/07/2024] [Accepted: 06/13/2024] [Indexed: 07/07/2024]
Abstract
BACKGROUND Organophosphate esters (OPEs), used ubiquitously as flame retardants and plasticizers in consumer products, are suspected of having developmental toxicity. OBJECTIVES Our study aimed to estimate associations between prenatal exposure to OPEs and fetal growth, including both ultrasound (head circumference, abdominal circumference, femur length, and estimated fetal weight) and delivery [birth weight z-score, small-for-gestational age (SGA), and large-for-gestational age (LGA)] measures of growth. METHODS In the LIFECODES Fetal Growth Study (2008-2018), an enriched case-cohort of 900 babies born at the small and large ends of the growth spectrum, we quantified OPE biomarkers in three urine samples per pregnant participant and abstracted ultrasound and delivery measures of fetal growth from medical records. We estimated associations between pregnancy-averaged log-transformed OPE biomarkers and repeated ultrasound measures of fetal growth using linear mixed-effects models, and delivery measures of fetal growth using linear (birth weight) and logistic (SGA and LGA) regression models. RESULTS Most OPE biomarkers were positively associated with at least one ultrasound measure of fetal growth, but associations with delivery measures were largely null. For example, an interquartile range (IQR; 1.31 ng / mL ) increase in bis(2-chloroethyl) phosphate concentration was associated with larger z-scores in head circumference [mean difference (difference): 0.09; 95% confidence interval (CI): 0.01, 0.17], abdominal circumference (difference: 0.10; 95% CI: 0.02, 0.18), femur length (difference: 0.11; 95% CI: 0.03, 0.19), and estimated fetal weight (difference: 0.13; 95% CI: 0.04, 0.22) but not birth weight (difference: 0.04; 95% CI: - 0.08 , 0.17). At delivery, an IQR (1.00 ng / mL ) increase in diphenyl phosphate (DPHP) concentration was associated with an SGA birth (odds ratio: 1.46; 95% CI: 1.10, 1.94). CONCLUSIONS In a large prospective cohort, gestational OPE exposures were associated with larger fetal size during pregnancy, but associations at delivery were null. DPHP concentrations were associated with heightened risk of an SGA birth. These findings suggest that OPE exposure may affect fetal development. https://doi.org/10.1289/EHP14647.
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Affiliation(s)
- Paige A. Bommarito
- Epidemiology Branch, Division of Intramural Research, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina, USA
| | - Danielle R. Stevens
- Epidemiology Branch, Division of Intramural Research, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina, USA
| | - Barrett M. Welch
- Epidemiology Branch, Division of Intramural Research, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina, USA
- School of Public Health, University of Nevada, Reno, Nevada, USA
| | - Maria Ospina
- Division of Laboratory Sciences, National Center for Environmental Health, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Antonia M. Calafat
- Division of Laboratory Sciences, National Center for Environmental Health, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - John D. Meeker
- Department of Environmental Health Sciences, University of Michigan School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - David E. Cantonwine
- Division of Maternal-Fetal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas F. McElrath
- Division of Maternal-Fetal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kelly K. Ferguson
- Epidemiology Branch, Division of Intramural Research, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina, USA
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5
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Wei CF, Mukherjee SK, Ekramullah SM, Arman DM, Islam MJ, Azim M, Rahman A, Rahman MN, Ziauddin M, Tindula G, Suchanda HS, Gomberg DF, Weisskopf MG, Liang L, Warf BC, Christiani DC, Mazumdar M. Arsenic modifies the effect of folic acid in spina bifida prevention, a large hospital-based case-control study in Bangladesh. Environ Health 2024; 23:51. [PMID: 38831396 PMCID: PMC11145859 DOI: 10.1186/s12940-024-01091-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 05/19/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Spina bifida, a developmental malformation of the spinal cord, is associated with high rates of mortality and disability. Although folic acid-based preventive strategies have been successful in reducing rates of spina bifida, some areas continue to be at higher risk because of chemical exposures. Bangladesh has high arsenic exposures through contaminated drinking water and high rates of spina bifida. This study examines the relationships between mother's arsenic exposure, folic acid, and spina bifida risk in Bangladesh. METHODS We conducted a hospital-based case-control study at the National Institute of Neurosciences & Hospital (NINS&H) in Dhaka, Bangladesh, between December 2016 and December 2022. Cases were infants under age one year with spina bifida and further classified by a neurosurgeon and imaging. Controls were drawn from children seen at NINS&H and nearby Dhaka Shishu Hospital. Mothers reported folic acid use during pregnancy, and we assessed folate status with serum assays. Arsenic exposure was estimated in drinking water using graphite furnace atomic absorption spectrophotometry (GF-AAS) and in toenails using inductively coupled plasma mass spectrometry (ICP-MS). We used logistic regression to examine the associations between arsenic and spina bifida. We used stratified models to examine the associations between folic acid and spina bifida at different levels of arsenic exposure. RESULTS We evaluated data from 294 cases of spina bifida and 163 controls. We did not find a main effect of mother's arsenic exposure on spina bifida risk. However, in stratified analyses, folic acid use was associated with lower odds of spina bifida (adjusted odds ratio [OR]: 0.50, 95% confidence interval [CI]: 0.25-1.00, p = 0.05) among women with toenail arsenic concentrations below the median value of 0.46 µg/g, and no association was seen among mothers with toenail arsenic concentrations higher than 0.46 µg/g (adjusted OR: 1.09, 95% CI: 0.52-2.29, p = 0.82). CONCLUSIONS Mother's arsenic exposure modified the protective association of folic acid with spina bifida. Increased surveillance and additional preventive strategies, such as folic acid fortification and reduction of arsenic, are needed in areas of high arsenic exposure.
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Affiliation(s)
- Chih-Fu Wei
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, 655 Huntington Avenue, Boston, MA, 02115, USA
| | - Sudipta Kumer Mukherjee
- Department of Paediatric Neurosurgery, National Institute of Neurosciences & Hospital, Sher-e-Bangla Nagar, Agargoan, Dhaka, 1207, Bangladesh
| | - Sheikh Muhammad Ekramullah
- Department of Paediatric Neurosurgery, National Institute of Neurosciences & Hospital, Sher-e-Bangla Nagar, Agargoan, Dhaka, 1207, Bangladesh
| | - D M Arman
- Department of Paediatric Neurosurgery, National Institute of Neurosciences & Hospital, Sher-e-Bangla Nagar, Agargoan, Dhaka, 1207, Bangladesh
| | - Md Joynul Islam
- Department of Clinical Neurosurgery, National Institute of Neurosciences & Hospital, Sher-e-Bangla Nagar, Agargoan, Dhaka, 1207, Bangladesh
| | | | - Asifur Rahman
- Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh
| | - Md Nafaur Rahman
- Department of Paediatric Neurosurgery, National Institute of Neurosciences & Hospital, Sher-e-Bangla Nagar, Agargoan, Dhaka, 1207, Bangladesh
| | - Md Ziauddin
- Department of Paediatric Neurosurgery, National Institute of Neurosciences & Hospital, Sher-e-Bangla Nagar, Agargoan, Dhaka, 1207, Bangladesh
| | - Gwen Tindula
- Department of Epidemiology and Population Health, Stanford University, Palo Alto, , 300 Pasteur Drive, CA, 94305, USA
| | - Hafiza Sultana Suchanda
- Pediatric Neurosurgery Research Committee, National Institute of Neurosciences & Hospital, Sher-e-Bangla Nagar, Agargoan, Dhaka, 1207, Bangladesh
| | - Diana F Gomberg
- Department of Neurology, Boston Children's Hospital, BCH3443, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Marc G Weisskopf
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, 655 Huntington Avenue, Boston, MA, 02115, USA
| | - Liming Liang
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, 655 Huntington Avenue, Boston, MA, 02115, USA
| | - Benjamin C Warf
- Department of Neurosurgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - David C Christiani
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, 655 Huntington Avenue, Boston, MA, 02115, USA
| | - Maitreyi Mazumdar
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, 655 Huntington Avenue, Boston, MA, 02115, USA.
- Department of Neurology, Boston Children's Hospital, BCH3443, 300 Longwood Ave, Boston, MA, 02115, USA.
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Farmer JG, Specht A, Punshon T, Jackson BP, Bidlack FB, Bakalar CA, Mukherjee R, Davis M, Steadman DW, Weisskopf MG. Lead exposure across the life course and age at death. THE SCIENCE OF THE TOTAL ENVIRONMENT 2024; 927:171975. [PMID: 38547974 PMCID: PMC11069331 DOI: 10.1016/j.scitotenv.2024.171975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 03/22/2024] [Accepted: 03/23/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Lead (Pb) exposure has been associated with an increased risk of all-cause mortality, even at low levels. Little is known about how the timing of Pb exposure throughout life may influence these relationships. Quantifying the amount of Pb present in various tissues of the body provides measurements of exposure from different periods of life. These include bone, tooth enamel, which is the hard outer layer of the crown, and tooth cementum, which is the calcified connective tissue covering the tooth root. The purpose of the study was to examine Pb exposure at multiple periods throughout life, including childhood (enamel), adulthood (cementum), and later life (bone), and to estimate their associations with age at death. METHODS 208 skeleton donors (born 1910-1960) from an ongoing case-control study were included in this study. Pb was measured in tibia (shin), bone using X-Ray Florescence and in teeth using Laser-Ablation Inductively Coupled Plasma Mass Spectroscopy. After excluding unusually high measurements (>2sd), this resulted in a final sample of 111 with all exposure measures. Correlations across measures were determined using partial Spearman correlations. Associations between Pb exposure and age at death were estimated using Multivariable Linear Regression. RESULTS Pb measures across exposure periods were all significantly correlated, with the highest correlation between cementum and tibia measures (r = 0.61). Donors were largely female (63.0 %), White (97.3 %), and attended some college (49.5 %). Single exposure models found that higher tooth cementum Pb (-1.27; 95 % CI: -2.48, -0.06) and tibia bone Pb (-0.91; 95 % CI: -1.67, -0.15) were significantly associated with an earlier age at death. When considered simultaneously, only cementum Pb remained significant (-1.51; 95 % CI: -2.92, -0.11). Secondary analyses suggest that the outer cementum Pb may be especially associated with an earlier age at death. CONCLUSION Results suggest that higher Pb exposure is associated with an earlier age at death, with adulthood as the life period of most relevance. Additional studies using Pb exposure measures from different life stages should be conducted.
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Affiliation(s)
- Justin G Farmer
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, 655 Huntington Ave, Boston, MA, United States.
| | - Aaron Specht
- School of Health Sciences, Purdue University, 550 W Stadium Ave, West Lafayette, IN, United States
| | - Tracy Punshon
- Department of Biological Sciences, Dartmouth College, Hanover, NH, United States
| | - Brian P Jackson
- Department of Earth Sciences, Dartmouth College, Hanover, NH, United States
| | | | - Charlotte A Bakalar
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, 655 Huntington Ave, Boston, MA, United States
| | - Rajarshi Mukherjee
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, 655 Huntington Ave, Boston, MA, United States
| | - Mary Davis
- Department of Anthropology, University of Tennessee Knoxville, 1621 Cumberland Avenue, Knoxville, TN, United States
| | - Dawnie W Steadman
- Department of Anthropology, University of Tennessee Knoxville, 1621 Cumberland Avenue, Knoxville, TN, United States
| | - Marc G Weisskopf
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, 655 Huntington Ave, Boston, MA, United States; Department of Epidemiology, Harvard T.H. Chan School of Public Health, 655 Huntington Ave, Boston, MA, United States
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7
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Liddie JM, Vieira CLZ, Coull BA, Sparrow D, Koutrakis P, Weisskopf MG. Associations between solar and geomagnetic activity and cognitive function in the Normative Aging study. ENVIRONMENT INTERNATIONAL 2024; 187:108666. [PMID: 38648690 PMCID: PMC11146138 DOI: 10.1016/j.envint.2024.108666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 03/22/2024] [Accepted: 04/15/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Studies show that changes in solar and geomagnetic activity (SGA) influence melatonin secretion and the autonomic nervous system. We evaluated associations between solar and geomagnetic activity and cognitive function in the Normative Aging Study from 1992 to 2013. METHODS We used logistic and linear generalized estimating equations and regressions to evaluate the associations between moving averages of sunspot number (SSN) and Kp index (a measure of geomagnetic activity) and a binary measure for Mini-Mental State Examination (MMSE) scores (≤25 or > 25) and six other cognitive tests as continuous measures, combined into one global composite score and considered separately. RESULTS A one-IQR increase in same-day SSN and Kp index were associated with 17% (95% CI: 3%, 34%) and 19% (95% CI: 4%, 36%) increases in the odds of low MMSE score. We observed small increases in the global cognitive score with increasing SSN, although we observed decreases specifically in relation to the backwards digit span test. CONCLUSIONS Periods of high SGA were associated with cognitive function. SGA may not equally impact all aspects of cognitive function, as evidenced by differences in associations observed for the MMSE, global cognitive score, and individual cognitive tests. Given that much of the pathology of cognitive decline in the elderly remains unexplained, studies specifically targeting decline and with longer follow-up periods are warranted.
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Affiliation(s)
- Jahred M Liddie
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Carolina L Z Vieira
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Brent A Coull
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - David Sparrow
- VA Normative Aging Study, Veterans Affairs Boston Healthcare System, Boston, MA, USA; Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Petros Koutrakis
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Marc G Weisskopf
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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8
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Chen C, Chen H, Kaufman JS, Benmarhnia T. Differential Participation, a Potential Cause of Spurious Associations in Observational Cohorts in Environmental Epidemiology. Epidemiology 2024; 35:174-184. [PMID: 38290140 PMCID: PMC10826917 DOI: 10.1097/ede.0000000000001711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 12/18/2023] [Indexed: 02/01/2024]
Abstract
Differential participation in observational cohorts may lead to biased or even reversed estimates. In this article, we describe the potential for differential participation in cohorts studying the etiologic effects of long-term environmental exposures. Such cohorts are prone to differential participation because only those who survived until the start of follow-up and were healthy enough before enrollment will participate, and many environmental exposures are prevalent in the target population and connected to participation via factors such as geography or frailty. The relatively modest effect sizes of most environmental exposures also make any bias induced by differential participation particularly important to understand and account for. We discuss key points to consider for evaluating differential participation and use causal graphs to describe two example mechanisms through which differential participation can occur in health studies of long-term environmental exposures. We use a real-life example, the Canadian Community Health Survey cohort, to illustrate the non-negligible bias due to differential participation. We also demonstrate that implementing a simple washout period may reduce the bias and recover more valid results if the effect of interest is constant over time. Furthermore, we implement simulation scenarios to confirm the plausibility of the two mechanisms causing bias and the utility of the washout method. Since the existence of differential participation can be difficult to diagnose with traditional analytical approaches that calculate a summary effect estimate, we encourage researchers to systematically investigate the presence of time-varying effect estimates and potential spurious patterns (especially in initial periods in the setting of differential participation).
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Affiliation(s)
- Chen Chen
- From the Scripps Institution of Oceanography, University of California San Diego, La Jolla, CA
| | - Hong Chen
- Environmental Health Science and Research Bureau, Health Canada, Ottawa, Ontario, Canada
- Public Health Ontario, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Jay S. Kaufman
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Tarik Benmarhnia
- From the Scripps Institution of Oceanography, University of California San Diego, La Jolla, CA
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9
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Wei CF, Mukherjee SK, Ekramullah SM, Arman DM, Islam MJ, Azim M, Rahman A, Rahman MN, Ziauddin M, Tindula G, Suchanda HS, Gomberg DF, Weisskopf MG, Liang L, Warf BC, Christiani DC, Mazumdar M. Arsenic modifies the effect of folic acid in spina bifida prevention, a large hospital-based case-control study in Bangladesh. RESEARCH SQUARE 2024:rs.3.rs-3989039. [PMID: 38464105 PMCID: PMC10925447 DOI: 10.21203/rs.3.rs-3989039/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
Background Spina bifida, a developmental malformation of the spinal cord, is associated with high rates of mortality and disability. Although folic acid-based preventive strategies have been successful in reducing rates of spina bifida, some areas continue to be at higher risk because of chemical exposures. Bangladesh has high arsenic exposures through contaminated drinking water and high rates of spina bifida. Methods We conducted a hospital-based case-control study at the National Institute of Neurosciences & Hospital (NINS&H) in Dhaka, Bangladesh, between December 2016 and December 2022. Cases were infants under age one year with spina bifida and further classified using data from observations by neurosurgeons and available imaging. Controls were drawn from children who presented to NINS&H or Dhaka Shishu Hospital (DSH) during the same study period. Mothers reported folic acid use during pregnancy, and we assessed folate status with serum assays. Arsenic exposure was estimated in drinking water using graphite furnace atomic absorption spectrophotometry (GF-AAS) and in toenails using inductively coupled plasma mass spectrometry (ICP-MS). Results We evaluated data from 294 cases of spina bifida and 163 controls. We did not find a main effect of mother's arsenic exposure on spina bifida risk. However, in stratified analyses, folic acid use was associated with lower odds of spina bifida (adjusted odds ratio [OR]: 0.50, 95% confidence interval [CI]: 0.25-1.00, p = 0.05) among women with toenail arsenic concentrations below the median, and no association was seen among mothers with toenail arsenic concentrations higher than median (adjusted OR: 1.09, 95% CI: 0.52-2.29, p = 0.82). Conclusions Mother's arsenic exposure modified the protective association of folic acid with spina bifida. Increased surveillance and additional preventive strategies, such as folic acid fortification and reduction of arsenic, are needed in areas of high arsenic exposure.
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Affiliation(s)
| | | | | | - D M Arman
- National Institute of Neurosciences & Hospital
| | | | | | | | | | - Md Ziauddin
- National Institute of Neurosciences & Hospital
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10
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Willis MD, Harris L, Campbell EJ, Chaskes M, Sawyer E, Harleman M, Ritz B, Hill EL, Hystad P. A population-based cohort study of electronic tolling, traffic congestion, and adverse birth outcomes. ENVIRONMENT INTERNATIONAL 2024; 183:108355. [PMID: 38056094 DOI: 10.1016/j.envint.2023.108355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 11/06/2023] [Accepted: 11/25/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND Although traffic-related air pollution is largely regulated at the federal level, congestion reduction projects may reduce local traffic and air pollution to levels that create positive co-benefits for population health. In recent years, many urban areas have implemented electronic tolling systems to improve traffic conditions. OBJECTIVE Quantify associations between implementing electronic tolling and local changes in traffic and infant health. METHODS Using a population-based birth cohort (Texas, 1999-2016), we calculated residential proximity to the nearest tolled road segment within 5 km (n = 625,279) and examined changes in local traffic before and after toll implementation. Using a difference-in-differences design, we compared four markers of adverse birth outcomes (term birth weight, term low birth weight, preterm birth, very preterm birth) among infants from pregnant people residing < 0.5 km from a road segment before and after the tolls were implemented and compared them to a contemporaneous population of pregnant people residing at 2-5 km. RESULTS We observed minimal changes in local traffic after the implementation of tolling. Among births within 500 m of a tolled road, we found little evidence of an association between the implementation of tolling and adverse birth outcomes (term birth weight [β: -4.5, 95 % CI: -11.7, 2.6], term low birth weight [OR: 1.00, 95 % CI: 0.89, 1.13], preterm birth [OR: 0.99, 95 % CI: 0.92, 1.05], very preterm birth [OR: 1.00, 95 % CI: 0.84, 1.18]), compared to the contemporaneous control group of births at 2-5 km. In sub-analyses, we found some evidence of a reduced association between toll booth removal and preterm birth (OR: 0.84, 95 % CI: 0.70, 1.01) but not for other outcomes or tolling types. DISCUSSION In this large population-based retrospective cohort study of births in Texas, we found little evidence that the implementation of tolling was consistently associated with improvements in local infant health outcomes.
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Affiliation(s)
- Mary D Willis
- Department of Epidemiology, School of Public Health, Boston University, 715 Albany Street, Boston, MA 02118, United States.
| | - Lena Harris
- Department of Economics, School of Arts and Sciences, University of Rochester, 238 Harkness Hall, P.O. Box 270156, Rochester, NY 14627, United States
| | - Erin J Campbell
- Department of Epidemiology, School of Public Health, Boston University, 715 Albany Street, Boston, MA 02118, United States
| | - Mira Chaskes
- Department of Economics, School of Arts and Sciences, University of Rochester, 238 Harkness Hall, P.O. Box 270156, Rochester, NY 14627, United States
| | - Ethan Sawyer
- Department of Economics, School of Arts and Sciences, University of Rochester, 238 Harkness Hall, P.O. Box 270156, Rochester, NY 14627, United States
| | - Max Harleman
- Department of Government and Sociology, College of Arts and Sciences, Georgia College and State University, 410 W. Greene Streer, Campus Box 18, Milledgeville, GA 31061, United States
| | - Beate Ritz
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, Box 951772 Suite 71-254 CHS, Los Angeles, CA 90095, United States; School of Nutrition and Public Health, College of Health, Oregon State University, 101 Milam Hall, Corvallis, OR 97331, United States
| | - Elaine L Hill
- Department of Economics, School of Arts and Sciences, University of Rochester, 238 Harkness Hall, P.O. Box 270156, Rochester, NY 14627, United States; Department of Public Health Sciences, School of Medicine and Dentistry, University of Rochester, 265 Crittenden Blvd, Rochester, NY 14642, United States
| | - Perry Hystad
- School of Nutrition and Public Health, College of Health, Oregon State University, 101 Milam Hall, Corvallis, OR 97331, United States
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11
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Hao H, Yoo SR, Strickland MJ, Darrow LA, D'Souza RR, Warren JL, Moss S, Wang H, Zhang H, Chang HH. Effects of air pollution on adverse birth outcomes and pregnancy complications in the U.S. state of Kansas (2000-2015). Sci Rep 2023; 13:21476. [PMID: 38052850 PMCID: PMC10697947 DOI: 10.1038/s41598-023-48329-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 11/24/2023] [Indexed: 12/07/2023] Open
Abstract
Neonatal mortality and morbidity are often caused by preterm birth and lower birth weight. Gestational diabetes mellitus (GDM) and gestational hypertension (GH) are the most prevalent maternal medical complications during pregnancy. However, evidence on effects of air pollution on adverse birth outcomes and pregnancy complications is mixed. Singleton live births conceived between January 1st, 2000, and December 31st, 2015, and reached at least 27 weeks of pregnancy in Kansas were included in the study. Trimester-specific and total pregnancy exposures to nitrogen dioxide (NO2), particulate matter with an aerodynamic diameter less than 2.5 μm (PM2.5), and ozone (O3) were estimated using spatiotemporal ensemble models and assigned to maternal residential census tracts. Logistic regression, discrete-time survival, and linear models were applied to assess the associations. After adjustment for demographics and socio-economic status (SES) factors, we found increases in the second and third trimesters and total pregnancy O3 exposures were significantly linked to preterm birth. Exposure to the second and third trimesters O3 was significantly associated with lower birth weight, and exposure to NO2 during the first trimester was linked to an increased risk of GDM. O3 exposures in the first trimester were connected to an elevated risk of GH. We didn't observe consistent associations between adverse pregnancy and birth outcomes with PM2.5 exposure. Our findings indicate there is a positive link between increased O3 exposure during pregnancy and a higher risk of preterm birth, GH, and decreased birth weight. Our work supports limiting population exposure to air pollution, which may lower the likelihood of adverse birth and pregnancy outcomes.
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Affiliation(s)
- Hua Hao
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, 1518 Clifton Rd., NE, Atlanta, GA, 30322, USA.
| | - Sodahm R Yoo
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, 30322, USA
| | - Matthew J Strickland
- Depatment of Health Analytics and Biostatistics, Epidemiology and Environmental Health, School of Public Health, University of Nevada, Reno, NV, 89557, USA
| | - Lyndsey A Darrow
- Depatment of Health Analytics and Biostatistics, Epidemiology and Environmental Health, School of Public Health, University of Nevada, Reno, NV, 89557, USA
| | - Rohan R D'Souza
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, 30322, USA
| | - Joshua L Warren
- Department of Biostatistics, School of Medicine, Yale University, New Haven, CT, 06510, USA
| | - Shannon Moss
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, 30322, USA
| | - Huaqing Wang
- Department of Landscape Architecture and Environment Planning, College of Agriculture and Applied Sciences, Utah State University, Logan, UT, 84322, USA
| | - Haisu Zhang
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, 1518 Clifton Rd., NE, Atlanta, GA, 30322, USA
| | - Howard H Chang
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, 1518 Clifton Rd., NE, Atlanta, GA, 30322, USA
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, 30322, USA
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12
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Leung M. Invited Perspective: Climate Change and Reproductive Health-the Perils of Oversimplification. ENVIRONMENTAL HEALTH PERSPECTIVES 2023; 131:121307. [PMID: 38149877 PMCID: PMC10752218 DOI: 10.1289/ehp13725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 10/03/2023] [Accepted: 11/29/2023] [Indexed: 12/28/2023]
Affiliation(s)
- Michael Leung
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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13
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Liu K, Kouis P, Nikolopoulos G, Kyprianou T, Nikolaidis K, Scoutellas V, Filippos T, Koutrakis P, Yiallouros P, Papatheodorou S. Ambient climatic factors and term birthweight: A study of critical windows of exposure in the Republic of Cyprus. ENVIRONMENTAL RESEARCH 2023; 237:116885. [PMID: 37607623 PMCID: PMC10592069 DOI: 10.1016/j.envres.2023.116885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 07/18/2023] [Accepted: 08/12/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND Reduced birthweight is associated with adverse perinatal and long-term outcomes. A few studies examined the association between climatic factors and birthweight with inconsistent results probably due to differences in exposure assessment, statistical models, climatic parameters, and study populations. METHODS We obtained data from the Republic of Cyprus birth registry from 2007 to 2020, and matched climatic exposures (i.e., temperature, relative humidity, temperature variability, humidity variability) by the hospital district at birth. We used distributed lag models to examine the association between term birthweight, temperature, humidity, and their variability to identify critical windows. Our models were adjusted for coarse particulate matter level (≤10 μm [PM10), and individual-level covariates. Subgroup analysis was conducted to examine effect modification by maternal age and education. RESULTS We identified two critical windows of exposure to ambient temperature at early and late pregnancy. The cumulative change of birthweight per 5 °C increases in mean weekly temperature was -57.27 (2%) (95% Confidence Interval [CI]: 99.62 (3.1%), -14.92 (0.5%)) and -79.2 (2.5%) (95%CI: 117.03 (3.5%), -41.52 (1.3%)) grams during weeks 1-8 and weeks 28-37, respectively. There was no significant effect of humidity, temperature variability, or humidity variability on birthweight. Based on subgroup analysis, mothers with post-secondary education were more sensitive to temperature, but the marginal significance of differences in effect estimates may be linked with differences in sample size. CONCLUSION Our study suggests that higher ambient temperature exposure during early and late pregnancy is associated with lower birthweight in main and subgroup analysis. The findings demonstrate in a country highly impacted by climate change like Cyprus that rising temperatures may be associated with perinatal outcomes in susceptible populations during sensitive windows of exposure.
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Affiliation(s)
- Kuangyliu Liu
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Harvard University, USA.
| | - Panayiotis Kouis
- Respiratory Physiology Laboratory, Medical School, University of Cyprus, Cyprus.
| | | | | | - Kleanthis Nikolaidis
- Department of Meteorology, Cyprus Ministry of Agriculture, Rural Development and Environment, Cyprus
| | | | - Tymvios Filippos
- Department of Meteorology, Cyprus Ministry of Agriculture, Rural Development and Environment, Cyprus.
| | - Petros Koutrakis
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Harvard University, USA
| | | | - Stefania Papatheodorou
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Harvard University, USA.
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14
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Xu K, Li Z, Qiao J, Wang S, Xie P, Zong Z, Hu C. Persistent organic pollutants exposure and risk of autism spectrum disorders: A systematic review and meta-analysis. ENVIRONMENTAL POLLUTION (BARKING, ESSEX : 1987) 2023; 336:122439. [PMID: 37619697 DOI: 10.1016/j.envpol.2023.122439] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 08/09/2023] [Accepted: 08/21/2023] [Indexed: 08/26/2023]
Abstract
Accumulating number of epidemiological studies has recently proposed that improvement in the risk of autism spectrum disorders (ASD) is associated with persistent organic pollutants (POPs) exposure. However, evidence from current researches is limited and inconsistent. Thus, we conducted a systematic review and meta-analysis to investigate the potential associations comprehensively. We systematically and extensively searched two electronic databases (PubMed and EMBASE) from inception to July 3, 2022 and an updated search was performed before submission. Summary odds ratios (ORs) and 95% confidence intervals (CIs) were derived from stratified random-effects meta-analyses by type of exposure and outcome. We also tested the potential heterogeneity across studies, conducted sensitivity analysis and evaluated publication bias. A total of 20 studies were finally included in our study. Meta-analytical effect estimates indicated a positive association between prenatal exposure to PCB-138, PCB-153 and PCB-170 and an increased risk of ASD, with OR of 1.89 (95% CI = 1.21-2.95, I2 = 0%), 1.61 (95% CI = 1.05-2.47, I2 = 0%) and 1.46 (95% CI = 1.03-2.06, I2 = 0%) respectively. In contrast, PFDA was found inversely associated with the risk of ASD (OR = 0.70, 95% CI = 0.52-0.94, I2 = 0%). The level of evidence supporting a link between ASD risk and exposure to PCB-138, PCB-153, PCB-170, and PFDA was respectively categorized as low, low, moderate, and low. In summary, this systematic review and meta-analysis suggest that exposure to PCB-138, PCB-153, and PCB-170 correlates with a heightened risk of ASD, with evidence levels rated as "low", "low", and "moderate", respectively. In contrast, PFDA exposure appears to be inversely associated with ASD risk, with a "low" level of supporting evidence. However, due to the limited number of studies available for each exposure and outcome pairing, these results should be interpreted with caution. Sufficiently powered studies are needed to validate our findings.
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Affiliation(s)
- Kexin Xu
- Department of Clinical Medicine, The Second School of Clinical Medicine, Anhui Medical University, 81 Meishan Road, Hefei, 230032, China
| | - Zhuoyan Li
- Department of Clinical Medicine, The Second School of Clinical Medicine, Anhui Medical University, 81 Meishan Road, Hefei, 230032, China
| | - Jianchao Qiao
- Department of Clinical Medicine, The Second School of Clinical Medicine, Anhui Medical University, 81 Meishan Road, Hefei, 230032, China
| | - Senzheng Wang
- Department of Clinical Medicine, The Second School of Clinical Medicine, Anhui Medical University, 81 Meishan Road, Hefei, 230032, China
| | - Pinpeng Xie
- Department of Clinical Medicine, The Second School of Clinical Medicine, Anhui Medical University, 81 Meishan Road, Hefei, 230032, China
| | - Zhiqiang Zong
- Department of Clinical Medicine, The Second School of Clinical Medicine, Anhui Medical University, 81 Meishan Road, Hefei, 230032, China
| | - Chengyang Hu
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, 230032, China; Department of Humanistic Medicine, School of Humanistic Medicine, Anhui Medical University, 81 Meishan Road, Hefei, 230032, China.
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15
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Barrett ES, Sharghi S, Thurston SW, Sobolewski Terry M, Loftus CT, Karr CJ, Nguyen RH, Swan SH, Sathyanarayana S. Associations of Exposure to Air Pollution during the Male Programming Window and Mini-Puberty with Anogenital Distance and Penile Width at Birth and at 1 Year of Age in the Multicenter U.S. TIDES Cohort. ENVIRONMENTAL HEALTH PERSPECTIVES 2023; 131:117001. [PMID: 37966231 PMCID: PMC10648757 DOI: 10.1289/ehp12627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 09/18/2023] [Accepted: 10/02/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND Ambient air pollution may be a developmental endocrine disruptor. In animal models, gestational and perinatal exposure to diesel exhaust and concentrated particulate matter alters anogenital distance (AGD), a marker of prenatal androgen activity, in both sexes. Little is known in humans. OBJECTIVES We examined exposure to fine particulate matter (PM 2.5 ) and nitrogen dioxide (NO 2 ) in relation to human AGD at birth and at 1 year of age, focusing on exposures during critical windows of reproductive development: the male programming window (MPW; gestational weeks 8-14) and mini-puberty (postnatal months 1-3). METHODS The Infant Development and Environment Study (TIDES) recruited first trimester pregnant women (n = 687 ) at four U.S. sites (Minneapolis, Minnesota; Rochester, New York; San Francisco, California; and Seattle, Washington) from 2010 to 2012. We measured anus to clitoris (AGD-AC) and anus to fourchette (AGD-AF) in female infants at birth; in males, we measured anus to penis (AGD-AP), anus to scrotum (AGD-AS), and penile width at birth and at 1 year of age. Using advanced spatiotemporal models, we estimated maternal exposure to PM 2.5 and NO 2 in the MPW and mini-puberty. Covariate-adjusted, sex-stratified linear regression models examined associations between PM 2.5 and NO 2 and AGD. RESULTS In males, a 1 - μ g / m 3 increase in PM 2.5 exposure during the MPW was associated with shorter AGD at birth, but a longer AGD at 1 year of age (e.g., birth AGD-AP: β = - 0.35 mm ; 95% CI: - 0.62 , - 0.07 ; AGD-AS: β = 0.37 mm ; 95% CI: 0.02, 0.73). Mini-pubertal PM 2.5 exposure was also associated with shorter male AGD-AP (β = - 0.50 mm ; 95% CI: - 0.89 , - 0.11 ) at 1 year of age. Although not associated with male AGD measures, 1 -ppb increases in NO 2 exposure during the MPW (β = - 0.07 mm ; 95% CI: - 0.02 , - 0.12 ) and mini-puberty (β = - 0.04 mm ; 95% CI: - 0.08 , 0.01) were both associated with smaller penile width at 1 year of age. Results were similar in multipollutant models, where we also observed that in females AGD-AC was inversely associated with PM 2.5 exposure, but positively associated with NO 2 exposure. DISCUSSION PM 2.5 and NO 2 exposures during critical pre- and postnatal windows may disrupt reproductive development. More work is needed to confirm these novel results and clarify mechanisms. https://doi.org/10.1289/EHP12627.
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Affiliation(s)
- Emily S. Barrett
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, New Jersey, USA
- Environmental and Occupational Health Sciences Institute, Rutgers University, Piscataway, New Jersey, USA
| | - Sima Sharghi
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Sally W. Thurston
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Marissa Sobolewski Terry
- Department of Environmental Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Christine T. Loftus
- Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, Washington, USA
| | - Catherine J. Karr
- Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Ruby H.N. Nguyen
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shanna H. Swan
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sheela Sathyanarayana
- Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
- Seattle Children’s Research Institute, University of Washington, Seattle, Washington, USA
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16
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Guilbert A, Bernard JY, Peyre H, Costet N, Hough I, Seyve E, Monfort C, Philippat C, Slama R, Kloog I, Chevrier C, Heude B, Ramus F, Lepeule J. Prenatal and childhood exposure to ambient air pollution and cognitive function in school-age children: Examining sensitive windows and sex-specific associations. ENVIRONMENTAL RESEARCH 2023; 235:116557. [PMID: 37423370 DOI: 10.1016/j.envres.2023.116557] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/16/2023] [Accepted: 07/03/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND Combined effect of both prenatal and early postnatal exposure to ambient air pollution on child cognition has rarely been investigated and periods of sensitivity are unknown. This study explores the temporal relationship between pre- and postnatal exposure to PM10, PM2.5, NO2 and child cognitive function. METHODS Using validated spatiotemporally resolved exposure models, pre- and postnatal daily PM2.5, PM10 (satellite based, 1 km resolution) and NO2 (chemistry-transport model, 4 km resolution) concentrations at the mother's residence were estimated for 1271 mother-child pairs from the French EDEN and PELAGIE cohorts. Scores representative of children's General, Verbal and Non-Verbal abilities at 5-6 years were constructed based on subscale scores from the WPPSI-III, WISC-IV or NEPSY-II batteries, using confirmatory factor analysis (CFA). Associations of both prenatal (first 35 gestational weeks) and postnatal (60 months after birth) exposure to air pollutants with child cognition were explored using Distributed Lag Non-linear Models adjusted for confounders. RESULTS Increased maternal exposure to PM10, PM2.5 and NO2, during sensitive windows comprised between the 15th and the 33rd gestational weeks, was associated with lower males' General and Non-verbal abilities. Higher postnatal exposure to PM2.5 between the 35th and 52nd month of life was associated with lower males' General, Verbal and Non-verbal abilities. Some protective associations were punctually observed for the very first gestational weeks or months of life for both males and females and the different pollutants and cognitive scores. DISCUSSION These results suggest poorer cognitive function at 5-6 years among males following increased maternal exposure to PM10, PM2.5 and NO2 during mid-pregnancy and child exposure to PM2.5 around 3-4 years. Apparent protective associations observed are unlikely to be causal and might be due to live birth selection bias, chance finding or residual confounding.
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Affiliation(s)
- Ariane Guilbert
- Team of Environmental Epidemiology Applied to Development and Respiratory Health, Institute for Advanced Biosciences (IAB), Université Grenoble Alpes, Inserm, CNRS, 38700, La Tronche, France.
| | - Jonathan Y Bernard
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Centre for Research in Epidemiology and StatisticS (CRESS), 75004, Paris, France
| | - Hugo Peyre
- Centre de Ressources Autisme Languedoc-Roussillon et Centre d'Excellence sur l'Autisme et les Troubles Neuro-développementaux, CHU Montpellier, 34090, Montpellier, France; Université Paris-Saclay, UVSQ, Inserm, CESP, Team DevPsy, 94807, Villejuif, France; Laboratoire de Sciences Cognitives et Psycholinguistique, Département d'Etudes Cognitives, Ecole Normale Supérieure, PSL University, EHESS, CNRS, 75005, Paris, France
| | - Nathalie Costet
- Team of Epidemiology and Exposure Science in Health and Environment, Research Center on Environmental and Occupational Health (IRSET), Inserm, Université Rennes, EHESP, 35000, Rennes, France
| | - Ian Hough
- Team of Environmental Epidemiology Applied to Development and Respiratory Health, Institute for Advanced Biosciences (IAB), Université Grenoble Alpes, Inserm, CNRS, 38700, La Tronche, France; Department of Geography and Environmental Development, Ben-Gurion University of the Negev, Be'er Sheva, Israel; Institute of Environmental Geosciences (IGE), Université Grenoble Alpes, 38400, Saint Martin D'Hères, France
| | - Emie Seyve
- Team of Environmental Epidemiology Applied to Development and Respiratory Health, Institute for Advanced Biosciences (IAB), Université Grenoble Alpes, Inserm, CNRS, 38700, La Tronche, France
| | - Christine Monfort
- Team of Epidemiology and Exposure Science in Health and Environment, Research Center on Environmental and Occupational Health (IRSET), Inserm, Université Rennes, EHESP, 35000, Rennes, France
| | - Claire Philippat
- Team of Environmental Epidemiology Applied to Development and Respiratory Health, Institute for Advanced Biosciences (IAB), Université Grenoble Alpes, Inserm, CNRS, 38700, La Tronche, France
| | - Rémy Slama
- Team of Environmental Epidemiology Applied to Development and Respiratory Health, Institute for Advanced Biosciences (IAB), Université Grenoble Alpes, Inserm, CNRS, 38700, La Tronche, France
| | - Itai Kloog
- Department of Geography and Environmental Development, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Cécile Chevrier
- Team of Epidemiology and Exposure Science in Health and Environment, Research Center on Environmental and Occupational Health (IRSET), Inserm, Université Rennes, EHESP, 35000, Rennes, France
| | - Barbara Heude
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Centre for Research in Epidemiology and StatisticS (CRESS), 75004, Paris, France
| | - Franck Ramus
- Laboratoire de Sciences Cognitives et Psycholinguistique, Département d'Etudes Cognitives, Ecole Normale Supérieure, PSL University, EHESS, CNRS, 75005, Paris, France
| | - Johanna Lepeule
- Team of Environmental Epidemiology Applied to Development and Respiratory Health, Institute for Advanced Biosciences (IAB), Université Grenoble Alpes, Inserm, CNRS, 38700, La Tronche, France.
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Xue T, Wang R, Tong M, Kelly FJ, Liu H, Li J, Li P, Qiu X, Gong J, Shang J, Zhu T. Estimating the exposure-response function between long-term ozone exposure and under-5 mortality in 55 low-income and middle-income countries: a retrospective, multicentre, epidemiological study. Lancet Planet Health 2023; 7:e736-e746. [PMID: 37673544 DOI: 10.1016/s2542-5196(23)00165-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 07/02/2023] [Accepted: 07/03/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND In 2021, WHO suggested new target concentration limits for long-term exposure to ambient ozone. However, the harmful effects of ozone on vulnerable children have not been sufficiently studied. We aimed to evaluate the association between long-term ozone exposure and mortality in children younger than 5 years (hereafter denoted under-5 mortality) in low-income and middle-income countries (LMICs) and to estimate this mortality burden for 97 LMICs. METHODS By combining information from 128 Demographic and Health Surveys, we evaluated the association between the survival status of more than 1·2 million children younger than 5 years from 2457 sampling strata in 55 LMICs and the average peak-season ozone concentration during the life course, using a fixed-effects Cox model. A non-linear exposure-response function was developed by integrating the marginal effects of within-strata variation in exposure. We extrapolated the function obtained from the 55 LMICs to estimate the under-5 mortality burden attributable to ozone exposure in 97 LMICs, in which more than 95% of global deaths in this age group occur. FINDINGS The fixed-effects model showed a robust association between ozone and under-5 mortality. According to the fully adjusted linear model, an increment of 10 ppb in the life-course average peak-season ozone concentration was associated with a 6·4% (95% CI 2·4-10·7) increase in the risk of under-5 mortality. The non-linear exposure-response function showed a sublinear curvature with a threshold, suggesting that the effect of ozone exposure was non-significant at concentrations lower than the first-stage interim target (100 μg/m3) recommended by WHO. Using this function, we estimate that, in 2010, long-term ozone exposure contributed to 153 361 (95% CI 17 077-276 768; 2·3% [0·3-4·1]) deaths of children younger than 5 years in 97 LMICs, which is equivalent to 56·8% of all ozone-related deaths in adults (269 785) in these countries. From 2003 to 2017, the ozone-related under-5 mortality burden decreased in most of the 97 LMICs. INTERPRETATION Long-term exposure to ozone concentrations higher than the WHO first-stage interim target is a risk factor for under-5 mortality, and ozone exposure contributes substantially to mortality in this age group in LMICs. Increased efforts should be made to control ambient ozone pollution as this will lead to positive health benefits. FUNDING Ministry of Science and Technology of the People's Republic of China and China National Natural Science Foundation.
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Affiliation(s)
- Tao Xue
- Institute of Reproductive and Child Health/National Health Commission Key Laboratory of Reproductive Health, School of Public Health, Peking University Health Science Centre, Beijing, China; Department of Epidemiology and Biostatistics/Ministry of Education Key Laboratory of Epidemiology of Major Diseases (PKU), School of Public Health, Peking University Health Science Centre, Beijing, China; Advanced Institute of Information Technology, Peking University, Hangzhou, China.
| | - Ruohan Wang
- Institute of Reproductive and Child Health/National Health Commission Key Laboratory of Reproductive Health, School of Public Health, Peking University Health Science Centre, Beijing, China; Department of Epidemiology and Biostatistics/Ministry of Education Key Laboratory of Epidemiology of Major Diseases (PKU), School of Public Health, Peking University Health Science Centre, Beijing, China
| | - Mingkun Tong
- Institute of Reproductive and Child Health/National Health Commission Key Laboratory of Reproductive Health, School of Public Health, Peking University Health Science Centre, Beijing, China; Department of Epidemiology and Biostatistics/Ministry of Education Key Laboratory of Epidemiology of Major Diseases (PKU), School of Public Health, Peking University Health Science Centre, Beijing, China
| | - Frank J Kelly
- Environmental Research Group, MRC Centre for Environment and Health, Imperial College London, London, UK
| | - Hengyi Liu
- Institute of Reproductive and Child Health/National Health Commission Key Laboratory of Reproductive Health, School of Public Health, Peking University Health Science Centre, Beijing, China; Department of Epidemiology and Biostatistics/Ministry of Education Key Laboratory of Epidemiology of Major Diseases (PKU), School of Public Health, Peking University Health Science Centre, Beijing, China
| | - Jiajianghui Li
- Institute of Reproductive and Child Health/National Health Commission Key Laboratory of Reproductive Health, School of Public Health, Peking University Health Science Centre, Beijing, China; Department of Epidemiology and Biostatistics/Ministry of Education Key Laboratory of Epidemiology of Major Diseases (PKU), School of Public Health, Peking University Health Science Centre, Beijing, China
| | - Pengfei Li
- Institute of Reproductive and Child Health/National Health Commission Key Laboratory of Reproductive Health, School of Public Health, Peking University Health Science Centre, Beijing, China; Department of Epidemiology and Biostatistics/Ministry of Education Key Laboratory of Epidemiology of Major Diseases (PKU), School of Public Health, Peking University Health Science Centre, Beijing, China; Advanced Institute of Information Technology, Peking University, Hangzhou, China
| | - Xinghua Qiu
- State Environmental Protection Key Laboratory of Atmospheric Exposure and Health Risk Management, Center for Environment and Health, Peking University, Beijing, China; College of Environmental Sciences and Engineering, Peking University, Beijing, China
| | - Jicheng Gong
- State Environmental Protection Key Laboratory of Atmospheric Exposure and Health Risk Management, Center for Environment and Health, Peking University, Beijing, China; College of Environmental Sciences and Engineering, Peking University, Beijing, China
| | - Jing Shang
- State Environmental Protection Key Laboratory of Atmospheric Exposure and Health Risk Management, Center for Environment and Health, Peking University, Beijing, China; College of Environmental Sciences and Engineering, Peking University, Beijing, China
| | - Tong Zhu
- State Environmental Protection Key Laboratory of Atmospheric Exposure and Health Risk Management, Center for Environment and Health, Peking University, Beijing, China; College of Environmental Sciences and Engineering, Peking University, Beijing, China.
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18
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Yu G, Yang L, Liu M, Wang C, Shen X, Fan L, Zhang J. Extreme Temperature Exposure and Risks of Preterm Birth Subtypes Based on a Nationwide Survey in China. ENVIRONMENTAL HEALTH PERSPECTIVES 2023; 131:87009. [PMID: 37585350 PMCID: PMC10431497 DOI: 10.1289/ehp10831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 07/15/2023] [Accepted: 07/17/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Previous studies have reported that ambient temperature may affect perinatal outcomes. However, whether extreme temperature affects the risk of preterm birth (PTB) remains controversial. Studies on the associations of extreme temperature with PTB subtypes are lacking. OBJECTIVES We aimed to investigate the associations of extreme climate events with the risks of PTB and its subtypes, discerning possible modifiers. METHODS Data on all singleton deliveries were obtained from the China Labor and Delivery Survey (CLDS), a nationwide investigation implemented in 2015 and 2016. PTB was defined as gestational weeks < 37 and then categorized as early (24-34 wk) and late PTBs (35-36 wk), and clinical subtypes [spontaneous PTB, preterm premature rupture of the fetal membranes (PPROM), iatrogenic PTB]. Ambient temperature data were provided by the China National Weather Data Sharing System. Five heat indexes and five cold indexes were used to define heat waves and cold spells. Generalized linear mixed models with a random term by hospital unit were used to assess the associations of short-term prenatal extreme temperature exposure. The Cox proportional hazard regression model was applied to assess the nonlinear associations of low- or high-temperature exposure at the whole and different trimesters of pregnancy with the risk of PTB. Stratified analyses were conducted to assess the possible modification by geographic region and fetal sex. RESULTS A total of 70,818 singleton births from 96 hospitals in China were included, among which 4,965 (7.01%) were PTBs. Exposure to extreme cold events 1 wk before delivery was associated with an increased PTB risk, with an adjusted odds ratio (aOR) [95% confidence intervals (CIs)] of 1.07 (95% CI: 1.04, 1.10) and 1.06 (1.04, 1.09) for the total days when the daily average temperature below the fifth percentile (fifth-days) and the 10th percentile (10th-days), 1.18 (1.04, 1.34) for the cold spells when the daily average temperature below the fifth percentile for two consecutive days (fifth-2D), 1.09 (1.03, 1.16) and 1.12 (1.06, 1.19) for the cold spells when the daily average temperature below the 10th percentile for three and two consecutive days (10th-3D and 10th-2D), respectively. Results of extreme temperature exposure during 2 weeks before delivery showed similarly significant associations. The association between cold spells and PTB tended to be stronger for late PTB than for early PTB. Cold spells were mainly associated with spontaneous PTB and late PPROM. A stratified analysis indicated that pregnant women in western and northern regions tended to be more sensitive to cold spells, and pregnant women with a female fetus appeared to be at a higher risk of PTB when exposed to cold spells. Pregnant women in late pregnancy were more susceptible to extreme temperatures. No significant or stable association was found between heat waves and preterm birth. DISCUSSION Exposure to cold spells was associated with an increased risk of PTB, especially late, spontaneous PTB and PPROM. The associations appeared to be more pronounced in the north and west regions and in pregnancies with female fetuses. https://doi.org/10.1289/EHP10831.
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Affiliation(s)
- Guoqi Yu
- Ministry of Education – Shanghai Key Laboratory of Children’s Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ling Yang
- Hainan Women and Children’s Medical Center, Hainan, China
| | - Ming Liu
- Department of Obstetrics, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Cuiping Wang
- Ministry of Education – Shanghai Key Laboratory of Children’s Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaoli Shen
- Shanghai Jiao Tong University School of Public Health, Shanghai, China
| | - Lichun Fan
- Hainan Women and Children’s Medical Center, Hainan, China
| | - Jun Zhang
- Ministry of Education – Shanghai Key Laboratory of Children’s Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Jiao Tong University School of Public Health, Shanghai, China
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Michel S, Atmakuri A, von Ehrenstein OS. Prenatal exposure to ambient air pollutants and congenital heart defects: An umbrella review. ENVIRONMENT INTERNATIONAL 2023; 178:108076. [PMID: 37454629 DOI: 10.1016/j.envint.2023.108076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 06/26/2023] [Accepted: 06/29/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Prenatal exposure to ambient air pollutants has been linked to congenital heart defects (CHD), but findings of existing systematic reviews have been mixed. OBJECTIVE To assess the epidemiological evidence on associations between prenatal exposure to ambient air pollutants and CHD subtypes, based on a systematic overview of reviews ("umbrella review"). METHODS We conducted a systematic search for reviews assessing associations between prenatal exposure to criteria air pollutants and CHD. The risk of bias was evaluated using the Risk of Bias in Systematic Reviews (ROBIS) tool. The certainty of the systematic review findings was graded using the Navigation Guide methodology. RESULTS We identified eleven systematic reviews, including eight with meta-analyses, assessing in total 35 primary studies of prenatal exposure to criteria air pollutants and various CHD subtypes. The certainty of the findings of four meta-analyses indicating an increased risk for coarctation of the aorta associated with nitrogen dioxide exposure was rated as moderate. The certainty of findings indicating positive, inverse, or null associations for other pollutant-subtype combinations was rated as very low to low, based on low precision and high statistical heterogeneity of summary odds ratios (SOR), substantial inconsistencies between review findings, and methodological limitations of the systematic reviews. DISCUSSION The inconsistent findings and high statistical heterogeneity of many SOR of the included systematic reviews may partly be traced to differences in methodological approaches, and the risk of bias across included reviews (e.g., inclusion criteria, systematic search strategies, synthesis methods) and primary studies (e.g., exposure assessment, diagnostic criteria). Adherence to appropriate systematic review guidelines for environmental health research, as well as rigorous evaluation of risk of bias in primary studies, are essential for future risk assessments and policy-making. Still, our findings suggest that prenatal exposure to ambient air pollutants may increase risks for at least some CHD subtypes.
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Affiliation(s)
- Sophie Michel
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California, USA.
| | - Aishwarya Atmakuri
- Department of Molecular, Cell, and Developmental Biology, University of California, Los Angeles, Los Angeles, California, USA
| | - Ondine S von Ehrenstein
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California, USA; Department of Community Health Sciences, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California, USA
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20
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Eaves LA, Choi G, Hall E, Sillé FC, Fry RC, Buckley JP, Keil AP. Prenatal Exposure to Toxic Metals and Neural Tube Defects: A Systematic Review of the Epidemiologic Evidence. ENVIRONMENTAL HEALTH PERSPECTIVES 2023; 131:86002. [PMID: 37647124 PMCID: PMC10467818 DOI: 10.1289/ehp11872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 05/31/2023] [Accepted: 07/25/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Neural tube defects (NTDs) affect > 300,000 pregnancies worldwide annually. Few nongenetic factors, other than folate deficiency, have been identified that may provide intervenable solutions to reduce the burden of NTDs. Prenatal exposure to toxic metals [arsenic (As), cadmium (Cd), mercury (Hg), manganese (Mn) and lead (Pb)] may increase the risk of NTDs. Although a growing epidemiologic literature has examined associations, to our knowledge no systematic review has been conducted to date. OBJECTIVE Through adaptation of the Navigation Guide systematic review methodology, we aimed to answer the question "does exposure to As, Cd, Hg, Mn, or Pb during gestation increase the risk of NTDs?" and to assess challenges to evaluating this question given the current evidence. METHODS We selected available evidence on prenatal As, Cd, Hg, Mn, or Pb exposure and risk of specific NTDs (e.g., spina bifida, anencephaly) or all NTDs via a comprehensive search across MEDLINE, Embase, Web of Science, and TOXLINE databases and applied inclusion/exclusion criteria. We rated the quality and strength of the evidence for each metal. We applied a customized risk of bias protocol and evaluated the sufficiency of evidence of an effect of each metal on NTDs. RESULTS We identified 30 studies that met our criteria. Risk of bias for confounding and selection was high in most studies, but low for missing data. We determined that, although the evidence was limited, the literature supported an association between prenatal exposure to Hg or Mn and increased risk of NTDs. For the remaining metals, the evidence was inadequate to establish or rule out an effect. CONCLUSION The role of gestational As, Cd, or Pb exposure in the etiology of NTDs remains unclear and warrants further investigation in high-quality studies, with a particular focus on controlling confounding, mitigating selection bias, and improving exposure assessment. https://doi.org/10.1289/EHP11872.
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Affiliation(s)
- Lauren A. Eaves
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (UNC-Chapel Hill), Chapel Hill, North Carolina, USA
- Institute for Environmental Health Solutions, Gillings School of Global Public Health, UNC-Chapel Hill, Chapel Hill, North Carolina, USA
| | - Giehae Choi
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Emily Hall
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Fenna C.M. Sillé
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Rebecca C. Fry
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (UNC-Chapel Hill), Chapel Hill, North Carolina, USA
- Institute for Environmental Health Solutions, Gillings School of Global Public Health, UNC-Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jessie P. Buckley
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Alexander P. Keil
- Department of Epidemiology, Gillings School of Global Public Health, UNC-Chapel Hill, Chapel Hill, North Carolina, USA
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21
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Gaughan C, Sorrentino KM, Liew Z, Johnson NP, Clark CJ, Soriano M, Plano J, Plata DL, Saiers JE, Deziel NC. Residential proximity to unconventional oil and gas development and birth defects in Ohio. ENVIRONMENTAL RESEARCH 2023; 229:115937. [PMID: 37076028 PMCID: PMC10198955 DOI: 10.1016/j.envres.2023.115937] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 03/30/2023] [Accepted: 04/16/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND Chemicals used or emitted by unconventional oil and gas development (UOGD) include reproductive/developmental toxicants. Associations between UOGD and certain birth defects were reported in a few studies, with none conducted in Ohio, which experienced a thirty-fold increase in natural gas production between 2010 and 2020. METHODS We conducted a registry-based cohort study of 965,236 live births in Ohio from 2010 to 2017. Birth defects were identified in 4653 individuals using state birth records and a state surveillance system. We assigned UOGD exposure based on maternal residential proximity at birth to active UOG wells and a metric specific to the drinking-water exposure pathway that identified UOG wells hydrologically connected to a residence ("upgradient UOG wells"). We estimated odds ratios (ORs) and 95% confidence intervals (CIs) for all structural birth defects combined and specific birth defect types using binary exposure metrics (presence/absence of any UOG well and presence/absence of an upgradient UOG well within 10 km), adjusting for confounders. Additionally, we conducted analyses stratified by urbanicity, infant sex, and social vulnerability. RESULTS The odds of any structural defect were 1.13 times higher in children born to mothers living within 10 km of UOGD than those born to unexposed mothers (95%CI: 0.98-1.30). Odds were elevated for neural tube defects (OR: 1.57, 95%CI: 1.12-2.19), limb reduction defects (OR: 1.99, 95%CI: 1.18-3.35), and spina bifida (OR 1.93; 95%CI 1.25-2.98). Hypospadias (males only) was inversely related to UOGD exposure (OR: 0.62, 95%CI: 0.43-0.91). Odds of any structural defect were greater in magnitude but less precise in analyses using the hydrological-specific metric (OR: 1.30; 95%CI: 0.85-1.90), in areas with high social vulnerability (OR: 1.27, 95%CI: 0.99-1.60), and among female offspring (OR: 1.28, 95%CI: 1.06-1.53). CONCLUSIONS Our results suggest a positive association between UOGD and certain birth defects, and findings for neural tube defects corroborate results from prior studies.
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Affiliation(s)
- Casey Gaughan
- Department of Ecology and Evolutionary Biology, Yale College, New Haven, CT, USA; Department of Environmental Health Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Keli M Sorrentino
- Department of Environmental Health Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Zeyan Liew
- Department of Environmental Health Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Nicholaus P Johnson
- Department of Environmental Health Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Cassandra J Clark
- Department of Environmental Health Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Mario Soriano
- Yale School of the Environment, Yale University, New Haven, CT, USA; High Meadows Environmental Institute, Princeton University, Princeton, NJ, USA
| | - Julie Plano
- Department of Environmental Health Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Desiree L Plata
- Civil and Environmental Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - James E Saiers
- Yale School of the Environment, Yale University, New Haven, CT, USA
| | - Nicole C Deziel
- Department of Environmental Health Sciences, Yale School of Public Health, New Haven, CT, USA.
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Leung M, Modest AM, Hacker MR, Wylie BJ, Wei Y, Schwartz J, Iyer HS, Hart JE, Coull BA, Laden F, Weisskopf MG, Papatheodorou S. Traffic-Related Air Pollution and Ultrasound Parameters of Fetal Growth in Eastern Massachusetts. Am J Epidemiol 2023; 192:1105-1115. [PMID: 36963378 PMCID: PMC10893850 DOI: 10.1093/aje/kwad072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 11/30/2022] [Accepted: 03/23/2023] [Indexed: 03/26/2023] Open
Abstract
Previous studies have examined the association between prenatal nitrogen dioxide (NO2)-a traffic emissions tracer-and fetal growth based on ultrasound measures. Yet, most have used exposure assessment methods with low temporal resolution, which limits the identification of critical exposure windows given that pregnancy is relatively short. Here, we used NO2 data from an ensemble model linked to residential addresses at birth to fit distributed lag models that estimated the association between NO2 exposure (resolved weekly) and ultrasound biometric parameters in a Massachusetts-based cohort of 9,446 singleton births from 2011-2016. Ultrasound biometric parameters examined included biparietal diameter (BPD), head circumference, femur length, and abdominal circumference. All models adjusted for sociodemographic characteristics, time trends, and temperature. We found that higher NO2 was negatively associated with all ultrasound parameters. The critical window differed depending on the parameter and when it was assessed. For example, for BPD measured after week 31, the critical exposure window appeared to be weeks 15-25; 10-parts-per-billion higher NO2 sustained from conception to the time of measurement was associated with a lower mean z score of -0.11 (95% CI: -0.17, -0.05). Our findings indicate that reducing traffic emissions is one potential avenue to improving fetal and offspring health.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Stefania Papatheodorou
- Correspondence to Dr. Stefania Papatheodorou, Department of Epidemiology, Harvard T. H. Chan School of Public Health, 677 Huntington Avenue, Kresge Building, Boston, MA, 02115 (e-mail: )
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23
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Nirel R, Shoham T, Rotem R, Ahmad WA, Koren G, Kloog I, Golan R, Levine H. Maternal exposure to particulate matter early in pregnancy and congenital anomalies in offspring: Analysis of concentration-response relationships in a population-based cohort with follow-up throughout childhood. THE SCIENCE OF THE TOTAL ENVIRONMENT 2023; 880:163082. [PMID: 37004765 DOI: 10.1016/j.scitotenv.2023.163082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 03/22/2023] [Accepted: 03/22/2023] [Indexed: 05/27/2023]
Abstract
Studies have suggested an association between particulate matter (PM) air pollution and certain congenital anomalies (CAs). However, most studies assumed a linear concentration-response relation and were based on anomalies that were ascertained at birth or up to 1 year of age. We investigated associations between exposures to PM during the first trimester of pregnancy and CAs in 9 organ systems using birth and childhood follow-up data from a leading health care provider in Israel. We conducted a retrospective population-based cohort study among 396,334 births, 2004-2015. Daily PM data at a 1 × 1 km spatial grid were obtained from a satellite-derived prediction models and were linked to the mothers' residential addresses at birth. Adjusted odds ratios (ORs) were estimated with logistic regression models using exposure levels as either continuous or categorical variables. We captured 57,638 isolated CAs with estimated prevalence of 96 and 136 anomalies per 1000 births in the first year of life and by age 6 years, respectively. Analysis of continuous PM with diameter < 2.5 μm (PM2.5) indicated a supra-linear relation with anomalies in the circulatory, respiratory, digestive, genital and integument systems (79 % of CAs). The slope of the concentration-response function was positive and steepest for PM2.5 lower than the median concentration (21.5 μg/m3) and had a less steep or negative slope at higher levels. Similar trends were observed for PM2.5 quartiles. For example, for cardiac anomalies, the ORs were 1.09 (95 % confidence interval: 1.02, 1.15), 1.04 (0.98, 1.10) and 1.00 (0.94, 1.07) for births in the second, third and fourth quartiles, respectively, when compared to the first quartile. In sum, this study adds new evidence for adverse effects of air pollution on neonatal health even with low-level air pollution. Information on late diagnosis of children with anomalies is important in evaluating the burden of disease.
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Affiliation(s)
- Ronit Nirel
- Department of Statistics and Data Science, The Hebrew University of Jerusalem, Jerusalem, Israel.
| | - Tomer Shoham
- Department of Statistics and Data Science, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ran Rotem
- Maccabi Institute of Research and Innovation, Maccabi Healthcare Services, Tel-Aviv, Israel; Department of Environmental Health, Harvard TH Chan School of Public Health, Boston, MA, United States
| | - Wiessam Abu Ahmad
- Braun School of Public Health and Community Medicine, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Gideon Koren
- The Dr. Miriam and Sheldon G. Adelson Medical School, Ariel University, Ariel, Israel
| | - Itai Kloog
- Department of Geography and Environmental Development, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Rachel Golan
- Department of Epidemiology, Biostatistics and Community Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Hagai Levine
- Braun School of Public Health and Community Medicine, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Garrison-Desany HM, Ladd-Acosta C, Hong X, Wang G, Burd I, Sanchez ZVDM, Wang X, Surkan PJ. Addressing the smoking-hypertension paradox in pregnancy: insight from a multiethnic US birth cohort. PRECISION NUTRITION 2023; 2:e00035. [PMID: 37745029 PMCID: PMC10312115 DOI: 10.1097/pn9.0000000000000035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/17/2023] [Accepted: 03/15/2023] [Indexed: 09/26/2023]
Abstract
Background Smoking during pregnancy has been associated with reduced risk of a spectrum of hypertensive (HTN) disorders, known as the "smoking-hypertension paradox." Objective We sought to test potential epidemiologic explanations for the smoking-hypertension paradox. Methods We analyzed 8510 pregnant people in the Boston Birth Cohort, including 4027 non-Hispanic Black and 2428 Hispanic pregnancies. Study participants self-reported tobacco, alcohol, cannabis, opioids, or cocaine use during pregnancy. We used logistic regression to assess effect modification by race/ethnicity, and confounding of concurrent substances on hypertensive disorders or prior pregnancy. We also investigated early gestational age as a collider or competing risk for pre-eclampsia, using cause-specific Cox models and Fine-Gray models, respectively. Results We replicated the paradox showing smoking to be protective against hypertensive disorders among Black participants who used other substances as well (aOR: 0.61, 95% CI: 0.41, 0.93), but observed null effects for Hispanic participants (aOR: 1.14, 95% CI: 0.55, 2.36). In our cause-specific Cox regression, the effects of tobacco use were reduced to null effects with pre-eclampsia (aOR: 0.81, 95% CI: 0.63, 1.04) after stratifying for preterm birth. For the Fine-Gray competing risk analysis, the paradoxical associations remained. The smoking paradox was either not observed or reversed after accounting for race/ethnicity, other substance use, and collider-stratification due to preterm birth. Conclusions These findings offer new insights into this paradox and underscore the importance of considering multiple sources of bias in assessing the smoking-hypertension association in pregnancy.
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Affiliation(s)
| | - Christine Ladd-Acosta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Xiumei Hong
- Center on the Early Life Origins of Disease, Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Guoying Wang
- Center on the Early Life Origins of Disease, Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Irina Burd
- Integrated Research Center for Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Xiaobin Wang
- Center on the Early Life Origins of Disease, Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Pamela J. Surkan
- Center on the Early Life Origins of Disease, Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Jardel H, Martin CL, Hoyo C, Rappazzo KM. Interplay of gestational parent exposure to ambient air pollution and diet characteristics on preterm birth. BMC Public Health 2023; 23:822. [PMID: 37143049 PMCID: PMC10161541 DOI: 10.1186/s12889-023-15676-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 04/14/2023] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND Despite many efforts, preterm birth (PTB) is poorly understood and remains a major public health problem in the United States. Toxicological work suggests gestational parent (GP) diet may modify the effect of ambient pollutants on birth outcomes. We assessed risk of PTB in humans in relation to fine particulate matter (PM2.5), ozone (O3), and nitrogen dioxide (NO2) and variation by diet. METHODS 684 GP-singleton infant pairs in the Newborn Epigenetics Study prospective birth cohort were attributed ambient air pollutant exposures for each trimester based on residence. Total energy intake, percent of energy intake from saturated fat, and percent of energy intake from total fat were dichotomized at the 75th percentile. >We used log binomial regressions to estimate risk ratios (RR (95%CI)) for PTB by pollutant interquartile ranges, adjusting for GP age, pre-pregnancy body mass index, GP race/ethnicity, GP education, season of conception, household income, and each diet factor. We assessed departure from additivity using interaction contrast ratios (ICRs). We addressed missing covariate data with multiple imputation. RESULTS Point estimates suggest that O3 may be inversely associated with PTB when exposure occurs in trimester 2 (min RR: 0.77, 95% CI: 0.39, 1.49), but may be harmful when exposure occurs in trimester 3 (max RR: 1.51, 95% CI: 0.62, 3.64). Additionally, PM2.5 may be inversely associated with PTB when considered with total fat and saturated fat in trimester 2. Imprecise ICRs suggest departure from additivity (evidence of modification) with some pollutant-diet combinations. CONCLUSIONS While confidence intervals are wide, we observed potential modification of pollutant associations by dietary factors. It is imperative that large cohorts collect the required data to examine this topic, as more power is necessary to investigate the nuances suggested by this work.
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Affiliation(s)
- Hanna Jardel
- Gillings School of Global Public Health, Department of Epidemiology, University of North Carolina Chapel Hill, Chapel Hill, NC, USA
- Oak Ridge Institute for Science and Education (ORISE) Postdoctoral Fellow at United States Environmental Protection Agency (US EPA), Research Triangle Park, NC, USA
| | - Chantel L Martin
- Gillings School of Global Public Health, Department of Epidemiology, University of North Carolina Chapel Hill, Chapel Hill, NC, USA
- Center for Environmental Health and Susceptibility, University of North Carolina Chapel Hill, Chapel Hill, NC, USA
| | - Cathrine Hoyo
- Department of Biological Sciences, North Carolina State University, Raleigh, NC, USA
| | - Kristen M Rappazzo
- Office of Research and Development, Center for Public Health and Environmental Assessment, U.S. Environmental Protection Agency, Research Triangle Park, NC, USA.
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Wilker EH, Osman M, Weisskopf MG. Ambient air pollution and clinical dementia: systematic review and meta-analysis. BMJ 2023; 381:e071620. [PMID: 37019461 PMCID: PMC10498344 DOI: 10.1136/bmj-2022-071620] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/28/2023] [Indexed: 04/07/2023]
Abstract
OBJECTIVE To investigate the role of air pollutants in risk of dementia, considering differences by study factors that could influence findings. DESIGN Systematic review and meta-analysis. DATA SOURCES EMBASE, PubMed, Web of Science, Psycinfo, and OVID Medline from database inception through July 2022. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Studies that included adults (≥18 years), a longitudinal follow-up, considered US Environmental Protection Agency criteria air pollutants and proxies of traffic pollution, averaged exposure over a year or more, and reported associations between ambient pollutants and clinical dementia. Two authors independently extracted data using a predefined data extraction form and assessed risk of bias using the Risk of Bias In Non-randomised Studies of Exposures (ROBINS-E) tool. A meta-analysis with Knapp-Hartung standard errors was done when at least three studies for a given pollutant used comparable approaches. RESULTS 2080 records identified 51 studies for inclusion. Most studies were at high risk of bias, although in many cases bias was towards the null. 14 studies could be meta-analysed for particulate matter <2.5 µm in diameter (PM2.5). The overall hazard ratio per 2 μg/m3 PM2.5 was 1.04 (95% confidence interval 0.99 to 1.09). The hazard ratio among seven studies that used active case ascertainment was 1.42 (1.00 to 2.02) and among seven studies that used passive case ascertainment was 1.03 (0.98 to 1.07). The overall hazard ratio per 10 μg/m3 nitrogen dioxide was 1.02 ((0.98 to 1.06); nine studies) and per 10 μg/m3 nitrogen oxide was 1.05 ((0.98 to 1.13); five studies). Ozone had no clear association with dementia (hazard ratio per 5 μg/m3 was 1.00 (0.98 to 1.05); four studies). CONCLUSION PM2.5 might be a risk factor for dementia, as well as nitrogen dioxide and nitrogen oxide, although with more limited data. The meta-analysed hazard ratios are subject to limitations that require interpretation with caution. Outcome ascertainment approaches differ across studies and each exposure assessment approach likely is only a proxy for causally relevant exposure in relation to clinical dementia outcomes. Studies that evaluate critical periods of exposure and pollutants other than PM2.5, and studies that actively assess all participants for outcomes are needed. Nonetheless, our results can provide current best estimates for use in burden of disease and regulatory setting efforts. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42021277083.
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Affiliation(s)
- Elissa H Wilker
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Environmental Heath, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Marwa Osman
- Department of Environmental Heath, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Marc G Weisskopf
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Environmental Heath, Harvard TH Chan School of Public Health, Boston, MA, USA
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27
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Chen WJ, Rector AM, Guxens M, Iniguez C, Swartz MD, Symanski E, Ibarluzea J, Ambros A, Estarlich M, Lertxundi A, Riano-Galán I, Sunyer J, Fernandez-Somoano A, Chauhan SP, Ish J, Whitworth KW. Susceptible windows of exposure to fine particulate matter and fetal growth trajectories in the Spanish INMA (INfancia y Medio Ambiente) birth cohort. ENVIRONMENTAL RESEARCH 2023; 216:114628. [PMID: 36279916 PMCID: PMC9847009 DOI: 10.1016/j.envres.2022.114628] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 10/13/2022] [Accepted: 10/18/2022] [Indexed: 06/16/2023]
Abstract
While prior studies report associations between fine particulate matter (PM2.5) exposure and fetal growth, few have explored temporally refined susceptible windows of exposure. We included 2328 women from the Spanish INMA Project from 2003 to 2008. Longitudinal growth curves were constructed for each fetus using ultrasounds from 12, 20, and 34 gestational weeks. Z-scores representing growth trajectories of biparietal diameter, femur length, abdominal circumference (AC), and estimated fetal weight (EFW) during early (0-12 weeks), mid- (12-20 weeks), and late (20-34 weeks) pregnancy were calculated. A spatio-temporal random forest model with back-extrapolation provided weekly PM2.5 exposure estimates for each woman during her pregnancy. Distributed lag non-linear models were implemented within the Bayesian hierarchical framework to identify susceptible windows of exposure for each outcome and cumulative effects [βcum, 95% credible interval (CrI)] were aggregated across adjacent weeks. For comparison, general linear models evaluated associations between PM2.5 averaged across multi-week periods (i.e., weeks 1-11, 12-19, and 20-33) and fetal growth, mutually adjusted for exposure during each period. Results are presented as %change in z-scores per 5 μg/m3 in PM2.5, adjusted for covariates. Weeks 1-6 [βcum = -0.77%, 95%CrI (-1.07%, -0.47%)] were identified as a susceptible window of exposure for reduced late pregnancy EFW while weeks 29-33 were positively associated with this outcome [βcum = 0.42%, 95%CrI (0.20%, 0.64%)]. A similar pattern was observed for AC in late pregnancy. In linear regression models, PM2.5 exposure averaged across weeks 1-11 was associated with reduced late pregnancy EFW and AC; but, positive associations between PM2.5 and EFW or AC trajectories in late pregnancy were not observed. PM2.5 exposures during specific weeks may affect fetal growth differentially across pregnancy and such associations may be missed by averaging exposure across multi-week periods, highlighting the importance of temporally refined exposure estimates when studying the associations of air pollution with fetal growth.
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Affiliation(s)
- Wei-Jen Chen
- Department of Medicine, Section of Epidemiology and Population Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Alison M Rector
- Department of Medicine, Section of Epidemiology and Population Sciences, Baylor College of Medicine, Houston, TX, USA; Department of Biostatistics and Data Science, The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Houston, TX, USA
| | - Monica Guxens
- Spanish Consortium for Research and Public Health (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain; Universitat Pompeu Fabra (UPF), Barcelona, Spain; ISGlobal, Barcelona, Spain; Department of Child and Adolescent Psychiatry/Psychology, Erasmus University Medical Centre (Erasmus MC), Rotterdam, the Netherlands
| | - Carmen Iniguez
- Spanish Consortium for Research and Public Health (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain; Department of Statistics and Operational Research, Universitat de València, València, Spain; Epidemiology and Environmental Health Joint Research Unit, The Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), Universitat Jaume I-Universitat de València, València, Spain
| | - Michael D Swartz
- Department of Biostatistics and Data Science, The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Houston, TX, USA
| | - Elaine Symanski
- Department of Medicine, Section of Epidemiology and Population Sciences, Baylor College of Medicine, Houston, TX, USA; Center for Precision Environmental Health, Baylor College of Medicine, Houston, TX, USA
| | - Jesús Ibarluzea
- Spanish Consortium for Research and Public Health (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain; Group of Environmental Epidemiology and Child Development, Biodonostia Health Research Institute, San Sebastian, Spain; Ministry of Health of the Basque Government, Sub-Directorate for Public Health and Addictions of Gipuzkoa, 20013, San Sebastian, Spain; Faculty of Psychology, Universidad del País Vasco (UPV/EHU), San Sebastian, Spain
| | - Albert Ambros
- Spanish Consortium for Research and Public Health (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain; ISGlobal, Barcelona, Spain
| | - Marisa Estarlich
- Spanish Consortium for Research and Public Health (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain; Epidemiology and Environmental Health Joint Research Unit, The Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), Universitat Jaume I-Universitat de València, València, Spain; Faculty of Nursing and Chiropody, Universitat de València, València, Spain
| | - Aitana Lertxundi
- Spanish Consortium for Research and Public Health (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain; Group of Environmental Epidemiology and Child Development, Biodonostia Health Research Institute, San Sebastian, Spain; Department of Preventive Medicine and Public Health, University of the Basque Country (UPV/EHU), Leioa, Spain
| | - Isolina Riano-Galán
- Spanish Consortium for Research and Public Health (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain; Servicio de Pediatría, Endocrinología pediátrica, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - Jordi Sunyer
- Spanish Consortium for Research and Public Health (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain; ISGlobal, Barcelona, Spain
| | - Ana Fernandez-Somoano
- Spanish Consortium for Research and Public Health (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain; IUOPA-Área de Medicina Preventiva y Salud Pública, Departamento de Medicina, Universidad de Oviedo, Oviedo, Spain
| | - Suneet P Chauhan
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Jennifer Ish
- Epidemiology Branch, National Institute of Environmental Health Sciences (NIEHS), National Institutes of Health (NIH), Department of Health and Human Services (DHHS), Durham, NC, USA
| | - Kristina W Whitworth
- Department of Medicine, Section of Epidemiology and Population Sciences, Baylor College of Medicine, Houston, TX, USA; Center for Precision Environmental Health, Baylor College of Medicine, Houston, TX, USA.
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28
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Leung M, Laden F, Coull BA, Modest AM, Hacker MR, Wylie BJ, Iyer HS, Hart JE, Wei Y, Schwartz J, Weisskopf MG, Papatheodorou S. Ambient temperature during pregnancy and fetal growth in Eastern Massachusetts, USA. Int J Epidemiol 2022:6887251. [PMID: 36495569 DOI: 10.1093/ije/dyac228] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 11/29/2022] [Indexed: 12/14/2022] Open
Abstract
Abstract
Background
Left unabated, rising temperatures pose an escalating threat to human health. The potential effects of hot temperatures on fetal health have been under-explored. Here, we examined the association between prenatal ambient temperature exposure and fetal growth measures in a Massachusetts-based pregnancy cohort.
Methods
We used ultrasound measurements of biparietal diameter (BPD), head circumference (HC), femur length and abdominal circumference (AC), in addition to birthweight (BW), from 9446 births at Beth Israel Deaconess Medical Center from 2011 to 2016. Ultrasound scans were classified into three distinct gestational periods: 16–23 weeks, 24–31 weeks, 32+ weeks; and z-scores were created for each fetal growth measure using the INTERGROWTH-21st standards. We fitted distributed lag models to estimate the time-varying association between weekly temperature and fetal growth, adjusting for sociodemographic characteristics, seasonal and long-term trends, humidity and particulate matter (PM2.5).
Results
Higher ambient temperature was associated with smaller fetal growth measures. The critical window of exposure appeared to be Weeks 1–20 for ultrasound parameters, and high temperatures throughout pregnancy were important for BW. Associations were strongest for head parameters (BPD and HC) in early to mid-pregnancy, AC late in pregnancy and BW. For example, a 5ºC higher cumulative temperature exposure was associated with a lower mean AC z-score of -0.26 (95% CI: -0.48, -0.04) among 24–31-Week scans, and a lower mean BW z-score of -0.32 (95% CI: -0.51, -0.12).
Conclusion
Higher temperatures were associated with impaired fetal growth. This has major health implications given that extreme temperatures are more common and escalating.
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Affiliation(s)
- Michael Leung
- Department of Epidemiology, Harvard T.H. Chan School of Public Health , Boston, MA, USA
- Department of Environmental Health, Harvard T.H. Chan School of Public Health , Boston, MA, USA
| | - Francine Laden
- Department of Epidemiology, Harvard T.H. Chan School of Public Health , Boston, MA, USA
- Department of Environmental Health, Harvard T.H. Chan School of Public Health , Boston, MA, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School , Boston, MA, USA
| | - Brent A Coull
- Department of Environmental Health, Harvard T.H. Chan School of Public Health , Boston, MA, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health , Boston, MA, USA
| | - Anna M Modest
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center , Boston, MA, USA
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School , Boston, MA, USA
| | - Michele R Hacker
- Department of Epidemiology, Harvard T.H. Chan School of Public Health , Boston, MA, USA
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center , Boston, MA, USA
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School , Boston, MA, USA
| | - Blair J Wylie
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center , Boston, MA, USA
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School , Boston, MA, USA
| | - Hari S Iyer
- Division of Population Sciences, Dana-Farber Cancer Institute , Boston, MA, USA
| | - Jaime E Hart
- Department of Environmental Health, Harvard T.H. Chan School of Public Health , Boston, MA, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School , Boston, MA, USA
| | - Yaguang Wei
- Department of Environmental Health, Harvard T.H. Chan School of Public Health , Boston, MA, USA
| | - Joel Schwartz
- Department of Epidemiology, Harvard T.H. Chan School of Public Health , Boston, MA, USA
- Department of Environmental Health, Harvard T.H. Chan School of Public Health , Boston, MA, USA
| | - Marc G Weisskopf
- Department of Epidemiology, Harvard T.H. Chan School of Public Health , Boston, MA, USA
- Department of Environmental Health, Harvard T.H. Chan School of Public Health , Boston, MA, USA
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Taniguchi Y, Yamazaki S, Nakayama SF, Sekiyama M, Michikawa T, Isobe T, Iwai-Shimada M, Kobayashi Y, Nitta H, Oba M, Kamijima M. Maternal Metals Exposure and Infant Weight Trajectory: The Japan Environment and Children's Study (JECS). ENVIRONMENTAL HEALTH PERSPECTIVES 2022; 130:127005. [PMID: 36516017 PMCID: PMC9749893 DOI: 10.1289/ehp10321] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 09/14/2022] [Accepted: 10/14/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND To our knowledge, the association of maternal exposure to metallic elements with weight trajectory pattern from the neonatal period has not been investigated. OBJECTIVES The goals of this study were to identify infant growth trajectories in weight in the first 3 y of life and to determine the associations of maternal blood levels of lead, cadmium, mercury, selenium, and manganese with growth trajectory. METHODS This longitudinal study, part of the Japan Environment and Children Study, enrolled 103,099 pregnant women at 15 Regional Centres across Japan between 2011 and 2014. Lead, cadmium, mercury, selenium, and manganese levels were measured in blood samples collected in the second (14-27 wk gestational age) or third trimester (≥28wk). Growth trajectory of 99,014 children was followed until age 3 y. Raw weight values were transformed to age- and sex-specific weight standard deviation (SD) scores, and latent-class group-based trajectory models were estimated to determine weight trajectories. Associations between maternal metallic element levels and weight trajectory were examined using multinomial logistic regression models after confounder adjustment. RESULTS We identified 5 trajectory patterns based on weight SD score: 4.74% of infants were classified in Group I, very small to small; 31.26% in Group II, moderately small; 21.91% in Group III, moderately small to moderately large; 28.06% in Group IV, moderately large to normal; and 14.03% in Group V, moderately large to large. On multinomial logistic regression, higher maternal lead and selenium levels tended to be associated with increased odds ratios (ORs) of poor weight SD score trajectories (Groups I and II), in comparison with Group III. Higher levels of mercury were associated with decreased ORs, whereas higher levels of manganese were associated with increased ORs of "moderately large" trajectories (Groups IV and V). DISCUSSION Maternal lead, mercury, selenium, and manganese blood levels affect infant growth trajectory pattern in the first 3 y of life. https://doi.org/10.1289/EHP10321.
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Affiliation(s)
- Yu Taniguchi
- Japan Environment and Children’s Study Programme Office, National Institute for Environmental Studies, Tsukuba, Japan
| | - Shin Yamazaki
- Japan Environment and Children’s Study Programme Office, National Institute for Environmental Studies, Tsukuba, Japan
| | - Shoji F. Nakayama
- Japan Environment and Children’s Study Programme Office, National Institute for Environmental Studies, Tsukuba, Japan
| | - Makiko Sekiyama
- Japan Environment and Children’s Study Programme Office, National Institute for Environmental Studies, Tsukuba, Japan
| | - Takehiro Michikawa
- Department of Environmental and Occupational Health, Toho University School of Medicine, Ota, Japan
| | - Tomohiko Isobe
- Japan Environment and Children’s Study Programme Office, National Institute for Environmental Studies, Tsukuba, Japan
| | - Miyuki Iwai-Shimada
- Japan Environment and Children’s Study Programme Office, National Institute for Environmental Studies, Tsukuba, Japan
| | - Yayoi Kobayashi
- Japan Environment and Children’s Study Programme Office, National Institute for Environmental Studies, Tsukuba, Japan
| | - Hiroshi Nitta
- Japan Environment and Children’s Study Programme Office, National Institute for Environmental Studies, Tsukuba, Japan
| | - Mari Oba
- Department of Medical Statistics, Toho University School of Medicine, Ota, Japan
| | - Michihiro Kamijima
- Department of Occupational and Environmental Health, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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30
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Blostein FA, Fisher J, Dou J, Schneper L, Ware EB, Notterman DA, Mitchell C, Bakulski KM. Polymethylation scores for prenatal maternal smoke exposure persist until age 15 and are detected in saliva in the Fragile Families and Child Wellbeing cohort. Epigenetics 2022; 17:2223-2240. [PMID: 35980258 PMCID: PMC9665138 DOI: 10.1080/15592294.2022.2112815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 08/05/2022] [Indexed: 01/18/2023] Open
Abstract
Prenatal maternal smoking is associated with low birthweight, neurological disorders, and asthma in exposed children. DNA methylation signatures can function as biomarkers of prenatal smoke exposure. However, the robustness of DNA methylation signatures across child ages, genetic ancestry groups, or tissues is not clear. Using coefficients from a meta-analysis of prenatal smoke exposure and DNA methylation in newborn cord blood, we created polymethylation scores of saliva DNA methylation from children at ages 9 and 15 in the Fragile Families and Child Wellbeing study. In the full sample at age 9 (n = 753), prenatal smoke exposure was associated with a 0.51 (95%CI: 0.35, 0.66) standard deviation higher polymethylation score. The direction and magnitude of the association was consistent in European and African genetic ancestry samples. In the full sample at age 15 (n = 747), prenatal smoke exposure was associated with a 0.48 (95%CI: 0.32, 0.63) standard deviation higher polymethylation score, and the association was attenuated among the European and Admixed-Latin genetic ancestry samples. The polymethylation score classified prenatal smoke exposure accurately (AUC age 9 = 0.77, age 15 = 0.76). Including the polymethylation score increased the AUC of base model covariates by 5 (95% CI: (2.1, 7.2)) percentage points, while including a single candidate site in the AHRR gene did not (P-value = 0.19). Polymethylation scores for prenatal smoking were portable across genetic ancestries and more accurate than an individual DNA methylation site. Polymethylation scores from saliva samples could serve as robust and practical biomarkers of prenatal smoke exposure.
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Affiliation(s)
- Freida A. Blostein
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Jonah Fisher
- Institute for Social Research, University of Michigan, Ann Arbor, Michigan, USA
| | - John Dou
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Lisa Schneper
- Department of Molecular Biology, Princeton University, Princeton, New Jersey, USA
| | - Erin B. Ware
- Department of Molecular Biology, Princeton University, Princeton, New Jersey, USA
| | - Daniel A. Notterman
- Department of Molecular Biology, Princeton University, Princeton, New Jersey, USA
| | - Colter Mitchell
- Institute for Social Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Kelly M. Bakulski
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
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31
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Peterson AK, Habre R, Niu Z, Amin M, Yang T, Eckel SP, Farzan SF, Lurmann F, Pavlovic N, Grubbs BH, Walker D, Al-Marayati LA, Grant E, Lerner D, Bastain TM, Breton CV. Identifying pre-conception and pre-natal periods in which ambient air pollution exposure affects fetal growth in the predominately Hispanic MADRES cohort. Environ Health 2022; 21:115. [PMID: 36434705 PMCID: PMC9701016 DOI: 10.1186/s12940-022-00925-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 10/24/2022] [Indexed: 05/20/2023]
Abstract
BACKGROUND It is well documented that persons of color experience disproportionate exposure to environmental contaminants, including air pollution, and have poorer pregnancy outcomes. This study assessed the critical windows of exposure to ambient air pollution on in utero fetal growth among structurally marginalized populations in urban Los Angeles. METHODS Participants (N = 281) from the larger ongoing MADRES pregnancy cohort study were included in this analysis. Fetal growth outcomes were measured on average at 32 [Formula: see text] 2 weeks of gestation by a certified sonographer and included estimated fetal weight, abdominal circumference, head circumference, biparietal diameter and femur length. Daily ambient air pollutant concentrations were estimated for four pollutants (particulate matter less than 2.5 µm (PM2.5) and less than 10 µm (PM10) in aerodynamic diameter, nitrogen dioxide (NO2), and 8-h maximum ozone (O3)) at participant residences using inverse-distance squared spatial interpolation from ambient monitoring data. Weekly gestational averages were calculated from 12 weeks prior to conception to 32 weeks of gestation (44 total weeks), and their associations with growth outcomes were modeled using adjusted distributed lag models (DLMs). RESULTS Participants were on average 29 years [Formula: see text] 6 old and predominately Hispanic (82%). We identified a significant sensitive window of PM2.5 exposure (per IQR increase of 6 [Formula: see text]3) between gestational weeks 4-16 for lower estimated fetal weight [Formula: see text] averaged4-16 = -8.7 g; 95% CI -16.7, -0.8). Exposure to PM2.5 during gestational weeks 1-23 was also significantly associated with smaller fetal abdominal circumference ([Formula: see text] averaged1-23 = -0.6 mm; 95% CI -1.1, -0.2). Additionally, prenatal exposure to PM10 (per IQR increase of 13 [Formula: see text]3) between weeks 6-15 of pregnancy was significantly associated with smaller fetal abdominal circumference ([Formula: see text] averaged6-15 = -0.4 mm; 95% CI -0.8, -0.1). DISCUSSION These results suggest that exposure to particulate matter in early to mid-pregnancy, but not preconception or late pregnancy, may have critical implications on fetal growth.
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Affiliation(s)
- Alicia K Peterson
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90032, USA
| | - Rima Habre
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90032, USA
| | - Zhongzheng Niu
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90032, USA
| | - Monica Amin
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90032, USA
| | - Tingyu Yang
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90032, USA
| | - Sandrah P Eckel
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90032, USA
| | - Shohreh F Farzan
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90032, USA
| | - Fred Lurmann
- Sonoma Technology Inc., Petaluma, CA, 94954, USA
| | | | - Brendan H Grubbs
- Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | - Daphne Walker
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | - Laila A Al-Marayati
- Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | - Edward Grant
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | - Deborah Lerner
- Eisner Health Medical Center, Los Angeles, CA, 90015, USA
| | - Theresa M Bastain
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90032, USA
| | - Carrie V Breton
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90032, USA.
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Bias in the association between advanced maternal age and stillbirth using left truncated data. Sci Rep 2022; 12:19214. [PMID: 36357770 PMCID: PMC9649623 DOI: 10.1038/s41598-022-23719-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 11/03/2022] [Indexed: 11/12/2022] Open
Abstract
Restriction to analysis of births that survive past a specified gestational age (typically 20 weeks gestation) leads to biased exposure-outcome associations. This bias occurs when the cause of restriction (early pregnancy loss) is influenced by both the exposure and unmeasured factors that also affect the outcome. The aim of this study is to estimate the magnitude of bias resulting from left truncated data in the association between advanced maternal age and stillbirth. We simulated data for the causal pathway under a collider-stratification mechanism. Simulation parameters were based on an observed birth cohort from Western Australia and a range of plausible values for the prevalence of early pregnancy loss, unmeasured factor U and the odds ratios for the selection effects. Selection effects included the effects of maternal age on early pregnancy loss, U on early pregnancy loss, and U on stillbirth. We compared the simulation scenarios to the observed birth cohort that was truncated to pregnancies that survived beyond 20 gestational weeks. We found evidence of marginal downward bias, which was most prominent for women aged 40 + years. Overall, we conclude that the magnitude of bias due to left truncation is minimal in the association between advanced maternal age and stillbirth.
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Sensitivity analysis for live birth bias in the Ulaanbaatar Gestation and Air Pollution Research study. Environ Epidemiol 2022; 6:e229. [DOI: 10.1097/ee9.0000000000000229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 09/09/2022] [Indexed: 11/06/2022] Open
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Siegel EL, Ghassabian A, Hipwell AE, Factor-Litvak P, Zhu Y, Steinthal HG, Focella C, Battaglia L, Porucznik CA, Collingwood SC, Klein-Fedyshin M, Kahn LG. Indoor and outdoor air pollution and couple fecundability: a systematic review. Hum Reprod Update 2022; 29:45-70. [PMID: 35894871 PMCID: PMC9825271 DOI: 10.1093/humupd/dmac029] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 05/27/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Air pollution is both a sensory blight and a threat to human health. Inhaled environmental pollutants can be naturally occurring or human-made, and include traffic-related air pollution (TRAP), ozone, particulate matter (PM) and volatile organic compounds, among other substances, including those from secondhand smoking. Studies of air pollution on reproductive and endocrine systems have reported associations of TRAP, secondhand smoke (SHS), organic solvents and biomass fueled-cooking with adverse birth outcomes. While some evidence suggests that air pollution contributes to infertility, the extant literature is mixed, and varying effects of pollutants have been reported. OBJECTIVE AND RATIONALE Although some reviews have studied the association between common outdoor air pollutants and time to pregnancy (TTP), there are no comprehensive reviews that also include exposure to indoor inhaled pollutants, such as airborne occupational toxicants and SHS. The current systematic review summarizes the strength of evidence for associations of outdoor air pollution, SHS and indoor inhaled air pollution with couple fecundability and identifies gaps and limitations in the literature to inform policy decisions and future research. SEARCH METHODS We performed an electronic search of six databases for original research articles in English published since 1990 on TTP or fecundability and a number of chemicals in the context of air pollution, inhalation and aerosolization. Standardized forms for screening, data extraction and study quality were developed using DistillerSR software and completed in duplicate. We used the Newcastle-Ottawa Scale to assess risk of bias and devised additional quality metrics based on specific methodological features of both air pollution and fecundability studies. OUTCOMES The search returned 5200 articles, 4994 of which were excluded at the level of title and abstract screening. After full-text screening, 35 papers remained for data extraction and synthesis. An additional 3 papers were identified independently that fit criteria, and 5 papers involving multiple routes of exposure were removed, yielding 33 articles from 28 studies for analysis. There were 8 papers that examined outdoor air quality, while 6 papers examined SHS exposure and 19 papers examined indoor air quality. The results indicated an association between outdoor air pollution and reduced fecundability, including TRAP and specifically nitrogen oxides and PM with a diameter of ≤2.5 µm, as well as exposure to SHS and formaldehyde. However, exposure windows differed greatly between studies as did the method of exposure assessment. There was little evidence that exposure to volatile solvents is associated with reduced fecundability. WIDER IMPLICATIONS The evidence suggests that exposure to outdoor air pollutants, SHS and some occupational inhaled pollutants may reduce fecundability. Future studies of SHS should use indoor air monitors and biomarkers to improve exposure assessment. Air monitors that capture real-time exposure can provide valuable insight about the role of indoor air pollution and are helpful in assessing the short-term acute effects of pollutants on TTP.
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Affiliation(s)
- Eva L Siegel
- Columbia University, Mailman School of Public Health, New York, NY, USA
| | | | - Alison E Hipwell
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Pam Factor-Litvak
- Columbia University, Mailman School of Public Health, New York, NY, USA
| | - Yeyi Zhu
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | | | - Carolina Focella
- New York University Grossman School of Medicine, New York, NY, USA
| | - Lindsey Battaglia
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | | | | | | | - Linda G Kahn
- Correspondence address. E-mail: https://orcid.org/0000-0002-6512-6160
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Requia WJ, Kill E, Papatheodorou S, Koutrakis P, Schwartz JD. Prenatal exposure to wildfire-related air pollution and birth defects in Brazil. JOURNAL OF EXPOSURE SCIENCE & ENVIRONMENTAL EPIDEMIOLOGY 2022; 32:596-603. [PMID: 34504295 DOI: 10.1038/s41370-021-00380-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 08/17/2021] [Accepted: 08/17/2021] [Indexed: 05/05/2023]
Abstract
BACKGROUND Birth defects are a major cause of poor health outcomes during both childhood and adulthood. A growing body of evidence demonstrated associations between air pollution exposure during pregnancy and birth defects. To date, there is no study looking at birth defects and exposure to wildfire-related air pollution, which is suggested as a type of air pollution source with high toxicity for reproductive health. OBJECTIVE Our study addresses this gap by examining the association between birth defects and wildfire smoke exposure in Brazil between 2001 and 2018. Based on known differences of impacts of wildfires across different regions of Brazil, we hypothesized differences in risks of birth defects for different regions. METHODS We used a logistic regression model to estimate the odds ratios (ORs) for individual birth defects (12 categories) associated with wildfire exposure during each trimester of pregnancy. RESULTS Among the 16,825,497 birth records in our study population, there were a total of 7595 infants born in Brazil between 2001 and 2018 with birth defects in any of the selected categories. After adjusting for several confounders in the primary analysis, we found statistically significant OR for three birth defects, including cleft lip/cleft palate [OR: 1.007 (95% CI: 1.001; 1.013)] during the second trimester of exposure, congenital anomalies of the respiratory system [OR: 1.013 (95% CI: 1.002; 1.023)] in the second trimester of exposure, and congenital anomalies of the nervous system [OR: 1.002 (95% CI: 1.001; 1.003)] during the first trimester of exposure for the regions South, North, and Midwest, respectively. SIGNIFICANCE Our results suggest that maternal exposure to wildfire smoke during pregnancy may increase the risk of an infant being born with some congenital anomaly. Considering that birth defects are associated with long-term disability, impacting families and the healthcare system (e.g., healthcare costs), our findings should be of great concern to the public health community. IMPACT STATEMENT Our study focused on the association between maternal exposure to wildfire smoke in Brazil during pregnancy and the risk of an infant being born with congenital anomalies, which presents serious public health and environmental challenges.
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Affiliation(s)
- Weeberb J Requia
- School of Public Policy and Government, Fundação Getúlio Vargas, Brasília, Distrito Federal, Brazil.
| | - Erick Kill
- Faculty of Medicine, Department of Pathology, University of Sao Paulo, Sao Paulo, Brazil
| | | | - Petros Koutrakis
- Department of Environmental Health, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Joel D Schwartz
- Department of Environmental Health, Harvard TH Chan School of Public Health, Boston, MA, USA
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Ulziikhuu B, Gombojav E, Banzrai C, Batsukh S, Enkhtuya E, Boldbaatar B, Bellinger DC, Lanphear BP, McCandless LC, Tamana SK, Allen RW. Portable HEPA Filter Air Cleaner Use during Pregnancy and Children's Cognitive Performance at Four Years of Age: The UGAAR Randomized Controlled Trial. ENVIRONMENTAL HEALTH PERSPECTIVES 2022; 130:67006. [PMID: 35730943 PMCID: PMC9221428 DOI: 10.1289/ehp10302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
BACKGROUND Developmental exposure to air pollution is associated with diminished cognitive abilities in observational studies, but no randomized controlled trial has examined the effect of reducing air pollution on cognition in children. OBJECTIVES We sought to quantify the impact of reducing exposure to particulate matter (PM) during pregnancy on children's cognitive performance at 4 y of age. METHODS In this single-blind, parallel-group, randomized controlled trial in Ulaanbaatar, Mongolia, we randomly assigned 540 nonsmoking pregnant women (268 intervention and 272 control) to receive 1-2 portable high-efficiency particulate air (HEPA) filter air cleaners or no air cleaners. The air cleaners were used from a median of 11 wk gestation until the end of pregnancy. The primary outcome was full-scale intelligence quotient (FSIQ) assessed using the Wechsler Preschool and Primary Scale of Intelligence, Fourth Edition (WPPSI-IV) when children were a median of 48 months old. We imputed missing outcome data using multiple imputation with chained equations, and our primary analysis was by intention to treat. RESULTS After excluding known miscarriages, stillbirths, neonatal deaths, and medical conditions that impeded cognitive testing and imputation, 475 (233 control and 242 intervention) children were included in our analyses. In an unadjusted analysis, the mean FSIQ of children who were randomly assigned to the intervention group was 2.5 points [95% confidence interval (CI): -0.4, 5.4 points] higher than that of children in the control group. After adjustment to account for an imbalance in preterm birth between groups, the effect estimate increased to 2.8 points (95% CI: -0.1, 5.7). CONCLUSIONS Reducing PM air pollution during pregnancy may improve cognitive performance in childhood. https://doi.org/10.1289/EHP10302.
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Affiliation(s)
| | | | | | - Sarangerel Batsukh
- Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Enkhtuul Enkhtuya
- Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | | | | | | | | | | | - Ryan W. Allen
- Simon Fraser University, Burnaby, British Columbia, Canada
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Yim G, Roberts A, Ascherio A, Wypij D, Kioumourtzoglou MA, Weisskopf AMG. Smoking During Pregnancy and Risk of Attention-deficit/Hyperactivity Disorder in the Third Generation. Epidemiology 2022; 33:431-440. [PMID: 35213510 PMCID: PMC9010055 DOI: 10.1097/ede.0000000000001467] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Animal experiments indicate that environmental factors, such as cigarette smoke, can have multigenerational effects through the germline. However, there are little data on multigenerational effects of smoking in humans. We examined the associations between grandmothers' smoking while pregnant and risk of attention-deficit/hyperactivity disorder (ADHD) in her grandchildren. METHODS Our study population included 53,653 Nurses' Health Study II (NHS-II) participants (generation 1 [G1]), their mothers (generation 0 [G0]), and their 120,467 live-born children (generation 2 [G2]). In secondary analyses, we used data from 23,844 mothers of the nurses who were participants in the Nurses' Mothers' Cohort Study (NMCS), a substudy of NHS-II. RESULTS The prevalence of G0 smoking during the pregnancy with the G1 nurse was 25%. ADHD was diagnosed in 9,049 (7.5%) of the grandchildren (G2). Grand-maternal smoking during pregnancy was associated with increased odds of ADHD among the grandchildren (adjusted odds ratio [aOR] = 1.2; 95% confidence interval [CI] = 1.1, 1.2), independent of G1 smoking during pregnancy. In the Nurses' Mothers' Cohort Study, odds of ADHD increased with increasing cigarettes smoked per day by the grandmother (1-14 cigarettes: aOR = 1.1; 95% CI = 1.0, 1.2; 15+: aOR = 1.2; 95% CI = 1.0, 1.3), compared with nonsmoking grandmothers. CONCLUSIONS Grandmother smoking during pregnancy is associated with an increased risk of ADHD among the grandchildren.
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Affiliation(s)
- Gyeyoon Yim
- From the Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Andrea Roberts
- From the Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Alberto Ascherio
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - David Wypij
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Children's Hospital Boston, Boston, MA
| | | | - And Marc G Weisskopf
- From the Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
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Ebdrup NH, Knudsen UB, Schullehner J, Arendt LH, Liew Z, Lyngsø J, Bay B, Clemmensen PJ, Sigsgaard T, Hansen B, Ramlau-Hansen CH. Nitrate in Drinking Water and Time to Pregnancy or Medically Assisted Reproduction in Women and Men: A Nationwide Cohort Study in the Danish National Birth Cohort. Clin Epidemiol 2022; 14:475-487. [PMID: 35444467 PMCID: PMC9014114 DOI: 10.2147/clep.s354926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 03/24/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose No studies have investigated if drinking water nitrate affects human fecundity. Experimental studies point at detrimental effects on fetal development and on female and male reproduction. This cohort study aimed to explore if female and male preconception and long-term exposure to nitrate in drinking water was associated with fecundability measured as time to pregnancy (TTP) or use of medically assisted reproduction (MAR) treatment. Methods The study population consisted of pregnant women recruited in their first trimester in 1996–2002 to the Danish National Birth Cohort. Preconception drinking-water nitrate exposure was estimated for the pregnant women (89,109 pregnancies), and long-term drinking water nitrate exposure was estimated from adolescence to conception for the pregnant women (77,474 pregnancies) and their male partners (62,000 pregnancies) by linkage to the national drinking water quality-monitoring database Jupiter. Difference in risk of TTP >12 months or use of MAR treatment between five exposure categories and log-transformed continuous models of preconception and long-term nitrate in drinking water were estimated. Binominal regression models for risk ratios (RR) were adjusted for age, occupation, education, population density, and lifestyle factors. Results Nitrate in drinking water (median preconception exposure: 1.9 mg/L; median long-term exposure: 3.3 mg/L) was not associated with TTP >12 months or use of MAR treatment, neither in the categorical nor in the continuous models. Conclusion We found no association between preconception or long-term exposure to drinking water nitrate and fecundability.
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Affiliation(s)
- Ninna Hinchely Ebdrup
- Department of Obstetrics and Gynecology, Horsens Regional Hospital, Horsens, Denmark
- Department of Public Health, Aarhus University, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Correspondence: Ninna Hinchely Ebdrup, Department of Obstetrics and Gynecology, Horsens Regional Hospital, Regionshospitalet Horsens, Sundvej 30, Horsens, 8700, Denmark, Tel +4528472111, Email
| | - Ulla Breth Knudsen
- Department of Obstetrics and Gynecology, Horsens Regional Hospital, Horsens, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jörg Schullehner
- Department of Public Health, Aarhus University, Aarhus, Denmark
- Geological Survey of Denmark and Greenland, Aarhus, Denmark
| | - Linn Håkonsen Arendt
- Department of Public Health, Aarhus University, Aarhus, Denmark
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - Zeyan Liew
- Department of Environmental Health Sciences, Yale School of Public Health, New Haven, CT, USA
- Yale Center for Perinatal, Pediatric, and Environmental Epidemiology, Yale School of Public Health, New Haven, CT, USA
| | - Julie Lyngsø
- Department of Public Health, Aarhus University, Aarhus, Denmark
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - Bjørn Bay
- Department of Obstetrics and Gynecology, Horsens Regional Hospital, Horsens, Denmark
- Maigaard Fertility Clinic, Aarhus, Denmark
| | | | - Torben Sigsgaard
- Department of Public Health, Aarhus University, Aarhus, Denmark
- Centre for Integrated Register-based Research at Aarhus University, Aarhus, Denmark
- Danish Big Data Centre for Environment and Health (BERTHA), Aarhus University, Aarhus, Denmark
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Hertz‐Picciotto I, Korrick SA, Ladd‐Acosta C, Karagas MR, Lyall K, Schmidt RJ, Dunlop AL, Croen LA, Dabelea D, Daniels JL, Duarte CS, Fallin MD, Karr CJ, Lester B, Leve LD, Li Y, McGrath M, Ning X, Oken E, Sagiv SK, Sathyanaraya S, Tylavsky F, Volk HE, Wakschlag LS, Zhang M, O'Shea TM, Musci RJ. Maternal tobacco smoking and offspring autism spectrum disorder or traits in ECHO cohorts. Autism Res 2022; 15:551-569. [PMID: 35199959 PMCID: PMC9304219 DOI: 10.1002/aur.2665] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 12/16/2021] [Accepted: 12/16/2021] [Indexed: 12/13/2022]
Abstract
Given inconsistent evidence on preconception or prenatal tobacco use and offspring autism spectrum disorder (ASD), this study assessed associations of maternal smoking with ASD and ASD-related traits. Among 72 cohorts in the Environmental Influences on Child Health Outcomes consortium, 11 had ASD diagnosis and prenatal tobaccosmoking (n = 8648). and 7 had Social Responsiveness Scale (SRS) scores of ASD traits (n = 2399). Cohorts had diagnoses alone (6), traits alone (2), or both (5). Diagnoses drew from parent/caregiver report, review of records, or standardized instruments. Regression models estimated smoking-related odds ratios (ORs) for diagnoses and standardized mean differences for SRS scores. Cohort-specific ORs were meta-analyzed. Overall, maternal smoking was unassociated with child ASD (adjusted OR, 1.08; 95% confidence interval [CI], 0.72-1.61). However, heterogeneity across studies was strong: preterm cohorts showed reduced ASD risk for exposed children. After excluding preterm cohorts (biased by restrictions on causal intermediate and exposure opportunity) and small cohorts (very few ASD cases in either smoking category), the adjusted OR for ASD from maternal smoking was 1.44 (95% CI, 1.02-2.03). Children of smoking (versus non-smoking) mothers had more ASD traits (SRS T-score + 2.37 points, 95% CI, 0.73-4.01 points), with results homogeneous across cohorts. Maternal preconception/prenatal smoking was consistently associated with quantitative ASD traits and modestly associated with ASD diagnosis among sufficiently powered United States cohorts of non-preterm children. Limitations resulting from self-reported smoking and unmeasured confounders preclude definitive conclusions. Nevertheless, counseling on potential and known risks to the child from maternal smoking is warranted for pregnant women and pregnancy planners. LAY SUMMARY: Evidence on the association between maternal prenatal smoking and the child's risk for autism spectrum disorder has been conflicting, with some studies reporting harmful effects, and others finding reduced risks. Our analysis of children in the ECHO consortium found that maternal prenatal tobacco smoking is consistently associated with an increase in autism-related symptoms in the general population and modestly associated with elevated risk for a diagnosis of autism spectrum disorder when looking at a combined analysis from multiple studies that each included both pre- and full-term births. However, this study is not proof of a causal connection. Future studies to clarify the role of smoking in autism-like behaviors or autism diagnoses should collect more reliable data on smoking and measure other exposures or lifestyle factors that might have confounded our results.
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Affiliation(s)
- Irva Hertz‐Picciotto
- Department of Public Health Sciences and MIND InstituteUniversity of California, Davis School of MedicineDavisCaliforniaUSA
| | - Susan A. Korrick
- Channing Division of Network Medicine, Brigham and Women's HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Christine Ladd‐Acosta
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Margaret R. Karagas
- Department of EpidemiologyGeisel School of Medicine at DartmouthHannoverNew HampshireUSA
| | - Kristen Lyall
- A.J. Drexel Autism InstituteDrexel UniversityPhiladelphiaPennsylvaniaUSA
| | - Rebecca J. Schmidt
- Department of Public Health Sciences and MIND InstituteUniversity of California, Davis School of MedicineDavisCaliforniaUSA
| | - Anne L. Dunlop
- Department of Gynecology & ObstetricsEmory University School of MedicineAtlantaGeorgiaUSA
| | - Lisa A. Croen
- Division of ResearchKaiser PermanenteOaklandCaliforniaUSA
| | - Dana Dabelea
- LEAD Center and Department of EpidemiologyColorado School of Public HealthAuroraColoradoUSA
| | - Julie L. Daniels
- Departments of Epidemiology and Maternal and Child Health; Gillings School of Global Public HealthUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Cristiane S. Duarte
- Department of PsychiatryColumbia University, New York State Psychiatric InstituteNew YorkNew YorkUSA
| | - M. Daniele Fallin
- Department of Mental HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Catherine J. Karr
- Departments of Pediatrics and Environmental & Occupational Health SciencesUniversity of WashingtonSeattleWashingtonUSA
| | - Barry Lester
- Brown Center for the Study of Children at Risk and Departments of Psychiatry and Human Behavior and Pediatrics, Alpert Medical School, Brown UniversityWomen and Infants Hospital in Rhode IslandProvidenceRhode IslandUSA
| | | | - Yijun Li
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Monica McGrath
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Xuejuan Ning
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Emily Oken
- Department of Population MedicineHarvard Medical School and Harvard Pilgrim Health Care InstituteBostonMassachusettsUSA
| | - Sharon K. Sagiv
- Center for Environmental Research and Children's HealthUniversity of California, Berkeley, School of Public HealthBerkeleyCaliforniaUSA
| | - Sheela Sathyanaraya
- Department of Pediatrics, Seattle Children's Research InstituteUniversity of WashingtonSeattleWashingtonUSA
| | - Frances Tylavsky
- Department of Preventive MedicineUniversity of Tennessee Health Science CenterMemphisTennesseeUSA
| | - Heather E. Volk
- Department of Mental HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Lauren S. Wakschlag
- Department of Medical Social Sciences, Feinberg School of Medicine, and Institute for Innovations in Developmental SciencesNorthwestern UniversityChicagoIllinoisUSA
| | - Mingyu Zhang
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - T. Michael O'Shea
- Department of PediatricsUniversity of North Carolina at Chapel Hill School of MedicineChapel HillNorth CarolinaUSA
| | - Rashelle J. Musci
- Department of Mental HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
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Rotem RS, Chodick G, Davidovitch M, Bellavia A, Weisskopf MG. Maternal Thyroid Anomalies and Attention-Deficit Hyperactivity Disorder in Progeny. Am J Epidemiol 2022; 191:430-440. [PMID: 34791037 DOI: 10.1093/aje/kwab272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 09/21/2021] [Accepted: 11/09/2021] [Indexed: 11/12/2022] Open
Abstract
Previous epidemiologic investigations suggested that maternal thyroid anomalies are a possible causal factor in attention-deficit hyperactivity disorder (ADHD) in progeny, yet clinical trials indicated that levothyroxine treatment was ineffective in preventing neurodevelopmental impairments. We used an Israeli cohort of 385,542 singleton births from 1999-2012 to explore the interrelated roles of maternal thyroid conditions, laboratory gestational thyroid hormone measurements, use of thyroid medications, and offspring ADHD. Analyses were performed using Cox proportional hazards models. Results indicated that maternal hypothyroidism diagnosis was associated with an elevated progeny ADHD hazard (adjusted hazard ratio = 1.14, 95% confidence interval = 1.10, 1.18). However, this association was unmitigated by gestational use of levothyroxine and was unexplained by maternal gestational thyroid hormone levels. Associations with gestational thyrotropin values and hypothyroxinemia were also observed but were robust only in mothers without other records indicative of a thyroid problem. Results indicated that maternal thyroid hypofunction was associated with progeny ADHD but possibly not due to a direct causal relationship. Instead, maternal thyroid hypofunction may serve as a proxy indicator for other factors that affect neurodevelopment through thyroid hormone independent pathways, which are thus unaffected by pharmaceutical treatments for thyroid hypofunction. Factors known to disrupt thyroid functioning should be examined for their independent ADHD-related effects.
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Leung M, Weisskopf MG, Laden F, Coull BA, Modest AM, Hacker MR, Wylie BJ, Wei Y, Schwartz J, Papatheodorou S. Exposure to PM2.5 during Pregnancy and Fetal Growth in Eastern Massachusetts, USA. ENVIRONMENTAL HEALTH PERSPECTIVES 2022; 130:17004. [PMID: 34989624 PMCID: PMC8734565 DOI: 10.1289/ehp9824] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 12/09/2021] [Accepted: 12/15/2021] [Indexed: 05/29/2023]
Abstract
BACKGROUND Prior studies have examined the association between fine particulate matter [PM ≤2.5μm in aerodynamic diameter (PM2.5)] and fetal growth with either limited spatial or temporal resolution. OBJECTIVES In this study, we examined the association between PM2.5 exposure during pregnancy and fetal growth measures (ultrasound parameters and birth weight) in a pregnancy cohort using spatiotemporally resolved PM2.5 in Eastern Massachusetts, USA. METHODS We used ultrasound measures of biparietal diameter (BPD), head circumference, femur length, and abdominal circumference (AC), in addition to birth weight, from 9,446 pregnancies that were delivered at the Beth Israel Deaconess Medical Center from 2011-2016. We used linear mixed-effects models to examine the associations of PM2.5 in two exposure windows (the first 16 wk of pregnancy and the cumulative exposure up until the assessment of fetal growth) with anatomic scans (ultrasound measures at<24 wk), growth scans (ultrasound measures at≥24wk), and birth weight. All models were adjusted for sociodemographic characteristics, long-term trends, and temperature. RESULTS Higher PM2.5 exposure in the first 16 wk was associated with smaller fetal growth measures, where associations were particularly strong for BPD, AC, and birth weight. For example, a 5-μg/m3 increase in PM2.5 was associated with a lower mean BPD z-score of -0.19 (95% CI: -0.31, -0.06) before 24 wk, a lower mean AC z-score of -0.15 (95% CI: -0.28, -0.01) after 24 wk, and a lower mean birth weight z-score of -0.11 (95% CI: -0.20, -0.01). Analyses examining the associations with cumulative PM2.5 exposure up until the assessment of fetal growth produced attenuated associations. CONCLUSIONS Higher gestational exposure to PM2.5 was associated with smaller fetal growth measures at levels below the current national standards. https://doi.org/10.1289/EHP9824.
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Affiliation(s)
- Michael Leung
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Marc G. Weisskopf
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Francine Laden
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Brent A. Coull
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Anna M. Modest
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts, USA
| | - Michele R. Hacker
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts, USA
| | - Blair J. Wylie
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts, USA
| | - Yaguang Wei
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Joel Schwartz
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Stefania Papatheodorou
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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Stayner LT, Jensen AS, Schullehner J, Coffman VR, Trabjerg BB, Olsen J, Hansen B, Pedersen M, Pedersen CB, Sigsgaard T. Nitrate in drinking water and risk of birth defects: Findings from a cohort study of over one million births in Denmark. THE LANCET REGIONAL HEALTH. EUROPE 2022; 14:100286. [PMID: 35141697 PMCID: PMC8814759 DOI: 10.1016/j.lanepe.2021.100286] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background A few studies have reported an increased risk of birth defects (BD) with maternal exposure to nitrate in drinking water. We examined this association in a large cohort study with well-characterized exposure. Methods Danish singletons liveborn to Danish-born parents from 1991–2013 were identified using civil and patient registries (n=1,018,914). Exposure to nitrate was estimated using a spatial model based on national data linked with individual addresses. Odds ratios (OR) and 95% confidence intervals (95% CI) were estimated using logistic regression. Findings In total, 33,182 cases of BD were identified. Nitrate concentrations were generally well below US and EU standards. We observed an exposure-response relationship (p=0·004) between nitrate during pregnancy and eye BD, and increased risk in the highest exposure group (≥25 mg/L nitrate) (OR: 1·29; 95% CI: 1·00, 1·66). An interaction was observed between maternal age and continuous nitrate exposure for nervous system BD (p<0·001) indicating an increased risk among mothers <25 years-of-age (OR for 10 mg/L (OR10): 1·20; 95% CI: 1·06, 1·35). An interaction (p<0.01) with maternal age and continuous nitrate exposure was also observed for ear, face, and neck BD indicating an increased risk among babies born to mothers <25 years-of-age (OR10: 1·35; 95% CI: 1·11, 1·66). There was evidence of an inverse exposure-response relationship for any, digestive system, female genital, and urinary BD. Interpretation Our study is the first to report an association between nitrate and eye BD and BD of the ear, face, and neck. It also provides support to prior reports of increased risk of nervous system BD. Funding This study was supported by a grant from the United States National Institute of Environmental Health Sciences (R01 ES027823-01A1).
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Khadka A, Canning D. Understanding the Pathways from Prenatal and Post-Birth PM 2.5 Exposure to Infant Death: An Observational Analysis Using US Vital Records (2011-2013). INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 19:258. [PMID: 35010519 PMCID: PMC8751133 DOI: 10.3390/ijerph19010258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 11/24/2021] [Accepted: 12/23/2021] [Indexed: 06/14/2023]
Abstract
We studied the relationship of prenatal and post-birth exposure to particulate matter < 2.5 μm in diameter (PM2.5) with infant mortality for all births between 2011 and 2013 in the conterminous United States. Prenatal exposure was defined separately for each trimester, post-birth exposure was defined in the 12 months following the prenatal period, and infant mortality was defined as death in the first year of life. For the analysis, we merged over 10 million cohort-linked live birth-infant death records with daily, county-level PM2.5 concentration data and then fit a Structural Equation Model controlling for several individual- and county-level confounders. We estimated direct paths from the two exposures to infant death as well as indirect paths from the prenatal exposure to the outcome through preterm birth and low birth weight. Prenatal PM2.5 exposure was positively associated with infant death across all trimesters, although the relationship was strongest in the third trimester. The direct pathway from the prenatal exposure to the outcome accounted for most of this association. Estimates for the post-birth PM2.5-infant death relationship were less precise. The results from our study add to a growing literature that provides evidence in favor of the potential harmful effects on human health of low levels of air pollution.
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Affiliation(s)
- Aayush Khadka
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, CA 94110, USA
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA 02115, USA;
| | - David Canning
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA 02115, USA;
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Tamana SK, Gombojav E, Kanlic A, Banzrai C, Batsukh S, Enkhtuya E, Boldbaatar B, Lanphear BP, Lear SA, McCandless LC, Venners SA, Allen RW. Portable HEPA filter air cleaner use during pregnancy and children's body mass index at two years of age: The UGAAR randomized controlled trial. ENVIRONMENT INTERNATIONAL 2021; 156:106728. [PMID: 34218184 DOI: 10.1016/j.envint.2021.106728] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 06/10/2021] [Accepted: 06/17/2021] [Indexed: 06/13/2023]
Abstract
IMPORTANCE Gestational exposure to particulate matter (PM) air pollution may increase the risk of childhood obesity, but the impact of reducing air pollution during pregnancy on obesity-related outcomes in childhood has not been examined. OBJECTIVE To assess the impact of reducing gestational PM exposure on body mass index (BMI) at two years of age. METHODS In this single-blind, parallel group randomized controlled trial in Ulaanbaatar Mongolia, we randomly assigned 540 pregnant women to receive 1-2 portable high efficiency particulate air (HEPA) filter air cleaners or no air cleaners. We measured height and weight when children were a mean age of 23.8 months. Our primary outcome was age- and sex-specific BMI z-score based on the World Health Organization 2007 Growth Charts. Secondary outcomes included age- and sex-specific weight z score, overweight/obesity (defined as BMI z-score > 2.00), and catch-up growth (defined using various cut-offs to identify children with relatively low birth weight for sex and gestational age and relatively high age- and sex-specific weight in childhood). We imputed missing outcome data using multiple imputation with chained equations and our primary analysis was by intention to treat (ITT). We estimated intervention effects on continuous and binary outcomes using linear and logistic regression, respectively. RESULTS After excluding known miscarriages, still births, and neonatal deaths our analysis included 480 children (235 control and 245 intervention). The mean (SD) child BMI z score was 0.79 (1.0); 9.8% of children were overweight or obese. The mean BMI z score of children who were randomly assigned to the intervention group was 0.16-units lower (95% CI: -0.35, 0.04) than children in the control group. The intervention was also associated with reductions in overweight/obesity (odds ratio = 0.59; 95% CI: 0.31, 1.12). Catch-up growth occurred less frequently in the intervention group, but effect estimates varied depending on the specific definition of catch-up growth and confidence intervals consistently spanned no effect. CONCLUSIONS We found that the use of portable air cleaners during pregnancy was associated with improvements in obesity-related outcomes, although some effect estimates lacked precision. Reducing PM exposure during pregnancy may lead to improvements in cardiometabolic health in childhood.
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Affiliation(s)
- Sukhpreet K Tamana
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Enkhjargal Gombojav
- School of Public Health, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Adriana Kanlic
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Chimeglkham Banzrai
- Institute of Medical Sciences, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Sarangerel Batsukh
- School of Public Health, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Enkhtuul Enkhtuya
- School of Public Health, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Buyantushig Boldbaatar
- School of Public Health, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Bruce P Lanphear
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Scott A Lear
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | | | - Scott A Venners
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Ryan W Allen
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada.
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Enkhbat U, Gombojav E, Banzrai C, Batsukh S, Boldbaatar B, Enkhtuya E, Ochir C, Bellinger DC, Lanphear BP, McCandless LC, Allen RW. Portable HEPA filter air cleaner use during pregnancy and children's behavior problem scores: a secondary analysis of the UGAAR randomized controlled trial. Environ Health 2021; 20:78. [PMID: 34225757 PMCID: PMC8258951 DOI: 10.1186/s12940-021-00763-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 06/21/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Developmental exposure to particulate matter (PM) air pollution may impair children's behaviors. Our objectives were to quantify the impact of reducing indoor PM using portable HEPA filter air cleaners during pregnancy on behavioral problems in children and to assess associations between indoor fine PM (PM2.5) concentrations during pregnancy and children's behavior. METHODS This is a secondary analysis of a single-blind parallel-group randomized controlled trial in which we randomly assigned 540 non-smoking pregnant women to receive 1 or 2 HEPA filter air cleaners or no air cleaners. We administered the Behavior Assessment System for Children (BASC-3) to caregivers when children were a mean age of 23 months, and again at a mean age of 48 months. Primary outcomes were the four BASC-3 composite scales: externalizing problems, internalizing problems, adaptive skills, and the behavioral symptoms index. We imputed missing data using multiple imputation with chained equations. The primary analysis was by intention-to-treat. In a secondary analysis, we evaluated associations between BASC-3 composite indices and modeled trimester-specific PM2.5 concentrations inside residences. RESULTS We enrolled participants at a median of 11 weeks gestation. After excluding miscarriages, still births and neonatal deaths, our analysis included 478 children (233 control and 245 intervention). We observed no differences in the mean BASC-3 scores between treatment groups. An interquartile increase (20.1 µg/m3) in first trimester PM2.5 concentration was associated with higher externalizing problem scores (2.4 units, 95% CI: 0.7, 4.1), higher internalizing problem scores (2.4 units, 95% CI: 0.7, 4.0), lower adaptive skills scores (-1.5 units, 95% CI: -3.0, 0.0), and higher behavior symptoms index scores (2.3 units, 95% CI: 0.7, 3.9). Third trimester PM2.5 concentrations were also associated with some behavioral indices at age 4, but effect estimates were smaller. No significant associations were observed with PM2.5 concentrations during the second trimester or for any of the BASC indices when children were 2 years old. CONCLUSION We found no benefit of reducing indoor particulate air pollution during pregnancy on parent-reported behaviors in children. Associations between indoor PM2.5 concentrations in the first trimester and behavioral scores among 4-year old children suggest that it may be necessary to intervene early in pregnancy to protect children, but these exploratory findings should be interpreted cautiously. TRIAL REGISTRATION ClinicalTrials.gov: NCT01741051.
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Affiliation(s)
- Undarmaa Enkhbat
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC Canada
- School of Public Health, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Enkhjargal Gombojav
- School of Public Health, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Chimeglkham Banzrai
- Institute of Medical Sciences, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Sarangerel Batsukh
- School of Public Health, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Buyantushig Boldbaatar
- School of Public Health, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Enkhtuul Enkhtuya
- School of Public Health, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Chimedsuren Ochir
- School of Graduate Studies, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | | | - Bruce P. Lanphear
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC Canada
| | | | - Ryan W. Allen
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC Canada
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